(611) From Delivery to Prevention: Building Bridges to Longterm Cardiometabolic Care

The postpartum (PP) period is a key window to impact long-term health, especially for those with cardiometabolic diseases in pregnancy who need intensified follow-up. In 2022, we established a Postpartum Cardiometabolic Clinic (PPMC), offering counseling at 12 weeks PP to address health risks & coordinate referrals to primary (PCP) & specialty health care. While early pilot data showed improved PCP and cardiology follow-up, we now assess referrals and lab monitoring at 1 year PP.

Study Design:

We performed a retrospective cohort study of subjects referred to PPMC. Data including follow-up with providers were compared between those who attended vs did not attend PPMC. Continuous and categorical variables were compared using Wilcoxon Rank Sum Tests and Chi-Square/Fisher’s exact tests as appropriate. Log binomial regressions calculating adjusted risk ratios (ARR) were performed.

Results:

Of N=382 referrals, 58% (n=220) attended PPMC (Table 1). Those who attended vs did not attend PPMC were more likely to have follow-up scheduled with PCP (59.6% vs 37.0%, p< 0.01), cardiology (56.8% vs. 25.9%, p< 0.01), & a trend with mental health providers (14.6% vs. 9.3%, p=0.12) within 1 year PP. Those who attended PPMC were also more likely to have lipids (37.7% vs. 19.1%, p< 0.001), hemoglobin A1c (36.8% vs. 22.8%, p=0.003), & 2-hour glucose tolerance test drawn (9.1% vs. 1.2%, p=0.001) (Table 2). Controlling for age, race, parity, education & insurance, those attending PPMC had a 1.4-fold higher likelihood of PCP follow-up (ARR 1.4, 95% CI 1.1-1.7, p=0.006) & 2-fold higher likelihood of cardiology follow-up (ARR 2.0, 95% CI 1.5-2.7 p< 0.001).

Conclusion:

Our findings underscore the need to shift the PP care model from a single visit to a longitudinal, multidisciplinary approach. A targeted counseling visit was associated with significant improvements in long-term follow-up, highlighting the powerful impact of individualized care in empowering patients & facilitating care transitions. PPMC represents a scalable, patient-centered intervention to bridge care gaps & optimize long-term cardiometabolic health.