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Moon KJ, Chang LV, Bryant I, Hasenstab KA, Norris AH, Nawaz S. Association of Medicaid Reimbursement Policies with Provision of Long-Acting Reversible Contraception in the Postpartum Period, 2012-2018. J Womens Health (Larchmt) 2024; 33:573-583. [PMID: 38488052 DOI: 10.1089/jwh.2023.0643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
Background: To address reimbursement challenges associated with long-acting reversible contraception (LARC) in the postpartum period, state Medicaid programs have provided additional payments ("carve-outs"). Implementation has been heterogeneous, with states providing separate payments for the device only, procedure only, or both the device and procedure. Methods: Claims data were drawn from 210,994 deliveries in the United States between 2012 and 2018. Using generalized estimating equations, we assess the relationship between Medicaid carve-out policies and the likelihood of LARC placement at (1) 3 days postpartum, (2) 60 days postpartum, and (3) 1 year postpartum, in Medicaid and commercially insured populations. Results: Among Medicaid beneficiaries, the likelihood of receiving LARC was higher in states with any carve-out, compared with states without carve-outs, at 3 days (adjusted odds ratio [aOR] 1.49 [95% confidence interval: 1.33-1.67], p < 0.001), 60 days (aOR: 1.40 [95% CI: 1.35-1.46], p < 0.001), and 1 year postpartum (aOR: 1.15 [95% CI: 1.11-1.20], p < 0.001). Adjustments were made for geographic region, seasonality, and patient age. Heterogeneity was observed by carve-out type; device carve-outs were consistently associated with greater likelihood of postpartum LARC placement, compared with states with no carve-outs. Similar trends were observed among commercially insured patients. Conclusion: Findings support the effectiveness of Medicaid carve-outs on postpartum LARC provision, particularly for device carve-outs, which were associated with increased postpartum LARC placement at 3 days, 60 days, and 1 year postpartum. This outcome suggests that policies to address cost-related barriers associated with LARC devices may prove most useful in overcoming barriers to immediate postpartum LARC placement, with the overarching aim of promoting reproductive autonomy.
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Affiliation(s)
- Kyle J Moon
- Center for Health Outcomes and Policy Evaluation Studies, Ohio State University College of Public Health, Columbus, Ohio, USA
| | - Lenisa V Chang
- Department of Economics, Lindner College of Business, University of Cincinnati, Cincinnati, Ohio, USA
| | - Ian Bryant
- Center for Health Outcomes and Policy Evaluation Studies, Ohio State University College of Public Health, Columbus, Ohio, USA
- Department of Economics, Lindner College of Business, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kathryn A Hasenstab
- Center for Health Outcomes and Policy Evaluation Studies, Ohio State University College of Public Health, Columbus, Ohio, USA
| | - Alison H Norris
- Division of Epidemiology, Ohio State University College of Public Health, Columbus, Ohio, USA
- Division of Infectious Diseases, Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Saira Nawaz
- Center for Health Outcomes and Policy Evaluation Studies, Ohio State University College of Public Health, Columbus, Ohio, USA
- Division of Health Services Management and Policy, Ohio State University College of Public Health, Columbus, Ohio, USA
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Busse CE, Latour CD, Dejene SZ, Knittel AK, Wood ME, Kinlaw AC, Dissanayake MV. Incidence of new outpatient long-acting reversible contraceptive insertions among a commercially insured, US population from 2010 to 2020. Contracept X 2023; 5:100101. [PMID: 37823033 PMCID: PMC10562738 DOI: 10.1016/j.conx.2023.100101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 09/07/2023] [Accepted: 09/13/2023] [Indexed: 10/13/2023] Open
Abstract
Objectives Characterize new use of long-acting reversible contraceptives (LARCs), highly effective contraceptive methods, in a broad population over time. Study Design We constructed a retrospective cohort of commercially insured individuals aged 15 to 54 years from 2010 to 2020 and estimated monthly incidence of new LARC insertions. Results The monthly standardized incidence increased from 6.0 insertions per 10,000 individuals in January 2010 to 14.1 in December 2020, with a dip in insertions after March 2020. Hormonal intrauterine devices were consistently the most inserted LARC; implants were increasingly favored over time. Conclusions LARCs are increasingly popular forms of contraception among commercially insured individuals. Implications Given the increasing popularity, ensuring access to LARCs is critical.
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Affiliation(s)
- Clara E. Busse
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Chase D. Latour
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sara Z. Dejene
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Andrea K. Knittel
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Mollie E. Wood
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Alan C. Kinlaw
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina School of Pharmacy, Chapel Hill, NC, United States
| | - Mekhala V. Dissanayake
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Rosa Bolling K, Wahdan Y, Warnock N, Lott J, Schoendorf J, Pisa F, Gomez-Espinosa E, Kistler K, Maiese B. Utilisation, effectiveness, and safety of immediate postpartum intrauterine device insertion: a systematic literature review. BMJ SEXUAL & REPRODUCTIVE HEALTH 2023; 49:e1. [PMID: 36600467 PMCID: PMC10176355 DOI: 10.1136/bmjsrh-2022-201579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 10/25/2022] [Indexed: 05/14/2023]
Abstract
BACKGROUND Intrauterine devices (IUDs) are highly effective contraception. IUDs inserted directly following delivery provide immediate birth control and may decrease unintended pregnancies, including short-interval pregnancies, thereby mitigating health risks and associated economic burden. METHODS This systematic literature review included published global data on the utilisation, effectiveness, and safety of postpartum intrauterine devices (PPIUDs) of any type. English language articles indexed in MEDLINE, Embase, and Cochrane from January 2010-October 2021 were included. RESULTS 133 articles met the inclusion criteria (46% interventional studies; 54% observational; n=87 from lower-income countries; n=46 from higher-income countries). PPIUD use was low in higher-income countries (6/10 000 US deliveries in 2013-2016) and varied widely in lower-income countries (2%-46%). Across both higher- and lower-income countries, in most studies (79%), >80% of women with PPIUDs had an IUD in place by 3 months; at 6 and 12 months, 76% and 54% of included studies reported that >80% of women had an IUD in place; reason for discontinuation was infrequently reported. Pregnancies were rare (96 pregnancies across 12 191 women from 37 studies reporting data) and were generally unrelated to device failure, but rather occurred in women no longer using a PPIUD. Expulsions occurred mainly in the early outpatient period and ranged widely (within 3 months: 0-41%). Abnormal bleeding, infections, or perforations were rare. CONCLUSIONS PPIUDs are safe and effective. Long-term follow-up data are limited. Future research elucidating reasons underlying lack of PPIUD use is warranted.
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Affiliation(s)
| | | | | | - Jason Lott
- Bayer Healthcare, Whippany, New Jersey, USA
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Ferat RM, Haddad LB, Westhoff CL, Hubacher D. Recap of the sixth international symposium on intrauterine devices and systems for women's health. Contraception 2022; 116:14-21. [PMID: 35882359 DOI: 10.1016/j.contraception.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 01/31/2023]
Abstract
Due to the COVID-19 pandemic, the Sixth International Symposium on Intrauterine Devices and Systems for Women's Health was held as a series of seven 2-hour webinars between May 28, 2020, and June 22, 2021. This Symposium featured 48 different presenters and moderators covering a wide range of topics to highlight new IUD issues and update general IUD knowledge, just as it was done in previous symposia dating back to 1962 [1-5]. A total of 1346 people attended remotely to observe the events live. In this article, we share summaries of the presentations from the sixth symposium. These summaries, provided by the presenters, are meant to archive the symposium. This article gives the reader an overview of the topics and identifies the sessions' moderators and speakers charged with providing the content. Those interested in further detail, references, and information about the speakers can find more information on the conference website: www.iud2020.com. After the summaries, we share ideas for future IUD research and programmatic needs, as provided by Symposium's presenters and organizers. The authors' summaries are personal opinions and do not necessarily reflect the perspectives of the Symposium's organizers or the medical community at large. The Symposium was recorded and the sessions are available for viewing free of charge at the website, www.iud2020.comor on YouTube. As of July 2022, approximately 1700 visitors have viewed the recordings.
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Affiliation(s)
- Rachel M Ferat
- Columbia University Irving Medical Center, New York, NY, United States.
| | - Lisa B Haddad
- Population Council, Center for Biomedical Research, NY, USA
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- Columbia University Irving Medical Center
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Moniz MH, Spector-Bagdady K, Perritt JB, Heisler M, Loder CM, Wetmore MK, Harris LH. Balancing Enhanced Contraceptive Access with Risk of Reproductive Injustice: A United States Comparative Case Study. Contraception 2022; 113:88-94. [DOI: 10.1016/j.contraception.2022.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 04/05/2022] [Accepted: 04/07/2022] [Indexed: 11/03/2022]
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Feasibility and acceptability of a toolkit-based process to implement patient-centered, immediate postpartum long-acting reversible contraception services. Am J Obstet Gynecol 2022; 226:394.e1-394.e16. [PMID: 34655551 PMCID: PMC8917096 DOI: 10.1016/j.ajog.2021.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 10/04/2021] [Accepted: 10/08/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND National guidelines recommend that maternity systems provide patient-centered access to immediate postpartum long-acting reversible contraception (ie, insertion of an intrauterine device or implant during the delivery hospitalization). Hospitals face significant barriers to offering these services, and efforts to improve peripartum contraception care quality have met with mixed success. Implementation toolkits-packages of resources and strategies to facilitate the implementation of new services-are a promising approach for guiding clinical practice change. OBJECTIVE This study aimed to develop a theory-informed toolkit, evaluate the feasibility of toolkit-based implementation of immediate postpartum long-acting reversible contraception care in a single site, and refine the toolkit and implementation process for future effectiveness testing. STUDY DESIGN We conducted a single-site feasibility study of the toolkit-based implementation of immediate postpartum contraception services at a large academic medical center in 2017 to 2020. Based on previous qualitative work, we developed a theory-informed implementation toolkit. A stakeholder panel selected toolkit resources to use in a multicomponent implementation intervention at the study site. These resources included tools and strategies designed to optimize implementation conditions (ie, implementation leadership, planning, and evaluation; the financial environment; engagement of key stakeholders; patient needs; compatibility with workflow; and clinician and staff knowledge, skills, and attitudes). The implementation intervention was executed from January 2018 to April 2019. Study outcomes included implementation outcomes (ie, provider perceptions of the implementation process and implementation tools [assessed via online provider survey]) and healthcare quality outcomes (ie, trends in prenatal contraceptive counseling, trends in immediate postpartum long-acting reversible contraceptive utilization [both ascertained by institutional administrative data], and the patient experience of contraceptive care [assessed via serial, cross-sectional, online patient survey items adapted from the National Quality Forum-endorsed, validated Person-Centered Contraceptive Counseling measure]). RESULTS In the implementation process, among 172 of 401 eligible clinicians (43%) participating in surveys, 70% were "extremely" or "somewhat" satisfied with the implementation process overall. In the prenatal contraceptive counseling, among 4960 individuals undergoing childbirth at the study site in 2019, 1789 (36.1%) had documented prenatal counseling about postpartum contraception. Documented counseling rates increased overall throughout 2019 (Q1, 12.5%; Q4, 51.0%) but varied significantly by clinic site (Q4, range 30%-79%). Immediate postpartum long-acting reversible contraception utilization increased throughout the study period (before implementation, 5.46% of deliveries; during implementation, 8.95%; after implementation, 8.58%). In the patient experience of contraceptive care, patient survey respondents (response rate, 15%-29%) were largely White (344/425 [81%]) and highly educated (309/425 [73%] with at least a 4-year college degree), reflecting the study site population. Scores were poor across settings, with modest improvements in the hospital setting from 2018 to 2020 (prenatal visits, 67%-63%; hospitalization, 45%-58%; outpatient after delivery, 69%-65%). Based on these findings, toolkit refinements included additional resources designed to routinize prenatal contraceptive counseling and support a more patient-centered experience of contraceptive care. CONCLUSION A toolkit-based process to implement immediate postpartum long-acting reversible contraceptive services at a single academic center was associated with high acceptability but mixed healthcare quality outcomes. Toolkit resources were added to optimize counseling rates and the patient experience of contraceptive care. Future research should formally test the effectiveness of the refined toolkit in a multisite, prospective trial.
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Kroelinger CD, Okoroh EM, Uesugi K, Romero L, Sappenfield OR, Howland JF, Cox S. Immediate Postpartum Long-Acting Reversible Contraception: Review of Insertion and Device Reimbursement Policies. Womens Health Issues 2021; 31:523-531. [PMID: 34602326 DOI: 10.1016/j.whi.2021.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 08/31/2021] [Accepted: 09/02/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Previous assessment of statewide policies on long-acting reversible contraception (LARC) indicate that an increasing number of states are implementing policies specifically for provision immediately postpartum, supported by current clinical guidelines. Less is known about how state policies describe payment methodologies for the insertion procedure and device costs. METHODS We conducted a systematic, web-based review of publicly available statewide policy language on immediate postpartum LARC among all 50 states. We examined the payor/s identified in the policy and policy type, if the policy included language on the global obstetric fee, whether providers and/or facilities were authorized to bill for procedure or device costs, and if the billing mechanism was identified as inpatient and/or outpatient services. RESULTS Three-fourths of states (76%; n = 38) had statewide policies on immediate postpartum LARC. All policies identified Medicaid as the payor, although two also included non-Medicaid plans. Language allowing for reimbursement separate from the global obstetric fee for insertion procedures was present in 76% of states; 23 states permit it and 6 do not. Device cost reimbursement separate from the fee was identified in more state policies (92%); 31 states allow it and 4 do not. More policies included inpatient or outpatient billing mechanisms for device costs (82%; n = 31) than insertion procedures (50%; n = 19). CONCLUSIONS Medicaid reimbursement policies for immediate postpartum LARC services vary by state reimbursement process, type, and mechanism. Observed differences indicate payment methodologies more often include the cost of the device than provider reimbursement (31 states vs. 23 states). Fewer than one-half of states offer reimbursement for provider insertion fees, a significant systems barrier to contraceptive access for women who choose LARC immediately postpartum.
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Affiliation(s)
- Charlan D Kroelinger
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Ekwutosi M Okoroh
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Keriann Uesugi
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Lisa Romero
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Olivia R Sappenfield
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Julia F Howland
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Shanna Cox
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Implementing immediate postpartum contraception: a comparative case study at 11 hospitals. Implement Sci Commun 2021; 2:42. [PMID: 33845922 PMCID: PMC8042857 DOI: 10.1186/s43058-021-00136-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/19/2021] [Indexed: 12/27/2022] Open
Abstract
Background Immediate postpartum long-acting reversible contraception (LARC) is an evidence-based practice, but hospitals face significant barriers to its adoption. Our objective was to examine how organizational context (e.g., size, employee attitudes toward the clinical practice) and implementation strategies (i.e., the actions taken to routinize a clinical practice) drive successful implementation of immediate postpartum LARC services, with a goal of informing the design of future implementation interventions. Methods We conducted a comparative case study of the implementation of inpatient postpartum contraceptive care at 11 US maternity hospitals. In 2017–2018, we conducted site visits that included semi-structured key informant interviews informed by the Consolidated Framework for Implementation Research. Qualitative measures of implementation success included stakeholder satisfaction, routinization, and sustainability of immediate postpartum LARC services. Qualitative content analysis and cross-case synthesis explored relationships among organizational context, implementation strategies, and implementation success. Results We completed semi-structured interviews with 78 clinicians, nurses, residents, pharmacy and revenue cycle staff, and hospital administrators. Successful implementation required three essential conditions: effective implementation champions, an enabling financial environment, and hospital administrator engagement. Six other contextual conditions were influential: trust and effective communication, alignment with stakeholders’ professional values, perception of meeting patients’ needs, robust learning climate, compatibility with workflow, and positive attitudes and adequate knowledge about the clinical practice. On average, sites used 18 (range 11-22) strategies. Strategies to optimize the financial environment and train clinicians and staff were commonly used. Strategies to plan and evaluate implementation and to engage patients emerged as promising to address barriers to practice change, yet were often underused. Conclusions Implementation efforts in maternity settings may be more successful if they select strategies to optimize local conditions for success. Our findings elucidate key contextual conditions to target and provide a menu of promising implementation strategies for incorporating recommended contraceptive services into routine maternity practice. Additional prospective research should evaluate whether these strategies effectively optimize local conditions for successful implementation in a variety of settings. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00136-7.
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Yadav S. Out-Of-Pocket Spending For Maternity Care. Health Aff (Millwood) 2021; 39:1649. [PMID: 32897787 DOI: 10.1377/hlthaff.2020.01367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Cost sharing, postpartum contraceptive use, and short interpregnancy interval rates among commercially insured women. Am J Obstet Gynecol 2021; 224:282.e1-282.e17. [PMID: 32898503 DOI: 10.1016/j.ajog.2020.08.109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/07/2020] [Accepted: 08/28/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Increasing access to effective birth control after childbirth may meet many women's preferences and reduce short interpregnancy interval rates. Eliminating out-of-pocket costs for contraception has been reported to increase the use of the most effective methods among women with employer-based insurance, but the prevalence and effects of patient cost sharing for contraception have not been studied during the postpartum period. OBJECTIVE This study aimed to examine the association between cost sharing for long-acting reversible contraception and postpartum contraception use patterns and pregnancies in the 12 months after delivery. STUDY DESIGN We conducted a retrospective cohort analysis of commercially insured women undergoing childbirth from 2014 to 2018 using Optum's (Eden Prairie, MN) de-identified Clinformatics Data Mart database. This large national database includes nonretired employees and their dependents who are enrolled in health insurance plans sponsored by large- or medium-sized US-based employers. Women with 12 months of continuous enrollment postpartum were included. Childbirth, pregnancy, and contraceptive method (female sterilization, long-acting reversible contraceptives, other hormonal methods, and no prescription method observed) were identified using claims data. Contraceptive use patterns were observed at 3, 6, and 12 months postpartum and adjusted for individual and plan characteristics. Median out-of-pocket costs were $0 for sterilization and other hormonal methods but nonzero for long-acting reversible contraception. We therefore used simple and multivariable logistic regressions to examine the association between plan-level cost sharing (no cost sharing, $0; low cost sharing, >$0-<$200; and high cost sharing, ≥$200 out-of-pocket cost) for any long-acting reversible contraceptive insertion and contraceptive use patterns and short interpregnancy interval rates, controlling for age, household income, race and ethnicity, region, and insurance plan type. RESULTS Among 25,298 plans with cost sharing data, we identified 172,941 women with continuous enrollment for 12 months postpartum, including 82,500 (47.7%) in no cost sharing, 22,595 (13.1%) in low cost sharing, and 67,846 (39.2%) in high cost sharing plans. The percentage of postpartum women in the study sample using any prescription contraceptive method was 39.5% by 3 months, 43.8% by 6 months, and 46.0% by 12 months. At all time points, postpartum women in no cost sharing plans had a higher predicted probability of long-acting reversible contraceptive use (eg, at 12 months: no cost sharing, 22.0%; low cost-sharing, 17.5%; high cost sharing, 18.3%; P<.001) and a lower predicted probability of no prescription method use (eg, at 12 months: no cost sharing, 51.8%; low cost sharing, 55.0%; high cost sharing, 54.9%; P<.001) than those in low or high cost sharing plans. Predicted probabilities of female sterilization and other hormonal method use did not differ substantively by plan cost sharing for long-acting reversible contraception at any time point. The proportion of women experiencing a short interpregnancy interval was low (1.9% by 3 months, 1.9% by 6 months, 2.0% by 12 months) and did not differ by plan cost sharing for long-acting reversible contraception at any time point. CONCLUSION Out-of-pocket costs for long-acting reversible contraception influence the method of contraception used by postpartum women with employer-based insurance. Eliminating financial barriers to long-acting reversible contraception access after childbirth may help women initiate their preferred method and increase the use of long-acting reversible contraceptives among interested women who otherwise might utilize less effective methods.
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Bonawitz K, Wetmore M, Heisler M, Dalton VK, Damschroder LJ, Forman J, Allan KR, Moniz MH. Champions in context: which attributes matter for change efforts in healthcare? Implement Sci 2020; 15:62. [PMID: 32762726 PMCID: PMC7409681 DOI: 10.1186/s13012-020-01024-9] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 07/20/2020] [Indexed: 11/10/2022] Open
Abstract
Background Research to date has focused on strategies and resources used by effective champions of healthcare change efforts, rather than personal characteristics that contribute to their success. We sought to identify and describe champion attributes influencing outcomes of healthcare change efforts. To examine attributes of champions, we used postpartum contraceptive care as a case study, because recommended services are largely unavailable, and implementation requires significant effort. Methods We conducted a comparative case study of the implementation of inpatient postpartum contraceptive care at 11 U.S. maternity hospitals in 2017–18. We conducted site visits that included semi-structured key informant interviews informed by the Consolidated Framework for Implementation Research (CFIR). Phase one analysis (qualitative content analysis using a priori CFIR codes and cross-case synthesis) showed that implementation leaders (“champions”) strongly influenced outcomes across sites. To understand champion effects, phase two inductive analysis included (1) identifying and elaborating key attributes of champions; (2) rating the presence or absence of each attribute in champions; and 3) cross-case synthesis to identify patterns among attributes, context, and implementation outcomes. Results We completed semi-structured interviews with 78 clinicians, nurses, residents, pharmacy and revenue cycle staff, and hospital administrators. All identified champions were obstetrician-gynecologists. Six key attributes of champions emerged: influence, ownership, physical presence at the point of change, persuasiveness, grit, and participative leadership style. These attributes promoted success by enabling champions to overcome institutional siloing, build and leverage professional networks, create tension for change, cultivate a positive learning climate, optimize compatibility with existing workflow, and engage key stakeholders. Not all champion attributes were required for success, and having all attributes did not guarantee success. Conclusions Effective champions appear to leverage six key attributes to facilitate healthcare change efforts. Prospective evaluations of the interactions among champion attributes, context, and outcomes may further elucidate how champions exert their effects.
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Affiliation(s)
- Kirsten Bonawitz
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Marisa Wetmore
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Michele Heisler
- Department of Internal Medicine, University of Michigan Medical School, 300 North Ingalls, Ann Arbor, MI, 48109, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Rd., Building #10, Rm G016, Ann Arbor, MI, 48109-5276, USA
| | - Vanessa K Dalton
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Rd., Building #10, Rm G016, Ann Arbor, MI, 48109-5276, USA
| | - Laura J Damschroder
- Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Ann Arbor, MI, 48105, USA
| | - Jane Forman
- Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Ann Arbor, MI, 48105, USA
| | - Katie R Allan
- Geisel School of Medicine, Dartmouth, 1 Rope Ferry Rd, Hanover, NH, 03755, USA
| | - Michelle H Moniz
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Rd., Building #10, Rm G016, Ann Arbor, MI, 48109-5276, USA.
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