New clinical performance measures for contraceptive care: their importance to healthcare quality

Prioritizing patient experience: Validation of the person-centered contraceptive counseling measure as a performance measure

OBJECTIVE

A performance measure assessing how often patients experience patient-centered contraceptive counseling can inform quality improvement in contraceptive care and enable efforts to enhance equity in the provision of this care. We sought to test the validity and reliability of the Person-Centered Contraceptive Counseling (PCCC) measure as a performance measure, in preparation for application for endorsement from the National Quality Forum.

STUDY DESIGN

We combined data from two research studies, a statewide quality improvement assessment, and a dedicated data collection effort at nine sites, all collected between 2009 and 2019 at 22 total sites in the United States, to evaluate the validity and reliability of the four-item PCCC measure aggregated at the provider and facility level. We scored the PCCC dichotomously as a "top-box" score of 20 versus less than 20. We assessed reliability using the Spearman-Brown coefficient, and validity by comparing scores on the PCCC to aggregated scores on single-item measures of patient satisfaction.

RESULTS

We included 22 facilities and 34 providers in the analyses. The average PCCC top-box score by provider and facility was 81% and 79%, respectively. We found adequate reliability with panel sizes of 20-50. PCCC scores were strongly associated with the single-item measures of satisfaction. There were notable disparities by race/ethnicity and language (Spanish vs English) in PCCC scores.

DISCUSSION

The PCCC is a valid and reliable performance measure for use at the provider and facility level. The development and use of the measures of patient experience, like the PCCC, is critical for prioritizing patient-centeredness in reproductive health care.

IMPLICATIONS

The PCCC measure can facilitate the identification of gaps and disparities in patient-centered contraceptive counseling and enable quality improvement to promote quality, equitable contraceptive care. Using this measure provides the opportunity to enhance patient experience of care and build trust between contraceptive providers and the communities they serve.

Association of Title X clinic status with receipt of person-centered contraceptive counseling: a population-based study

OBJECTIVE

To describe receipt of person-centered contraceptive counseling among reproductive-aged women in the United States who sought contraceptive care at Title X clinics, non-Title X public clinics, and private clinics.

STUDY DESIGN

We conducted a secondary analysis of the 2017-2019 wave of the National Survey of Family Growth (NSFG). The sample included female respondents ages 15-49 who received contraceptive services in the past year and completed the Person-Centered Contraceptive Counseling (PCCC) measure, a quality metric evaluating interpersonal quality of the care received. We used multivariable logistic regression to estimate the predicted probability of receiving person-centered contraceptive counseling by source of care, adjusted for individual-level characteristics.

RESULTS

Of 2,225 (weighted N=26,599,620) eligible respondents, 6.9% received care at a Title X clinic, 8.2% at a non-Title X public clinic, and 84.9% at a private clinic. The adjusted predicted probability of receiving person-centered contraceptive counseling among respondents attending private clinics was 50.6% (95% CI 46.3-54.8%) compared with 51.3% (95% CI 40.4-62.3%) at Title X clinics and 52.4% (95% CI 44.0-60.7%) at other public clinics. Respondents with incomes ≥300% above the federal poverty level (FPL) had higher odds of reporting receipt of person-centered counseling compared to those with incomes below 100% of the FPL (aOR = 2.12; 95% CI 1.47-3.06). Non-Latina Black respondents had lower odds of receiving person-centered contraceptive counseling (aOR = 0.69; 95% CI 0.51-0.94), compared to non-Latina white respondents.

CONCLUSION

Title X clinics perform as well as the private sector in delivering person-centered contraceptive counseling.

IMPLICATIONS

Title X clinics provide quality person-centered contraceptive counseling on par with the private sector, despite serving populations that are often less likely to report high quality care. Broad implementation of the PCCC measure will permit tracking person-centered contraceptive care across diverse practice settings and populations.

Medicaid Payments For Immediate Postpartum Long-Acting Reversible Contraception: Evidence From South Carolina

In 2012 South Carolina's Medicaid program was the first state Medicaid program to separate payment for the immediate postpartum placement of long-acting reversible contraception (intrauterine devices and contraceptive implants) from its global maternity payment. Examining data on all Medicaid-insured South Carolina women giving birth from 2010 to 2014, we found that the new policy achieved its explicit goal: increasing the availability of immediate postpartum long-acting reversible contraception. Among adolescents, for whom most pregnancies are unintended, this represented new use of long-acting reversible options, rather than substitution for sterilization or for short-acting reversible methods. Therefore, the new policy also significantly increased use of highly effective postpartum contraception in an age group that is particularly vulnerable to closely spaced, higher-risk repeat pregnancies. However, fewer than half of facilities began to offer immediate postpartum long-acting reversible contraceptives after the policy change. Additional policy approaches may be needed to achieve widespread availability of this option.

Development of the Person-Centered Contraceptive Counseling scale (PCCC), a short form of the Interpersonal Quality of Family Planning care scale

OBJECTIVE

Person-centeredness is a critical component of quality in family planning. We previously validated an 11-item Interpersonal Quality of Family Planning (IQFP) scale. We sought to create a parsimonious version of the scale in preparation for testing its appropriateness as a patient-reported outcome performance measure.

STUDY DESIGN

To explore clarity and importance of each of the 11 items, we conducted English and Spanish cognitive interviews with patients who received contraceptive counseling (n = 33) at 3 publicly funded California clinics. We triangulated these results with psychometric analysis of previously collected IQFP data (n = 1097) to assess validity and reliability of selected item combinations.

RESULTS

The 11-item IQFP scale was reduced to a 4-item scale (the Person-Centered Contraceptive Counseling scale, or PCCC) that includes items evaluating provider performance regarding respect for patients, information provision, and eliciting and honoring patient preferences for birth control. Interview participants deemed the items included in the 4-item PCCC important and clear in both English and Spanish versions of the instrument. The 4-item PCCC retained the 11-item IQFP's psychometric properties, including internal consistency (Cronbach's alpha = 0.92 vs 0.97 for the PCCC and IQFP, respectively) and a consistent single factor analysis solution (factor loadings = 0.86-0.92 and 0.81-0.91). The 4-item PCCC additionally retained the construct and predictive validity of the IQFP.

CONCLUSIONS

The 4-item PCCC is a valid and reliable as a measure of person-centered contraceptive counseling that reflects patients' perspectives on contraceptive counseling.

IMPLICATIONS

Person-centered measures such as the 4-item PCCC can help inform efforts to improve health care quality. Future work will investigate the validity and reliability of the 4-item PCCC as a performance measure to determine the appropriateness of its use in the quality improvement context.

Adolescent Birth Rates and Rural-Urban Differences by Levels of Deprivation and Health Professional Shortage Areas in the United States, 2017-2018

Objectives. To examine the differences in adolescent birth rates by deprivation and Health Professional Shortage Areas (HPSAs) in rural and urban counties of the United States in 2017 and 2018.Methods. We analyzed available data on birth rates for females aged 15 to 19 years in the United States using the restricted-use natality files from the National Center for Health Statistics, American Community Survey 5-year population estimates, and the Area Health Resources Files.Results. Rural counties had an additional 7.8 births per 1000 females aged 15 to 19 years (b = 7.84; 95% confidence interval [CI] = 7.13, 8.55) compared with urban counties. Counties with the highest deprivation had an additional 23.1 births per 1000 females aged 15 to 19 years (b = 23.12; 95% CI = 22.30, 23.93), compared with less deprived counties. Rural counties with whole shortage designation had an additional 8.3 births per 1000 females aged 15 to 19 years (b = 8.27; 95% CI = 6.86, 9.67) compared with their urban counterparts.Conclusions. Rural communities across deprivation and HPSA categories showed disproportionately high adolescent birth rates. Future research should examine the extent to which contraceptive access differs among deprived and HPSA-designated rural communities and the impact of policies that may create barriers for rural communities.

Understanding the extent of contraceptive non-use among women at risk of unintended pregnancy, National Survey of Family Growth 2011-2017

Objective

To describe characteristics of U.S. contraceptive non-users to inform tailored contraceptive access initiatives.

Study design

We used National Survey of Family Growth data from 2011 to 2017 to identify characteristics of contraceptive non-users compared to other women ages 15–44 at risk for unintended pregnancy. We also examined reasons for not using contraception by when non-users expected their next birth. We calculated unadjusted and adjusted prevalence ratios using two definitions of contraceptive non-use: (1) contraceptive non-use during the interview month, and (2) a more refined definition based on contraception use during the most recent month of sexual intercourse and expectation of timing of next birth. We considered p-values < 0.05 statistically significant.

Results

Approximately 20% (n = 2844) of 12,071 women at risk of unintended pregnancy were classified as standard contraceptive non-users. After adjusting for all other variables, non-users were more likely to be low-income, uninsured, never married, expect a birth within 2 years, and have zero or one parity. The top reasons for contraceptive non-use were not minding if they got pregnant (22.6%), worried about contraceptive side effects (21.0%), and not thinking they could get pregnant (17.6%). After applying the more refined non-user definition, we identified 5.7% (n = 721) of women as non-users; expecting a birth within 2–5 years and having a parity of one were associated with non-use after adjustment of all other factors.

Conclusion

Our more refined definition of non-users could be used in future studies examining the causes of unintended pregnancy and to inform programmatic interventions to reduce unintended pregnancy.

Implications

Describing contraceptive non-users and reasons for contraceptive non-use could help us better understand reasons for unintended pregnancy and inform tailored contraceptive access initiatives.

Evaluation of Medicaid Expansion Under the Affordable Care Act and Contraceptive Care in US Community Health Centers

Importance

Use of effective contraception decreases unintended pregnancy. It is not known whether Medicaid expansion under the Affordable Care Act increased use of contraception for women who are underserved in the US health care safety net.

Objective

To evaluate the association of Medicaid expansion under the Affordable Care Act with changes in use of contraception among patients at risk of pregnancy at US community health centers, with the hypothesis that Medicaid expansion would be associated with increases in use of the most effective contraceptive methods (long-acting reversible contraception).

Design, Setting, and Participants

This was a participant-level retrospective cross-sectional study comparing receipt of contraception before (2013) vs immediately after (2014) and a longer time after (2016) Medicaid expansion. Electronic health record data from a clinical research network of community health centers across 24 states were included. The sample included all female patients ages 15 to 44 years at risk for pregnancy, with an ambulatory care visit at a participating community health center during the study period (315 clinics in expansion states and 165 clinics in nonexpansion states).

Exposures

Medicaid expansion status (by state).

Main Outcomes and Measures

Two National Quality Forum-endorsed contraception quality metrics, calculated annually: the proportion of women at risk of pregnancy who received (1) either a moderately effective or most effective method (hormonal and long-acting reversible contraception) methods and (2) the most effective method (long-acting reversible contraception).

Results

The sample included 310 132 women from expansion states and 235 408 women from nonexpansion states. The absolute adjusted increase in use of long-acting reversible contraceptive methods was 0.58 (95% CI, 0.13-1.05) percentage points greater among women in expansion states compared with nonexpansion states in 2014 and 1.19 (95% CI, 0.41-1.96) percentage points larger in 2016. Among adolescents, the association was larger, particularly in the longer term (2014 vs 2013: absolute difference-in-difference, 0.80 [95% CI, 0.30-1.30] percentage points; 2016 vs 2013: absolute difference, 1.79 [95% CI, 0.88-2.70] percentage points). Women from expansion states who received care at a Title X clinic had the highest percentage of women receiving most effective contraceptive methods compared with non-Title X clinics and nonexpansion states.

Conclusions and Relevance

In this study, Medicaid expansion was associated with an increase in use of long-acting reversible contraceptive methods among women at risk of pregnancy seeking care in the US safety net system, and gains were greatest among adolescents.

Payment for Contraceptive Services in Safety Net Clinics: Roles of Affordable Care Act, Title X, and State Programs

OBJECTIVES

We describe payor for contraceptive visits 2013-2014, before and after Medicaid expansion under the Affordable Care Act (ACA), in a large network of safety-net clinics. We estimate changes in the proportion of uninsured contraceptive visits and the independent associations of the ACA, Title X, and state family planning programs.

METHODS

Our sample included 237 safety net clinics in 11 states with a common electronic health record. We identified contraception-related visits among women aged 10-49 years using diagnosis and procedure codes. Our primary outcome was an indicator of an uninsured visit. We also assessed payor type (public/private). We included encounter, clinic, county, and state-level covariates. We used interrupted time series and logistic regression, and calculated multivariable absolute predicted probabilities.

RESULTS

We identified 162,666 contraceptive visits in 219 clinics. There was a significant decline in uninsured contraception-related visits in both Medicaid expansion and nonexpansion states, with a slightly greater decline in expansion states (difference-in-difference: -1.29 percentage points; confidence interval: -1.39 to -1.19). The gap in uninsured visits between expansion and nonexpansion states widened after ACA implementation (from 2.17 to 4.1 percentage points). The Title X program continues to fill gaps in insurance in Medicaid expansion states.

CONCLUSIONS

Uninsured contraceptive visits at safety net clinics decreased following Medicaid expansion under the ACA in both expansion and nonexpansion states. Overall, levels of uninsured visits are lower in expansion states. Title X continues to play an important role in access to care and coverage. In addition to protecting insurance gains under the ACA, Title X and state programs should continue to be a focus of research and advocacy.

Impact of the Rochester LARC Initiative on adolescents' utilization of long-acting reversible contraception

BACKGROUND

Preventing unintended teen pregnancy is a national public health priority, and increasing access to long-acting reversible contraception is part of the recommended strategy for the achievement of this goal. Nevertheless, adolescent long-acting reversible contraceptive use across the nation has remained low, even after national and state-level programs increased coverage for no-cost contraception. One persistent barrier is misinformation about the safety, efficacy, and availability of long-acting reversible contraception for teens. To overcome this barrier, the Hoekelman Center, in collaboration with multiple partners, designed and implemented a community health intervention. The Greater Rochester LARC Initiative disseminated accurate information about contraceptive options with a focus on long-acting reversible methods by delivering interactive lunch-and-learn talks throughout the Greater Rochester, NY area. Audiences included both healthcare providers and adults who work with adolescents in nonmedical community-based organizations.

OBJECTIVE

The primary purpose of this study was to evaluate the community-level impact of the Greater Rochester LARC Initiative on adolescent long-acting reversible contraception use.

STUDY DESIGN

Our evaluation design was pre-post with a nonrandomized control group. We used publicly available Youth Risk Behavior Surveillance System data from the years 2013, 2015, and 2017 for our intervention site of Rochester, NY, New York City, New York State, and the United States overall. These years cover the time before and after the intervention began in 2014. We used z-statistics in investigating the hypothesis that long-acting reversible contraception use increased more in Rochester than in the comparison populations.

RESULTS

Between 2013 and 2017, long-acting reversible contraception use in Rochester rose from 4-24% of sexually active female high school students (P<.0001). Over the same period, long-acting reversible contraception use in New York State rose from 1.5-4.8%, and in New York City long-acting reversible contraception use rose from 2.7-5.3%. In the United States overall, long-acting reversible contraception use rose from 1.8-5.3%. Thus, the increase in long-acting reversible contraception use in Rochester was larger than the secular trend in the control groups (P<.0001).

CONCLUSION

Adolescent long-acting reversible contraceptive use increased significantly more in Rochester than in the nation as a whole. This finding is consistent with a substantial positive impact of the Greater Rochester LARC Initiative, which implies that similar interventions could be useful complements to unintended teen pregnancy prevention programs elsewhere and might be helpful more generally for the diffusion of evidence-based health-improvement practices.

Long-acting reversible contraceptive (LARCs) methods

Unplanned pregnancy (UP) is a public health problem, which affects millions of women worldwide. Providing long-acting reversible contraceptive (LARC) methods is an excellent strategy to avoid or at least reduce UP, because the effectiveness of these methods is higher than other methods, and is indeed comparable to that of permanent contraception. As the initial introduction of the inert plastic intrauterine device (IUD) and of the six-rod implant, pharmaceutical companies have introduced a copper IUD (Cu-IUD), different models of levonorgestrel-releasing intrauterine system (LNG IUS), and one and two-rod implants, which certainly improved women's LARC options. The main characteristic of LARCs is that they provide high contraceptive effectiveness with a single intervention, and that they can be used for a long time. Emerging evidence from the last few years has demonstrated that it is possible to extend the use of the 52 mg LNG IUS and of the etonogestrel-implant beyond five- and three years, respectively, which adds new value to these LARCs.

Patterns and trends in contraceptive use among women attending Title X clinics and a national sample of low-income women

Objectives

To describe the types of contraception used by women attending Title X-funded clinics and a comparable group of low-income reproductive-age women at risk of unintended pregnancy.

Study design

We estimated the percentage of reproductive aged (15-44 years) women using contraception, by method type and level of effectiveness in preventing pregnancy (i.e., most, moderately, and less effective), using Title X Family Planning Annual Report (2006-2016) and National Survey of Family Growth (2006-2015) data. We divided most effective methods into permanent (female and male sterilization) and reversible (long-acting reversible contraceptives [LARCs]) methods.

Results

Among Title X clients during 2006-2016, use of LARCs increased (3-14%); use of moderately effective methods decreased (64-54%); and use of sterilization (~ 2%), less effective methods (21-20%), and no method (8-7%) was unchanged. These same trends in contraceptive use were observed in a comparable group of women nationally during 2006-2015, during which LARC use increased (5-19%, p < .001); moderately effective method use decreased (60-48%, p < .001); and use of sterilization (~5%), less effective methods (19%), and no method (11-10%) was unchanged.

Conclusions

The contraceptive method mix among Title X clients differs from that of low-income women at risk of unintended pregnancy nationally, but general patterns and trends are similar in the two populations. Research is needed to understand whether method use patterns among low-income women reflect their preferences, access, or the conditions of the supply environment.

Implications

This study contributes to our understanding of patterns and trends in contraceptive use among two groups of reproductive-age women - Title X clients and low-income women nationally who are at risk of unintended pregnancy. The findings highlight areas for further research.

Lessons Learned in Creating Interoperable Fast Healthcare Interoperability Resources Profiles for Large-Scale Public Health Programs

OBJECTIVE

This article describes lessons learned from the collaborative creation of logical models and standard Health Level Seven (HL7) Fast Healthcare Interoperability Resources (FHIR) profiles for family planning and reproductive health. The National Health Service delivery program will use the FHIR profiles to improve federal reporting, program monitoring, and quality improvement efforts.

MATERIALS AND METHODS

Organizational frameworks, work processes, and artifact testing to create FHIR profiles are described.

RESULTS

Logical models and FHIR profiles for the Family Planning Annual Report 2.0 dataset have been created and validated.

DISCUSSION

Using clinical element models and FHIR to meet the needs of a real-world use case has been accomplished but has also demonstrated the need for additional tooling, terminology services, and application sandbox development.

CONCLUSION

FHIR profiles may reduce the administrative burden for the reporting of federally mandated program data.

State-Identified Implementation Strategies to Increase Uptake of Immediate Postpartum Long-Acting Reversible Contraception Policies

BACKGROUND

In 2014, the Association of State and Territorial Health Officials (ASTHO) convened a multistate Immediate Postpartum Long-Acting Reversible Contraception (LARC) Learning Community to facilitate cross-state collaboration in implementation of policies. The Learning Community model was based on systems change, through multistate peer-to-peer learning and strategy-sharing activities. This study uses interview data from 13 participating state teams to identify state-implemented strategies within defined domains that support policy implementation.

MATERIALS AND METHODS

Semistructured interviews were conducted by the ASTHO team with state team members participating in the Learning Community. Interviews were transcribed and implementation strategies were coded. Using qualitative analysis, the state-reported domains with the most strategies were identified.

RESULTS

The five leading domains included the following: stakeholder partnerships; provider training; outreach; payment streams/reimbursement; and data, monitoring and evaluation. Stakeholder partnership was identified as a cross-cutting domain. Every state team used strategies for stakeholder partnerships and provider training, 12 reported planning or engaging in outreach efforts, 11 addressed provider and facility reimbursement, and 10 implemented data evaluation strategies. All states leveraged partnerships to support information sharing, identify provider champions, and pilot immediate postpartum LARC programs in select delivery facilities.

CONCLUSIONS

Implementing immediate postpartum LARC policies in states involves leveraging partnerships to develop and implement strategies. Identifying champions, piloting programs, and collecting facility-level evaluation data are scalable activities that may strengthen state efforts to improve access to immediate postpartum LARC, a public health service for preventing short interbirth intervals and unintended pregnancy among postpartum women.

It's Not Planned, But Is It Okay? The Acceptability of Unplanned Pregnancy Among Young People

BACKGROUND

It is well-established that current measures of pregnancy intentions fail to capture the complexity of couples' lived experiences and decisions regarding reproductive decision making. Despite limitations, these measures guide programs, policy, and clinical practice. Herein, we explore prospective pregnancy acceptability, which captures whether individuals anticipate considering an unexpected pregnancy welcomed, manageable, or okay.

METHODS

Individual qualitative interviews were conducted with 50 young (ages 18-24 years) women and their male partners (N = 100) to elucidate prospective pregnancy desires and perspectives on pregnancy planning. Using a thematic approach, we analyzed data from a subsample (n = 88) of participants who did not currently desire a pregnancy.

RESULTS

Despite lack of pregnancy desire, 37 participants indicated that a pregnancy would be acceptable. Several themes emerged as reasons for pregnancy acceptability, including feeling prepared for children, relational stability, having knowledge of what it takes to parent, and taking a "whatever happens" approach toward pregnancy planning. Notably, a number of reasons for pregnancy acceptability were also described as reasons for lack of acceptability. For example, although many parents in the sample found pregnancy acceptable owing to their knowledge of the time and resources that raising children required, other parents found pregnancy unacceptable for this same reason.

CONCLUSIONS

Acceptability captures nuances of prospective views on pregnancy and what it means for young people's lives that current intentions language and framing often neglects. Additionally, acceptability may be a construct that resonates with the perspectives and lives of young people for whom the notion of active pregnancy planning is not salient.

Use of an electronic health record data sharing system for identifying current contraceptive use within the WWAMI region Practice and Research Network

OBJECTIVE

To evaluate the ability of electronic health record (EHR) data extracted into a data-sharing system to accurately identify contraceptive use.

STUDY DESIGN

We compared rates of contraceptive use from electronic extraction of EHR data via a data-sharing system and manual abstraction of the EHR among 142 female patients ages 15-49 years from a family medicine clinic within a primary care practice-based research network (PBRN). Cohen's kappa coefficient measured agreement between electronic extraction and manual abstraction.

RESULTS

Manual abstraction identified 62% of women as contraceptive users, whereas electronic extraction identified only 27%. Long acting reversible (LARC) methods had 96% agreement (Cohen's kappa 0.78; confidence interval, 0.57-0.99) between electronic extraction and manual abstraction. EHR data extracted via a data-sharing system was unable to identify barrier or over-the-counter contraceptives.

CONCLUSIONS

Electronic extraction found substantially lower overall rates of contraceptive method use, but produced more comparable LARC method use rates when compared to manual abstraction among women in this study's primary care clinic.

IMPLICATIONS

Quality metrics related to contraceptive use that rely on EHR data in this study's data-sharing system likely under-estimated true contraceptive use.

A Web-Based Decision Tool to Improve Contraceptive Counseling for Women With Chronic Medical Conditions: Protocol For a Mixed Methods Implementation Study

BACKGROUND

Women with chronic medical conditions, such as diabetes and hypertension, have a higher risk of pregnancy-related complications compared with women without medical conditions and should be offered contraception if desired. Although evidence based guidelines for contraceptive selection in the presence of medical conditions are available via the United States Medical Eligibility Criteria (US MEC), these guidelines are underutilized. Research also supports the use of decision tools to promote shared decision making between patients and providers during contraceptive counseling.

OBJECTIVE

The overall goal of the MiHealth, MiChoice project is to design and implement a theory-driven, Web-based tool that incorporates the US MEC (provider-level intervention) within the vehicle of a contraceptive decision tool for women with chronic medical conditions (patient-level intervention) in community-based primary care settings (practice-level intervention). This will be a 3-phase study that includes a predesign phase, a design phase, and a testing phase in a randomized controlled trial. This study protocol describes phase 1 and aim 1, which is to determine patient-, provider-, and practice-level factors that are relevant to the design and implementation of the contraceptive decision tool.

METHODS

This is a mixed methods implementation study. To customize the delivery of the US MEC in the decision tool, we selected high-priority constructs from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework to drive data collection and analysis at the practice and provider level, respectively. A conceptual model that incorporates constructs from the transtheoretical model and the health beliefs model undergirds patient-level data collection and analysis and will inform customization of the decision tool for this population. We will recruit 6 community-based primary care practices and conduct quantitative surveys and semistructured qualitative interviews with women who have chronic medical conditions, their primary care providers (PCPs), and clinic staff, as well as field observations of practice activities. Quantitative survey data will be summarized with simple descriptive statistics and relationships between participant characteristics and contraceptive recommendations (for PCPs), and current contraceptive use (for patients) will be examined using Fisher exact test. We will conduct thematic analysis of qualitative data from interviews and field observations. The integration of data will occur by comparing, contrasting, and synthesizing qualitative and quantitative findings to inform the future development and implementation of the intervention.

RESULTS

We are currently enrolling practices and anticipate study completion in 15 months.

CONCLUSIONS

This protocol describes the first phase of a multiphase mixed methods study to develop and implement a Web-based decision tool that is customized to meet the needs of women with chronic medical conditions in primary care settings. Study findings will promote contraceptive counseling via shared decision making and reflect evidence-based guidelines for contraceptive selection.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03153644; https://clinicaltrials.gov/ct2/show/NCT03153644 (Archived by WebCite at http://www.webcitation.org/6yUkA5lK8).

From theory to application: using performance measures for contraceptive care in the Title X family planning program

OBJECTIVE

The objective was to describe a Performance Measure Learning Collaborative (PMLC) designed to help Title X family planning grantees use new clinical performance measures for contraceptive care.

STUDY DESIGN

Twelve Title X grantee-service site teams participated in an 8-month PMLC from November 2015 to June 2016; baseline was assessed in October 2015. Each team documented their selected best practices and strategies to improve performance, and calculated the contraceptive care performance measures at baseline and for each of the subsequent 8 months.

RESULTS

PMLC sites implemented a mix of best practices: (a) ensuring access to a broad range of methods (n=7 sites), (b) supporting women through client-centered counseling and reproductive life planning (n=8 sites), (c) developing systems for same-day provision of all methods (n=10 sites) and (d) utilizing diverse payment options to reduce cost as a barrier (n=4 sites). Ten sites (83%) observed an increase in the clinical performance measures focused on most and moderately effective methods (MME), with a median percent change of 6% for MME (from a median of 73% at baseline to 77% post-PMLC).

CONCLUSION

Evidence suggests that the PMLC model is an approach that can be used to improve the quality of contraceptive care offered to clients in some settings. Further replication of the PMLC among other groups and beyond the Title X network will help strengthen the current model through lessons learned.

IMPLICATIONS

Using the performance measures in the context of a learning collaborative may be a useful strategy for other programs (e.g., Federally Qualified Health Centers, Medicaid, private health plans) that provide contraceptive care. Expanded use of the measures may help increase access to contraceptive care to achieve national goals for family planning.