Use of effective contraception following provision of the progestogen-only pill for women presenting to community pharmacies for emergency contraception (Bridge-It): a pragmatic cluster-randomised crossover trial

Interventions to Expand Community Pharmacists' Scope of Practice

BACKGROUND

The role of community pharmacists has evolved beyond the dispensing of medicines. The aim of this scoping review was to describe the interventions that expand the pharmacist's scope of practice within a community pharmacy setting and assess their effectiveness.

METHODS

We performed a scoping review to identify randomised controlled trials (RCTs), published worldwide from 2013 to 2024, which focused on interventions designed to expand pharmacists' scope of practice in the community. The review was undertaken in accordance with the Joanna Briggs Institute methodology for scoping reviews. To address the aim of this scoping review, the included RCTs were mapped to themes influenced by the Professional Practice Standards 2023 as developed by the Pharmaceutical Society of Australia: medication management, collaborative care and medication adherence.

RESULTS

Twelve studies demonstrated the potential to expand community pharmacists' scope of practice. Two RCTs resulted in no effect of the intervention. One RCT (conducted in Italy) led to an actual change to community pharmacists' scope of practice, with a statistically significant improvement in the proportion of patients with controlled asthma.

CONCLUSIONS

On the whole, this scoping review synthesised the findings of peer-reviewed RCT studies that revealed expanding community pharmacists' scope of practice may result in improved patient outcomes, a reduced burden for the healthcare system, and greater productivity.

Expanding community pharmacists' scope of practice in relation to contraceptive counselling and referral: a protocol for a pragmatic, stepped-wedge, cluster randomised trial (ALLIANCE)

INTRODUCTION

Improving access to effective contraception has the potential to reduce unintended pregnancy and abortion rates. Community pharmacists could play an expanded role in contraceptive counselling and referral to contraceptive prescribers particularly when women are already attending community pharmacy to obtain emergency contraceptive pills (ECPs) or to have medical abortion (MA) medicines dispensed. The ALLIANCE trial aims to compare the subsequent uptake of effective contraception (hormonal or intrauterine) in women seeking ECP or MA medicines, who receive the ALLIANCE community pharmacy-based intervention with those who do not receive the intervention.

METHODS AND ANALYSIS

ALLIANCE is a stepped-wedge pragmatic cluster randomised trial in Australian community pharmacies. The ALLIANCE intervention involves community pharmacists delivering structured, patient-centred, effectiveness-based contraceptive counselling (and a referral to a contraceptive prescriber where appropriate) to women seeking either ECPs or to have MA medicines dispensed. Women participants will be recruited by participating pharmacists. A total of 37 pharmacies and 1554 participants will be recruited. Pharmacies commence in the control phase and are randomised to transition to the intervention phase at different time points (steps). The primary outcome is the self-reported use of effective contraception at 4 months; secondary outcomes include use of effective contraception and the rate of pregnancies or induced abortions at 12 months. A process and economic evaluation of the trial will also be undertaken.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Monash University Human Research Ethics Committee (#34563). An explanatory statement will be provided and written consent will be obtained from all participants (pharmacy owner, pharmacist and women) before their commencement in the trial. Dissemination will occur through a knowledge exchange workshop, peer-reviewed journal publications, presentations, social media and conferences.

TRIAL REGISTRATION NUMBER

ACTRN12622001024730.

Improving access to quality contraceptive counselling in community pharmacy: examining the knowledge, attitudes and practices of community pharmacists in Australia

BACKGROUND

Across most of Australia, the role of community pharmacists in contraceptive care has been unchanged since 2004. To understand their current scope of practice and potential for practice advancements, we examined community pharmacists' contraceptive knowledge and their attitudes, practices and perceived barriers to and benefits of contraceptive counselling provision.

METHODS

A nationwide postal survey was conducted between September and December 2020. We contacted a state/territory-stratified sample of 2149 community pharmacies and limited eligibility to one pharmacist per pharmacy. Summary statistics of respondent characteristics and parametric (χ², linear regression) and non-parametric (Mann-Whitney, logistic regression) tests were computed for the outcomes: practices, knowledge (reported and tested), confidence, attitudes, barriers and benefits.

RESULTS

Eligible responses were received from 366 pharmacies (19%). Pharmacists' median age was 34. Most (85% of) pharmacists agreed that contraceptive counselling fits within their current professional activities and emphasised benefits to their patients, including improved access to contraceptive decision support (80%), as being key motivators of counselling. A lack of payment mechanisms (66%), training opportunities (55%) and technical assistance tools (54%) were the most important barriers. Self-rated knowledge and confidence were highest for combined oral contraceptive pills and lowest for the copper intrauterine device (IUD). When tested, pharmacists were very knowledgeable about method, dosage, frequencies and costs, and relatively less knowledgeable about side-effects and IUD suitability for adolescents.

CONCLUSIONS

Community pharmacists provide contraceptive information and counselling but lack the necessary resources and support to be able to consistently provide quality, person-centred care. Remuneration mechanisms, training opportunities and pharmacy-specific professional resources need to be explored.

Advancing Reproductive Health through Policy-Engaged Research in Abortion Care

Mifepristone medication abortion was first approved in China and France more than 30 years ago and is now used in more than 60 countries worldwide. It is a highly safe and effective method that has the potential to increase population access to abortion in early pregnancy, closer to home. In both Canada and the United States, the initial regulations for distribution, prescribing, and dispensing of mifepristone were highly restricted. However, in Canada, where mifepristone was made available in 2017, most restrictions on the medication were removed in the first year of its availability. The Canadian regulation of mifepristone as a normal prescription makes access possible in community primary care through a physician or nurse practitioner prescription, which any pharmacist can dispense. In this approach, people decide when and where to take their medication. We explore how policy-maker-engaged research advanced reproductive health policy and facilitated this rapid change in Canada. We discuss the implications of these policy advances for self-management of abortion and demonstrate how in Canada patients "self-manage" components of the abortion process within a supportive health care system.

Opportunities for Increasing Access to Effective Contraception in Australia

Effective contraception can prevent unintended pregnancies, however there is an unmet need for effective contraception in Australia. Despite their being a range of contraceptive methods available, access to these remains equitable and uptake of the most effective methods is low. There is an opportunity to reduce the rate of unintended pregnancies in Australia by improving the uptake of effective contraception for those who desire this. Improving access will require increasing consumer health literacy about contraception, as well as the option of telehealth as a mode of service delivery, and stronger investment in contraceptive services through appropriate reimbursement for providers. There is also a need to test new models of care to increase access to and use of effective contraception in Australia, including nurse and midwifery-led models of contraceptive care and pharmacy involvement in contraceptive counseling.

Uptake of long-acting reversible contraception after telemedicine delivered abortion during Covid-19

BACKGROUND

During COVID-19, early medical abortion (EMA) at home in Scotland was largely delivered by telemedicine. Short-acting post-abortion contraception was provided with EMA medications, but long-acting reversible contraception (LARC) (implant, injectable and intrauterine device) required an in-person visit. We wished to assess LARC uptake following telemedicine abortion, and factors associated with method receipt.

METHODS

A prospective observational cohort study of patients accessing abortion via NHS Lothian (October 2020 to February 2021). Patients were offered contraception at telemedicine consultation and their choice was recorded in their clinical notes. Those wishing LARC were directed to the service's rapid-access LARC clinic. We reviewed electronic patient records six weeks post-abortion to determine whether patients received their chosen method.

RESULTS

944 patients had an abortion; 768 (81.4%) had EMA, 131 (13.9%) had a medical or surgical abortion in hospital. The most popular contraceptive method was the progestogen-only pill (n = 324, 34%). 330 patients (35%) requested LARC but less than half (153/330; 46%) received this. Of patients choosing LARC, those who attended the clinic for a pre-abortion ultrasound, or had an abortion in hospital, were more likely to initiate LARC than those having full telemedicine EMA. Nulliparity, gestation over 7 weeks, and age under-26 years were also positively associated with initiating LARC.

CONCLUSION

During COVID-19 there was demand for post-abortion LARC but less than half of patients received this by six weeks. Provision was enhanced when in-person clinical interactions took place. Interventions are required to facilitate timely access and initiation of LARC with telemedicine delivered abortion care.

Effectiveness and Harms of Contraceptive Counseling and Provision Interventions for Women : A Systematic Review and Meta-analysis

BACKGROUND

The effectiveness and harms of contraceptive counseling and provision interventions are unclear.

PURPOSE

To evaluate evidence of the effectiveness of contraceptive counseling and provision interventions for women to increase use of contraceptives and reduce unintended pregnancy, as well as evidence of their potential harms.

DATA SOURCES

English-language searches of Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, SocINDEX, and MEDLINE (1 January 2000 to 3 February 2022) and reference lists of key studies and systematic reviews.

STUDY SELECTION

Randomized controlled trials of interventions providing enhanced contraceptive counseling, contraceptives, or both versus usual care or an active control.

DATA EXTRACTION

Dual extraction and quality assessment of studies; results combined using a profile likelihood random-effects model.

DATA SYNTHESIS

A total of 38 trials (43 articles [25 472 participants]) met inclusion criteria. Contraceptive use was higher with various counseling interventions (risk ratio [RR], 1.39 [95% CI, 1.16 to 1.72]; I ² = 85.3%; 10 trials), provision of emergency contraception in advance of use (RR, 2.12 [CI, 1.79 to 2.36]; I ² = 0.0%; 8 trials), and counseling or provision postpartum (RR, 1.15 [CI, 1.01 to 1.52]; I ² = 6.6%; 5 trials) or at the time of abortion (RR, 1.19 [CI, 1.09 to 1.32]; I ² = 0.0%; 5 trials) than with usual care or active controls in multiple clinical settings. Pregnancy rates were generally lower with interventions, although most trials were underpowered and did not distinguish pregnancy intention. Interventions did not increase risk for sexually transmitted infections (STIs) (RR, 1.05 [CI, 0.87 to 1.25]; I ² = 0.0%; 5 trials) or reduce condom use (RR, 1.03 [CI, 0.94 to 1.13]; I ² = 0.0%; 6 trials).

LIMITATION

Interventions varied; few trials were adequately designed to determine unintended pregnancy outcomes.

CONCLUSION

Contraceptive counseling and provision interventions that provide services beyond usual care increase contraceptive use without increasing STIs or reducing condom use. Contraceptive care in clinical practice could be improved by implementing enhanced contraceptive counseling, provision, and follow-up; providing emergency contraception in advance; and delivering contraceptive services immediately postpartum or at the time of abortion.

PRIMARY FUNDING SOURCE

Resources Legacy Fund. (PROSPERO: CRD42020192981).

[Worldwide contraception]

The latest statistics concerning contraceptive use in the world have been published in 2019 by the United Nations. Among the 1.9 billion of women of reproductive age (15-49 years), 1.1 billion have a need for family planning. Among them, 190 millions are not using any contraception, although they wanted to avoid a pregnancy. There is a significant discrepancy among continents concerning the percentage of contraceptive use and the distribution of the different types of contraception. Female sterilization is the most widespread method of contraception since it represents 24% of all contraception methods used. Male condoms is used by 21% of couples. Thus, progress is still needed to disseminate effective, well tolerated and potentially reversible methods of contraception. Education of females, couples, medical and paramedical staff is one of the priority targets to improve contraception throughout the world.

Views of clinicians towards providing contraceptive advice and contraception to women following early pregnancy loss: a qualitative study

INTRODUCTION

National guidelines advise that clinicians caring for women post-pregnancy should give women opportunities to discuss contraception, regardless of pregnancy outcome, and provide contraception to women who choose to take up a method. This study aimed to explore knowledge, views and needs of Early Pregnancy Unit (EPU) clinicians around discussing and offering contraception and discussing pregnancy intendedness with women after early pregnancy loss using a qualitative approach.

METHODS

Semi-structured, audio-recorded interviews with 11 clinicians from a single regional EPU in Edinburgh, Scotland. Interviews were transcribed verbatim and analysed thematically.

RESULTS

Clinicians were reluctant to discuss contraception as they believed women would find the topic overwhelming and distressing. Thoughts on discussing pregnancy intendedness were polarised; some considered it insensitive, and others essential. Barriers to discussing contraception and providing it were numerous and included time pressure, and inadequate knowledge and training on contraception. Participants suggested training on contraception, closer working with sexual and reproductive health (SRH) services, and availability of information on contraception specifically aimed at women who have experienced an early pregnancy loss could facilitate discussions and method provision.

CONCLUSIONS

EPU clinicians require ongoing training and support to be effective at discussing pregnancy intendedness and discussing and providing post-pregnancy contraception. This will require close working with SRH services and development of sensitive information around contraception for women experiencing an early pregnancy loss.

Effect of the Covid pandemic on progestogen-only and oestrogen-containing contraceptive prescribing in general practice: a retrospective analysis of English prescribing data

OBJECTIVES

This paper looks at how trends in contraceptive prescribing by General Practices in England were affected by the Covid pandemic and lockdown. It compares English prescribing data from May 2014 to May 2021, including the period of 'lockdown', from April 20-June 20.

DESIGN & SETTING

A retrospective analysis of the English Prescribing Dataset which reports monthly on prescribed items from English General Practices was carried out. Data on all forms of prescribed contraceptive methods were extracted using British National Formulary (BNF) codes, and total quantities tabulated by method, then transformed into 'months of contraception provided' by each method.

RESULTS

Prescription of the combined oral contraceptive pill reduced by 22% during the period of lockdown compared to the same three months in 2019. Prescriptions of Progestogen-Only pills remained stable. This continued a trend in oral contraceptive prescribing evident from May14. Prescription of long-acting methods reduced during the period of lockdown, with the greatest reductions in implants (76% reduction from pre-lockdown levels), intra-uterine systems (79% reduction from pre-lockdown levels) and intrauterine devices (76% reduction from pre-lockdown levels). These rates of contraceptive provision recovered quickly after the period of lockdown ended.

CONCLUSIONS

The disruption of face-to-face contraceptive consultations in General Practice during a Covid-19 'lockdown' has resulted in a reduction in oestrogen -containing methods compared to progestogen-only methods, which require less face-to-face monitoring. Implant and intrauterine contraceptive device prescription reduced by three quarters over the first three months of lockdown, but rebounded in the next year.

Effect of the COVID-19 pandemic on contraceptive prescribing in general practice: a retrospective analysis of English prescribing data between 2019 and 2020

OBJECTIVES

This paper looks at how contraceptive prescribing by General Practices in England was affected by the COVID-19pandemic and lockdown. It compares English prescribing data in April - June 2019, the year before COVID19, and April-June 2020, the first three months of 'lockdown'.

DESIGN & SETTING

This paper is based on retrospective analysis of the English Prescribing Dataset which reports monthly on prescribed items from English General Practices. Data on all forms of prescribed contraceptive methods were extracted using BNF codes, and total quantities tabulated by method. To reach the total number of months of contraception provided, total quantities were divided or multiplied according the frequency with which the method is taken per month or the numbers of months of contraception provided.

RESULTS

Prescription of the combined oral contraceptive pill reduced by 22% during the period of lockdown compared to the same three months in 2019. Prescriptions of Progestogen-Only pills remained stable. Prescription of long-acting methods reduced, with the greatest reductions in implants (76% reduction from pre-lockdown levels), intra-uterine systems (79% reduction from pre-lockdown levels) and intrauterine devices (76% reduction from pre-lockdown levels).

CONCLUSIONS

The disruption of face-to-face contraceptive consultations in General Practice during a COVID-19 'lockdown' has resulted in a reduction in oestrogen -containing methods compared to progestogen-only methods, which require less face-to-face monitoring. Implant and intrauterine contraceptive device prescription reduced by three quarters over the first three months of lockdown, which has the potential to result in a rise in unintended pregnancies.

Improving effective contraception uptake through provision of bridging contraception within community pharmacies: findings from the Bridge-it Study process evaluation

OBJECTIVE

To present process evaluation results from the Bridge-it Study, a pragmatic cluster randomised cross-over trial to improve effective contraception uptake through provision of the progestogen only pill (POP) plus sexual and reproductive health (SRH) clinic rapid-access to women presenting to community pharmacies for emergency contraception (EC).

RESEARCH DESIGN AND METHODS

A multimethod process evaluation was conducted to assess intervention implementation, mechanisms of change and contextual factors. Data were gathered from screening logs (n=599), observations of pharmacist training, analysis of data from 4-month follow-up questionnaires (n=406), monitoring of contemporaneous events and qualitative interviews with 22 pharmacists, 5 SRH clinical staff and 36 study participants in three participating UK sites in Lothian, Tayside and London.

RESULTS

The intervention was largely delivered as intended and was acceptable. Pharmacists', SRH clinical staff and participants' accounts highlighted that providing a supply of POP with EC from the pharmacy as routine practice may have positive impacts on contraceptive practices in the short term, and potentially longer term. Key mechanisms of change included ease of access, increased awareness of contraception and services, and greater motivation and perceptions of self-efficacy. Few participants took up the offer to attend an SRH service (rapid-access component), and existing barriers within the SRH context were apparent (eg, lack of staff). Participant accounts highlight persistent barriers to accessing and using routine effective contraception remain.

CONCLUSIONS

Implementation appeared to be acceptable and feasible, highlighting the potential for provision of POP within EC consultations as routine practice in community pharmacies. However, lack of engagement with the rapid access component of the intervention and existing barriers within the SRH context suggest that signposting to SRH services may be sufficient. Wider implementation should consider ways to address key implementation challenges to increase effectiveness and sustainability, and to overcome persistent barriers to accessing and using effective contraception.

TRIAL REGISTRATION NUMBER

ISRCTN70616901.

[Contraceptive dynamics before and after the use of emergency contraception: contraceptive discontinuities and bridging]

The study's objectives were to estimate the occurrence of bridging, that is, the degree to which women that had not been using contraceptive methods began to use them in the month following the use of emergency contraception, and to estimate the rates of contraceptive discontinuity before and after the use of emergency contraception. Data collection occurred through a retrospective daily history on the use of methods in the 30 days before and after the use of emergency contraception, with 2,051 users of primary health care units in São Paulo, Aracaju (Sergipe), and Cuiabá (Mato Grosso), Brazil. The study's results showed that on average, women began their use of the method 7.6 days (SD = 2.4) after the use of emergency contraception, and that discontinuity occurred 17.1 days (SD = 7.0) after its use. Most of the women used the method continuously 30 days before (44.4%) and 30 days after (65.7%) emergency contraception. Only 8.1% of the women who had not been using the method before emergency contraception used it afterwards (bridging). Age 35 years or older (OR = 1.8; 95%CI: 1.4-2.6) was associated with the use of contraceptive methods after the use of emergency contraception among women who had not been using methods before. Residence in Aracaju (OR = 0.7; 95%CI: 0.4-0.9) showed an inverse association. In conclusion, a negligible portion of women who had not been using contraceptive methods before emergency contraception began using them afterwards (bridging).

What can a learning healthcare system teach us about improving outcomes?

PURPOSE OF REVIEW

This review describes the learning healthcare system paradigm, recent examples, and future directions. Patients, clinicians, and health systems frequently encounter decisions between available treatments, technologies, and healthcare delivery methods with little or no evidence about the comparative effectiveness and safety of the available options. Learning healthcare systems endeavor to recognize such knowledge gaps, integrate comparative effectiveness research - including clinical trials - into clinical care to address the knowledge gaps, and seamlessly implement the results into practice to improve care and patient outcomes.

RECENT FINDINGS

Recent studies comparing the effectiveness of diagnostic tests and treatments, using information technology to identify patients likely to experience an outcome or benefit from an intervention, and evaluating models of healthcare delivery have demonstrated how a learning healthcare system approach can reduce arbitrary variation in care, decrease cost, and improve patient outcomes.

SUMMARY

Learning healthcare systems have the potential to answer questions of importance to patients, clinicians, and health system leaders, improve efficiency of healthcare delivery, and improve patient outcomes. Achieving this goal will require realignment of the culture around clinical care, institutional and federal investment, expanded stakeholder engagement, tailored ethical and regulatory guidance, and methodologic advances in information technology and biostatistics.

Provision of the progestogen-only pill by community pharmacies as bridging contraception for women receiving emergency contraception: the Bridge-it RCT

INTRODUCTION

Unless women start effective contraception after using emergency contraception, they remain at risk of unintended pregnancy. Most women in the UK obtain emergency contraception from community pharmacies that are unable to provide ongoing contraception (apart from barrier methods which have high failure rates). This means that women need an appointment with a general practitioner or at a sexual and reproductive health clinic. We conducted a pragmatic cluster randomised cohort crossover trial to determine whether or not pharmacist provision of a bridging supply of a progestogen-only pill plus the invitation to attend a sexual and reproductive health clinic resulted in increased subsequent use of effective contraception (hormonal or intrauterine).

METHODS

Twenty-nine pharmacies in three UK cities recruited women receiving emergency contraception (levonorgestrel). In the intervention, women received a 3-month supply of the progestogen-only pill (75 µg of desogestrel) plus a card that provided rapid access to a local sexual and reproductive health clinic. In the control arm, pharmacists advised women to attend their usual contraceptive provider. The primary outcome was reported use of an effective contraception (hormonal and intrauterine methods) at 4 months. Process evaluation was also conducted to inform any future implementation.

RESULTS

The study took place December 2017 and June 2019 and recruited 636 women to the intervention (n = 316) and control groups (n = 320). There were no statistically significant differences in demographic characteristics between the groups. Four-month follow-up data were available for 406 participants: 63% (198/315) of the control group and 65% (208/318) of the intervention group. The proportion of participants reporting use of effective contraception was 20.1% greater (95% confidence interval 5.2% to 35.0%) in the intervention group (58.4%, 95% confidence interval 48.6% to 68.2%) than in the control group (40.5%, 95% confidence interval 29.7% to 51.3%) (adjusted for recruitment period, treatment arm and centre; p = 0.011). The proportion of women using effective contraception remained statistically significantly larger, when adjusted for age, current sexual relationship and history of past use of effective contraception, and was robust to the missing data. There were no serious adverse events.

CONCLUSION

Provision of a bridging supply of the progestogen-only pill with emergency contraception from a pharmacist and the invitation to a sexual and reproductive health clinic resulted in a significant increase in self-reported subsequent use of effective contraception. This simple intervention has the potential to prevent more unintended pregnancies for women after emergency contraception.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN70616901.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 27. See the NIHR Journals Library website for further project information.