From Hypertensive Pregnancy to Heart Health: Understanding and Addressing Multi-Level Barriers to Cardiovascular Health after Hypertensive Disorders of Pregnancy

PROJECT SUMMARY Hypertensive disorders of pregnancy (HDPs) affect 10% of pregnancies in the United States and are associated with future cardiovascular disease (CVD) risk, with significantly higher prevalence and worse outcomes among Black women and women with low incomes. Timely identification and management of CVD risk factors (e.g., blood pressure control) after HDPs leads to substantial and sustained improvements in cardiovascular health. Yet only 25-50% of patients receive recommended care in the year after HDPs, with further inequities by race and income. Therefore, inadequate care after HDPs is a critical missed opportunity to promote cardiovascular health and health equity among women. Unfortunately, efforts to improve cardiovascular health after HDPs are limited by key gaps in evidence and approach. First, there is a general need for more data on CVD risk and cardiovascular health in diverse populations. Second, such data must be followed rigorous implementation of evidence-based interventions that address social and structural factors, with stakeholder engagement. In response, Dr. Murray Horwitz has developed a plan to address large knowledge gaps, work with diverse stakeholders to adapt an evidence-based intervention and prepare for its successful implementation, and pilot-test the intervention, to improve cardiovascular health equity after HDPs. Her 3 specific aims are to: (1) Examine the distribution of cardiovascular health (measured by Life’s Essential 8) in a diverse nationwide sample of patients with prior HDPs (n~40,000), then identify key care gaps along the pathway from HDPs to cardiovascular health (e.g., access to outpatient care, CVD risk assessment), and finally identify multi-level predictors of a key point of drop-off (e.g., access to outpatient care). These findings will inform adaptations to a postpartum patient navigation intervention, to ensure that it addresses priority populations and modifiable barriers to cardiovascular health after HDPs. (2) Conduct stakeholder- engaged qualitative research in 2 health care settings, to contextualize care pathways in the year after HDPs, then identify potential implementation barriers for the planned patient navigation intervention. Findings will be used to refine the implementation strategy for the intervention, prior to pilot testing. (3) Conduct a pilot randomized controlled trial to test the feasibility and acceptability of a postpartum patient navigation intervention, adapted to improve cardiovascular health after HDPs, in a large safety net hospital (n=30/group, 60 total). Trial results will inform further improvements to the intervention and implementation strategy, to be followed by multi-site effectiveness testing. Her research aims reflect the NHLBI’s Strategic Vision, to, “Reduce health disparities and inequities […] by leveraging epidemiology […] to understand and solve complex health problems.” They also serve as vehicles for her training goals, as follows: (1) Develop expertise in advanced modeling techniques, specifically multi-level modeling and risk prediction; (2) Establish competency in learning health system science, specifically in the areas of community engagement, equity & justice, improvement & implementation science frameworks, and research methods; and (3) Gain skills in pragmatic clinical trial design & conduct. This award will facilitate Dr. Murray Horwitz’s long-term goal of becoming an independent investigator who develops and disseminates interventions that improve cardiovascular health and health equity among women.