System factors influencing the postpartum transition to primary care for cardiovascular disease risk management among women with hypertensive disorders in pregnancy

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PROJECT SUMMARY Cardiovascular disease (CVD) is the leading cause of death among women in the United States. Women who experience hypertensive disorders in pregnancy (HDP), including chronic hypertension, gestational hypertension, and pre-eclampsia/eclampsia, face substantially higher future CVD risk. About one in seven women experience HDP by the end of their childbearing years, with higher rates among women of color. Transitioning to primary care postpartum is recommended for all women, but has particular urgency for women with HDP. Women with HDP have a high risk of adverse outcomes in the immediate postpartum period (e.g. maternal morbidity and mortality), one to three years postpartum (e.g., hypertension, metabolic syndrome onset), and long-term (e.g. ischemic heart disease, heart failure, stroke). The limited existing research on postpartum primary care utilization shows that up to 80% of women who experienced HDP do not receive primary care in the year following birth. Primary care is an appropriate setting for short and long-term CVD risk management, including identification and treatment of hypertension and hyperlipidemia. However, little is known about the primary care provided for postpartum women with HDP and whether it responds to their heightened CVD risk. Despite low rates of postpartum transition to primary care for women with HDP, little is known about how systems factors impact this transition and primary care CVD risk assessment and management in the postpartum year. Using an explanatory-sequential mixed methods design, we examine the postpartum transition to primary care for CVD risk management for women with HDP in Massachusetts and nationally. These aims address NHLBI’s strategic objective to “investigate factors that account for differences in health among populations,” which includes managing cardiometabolic risk to improve health trajectories in sex-specific populations. The specific aims are 1) To determine the role of systems factors in the transition to preventive primary care for women with HDP in the postpartum year; 2) To characterize and examine clinician and organizational factors influencing cardiometabolic risk assessment and management in primary care in the postpartum year; and 3) To identify organizational and contextual factors shaping the postpartum transition to primary care and CVD risk management in primary care. With input from a multi-stakeholder advisory board, we will integrate results across aims to develop practice and policy recommendations to improve care quality for women with HDP to reduce future CVD risk. Results from this study will contribute to an improved understanding of systems factors associated with successful transition to postpartum primary care for women at high CVD risk, and help to identify interventions, healthcare quality metrics, and policy levers to improve clinical practice.