The Impact of a Behavioral-Economics Informed Intervention on Primary Care Utilization for Postpartum Individuals with Chronic Conditions: A Randomized Controlled Trial

ImportanceOver 30% of pregnant people have at least one chronic medical condition, and nearly 20% develop gestational diabetes or pregnancy-related hypertension, increasing the risk of future chronic disease. While these individuals are often monitored closely during pregnancy, they face significant barriers when transitioning to primary care following delivery, due in part to a lack of health care support for this transition. ObjectiveTo evaluate the impact of an intervention designed to improve postpartum primary care engagement by reducing patient administrative burden and information gaps. DesignIndividual-level randomized controlled trial conducted from November 3, 2022 to October 11, 2023. SettingOne hospital-based and five community-based outpatient obstetric clinics affiliated with a large academic medical center. ParticipantsParticipants included English- and Spanish-speaking pregnant or recently postpartum adults with obesity, anxiety, depression, diabetes mellitus, chronic hypertension, gestational diabetes, or pregnancy-related hypertension, and a primary care practitioner (PCP) listed in their electronic health record (EHR). InterventionA behavioral economics-informed intervention bundle, including default scheduling of postpartum PCP appointments and tailored messages. Main OutcomeCompletion of a PCP visit for routine or chronic condition care within 4 months of delivery. Results360 patients were randomized (Control: N=176, Intervention: N=184). Individuals had mean (SD) age 34.1 (4.9) years and median gestational age of 36.3 weeks (interquartile range (IQR) 34.0-38.6 weeks) at enrollment. The distribution of self-reported races was 7.4% Asian, 6.8% Black, 15.0% multiple races or "Other," and 68.6% White. Most (75.8%) participants had anxiety or depression, 15.9% had a chronic or pregnancy-related hypertensive disorder, 19.8% had pre-existing or gestational diabetes, and 40.4% had a pre-pregnancy BMI [≥]30 kg/m2. Medicaid was the primary payer for 21.9% of patients. PCP visit completion within 4 months occurred in 22.0% in the control group and 40.0% in the intervention group. In regression models accounting for randomization strata, the intervention increased PCP visit completion by 18.7 percentage points (95%CI 10.7-29.1). Intervention participants also had fewer postpartum readmissions (1.7 vs. 5.8%) and increased receipt of the following services by a PCP: blood pressure screening (42.8 vs. 28.3%), weight assessment (42.8 vs. 27.7%), and depression screening (32.8 vs. 16.8%). Conclusions and RelevanceIn this randomized trial of pregnant individuals with or at risk for chronic health conditions, default PCP visit scheduling, tailored messages, and reminders substantially improved postpartum primary care engagement. The current lack of support for postpartum transitions to primary care is a missed opportunity to improve recently pregnant individuals short- and long-term health. Reducing patient administrative burdens may represent relatively low-resource, high-impact approaches to improving postpartum health and wellbeing. Trial RegistrationNCT05543265. KEY POINTSO_ST_ABSQuestionC_ST_ABSWhat is the impact of a behavioral economic intervention designed to reduce patient administrative burden and information gaps on primary care practitioner (PCP) visit completion in the postpartum period? FindingsIn this randomized clinical trial of 360 patients, default PCP scheduling, tailored messages, and reminders increased postpartum PCP visit rates by 19 percentage points for individuals with or at high risk for chronic disease. MeaningA multi-faceted and relatively low-resource behavioral economic intervention may improve postpartum health and well-being.