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Leon-Larios F, Alonso Llamazares MJ, Mausbach Reisen H, Parra Ribes I, Rey Novoa M, Lahoz-Pascual I. Impact of the hands-on clinical training program for subdermic implant on contraceptive counseling and users' choice in Spain: A 6-month follow-up study. Contraception 2024; 132:110372. [PMID: 38237672 DOI: 10.1016/j.contraception.2024.110372] [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] [Received: 09/04/2023] [Revised: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 01/27/2024]
Abstract
OBJECTIVES The study aimed to evaluate the impact of a structured subdermic implant training program on healthcare providers and its effect on the integration of this contraceptive method into patient counselling. STUDY DESIGN The study was a longitudinal experiment with an intervention group, assessing changes at three points: before the training, immediately after, and six months later. The training consisted of a four-hour session combining theory and practical application, conducted by experts in contraception. RESULTS Out of the participants, 376 healthcare professionals (a 34.3% response rate) completed the training and subsequent questionnaires. Post-training, there was an increase in the inclusion of the implant in contraceptive advice and a rise in the monthly number of implants. Knowledge about the implant, including insertion, positioning, removal, and replacement, significantly improved after six months (p<0.05), particularly among general practitioners. CONCLUSIONS The training program successfully enhanced knowledge and handling of the contraceptive implant, leading to its increased recommendation by healthcare providers and selection by patients. Theoretical and practical training in contraception should be compulsory for healthcare providers involved in contraceptive counselling. IMPLICATIONS A training program that includes lectures, video material, and hands-on demonstrations is effective for developing skills in administering the subdermic implant and its integration into contraceptive counselling. Such training should be regular and required for all healthcare professionals providing contraceptive advice.
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Affiliation(s)
- Fatima Leon-Larios
- Nursing Department, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, Facultad de Enfermería, Fisioterapia y Podología, Sevilla, España.
| | - Maria Jesus Alonso Llamazares
- Unidad de Salud Sexual y Reproductiva, Distrito Sanitario Málaga-Guadalhorce, Servicio Andaluz de Salud, Málaga, España
| | | | | | - Modesto Rey Novoa
- Departamento de Obstetricia y Ginecología, Complejo Asistencial Universitario de Burgos, Burgos, España
| | - Isabel Lahoz-Pascual
- Departamento de Obstetricia y Ginecología, Hospital Universitario Lozano Blesa, Zaragoza, España
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McColl R, Gifford K, McDuffie MJ, Boudreaux M. Same-day long-acting reversible contraceptive utilization after a statewide contraceptive access initiative. Am J Obstet Gynecol 2023; 228:451.e1-451.e8. [PMID: 36565901 PMCID: PMC10065916 DOI: 10.1016/j.ajog.2022.12.304] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 12/01/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Same-day placement of long-acting reversible contraceptives, occurring when the device is requested and placed within a single visit, reduces barriers to the patient and reduces unintended pregnancies. Despite the safety and efficacy of same-day placement, access to same-day services remains low. OBJECTIVE This study aimed to evaluate the effects of the Delaware Contraceptive Access Now initiative, a statewide initiative in Delaware focused on increasing same-day access to effective contraception on same-day receipt of long-acting reversible contraceptives. STUDY DESIGN We used Medicaid claims and encounter data to identify instances of same-day and multivisit receipts of long-acting reversible contraceptives among Medicaid-enrolled individuals in Delaware and Maryland aged 15-44 years who were covered in a full-benefits or family planning Medicaid aid category during the month of the placement and the 2 previous months. We used a difference-in-differences design that compared changes in the outcome from before to after implementation of the initiative among placements at agencies that participated in the initiative (n=6676) vs 2 alternative comparison groups: placements at Delaware agencies that did not participate (n=688) and placements in Maryland (n=35,847). RESULTS We found that the intervention was associated with a 13.3 percentage point increase (95% confidence interval, 1.9%-24.7%) in receipt of same-day long-acting reversible contraceptives using a nonparticipating Delaware comparison group, a 21.1 percentage point increase (95% confidence interval, 13.7%-28.6%) using a Maryland comparison group, and a 21.0 percentage point increase (95% confidence interval, 14.1%-27.9%) using a pooled comparison group. The effects were larger for implants than intrauterine devices. CONCLUSION The Delaware Contraceptive Access Now initiative substantially increased the number of patients receiving long-acting reversible contraceptives through a single-visit encounter. Our findings suggested that coordinated interventions involving provider and staff training and capital investments that seed device stocking can increase the number of patients receiving same-day long-acting reversible contraceptives.
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Affiliation(s)
- Rebecca McColl
- Biden School of Public Policy and Administration, University of Delaware, Newark, DE.
| | - Katie Gifford
- Biden School of Public Policy and Administration, University of Delaware, Newark, DE
| | - Mary Joan McDuffie
- Biden School of Public Policy and Administration, University of Delaware, Newark, DE
| | - Michel Boudreaux
- University of Maryland School of Public Health, College Park, MD
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Reeves JA, Zapata LB, Curtis KM, Whiteman MK. Intrauterine Device Training, Attitudes, and Practices Among U.S. Health Care Providers: Findings from a Nationwide Survey. Womens Health Issues 2023; 33:45-53. [PMID: 36123229 DOI: 10.1016/j.whi.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 07/18/2022] [Accepted: 08/09/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Provider training in intrauterine device (IUD) procedures is a key strategy for improving evidence-based IUD care. We examined the influence of IUD training on IUD attitudes and practices among U.S. family planning providers. METHODS In 2019, we conducted a cross-sectional survey of U.S. family planning providers. We performed logistic regression to examine associations between training in routine IUD placement and specific IUD safety attitudes, confidence performing IUD procedures, and specific IUD practices. RESULTS Among 1,063 physicians and advanced practice clinicians, 85.1% reported training in routine IUD placement. Overall, IUD training was associated with accurately stating IUDs are safe for queried groups, including patients immediately postpartum (prevalence ratio [PR] 4.22; 95% confidence interval [CI] 1.29-13.85). Trained providers reported higher confidence in routine IUD placement for parous (PR 7.71; 95% CI 1.31-45.3) and nulliparous (PR 7.12; 95% CI 1.17-43.5) women and in IUD removal (PR 2.06; 95% CI 1.12-3.81). Among providers with IUDs available onsite, IUD training was associated with frequent same-day IUD provision for adults (PR 7.32; 95% CI 2.16-24.79) and adolescents (PR 7.63; 95% CI 2.22-26.24). Trained providers were also less likely to routinely use misoprostol before IUD placement for nulliparous (PR 0.19; 95% CI 0.11-0.33) and parous women (PR 0.07; 95% CI 0.03-0.16). CONCLUSION Training in routine IUD placement was associated with evidence-based IUD safety attitudes, confidence in performing IUD procedures, and clinical practices aligned with Centers for Disease Control and Prevention contraception guidance. Expanding IUD training might increase evidence-based care and patient access to the full range of contraception, including IUDs.
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Affiliation(s)
- Jennifer A Reeves
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Lauren B Zapata
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kathryn M Curtis
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Maura K Whiteman
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
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Vohra-Gupta S, Ela E, Vizcarra E, Petruzzi LJ, Hopkins K, Potter JE, White K. Evidence-based family planning services among publicly funded providers in Texas. BMC Health Serv Res 2022; 22:1498. [PMID: 36482413 PMCID: PMC9733229 DOI: 10.1186/s12913-022-08889-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Healthy Texas Women (HTW) is a fee-for-service family planning program that excludes affiliates of abortion providers. The HTW network includes providers who participate in Title X or the state Family Planning Program (FPP) and primary care providers without additional family planning funding (HTW-only). The objective of this study is to compare client volume and use of evidence-based practices among HTW providers. METHODS Client volume was determined from administrative data on unduplicated HTW clients served in fiscal year (FY) 2017. A sample of 114 HTW providers, stratified by region, completed a 2018 survey about contraceptive methods offered, adherence to evidence-based contraceptive provision, barriers to offering IUDs and implants, and counseling/referrals for pregnant patients. Differences by funding source were assessed using t-tests and chi-square tests. RESULTS Although HTW-only providers served 58% of HTW clients, most (72%) saw < 50 clients in FY2017. Only 5% of HTW providers received Title X or FPP funding, but 46% served ≥ 500 HTW clients. HTW-only providers were less likely than Title X providers to offer hormonal IUDs (70% vs. 92%) and implants (66% vs 96%); offer same-day placement of IUDs (21% vs 79%) and implants (21% vs 83%); and allow patients to delay cervical cancer screening when initiating contraception (58% vs 83%; all p < 0.05). There were few provider-level differences in counseling/referrals for unplanned pregnancy (p > 0.05). CONCLUSIONS HTW-only providers served fewer clients and were less likely to follow evidence-based practices. Program modifications that strengthen the provider network and quality of care are needed to support family planning services for low-income Texans.
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Affiliation(s)
- Shetal Vohra-Gupta
- grid.89336.370000 0004 1936 9924Steve Hicks School of Social Work, The University of Texas at Austin, 1925 San Jacinto Blvd, Austin, TX 78712 USA
| | - Elizabeth Ela
- grid.89336.370000 0004 1936 9924Population Research Center, University of Texas at Austin, 305 E. 23Rd Street, Austin, TX 78712 USA ,grid.89336.370000 0004 1936 9924Texas Policy Evaluation Project, The University of Texas at Austin, 116 Inner Campus Dr., Austin, TX 78712 USA
| | - Elsa Vizcarra
- grid.89336.370000 0004 1936 9924Population Research Center, University of Texas at Austin, 305 E. 23Rd Street, Austin, TX 78712 USA ,grid.89336.370000 0004 1936 9924Texas Policy Evaluation Project, The University of Texas at Austin, 116 Inner Campus Dr., Austin, TX 78712 USA
| | - Liana J. Petruzzi
- grid.89336.370000 0004 1936 9924Steve Hicks School of Social Work, The University of Texas at Austin, 1925 San Jacinto Blvd, Austin, TX 78712 USA
| | - Kristine Hopkins
- grid.89336.370000 0004 1936 9924Population Research Center, University of Texas at Austin, 305 E. 23Rd Street, Austin, TX 78712 USA ,grid.89336.370000 0004 1936 9924Texas Policy Evaluation Project, The University of Texas at Austin, 116 Inner Campus Dr., Austin, TX 78712 USA
| | - Joseph E. Potter
- grid.89336.370000 0004 1936 9924Population Research Center, University of Texas at Austin, 305 E. 23Rd Street, Austin, TX 78712 USA ,grid.89336.370000 0004 1936 9924Texas Policy Evaluation Project, The University of Texas at Austin, 116 Inner Campus Dr., Austin, TX 78712 USA
| | - Kari White
- grid.89336.370000 0004 1936 9924Steve Hicks School of Social Work, The University of Texas at Austin, 1925 San Jacinto Blvd, Austin, TX 78712 USA ,grid.89336.370000 0004 1936 9924Population Research Center, University of Texas at Austin, 305 E. 23Rd Street, Austin, TX 78712 USA ,grid.89336.370000 0004 1936 9924Texas Policy Evaluation Project, The University of Texas at Austin, 116 Inner Campus Dr., Austin, TX 78712 USA
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Simmons RG, Baayd J, Elliott S, Cohen SR, Turok DK. Improving access to highly effective emergency contraception: an assessment of barriers and facilitators to integrating the levonorgestrel IUD as emergency contraception using two applications of the Consolidated Framework for Implementation Research. Implement Sci Commun 2022; 3:129. [PMID: 36494859 PMCID: PMC9737706 DOI: 10.1186/s43058-022-00377-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 11/11/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Emergency contraception prevents unwanted pregnancy after sexual intercourse. New evidence has demonstrated that the levonorgestrel 52 mg IUD is a highly effective method of emergency contraception. However, translating this research finding into clinical practice faces existing barriers to IUD access, including costs and provider training, novel barriers of providing IUDs for emergency contraception at unscheduled appointments. The purpose of this study was to identify barriers and facilitators to the utilization of the levonorgestrel IUD as emergency contraception from client, provider, and health systems perspectives. METHODS We conducted English and Spanish-speaking focus groups (n=5) of both contraceptive users (n=22) and providers (n=13) to examine how the levonorgestrel IUD as EC was perceived and understood by these populations and to determine barriers and facilitators of utilization. We used findings from our focus groups to design a high-fidelity in-situ simulation scenario around EC that we pilot tested with clinical teams in three settings (a county health department, a community clinic, and a midwifery clinic), to further explore structural and health systems barriers to care. Simulation scenarios examined health system barriers to the provision of the levonorgestrel IUD as EC. We coded both focus groups and in-clinic simulations using the modified Consolidated Framework for Implementation Research (CFIR). We then applied our findings to the CFIR-Expert Recommendations for Implementing Change (ERIC) Barrier Busting Tool and mapped results to implement recommendations provided by participants. RESULTS Ultimately, 9 constructs from the CFIR were consistently identified across focus groups and simulations. Main barriers included suboptimal knowledge and acceptability of the intervention itself, appropriately addressing knowledge and education needs among both providers and contraceptive clients, and adequately accounting for structural barriers inherent in the health system. The CFIR-ERIC Barrier Busting Tool identified eight strategies to improve levonorgestrel IUD as EC access: identifying implementation champions, conducting educational meetings, preparing educational toolkits, involving patients and their partners in implementation, conducting a local needs assessment, distributing educational materials, and obtaining patient feedback. CONCLUSIONS To sustainably incorporate the levonorgestrel IUD as EC into clinical practice, education, health systems strengthening, and policy changes will be necessary.
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Affiliation(s)
- Rebecca G. Simmons
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132 USA
| | - Jami Baayd
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132 USA
| | - Sarah Elliott
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132 USA
| | - Susanna R. Cohen
- LIFT Simulation Design Lab, Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132 USA
| | - David K. Turok
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132 USA
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Boudreaux M, Gifford K, McDuffie MJ, McColl R, Kim T, Knight EK. Delaware Contraceptive Access Now and Contraceptive Initiation Among Medicaid Enrollees, 2015‒2020. Am J Public Health 2022; 112:S537-S540. [PMID: 35767779 PMCID: PMC10490315 DOI: 10.2105/ajph.2022.306938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 11/04/2022]
Abstract
Delaware Contraceptive Access Now was a statewide contraceptive access program implemented in Delaware between 2015 and 2020. We evaluated the association of the program with contraceptive initiation in Delaware's Medicaid program using a difference-in-differences design that compared changes in Delaware to changes in Maryland. Results suggest that program implementation was associated with increased initiation of long-acting reversible methods, particularly among adolescent patients aged 15 to 18 years. We found less-consistent evidence for changes to any contraceptive method. (Am J Public Health. 2022;112(S5):S537-S540. https://doi.org/10.2105/AJPH.2022.306938).
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Affiliation(s)
- Michel Boudreaux
- Michel Boudreaux and Taehyun Kim are with the Department of Health Policy and Management at the University of Maryland, College Park. Katie Gifford, Mary Joan McDuffie, and Rebecca McColl are with the Center for Community Research and Service at the Biden School of Public Policy and Administration, University of Delaware, Newark. Erin K. Knight is with the Department of Health at West Chester University, West Chester, PA
| | - Katie Gifford
- Michel Boudreaux and Taehyun Kim are with the Department of Health Policy and Management at the University of Maryland, College Park. Katie Gifford, Mary Joan McDuffie, and Rebecca McColl are with the Center for Community Research and Service at the Biden School of Public Policy and Administration, University of Delaware, Newark. Erin K. Knight is with the Department of Health at West Chester University, West Chester, PA
| | - Mary Joan McDuffie
- Michel Boudreaux and Taehyun Kim are with the Department of Health Policy and Management at the University of Maryland, College Park. Katie Gifford, Mary Joan McDuffie, and Rebecca McColl are with the Center for Community Research and Service at the Biden School of Public Policy and Administration, University of Delaware, Newark. Erin K. Knight is with the Department of Health at West Chester University, West Chester, PA
| | - Rebecca McColl
- Michel Boudreaux and Taehyun Kim are with the Department of Health Policy and Management at the University of Maryland, College Park. Katie Gifford, Mary Joan McDuffie, and Rebecca McColl are with the Center for Community Research and Service at the Biden School of Public Policy and Administration, University of Delaware, Newark. Erin K. Knight is with the Department of Health at West Chester University, West Chester, PA
| | - Taehyun Kim
- Michel Boudreaux and Taehyun Kim are with the Department of Health Policy and Management at the University of Maryland, College Park. Katie Gifford, Mary Joan McDuffie, and Rebecca McColl are with the Center for Community Research and Service at the Biden School of Public Policy and Administration, University of Delaware, Newark. Erin K. Knight is with the Department of Health at West Chester University, West Chester, PA
| | - Erin K Knight
- Michel Boudreaux and Taehyun Kim are with the Department of Health Policy and Management at the University of Maryland, College Park. Katie Gifford, Mary Joan McDuffie, and Rebecca McColl are with the Center for Community Research and Service at the Biden School of Public Policy and Administration, University of Delaware, Newark. Erin K. Knight is with the Department of Health at West Chester University, West Chester, PA
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Comfort AB, Rao L, Goodman S, Barney A, Glymph A, Schroeder R, McCulloch C, Harper CC. Improving Capacity at School-based Health Centers to Offer Adolescents Counseling and Access to Comprehensive Contraceptive Services. J Pediatr Adolesc Gynecol 2021; 34:26-32. [PMID: 32730800 PMCID: PMC7385555 DOI: 10.1016/j.jpag.2020.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 07/20/2020] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVES Many pediatric providers serving adolescents are not trained to offer comprehensive contraceptive services, including intrauterine devices (IUDs) and implants, despite high safety and satisfaction among adolescents. This study assessed an initiative to train providers at school-based health centers (SBHCs) to offer students the full range of contraceptive methods. DESIGN Surveys were administered at baseline pre-training and at follow-up 3 months post-training. Data were analyzed using generalized estimating equations for clustered data to examine clinical practice changes. SETTING Eleven contraceptive trainings at SBHCs across the United States from 2016-2019. PARTICIPANTS A total of 260 providers from 158 SBHCs serving 135,800 students. INTERVENTIONS On-site training to strengthen patient-centered counseling and to equip practitioners to integrate IUDs and implants into contraceptive services. MAIN OUTCOME MEASURES The outcomes included counseling experience on IUDs and implants, knowledge of patient eligibility, and clinician method skills. RESULTS At follow-up, providers were significantly more likely to report having enough experience to counsel on IUDs (adjusted odds ratio [aOR], 4.08; 95% confidence interval [CI], 2.62-6.36]) and implants (aOR, 3.06; 95% CI, 2.05-4.57). Provider knowledge about patient eligibility for IUDs, including for adolescents, increased (P < .001). Providers were more likely to offer same-visit IUD (aOR, 2.10; 95% CI, 1.41-3.12) and implant services (aOR, 1.66; 95% CI, 1.44-1.91). Clinicians' skills with contraceptive devices improved, including for a newly available low-cost IUD (aOR, 2.21; 95% CI, 1.45-3.36). CONCLUSIONS Offering evidence-based training is a promising approach to increase counseling and access to comprehensive contraceptive services at SBHCs.
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Affiliation(s)
- Alison B Comfort
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA.
| | - Lavanya Rao
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | - Suzan Goodman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | - Angela Barney
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | | | - Rosalyn Schroeder
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | - Charles McCulloch
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | - Cynthia C Harper
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
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Biggs MA, Tome L, Mays A, Kaller S, Harper CC, Freedman L. The Fine Line Between Informing and Coercing: Community Health Center Clinicians' Approaches to Counseling Young People About IUDs. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2020; 52:245-252. [PMID: 33289277 DOI: 10.1363/psrh.12161] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 08/10/2020] [Accepted: 08/24/2020] [Indexed: 06/12/2023]
Abstract
CONTEXT While community health centers (CHCs) are meeting increased demand for contraceptives, little is known about contraceptive counseling in these settings. Understanding how clinicians counsel about IUDs in CHCs, including whether they address or disregard young people's preferences and concerns during counseling, could improve contraceptive care. METHODS As part of a training program, 20 clinicians from 11 San Francisco Bay Area CHC sites who counsel young people about contraception were interviewed by telephone in 2015 regarding their IUD counseling approaches. An iterative grounded theory approach was used to analyze interview transcripts and identify salient themes related to clinicians' contraceptive counseling, IUD removal practices and efforts to address patient concerns regarding side effects. RESULTS Most clinicians offered comprehensive contraceptive counseling and method choice. While several clinicians viewed counseling as an opportunity to empower their patients to make contraceptive decisions without pressure, they also described a tension between guiding young people toward higher-efficacy methods and respecting patients' choices. Many clinicians engaged in what could be considered coercive practices by trying to dissuade patients from removals within a year of placement and offering to treat or downplay side effects. CONCLUSIONS Providers try to promote their young patients' autonomous decision making, but their support for high-efficacy methods can result in coercive practices. More training is needed to ensure that providers employ patient-centered counseling approaches, including honoring patient requests for removals.
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Affiliation(s)
- M Antonia Biggs
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | - Lucia Tome
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Aisha Mays
- Department of Family and Community Medicine, University of California, San Francisco
| | - Shelly Kaller
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | - Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco
| | - Lori Freedman
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
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Judge-Golden CP, Wiesenfeld HC, Chen BA, Borrero S. Adherence to Recommended Practices for Provision of Long-Acting Reversible Contraception Among Providers in a Large U.S. Health Care System. J Womens Health (Larchmt) 2020; 29:1586-1595. [PMID: 32667847 PMCID: PMC7757543 DOI: 10.1089/jwh.2019.8169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Background: There is little research examining adherence to practice guidelines for long-acting reversible contraception (LARC). We assessed same-day LARC provision and adherence to other guideline-recommended practices among providers in a large academic health care system. Materials and Methods: We surveyed 363 providers who had billed using LARC-related codes within the prior 12 months. Primary outcomes were, for women requesting an intrauterine device (IUD) or implant, the typical number of visits for method provision and ability to add an insertion procedure to an annual examination. We used chi-square tests and multivariable logistic regression to identify characteristics associated with primary outcomes and described other practices and barriers to same-day LARC. Results: Our response rate was 42% (153/363). A typical single visit for women requesting an IUD or implant was reported by 37% of IUD providers and 51% of implant providers, respectively, and was associated with obstetrician-gynecologist specialty versus family medicine (IUD: 44% vs. 12%, p = 0.001; implant: 57% vs. 26%, p = 0.002) and practicing in the county of the main academic medical center versus any other county (IUD: 48% vs. 20%, p = 0.001; implant: 65% vs. 27%, p < 0.001). High ability to add LARC insertion to an annual examination was reported by 48% of IUD providers and 51% of implant providers, with similar associations of specialty and county. Barriers to same-day LARC included scheduling constraints, insurance and billing concerns, and device stocking. Nearly all respondents provide LARC to nulliparous women and adolescents. Among IUD providers, 73% schedule routine follow-up after insertion. Conclusions: Same-day LARC provision is low among providers in a large academic health care system. Provider-identified barriers suggest interventions to improve LARC access, including incentivizing device stocking and billing and insurance education.
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Affiliation(s)
- Colleen P. Judge-Golden
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Center for Women's Health Research and Innovation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Harold C. Wiesenfeld
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
| | - Beatrice A. Chen
- Center for Women's Health Research and Innovation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
| | - Sonya Borrero
- Center for Women's Health Research and Innovation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania, USA
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10
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Harper CC, Comfort AB, Blum M, Rocca CH, McCulloch CE, Rao L, Shah N, Oquendo Del Toro H, Goodman S. Implementation science: Scaling a training intervention to include IUDs and implants in contraceptive services in primary care. Prev Med 2020; 141:106290. [PMID: 33096126 PMCID: PMC8032203 DOI: 10.1016/j.ypmed.2020.106290] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 10/10/2020] [Accepted: 10/13/2020] [Indexed: 10/23/2022]
Abstract
Building capacity for contraceptive services in primary care settings, including for intrauterine devices (IUDs) and implants, can help to broaden contraceptive access across the US. Following a randomized trial in family planning clinics, we brought a provider training intervention to other clinical settings including primary care in all regions. This implementation science study evaluates a national scale-up of a contraceptive training intervention to varied practice settings from 2013 to 2019 among 3216 clinic staff serving an estimated 1.6 million annual contraceptive patients. We measured providers' knowledge and clinical practice changes regarding IUDs and implants using survey data. We estimated the overall intervention effect, and its relative effectiveness in primary care settings, with generalized estimating equations for clustered data. Patient-centered counseling improved, along with comfort with method provision and removal. Provider knowledge increased (p < 0.001), as did evidence-based counseling for IUDs (aOR 3.3 95% CI 2.8-3.9) and implants (aOR 3.5, 95% CI 3.0-4.1), and clinician competency in copper and levonorgestrel IUDs (aORs 1.8-2.6 95% CIs 1.5-3.2) and implants (aOR 2.4 95% CI 2.0-2.9). While proficiency was lower initially in primary care, gains were significant and at times greater than in Planned Parenthood health clinics. This intervention was effectively scaled, including in primary care settings with limited prior experience with these methods. Recent changes to Title X family planning funding rules exclude several large family planning providers, shifting greater responsibility to primary care and other settings. Scaling effective contraceptive interventions is one way to ensure capacity to offer patients full contraceptive services.
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Affiliation(s)
- Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, United States of America.
| | - Alison B Comfort
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, United States of America
| | - Maya Blum
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, United States of America
| | - Corinne H Rocca
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, United States of America
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco School of Medicine, United States of America
| | - Lavanya Rao
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, United States of America
| | - Nishant Shah
- Consultant, Bixby Center for Global Reproductive Health, University of California, San Francisco, School of Medicine, United States of America
| | - Helen Oquendo Del Toro
- Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, United States of America
| | - Suzan Goodman
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, United States of America; Department of Family and Community Medicine, University of California, San Francisco School of Medicine, United States of America
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11
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Serpico JJ, Ricks JM, Smooth WG, Romanos C, Brook DL, Gallo MF. Access to single-visit IUD insertion at obstetrician-gynecology practices in Ohio: An audit study. Contraception 2020; 102:190-194. [DOI: 10.1016/j.contraception.2020.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 05/08/2020] [Accepted: 05/14/2020] [Indexed: 11/16/2022]
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12
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Abstract
Long-acting reversible contraceptives are the most effective methods to prevent pregnancy and also offer noncontraceptive benefits such as reducing menstrual blood flow and dysmenorrhea. The safety and efficacy of long-acting reversible contraception are well established for adolescents, but the rate of use remains low for this population. The pediatrician can play a key role in increasing access to long-acting reversible contraception for adolescents by providing accurate patient-centered contraception counseling and by understanding and addressing the barriers to use.
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Affiliation(s)
- Seema Menon
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin
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13
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Amico JR, Heintz C, Bennett AH, Gold M. Access to IUD removal: Data from a mystery-caller study. Contraception 2020; 101:122-129. [DOI: 10.1016/j.contraception.2019.10.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 10/18/2019] [Accepted: 10/27/2019] [Indexed: 11/24/2022]
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14
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Kaller S, Mays A, Freedman L, Harper CC, Biggs MA. Exploring young women's reasons for adopting intrauterine or oral emergency contraception in the United States: a qualitative study. BMC Womens Health 2020; 20:15. [PMID: 31992295 PMCID: PMC6986082 DOI: 10.1186/s12905-020-0886-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The recent focus on increasing access to long-acting reversible contraceptive methods has often overlooked the diverse reasons why women may choose less effective methods even when significant access barriers have been removed. While the copper intrauterine device (IUD) is considered an acceptable alternative to emergency contraception pills (ECPs), it is unclear to what extent low rates of provision and use are due to patient preferences versus structural access barriers. This study explores factors that influence patients' choice between ECPs and the copper IUD as EC, including prior experiences with contraception and attitudes toward EC methods, in settings where both options are available at no cost. METHODS We telephone-interviewed 17 patients seeking EC from three San Francisco Bay Area youth-serving clinics that offered the IUD as EC and ECPs as standard practice, regarding their experiences choosing an EC method. We thematically coded all interview transcripts, then summarized the themes related to reasons for choosing ECPs or the IUD as EC. RESULTS Ten participants left their EC visit with ECPs and seven with the IUD as EC option. Women chose ECPs because they were familiar and easily accessible. Reasons for not adopting the copper IUD included having had prior negative experiences with the IUD, concerns about its side effects and the placement procedure, and lack of awareness about the copper IUD. Women who chose the IUD as EC did so primarily because of its long-term efficacy, invisibility, lack of hormones, longer window of post-coital utility, and a desire to not rely on ECPs. Women who chose the IUD as EC had not had prior negative experiences with the IUD, had already been interested in the IUD, and were ready and able to have it placed that day. CONCLUSIONS This study highlights that women have varied and well-considered reasons for choosing each EC method. Both ECPs and the copper IUD are important and acceptable EC options, each with their own features offering benefits to patients. Efforts to destigmatize repeated use of ECPs and validate women's choice of either EC method are needed to support women in their EC method decision-making.
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Affiliation(s)
- Shelly Kaller
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612 USA
| | - Aisha Mays
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612 USA
| | - Lori Freedman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612 USA
| | - Cynthia C. Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 3333 California St, Suite 335, San Francisco, CA 94143 USA
| | - M. Antonia Biggs
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612 USA
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15
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Wani RT, Rashid I, Nabi SS, Dar H. Knowledge, attitude, and practice of family planning services among healthcare workers in Kashmir - A cross-sectional study. J Family Med Prim Care 2019; 8:1319-1325. [PMID: 31143714 PMCID: PMC6510098 DOI: 10.4103/jfmpc.jfmpc_96_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background: Researches have shown highest awareness but low utilization of contraceptives making the situation a serious challenge. Most of women in reproductive age group know little or have incorrect information about family planning methods. Even when they know the name of some of the contraceptives, they do not know where to get them or how to use it. These women have negative attitude about family planning, whereas some have heard false and misleading information, the current study aimed in assessing the knowledge, attitude, and practice of family planning among female healthcare workers in Kashmir valley. Method: A self-administered questionnaire was served to the female multipurpose health workers of District Anantnag and Baramulla at a training conducted in Department of Community Medicine, Government Medical College, Srinagar, Kashmir. Result: All the participants had heard about family planning methods. The major sources of information were trainers (78.8%). About 90.4% of the study participants gave correct response regarding the types of family planning. About 80.1% of the respondents had a favorable attitude toward family planning. Around three-fourths of the study participants practiced one or other method of family planning. Conclusion: Our study lead to the conclusion that the level of knowledge and attitude toward family planning was relatively low and FP utilization was quite low among the healthcare workers. In order to imbibe positive attitude among general public, the health workers need to be trained so as to inculcate the positive attitude in them leading to increased awareness among general public with regard to family planning.
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Affiliation(s)
- Rabbanie Tariq Wani
- Department of Community Medicine, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Imrose Rashid
- Department of Community Medicine, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Sheikh Sahila Nabi
- Department of Community Medicine, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Hibba Dar
- J and K Health Services, Jammu and Kashmir, India
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16
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Coleman-Minahan K, Dillaway CH, Canfield C, Kuhn DM, Strandberg KS, Potter JE. Low-Income Texas Women's Experiences Accessing Their Desired Contraceptive Method at the First Postpartum Visit. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2018; 50:189-198. [PMID: 30506996 PMCID: PMC6314803 DOI: 10.1363/psrh.12083] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/19/2018] [Accepted: 07/23/2018] [Indexed: 06/09/2023]
Abstract
CONTEXT Early access to contraception may increase postpartum contraceptive use. However, little is known about women's experiences receiving their desired method at the first postpartum visit or how access is associated with use. METHODS In a 2014-2016 prospective cohort study of low-income Texas women, data were collected from 685 individuals who desired a reversible contraceptive and discussed contraception with a provider at their first postpartum visit, usually within six weeks of birth. Women's experiences were captured using open- and closed-ended survey questions. Thematic and multivariate logistic regression analyses were employed to examine contraceptive access and barriers, and method use at three months postpartum. RESULTS Twenty-three percent of women received their desired method at the first postpartum visit; 11% a prescription for their desired pill, patch or ring; 8% a method (or prescription) other than that desired; and 58% no method. Among women who did not receive their desired method, 44% reported clinic-level barriers (e.g., method unavailability or no same-day provision), 26% provider-level barriers (e.g., inaccurate contraceptive counseling) and 23% cost barriers. Women who used private practices were more likely than those who used public clinics to report availability and cost barriers (odds ratios, 6.4 and 2.7, respectively). Forty-one percent of women who did not receive their desired method, compared with 86% of those who did, were using that method at three months postpartum. CONCLUSION Eliminating the various barriers that postpartum women face may improve their access to contraceptives. Further research is needed to improve the understanding of clinic- and provider-level barriers.
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Affiliation(s)
- Kate Coleman-Minahan
- Assistant Professor, College of Nursing, University of Colorado Anschutz Medical Campus, Aurora
| | - Chloe H Dillaway
- Graduate Student at Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Caitlin Canfield
- Evaluation Manager, Evaluation and Research, Louisiana Public Health Institute, New Orleans
| | - Daniela M Kuhn
- Research Associate, Population Research Center, University of Texas at Austin
| | | | - Joseph E Potter
- Professor, Population Research Center, University of Texas at Austin
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17
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Early DR, Dove MS, Thiel de Bocanegra H, Schwarz EB. Publicly Funded Family Planning: Lessons From California, Before And After The ACA’s Medicaid Expansion. Health Aff (Millwood) 2018; 37:1475-1483. [DOI: 10.1377/hlthaff.2018.0412] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Dawnte R. Early
- Dawnte R. Early is a research scientist with the State of California, in Sacramento
| | - Melanie S. Dove
- Melanie S. Dove is a postdoctoral fellow in general internal medicine at the University of California Davis, in Sacramento
| | - Heike Thiel de Bocanegra
- Heike Thiel de Bocanegra is an associate professor of obstetrics and gynecology at the Bixby Center for Global Reproductive Health, University of California San Francisco
| | - Eleanor B. Schwarz
- Eleanor B. Schwarz is a professor of general internal medicine at the University of California Davis
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18
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Moniz MH, Kirch MA, Solway E, Goold SD, Ayanian JZ, Kieffer EC, Clark SJ, Tipirneni R, Kullgren JT, Chang T. Association of Access to Family Planning Services With Medicaid Expansion Among Female Enrollees in Michigan. JAMA Netw Open 2018; 1:e181627. [PMID: 30646135 PMCID: PMC6324283 DOI: 10.1001/jamanetworkopen.2018.1627] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE To date, 32 states and the District of Columbia have expanded Medicaid programs under the Patient Protection and Affordable Care Act. It is vital to understand whether expanded health insurance coverage of low-income individuals improves access to family planning services as a first step toward improving reproductive health outcomes. OBJECTIVE To evaluate the association of Medicaid expansion coverage with access to birth control and family planning services among women of reproductive age enrolled in the Michigan expansion plan. DESIGN, SETTING, AND PARTICIPANTS In a survey study, from January 13 through December 15, 2016, telephone surveys of a stratified sample of enrollees in Michigan's Section 1115 Medicaid Expansion waiver program, the Healthy Michigan Plan (HMP), were conducted. Interviewers completed surveys for 4090 sampled enrollees, of whom 1166 were women aged 19 to 44 years. Surveys were conducted with a computer-assisted telephone interviewing system in English, Arabic, and Spanish. The sample was weighted to 113 565 women. Dates of data analysis were from January 27 through September 18, 2017. MAIN OUTCOMES AND MEASURES Self-reported change in access to birth control and family planning services through HMP (better, worse, about the same, or don't know/doesn't apply), compared with before enrollment. RESULTS Among the 1166 survey respondents aged 19 to 44 years (mean [SD] age, 31.0 [0.3] years) and the weighted sample of 113 565, 74.7% (95% CI, 72.2%-76.9%) lived in very-low-income households (<100% federal poverty level), 64.0% (95% CI, 60.5%-67.3%) reported at least 1 chronic medical condition, 23.5% (95% CI, 20.6%-26.6%) reported fair or poor health, and 17.7% (95% CI, 15.7%-19.9%) lived in rural settings. Overall, 35.5% (95% CI, 32.2%-39.0%) reported increased access to family planning services. After adjusting, those most likely to report increased access were women without health insurance coverage in the year preceding HMP enrollment (adjusted odds ratio [aOR], 2.02; 95% CI, 1.41-2.89) compared with women with health insurance for the full 12 months preceding enrollment; younger women (aOR for 19-24 years, 2.80 [95% CI, 1.75-4.50]; aOR for 25-34 years, 2.35 [95% CI, 1.60-3.45]) compared with women aged 35 to 44 years; and women with a recent visit to a primary care clinician (aOR 1.69; 95% CI, 1.03-2.76) compared with women without a primary care visit in the preceding 12 months. CONCLUSIONS AND RELEVANCE One in 3 women of reproductive age reported better ability to access birth control and family planning services through HMP compared with before enrollment. This finding suggests that Medicaid expansion is associated with improved access to family planning services, which may enable low-income women to maintain optimal reproductive health.
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Affiliation(s)
- Michelle H. Moniz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Matthias A. Kirch
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Erica Solway
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Susan D. Goold
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- School of Public Health, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor
| | - John Z. Ayanian
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- School of Public Health, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Edith C. Kieffer
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- School of Social Work, University of Michigan, Ann Arbor
| | - Sarah J. Clark
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Pediatrics, University of Michigan, Ann Arbor
| | - Renuka Tipirneni
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Jeffrey T. Kullgren
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor
- Veterans Affairs Ann Arbor Center for Clinical Management Research, University of Michigan, Ann Arbor
| | - Tammy Chang
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Family Medicine, University of Michigan, Ann Arbor
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White K, Hopkins K, Grossman D, Potter JE. Providing Family Planning Services at Primary Care Organizations after the Exclusion of Planned Parenthood from Publicly Funded Programs in Texas: Early Qualitative Evidence. Health Serv Res 2018; 53 Suppl 1:2770-2786. [PMID: 29053179 PMCID: PMC6056580 DOI: 10.1111/1475-6773.12783] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To explore organizations' experiences providing family planning during the first year of an expanded primary care program in Texas. DATA SOURCES Between November 2014 and February 2015, in-depth interviews were conducted with program administrators at 30 organizations: 7 women's health organizations, 13 established primary care contractors (e.g., community health centers, public health departments), and 10 new primary care contractors. STUDY DESIGN Interviews addressed organizational capacities to expand family planning and integrate services with primary care. DATA EXTRACTION Interview transcripts were analyzed using a theme-based approach. Themes were compared across the three types of organizations. PRINCIPAL FINDINGS Established and new primary care contractors identified several challenges expanding family planning services, which were uncommon among women's health organizations. Clinicians often lacked training to provide intrauterine devices and contraceptive implants. Organizations often recruited existing clients into family planning services, rather than expanding their patient base, and new contractors found family planning difficult to integrate because of clients' other health needs. Primary care contractors frequently described contraceptive provision protocols that were not evidence-based. CONCLUSIONS Many primary care organizations in Texas initially lacked the capacity to provide evidence-based family planning services that women's health organizations already provided.
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Affiliation(s)
- Kari White
- Department of Health Care Organization and PolicyUniversity of Alabama at BirminghamBirminghamAL
| | - Kristine Hopkins
- Population Research Center and the Department of SociologyThe University of Texas at AustinAustinTX
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH)Bixby Center for Global Reproductive HealthDepartment of Obstetrics, Gynecology and Reproductive SciencesUniversity of California, San FranciscoOaklandCA
| | - Joseph E. Potter
- Population Research Center and the Department of SociologyThe University of Texas at AustinAustinTX
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20
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Natavio M, Blotky E, Van Horn CM, Waters C, Ihenacho U, Silverstein E, Cortessis VK, Nelson AL. Availability of long-acting reversible contraceptives in Los Angeles County clinics through a Medicaid state plan amendment program. Contraception 2018; 98:471-475. [PMID: 30076832 DOI: 10.1016/j.contraception.2018.07.138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 06/19/2018] [Accepted: 07/25/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess the availability of long acting reversible contraceptive (LARC) methods in Los Angeles County through providers participating in a California State Medicaid State Plan Amendment Program called Family Planning, Access, Care and Treatment (Family PACT). STUDY DESIGN This was a cross-sectional telephone survey utilizing "secret shopper" methodology. From 855 Family PACT providers in Los Angeles County in 2015, a representative sample of 400 providers was selected for study. Young female researchers posing as potential patients called each sampled clinic to ask a scripted series of questions about LARC availability for Family PACT patients in that practice. RESULTS All but one eligible practice (99.7%) responded to our questions. Among the 336 responding practices, 284 said they accepted Family PACT. Of those accepting Family PACT, staff answering the telephone call at 61% said they did not provide any LARC method onsite, 2% provided all currently available LARC methods, and 6% provided same-day placement of any LARC. CONCLUSION The majority of Family PACT practices surveyed said that they did not provide any LARC onsite, and very few provided same-day LARC placement despite easy patient enrollment procedures, relatively reasonable reimbursement and concerted efforts to increase LARC use. Substantial barriers to greater uptake may rest at the provider level with either actual unavailability of LARC or staff perception of unavailability. IMPLICATIONS Only a minority of Family PACT practices said that LARC methods were available onsite, which imposes substantial restriction to access for women who are entitled to have access without cost. Other states developing programs should be aware of this challenge.
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Affiliation(s)
- Melissa Natavio
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California; Keck School of Medicine, University of Southern California, Los Angeles, California.
| | - Elizabeth Blotky
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Christine M Van Horn
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Caitlin Waters
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ugonna Ihenacho
- Department of Preventive Medicine, University of Southern California, Los Angeles, California; Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Emily Silverstein
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California; Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Victoria K Cortessis
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California; Department of Preventive Medicine, University of Southern California, Los Angeles, California; Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Anita L Nelson
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California; Keck School of Medicine, University of Southern California, Los Angeles, California
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Simmons KB, Zapata L, Curtis KM. Health Care Provider Perceptions of the Safety of IUDs for Women with HIV. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2018; 50:67-73. [PMID: 29603597 DOI: 10.1363/psrh.12056] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 12/03/2017] [Accepted: 01/16/2018] [Indexed: 06/08/2023]
Abstract
CONTEXT Women who are living with HIV use IUDs at a lower rate than the general population, and it is unclear whether health care providers' misconceptions about IUD safety contribute to this disparity. METHODS A 2013-2014 nationwide survey of 1,998 U.S. family planning providers assessed perceptions of IUD safety for women with HIV or other medical conditions. Multivariable logistic regression was used to examine associations between provider characteristics and whether individuals believed IUDs were safe for HIV-positive women. Data from public-sector providers and office-based physicians were analyzed separately. RESULTS Seven in 10 providers considered IUDs safe for women with HIV, and there were no differences by provider type. Among public-sector providers, some of the characteristics associated with believing that IUDs were unsafe for seropositive women were working at a clinic without Title X funding (odds ratio, 1.5), not being trained in IUD insertion (2.1) and not using the U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) for clinical guidance (1.8). Office-based physicians who did not use the guidelines also had an increased likelihood of believing that IUDs were unsafe for women with HIV (2.9), and physicians who had completed training 25 or more years ago were more likely than those who had done so less than five years ago to consider IUDs unsafe (3.3). CONCLUSIONS Greater use of evidence-based contraceptive guidance such as the U.S. MEC may help inform provider perceptions of IUD safety and hence contribute to increased contraceptive choice for women with HIV.
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Affiliation(s)
| | - Lauren Zapata
- Senior Research Scientist, Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta
| | - Kathryn M Curtis
- Health Scientist, Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta
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Thompson KM, Rocca CH, Stern L, Morfesis J, Goodman S, Steinauer J, Harper CC. Training contraceptive providers to offer intrauterine devices and implants in contraceptive care: a cluster randomized trial. Am J Obstet Gynecol 2018; 218:597.e1-597.e7. [PMID: 29577915 DOI: 10.1016/j.ajog.2018.03.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/06/2018] [Accepted: 03/16/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND US unintended pregnancy rates remain high, and contraceptive providers are not universally trained to offer intrauterine devices and implants to women who wish to use these methods. OBJECTIVE We sought to measure the impact of a provider training intervention on integration of intrauterine devices and implants into contraceptive care. STUDY DESIGN We measured the impact of a continuing medical education-accredited provider training intervention on provider attitudes, knowledge, and practices in a cluster randomized trial in 40 US health centers from 2011 through 2013. Twenty clinics were randomly assigned to the intervention arm; 20 offered routine care. Clinic staff participated in baseline and 1-year surveys assessing intrauterine device and implant knowledge, attitudes, and practices. We used a difference-in-differences approach to compare changes that occurred in the intervention sites to changes in the control sites 1 year later. Prespecified outcome measures included: knowledge of patient eligibility for intrauterine devices and implants; attitudes about method safety; and counseling practices. We used multivariable regression with generalized estimating equations to account for clustering by clinic to examine intervention effects on provider outcomes 1 year later. RESULTS Overall, we surveyed 576 clinic staff (314 intervention, 262 control) at baseline and/or 1-year follow-up. The change in proportion of providers who believed that the intrauterine device was safe was greater in intervention (60% at baseline to 76% at follow-up) than control sites (66% at both times) (adjusted odds ratio, 2.48; 95% confidence interval, 1.13-5.4). Likewise, for the implant, the proportion increased from 57-77% in intervention, compared to 61-65% in control sites (adjusted odds ratio, 2.57; 95% confidence interval, 1.44-4.59). The proportion of providers who believed they were experienced to counsel on intrauterine devices also increased in intervention (53-67%) and remained the same in control sites (60%) (adjusted odds ratio, 1.89; 95% confidence interval, 1.04-3.44), and for the implant increased more in intervention (41-62%) compared to control sites (48-50%) (adjusted odds ratio, 2.30; 95% confidence interval, 1.28-4.12). Knowledge scores of patient eligibility for intrauterine devices increased at intervention sites (from 0.77-0.86) 6% more over time compared to control sites (from 0.78-0.80) (adjusted coefficient, 0.058; 95% confidence interval, 0.003-0.113). Knowledge scores of eligibility for intrauterine device and implant use with common medical conditions increased 15% more in intervention (0.65-0.79) compared to control sites (0.67-0.66) (adjusted coefficient, 0.15; 95% confidence interval, 0.09-0.21). Routine discussion of intrauterine devices and implants by providers in intervention sites increased significantly, 71-87%, compared to in control sites, 76-82% (adjusted odds ratio, 1.97; 95% confidence interval, 1.02-3.80). CONCLUSION Professional guidelines encourage intrauterine device and implant competency for all contraceptive care providers. Integrating these methods into routine care is important for access. This replicable training intervention translating evidence into care had a sustained impact on provider attitudes, knowledge, and counseling practices, demonstrating significant changes in clinical care a full year after the training intervention.
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Soon R, Sung S, Cruz MRD, Chen JJ, Hiraoka M. Improving Human Papillomavirus (HPV) Vaccination in the Postpartum Setting. J Community Health 2018; 42:66-71. [PMID: 27476162 DOI: 10.1007/s10900-016-0230-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Although the HPV vaccine has been shown to be highly effective in preventing cervical dysplasia, vaccination rates remain low. The objective of this study was to assess the effectiveness of an electronic medical record (EMR) prompt on HPV vaccination rates in the postpartum setting. We conducted a pre-post intervention study among postpartum women ages 18-26 seen at an outpatient clinic from 09/01/2012-08/31/2013 (pre-intervention) and from 10/01/2013-03/31/2014 (post-intervention). The intervention was a drop-down menu that was inserted into the EMR postpartum note template inquiring about the patient's HPV vaccination status and whether or not the vaccine was administered at that visit. HPV vaccination uptake was compared pre and post-intervention. Of the 278 postpartum visits during the study period, 241 were eligible for analysis. There was a significant increase of the HPV vaccine uptake, from 1.2 % (2/173) among pre-intervention visits to 26.5 % (18/68) among post-intervention visits (p < 0.001). After adjusting for age, ethnicity, insurance, and religion, HPV vaccination was significantly higher at postpartum visits during the intervention period, with an adjusted OR = 93.49 [95 % CI 15.29-571.52]. Among visits in which the vaccine was not given, HPV vaccination was not discussed in 46 % and patients refused the vaccine in 40 % of visits. An EMR prompt in the postpartum note could be an effective way to promote HPV vaccination in the postpartum setting. It will likely take a combination of strategies to optimize vaccination uptake.
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Affiliation(s)
- Reni Soon
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine, University of Hawai'i, 1319 Punahou St, Ste 824, Honolulu, HI, 96826, USA.
| | - Stephen Sung
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine, University of Hawai'i, 1319 Punahou St, Ste 824, Honolulu, HI, 96826, USA
| | | | - John J Chen
- Office of Biostatistics and Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawai'i, 1319 Punahou St, Ste 824, Honolulu, HI, 96826, USA
| | - Mark Hiraoka
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine, University of Hawai'i, 1319 Punahou St, Ste 824, Honolulu, HI, 96826, USA
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Higgins TM, Dougherty AK, Badger GJ, Heil SH. Comparing long-acting reversible contraception insertion rates in women with Medicaid vs. private insurance in a clinic with a two-visit protocol. Contraception 2017; 97:76-78. [PMID: 28887052 DOI: 10.1016/j.contraception.2017.08.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 08/28/2017] [Accepted: 08/29/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This study examined whether women with Medicaid are less likely to receive long-acting reversible contraception (LARC) in a clinic requiring two visits for insertion. STUDY DESIGN LARC insertion and pregnancy rates were compared among women with Medicaid vs. private insurance, along with other predictors, in a retrospective chart review (N=447). RESULTS Univariately, fewer women with Medicaid vs. private insurance received LARC (66% vs. 79%, p<.01) and more become pregnant (18% vs. 6%, p<.001). Significant multivariate predictors of not receiving LARC were being unmarried and postpartum, both of which were associated with having Medicaid. CONCLUSION Women with Medicaid are less likely than women with private insurance to have a requested LARC device inserted when a clinic requires two visits for insertion.
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Affiliation(s)
- Tara M Higgins
- The University of Vermont College of Medicine, University of Vermont, Burlington, VT, USA
| | - Anne K Dougherty
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont, Burlington, VT, USA
| | - Gary J Badger
- Department of Medical Biostatistics, University of Vermont, Burlington, VT, USA
| | - Sarah H Heil
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT, USA; Department of Psychiatry, University of Vermont, Burlington, VT, USA; Department of Psychological Science, University of Vermont, Burlington, VT, USA.
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Yarger J, Daniel S, Biggs MA, Malvin J, Brindis CD. The Role of Publicly Funded Family Planning Sites In Health Insurance Enrollment. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2017; 49:103-109. [PMID: 28445624 DOI: 10.1363/psrh.12026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
CONTEXT Publicly funded family planning providers are well positioned to help uninsured individuals learn about health insurance coverage options and effectively navigate the enrollment process. Understanding how these providers are engaged in enrollment assistance and the challenges they face in providing assistance is important for maximizing their role in health insurance outreach and enrollment. METHODS In 2014, some 684 sites participating in California's family planning program were surveyed about their involvement in helping clients enroll in health insurance. Weighted univariate and bivariate analyses were conducted to examine enrollment activities and perceived barriers to facilitating enrollment by site characteristics. RESULTS Most family planning program sites provided eligibility screening (68%), enrollment education (77%), on-site enrollment assistance (55%) and referrals for off-site enrollment support (91%). The proportion of sites offering each type of assistance was highest among community clinics (83-96%), primary care and multispecialty sites (65-95%), Title X-funded sites (72-98%), sites with contracts to provide primary care services (64-93%) and sites using only electronic health records (66-94%). Commonly identified barriers to providing assistance were lack of staff time (reported by 52% of sites), lack of funding (47%), lack of physical space (34%) and lack of staff knowledge (33%); only 20% of sites received funding to support enrollment activities. CONCLUSIONS Although there were significant variations among them, publicly funded family planning providers in California are actively engaged in health insurance enrollment. Supporting their vital role in enrollment could help in the achievement of universal health insurance coverage.
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Affiliation(s)
- Jennifer Yarger
- research associate, Philip R. Lee Institute for Health Policy Studies and Bixby Center for Global Reproductive Health, University of California, San Francisco
| | - Sara Daniel
- project manager, Advancing New Standards in Reproductive Health, University of California, San Francisco
| | - M Antonia Biggs
- associate researcher, Advancing New Standards in Reproductive Health, University of California, San Francisco
| | - Jan Malvin
- project director, Philip R. Lee Institute for Health Policy Studies and Bixby Center for Global Reproductive Health, University of California, San Francisco
| | - Claire D Brindis
- director, Philip R. Lee Institute for Health Policy Studies and Bixby Center for Global Reproductive Health, University of California, San Francisco
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26
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Kelly PJ, Cheng A, Carlson K, Witt J. Advanced Practice Registered Nurses and Long‐Acting Reversible Contraception. J Midwifery Womens Health 2017; 62:190-195. [DOI: 10.1111/jmwh.12578] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 09/11/2016] [Accepted: 09/12/2016] [Indexed: 11/30/2022]
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Morroni C, Findley M, Westhoff C. Does using the "pregnancy checklist" delay safe initiation of contraception? Contraception 2017; 95:331-334. [PMID: 28131649 DOI: 10.1016/j.contraception.2017.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 01/17/2017] [Accepted: 01/17/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Chelsea Morroni
- University College London Institute for Women's Health and Institute for Global Health; The Botswana UPenn Partnership; University of the Witwatersrand, Wits Reproductive Health and HIV Institute.
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Turok DK, Eisenberg DL, Teal SB, Keder LM, Creinin MD. A prospective assessment of pelvic infection risk following same-day sexually transmitted infection testing and levonorgestrel intrauterine system placement. Am J Obstet Gynecol 2016; 215:599.e1-599.e6. [PMID: 27180886 DOI: 10.1016/j.ajog.2016.05.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 04/20/2016] [Accepted: 05/05/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Misperceptions persist that intrauterine device placement is related to pelvic infections and Chlamydia and gonorrhea testing results are needed prior to placement. OBJECTIVE We sought to evaluate the relationship of Chlamydia and gonorrhea screening to pelvic infection for up to 2 years following placement of the levonorgestrel 52-mg intrauterine system. STUDY DESIGN A total of 1751 nulliparous and multiparous females 16 to 45 years old enrolled in a multicenter trial designed to evaluate the efficacy and safety of a new levonorgestrel intrauterine system for up to 7 years. Participants had Chlamydia screening at study entry and yearly if they were age ≤25 years. Women also had baseline gonorrhea screening if testing had not been performed since starting their current sexual relationship. Those who changed sexual partners during the trial had repeated Chlamydia and gonorrhea testing. Intrauterine system insertion could occur on the same day as screening. Participants did not receive prophylactic antibiotics for intrauterine system placement. Investigators performed pelvic examinations after 12 and 24 months and when clinically indicated during visits at 3, 6, and 18 months after placement and unscheduled visits. Pelvic infection included any clinical diagnosis of pelvic inflammatory disease or endometritis. RESULTS Most participants (n = 1364, 79.6%) did not have sexually transmitted infection test results available prior to intrauterine system placement. In all, 29 (1.7%) participants had positive baseline testing for a sexually transmitted infection (Chlamydia, n = 25; gonorrhea, n = 3; both, n = 1); 6 of these participants had known results (all with Chlamydia infection) prior to intrauterine system placement and received treatment before enrollment. The 23 participants whose results were not known at the time of intrauterine system placement received treatment without intrauterine system removal and none developed pelvic infection. The incidence of positive Chlamydia testing was similar among those with and without known test results at the time of intrauterine system placement (1.9% vs 1.5%, respectively, P = .6). Nine (0.5%) participants had a diagnosis of pelvic infection over 2 years after placement, all of whom had negative Chlamydia screening on the day of or within 1 month after intrauterine system placement. Infections were diagnosed in 3 participants within 7 days, 1 at 39 days, and 5 at ≥6 months. Seven participants received outpatient antibiotic treatment and 2 (diagnoses between 6-12 months after placement) received inpatient treatment. Two (0.1%) participants had intrauterine system removal related to infection (at 6 days and at 7 months after placement), both of whom only required outpatient treatment. CONCLUSION Conducting Chlamydia and gonorrhea testing on the same day as intrauterine system placement is associated with a low risk of pelvic infection (0.2%). Over the first 2 years of intrauterine system use, infections are infrequent and not temporally related to intrauterine system placement. Pelvic infection can be successfully treated in most women with outpatient antibiotics and typically does not require intrauterine system removal. Women without clinical evidence of active infection can have intrauterine system placement and sexually transmitted infection screening, if indicated, on the same day.
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Affiliation(s)
- David K Turok
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - David L Eisenberg
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, MO
| | - Stephanie B Teal
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, CO
| | - Lisa M Keder
- Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California-Davis, Sacramento, CA.
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Pace LE, Dusetzina SB, Keating NL. Early Impact of the Affordable Care Act on Uptake of Long-acting Reversible Contraceptive Methods. Med Care 2016; 54:811-7. [PMID: 27213549 PMCID: PMC4982821 DOI: 10.1097/mlr.0000000000000551] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) required most private insurance plans to cover contraceptive services without patient cost-sharing as of January 2013 for most plans. Whether the ACA's mandate has impacted long-acting reversible contraceptives (LARC) use is unknown. OBJECTIVE The aim of this article is to assess trends in LARC cost-sharing and uptake before and one year after implementation of the ACA's contraceptive mandate. DESIGN A retrospective cohort study using Truven Health MarketScan claims data from January 2010 to December 2013. SUBJECTS Women aged 18-45 years with continuous insurance coverage with claims for oral contraceptive pills, patches, rings, injections, or LARC during 2010-2013 (N=3,794,793). MEASURES Descriptive statistics were used to assess trends in LARC cost-sharing and uptake from 2010 through 2013. Interrupted time series models were used to assess the association of time, ACA, and time after the ACA on LARC cost-sharing and initiation rates, adjusting for patient and plan characteristics. RESULTS The proportion of claims with $0 cost-sharing for intrauterine devices and implants, respectively, rose from 36.6% and 9.3% in 2010 to 87.6% and 80.5% in 2013. The ACA was associated with a significant increase in these proportions and in their rate of increase (level and slope change both P<0.001). LARC uptake increased over time with no significant change in level of LARC use after ACA implementation in January 2013 (P=0.44) and a slightly slower rate of growth post-ACA than previously reported (β coefficient for trend, -0.004; P<0.001). CONCLUSIONS The ACA has significantly decreased LARC cost-sharing, but during its first year had not yet increased LARC initiation rates.
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Affiliation(s)
- Lydia E. Pace
- Division of Women’s Health, Department of Internal Medicine, Brigham and Women’s Hospital, 1620 Tremont Street, 3 Floor, Boston, MA, 02120, Phone: 415-465-7223, Fax 617-525-7746
| | - Stacie B. Dusetzina
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 2203 Kerr Hall, CB# 7573, Chapel Hill, NC 27599, Phone: 919-962-5355
| | - Nancy L. Keating
- Division of General Internal Medicine, Department of Internal Medicine, Brigham and Women’s Hospital, Department of Health Care Policy, Harvard Medical School, Boston, MA, Phone: 617-432-3093
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Incorporating Long-acting Reversible Contraception Into Primary Care: A Training and Practice Innovation. Womens Health Issues 2016; 26:131-4. [DOI: 10.1016/j.whi.2015.09.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/09/2015] [Accepted: 09/15/2015] [Indexed: 11/18/2022]
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Foster DG, Barar R, Gould H, Gomez I, Nguyen D, Biggs MA. Projections and opinions from 100 experts in long-acting reversible contraception. Contraception 2015; 92:543-52. [PMID: 26515195 DOI: 10.1016/j.contraception.2015.10.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 10/13/2015] [Accepted: 10/15/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE This survey of published researchers of long-acting reversible contraceptives (LARCs) examines their opinions about important barriers to LARC use in the United States (US), projections for LARC use in the absence of barriers and attitudes toward incentives for clinicians to provide and women to use LARC methods. STUDY DESIGN We identified 182 authors of 59 peer-reviewed papers on LARC use published since 2013. A total of 104 completed an internet survey. We used descriptive and multivariate analyses to assess LARC use barriers and respondent characteristics associated with LARC projections and opinions. RESULTS The most commonly identified barrier was the cost of the device (63%), followed by women's knowledge of safety, method acceptability and expectations about use. A shortage of trained providers was a commonly cited barrier, primarily of primary care providers (49%). Median and modal projections of LARC use in the absence of these barriers were 25-29% of contracepting women. There was limited support for provider incentives and almost no support for incentives for women to use LARC methods, primarily out of concern about coercion. CONCLUSIONS Clinical and social science LARC experts project at least a doubling of the current US rate of LARC use if barriers to method provision and adoption are removed. While LARC experts recognize the promise of LARC methods to better meet women's contraceptive needs, they anticipate that the majority of US women will not choose LARC methods. Reducing unintended pregnancy rates will depend on knowledge, availability and use of a wider range of methods of contraception to meet women's individual needs. IMPLICATIONS Efforts to increase LARC use need to meet the dual goals of increasing access to LARC methods and protecting women's reproductive autonomy. To accomplish this, we need reasonable expectations for use, provider training, low-cost devices and noncoercive counseling, rather than incentives for provision or use.
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Affiliation(s)
- Diana Greene Foster
- University of California, San Francisco, Advancing New Standards in Reproductive Health, 1330 Broadway, Suite 1100, Oakland, CA 94612, USA.
| | - Rana Barar
- University of California, San Francisco, Advancing New Standards in Reproductive Health, 1330 Broadway, Suite 1100, Oakland, CA 94612, USA
| | - Heather Gould
- University of California, San Francisco, Advancing New Standards in Reproductive Health, 1330 Broadway, Suite 1100, Oakland, CA 94612, USA
| | - Ivette Gomez
- University of California, San Francisco, Advancing New Standards in Reproductive Health, 1330 Broadway, Suite 1100, Oakland, CA 94612, USA
| | - Deborah Nguyen
- University of California, San Francisco, Advancing New Standards in Reproductive Health, 1330 Broadway, Suite 1100, Oakland, CA 94612, USA
| | - M Antonia Biggs
- University of California, San Francisco, Advancing New Standards in Reproductive Health, 1330 Broadway, Suite 1100, Oakland, CA 94612, USA
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