Geographic differences in contraception provision and utilization among federally funded family planning clinics in South Carolina and Alabama

Differences in medicaid expansion effects on buprenorphine treatment utilization by county rurality and income: A pharmacy data claims analysis from 2009-2018

Background

Although use of buprenorphine for treating opioid use disorder increased over the past decade, buprenorphine utilization remains limited in lower-income and rural areas. We examine how the Affordable Care Act Medicaid expansion influenced buprenorphine initiation rates by county income and evaluate how associations differ by county rural-urban status.

Methods

This study used nationwide 2009-2018 IQVIA retail pharmacy data and a comparative interrupted time series framework-a hybrid framework combining regression discontinuity and difference-in-difference approaches. We used piecewise linear estimation to quantify changes in buprenorphine initiation rates before and after Medicaid expansion.

Results

The sample included observations from 376,704 county-months. We identified 5,227,340 new buprenorphine treatment episodes, with an average of 9.2 new buprenorphine episodes per month per 100,000 county residents. Among urban counties, those with the lowest median incomes experienced significantly larger increases in buprenorphine initiation rates associated with Medicaid expansion than counties with higher median incomes (5-year rates difference est=3525.3, se=1695.3, p = 0.04). However, among rural counties, there was no significant association between buprenorphine initiation rates and county median income after Medicaid expansion (5-year rates difference est=979.0, se=915.8, p = 0.29).

Conclusions

Medicaid expansion was associated with a reduction in income-related buprenorphine disparities in urban counties, but not in rural counties. To achieve more equitable buprenorphine access, future policies should target low-income rural areas.

Impact of the Choose Well Contraceptive Access Initiative on Method Use Among Women Enrolled in South Carolina's Medicaid Program: A Mid-line Assessment

INTRODUCTION

A six-year statewide contraceptive access initiative focused on equitable access to contraception, removing cost barriers, capacity building and training, raising consumer awareness, and expanding contraceptive care at safety net clinics was implemented in South Carolina beginning in 2017. This study assessed changes in contraceptive method use among women enrolled in the South Carolina Medicaid program during the first three years of Choose Well.

METHODS

Contraception use among a retrospective cohort of women aged 15 to 45 enrolled in South Carolina Medicaid from 2012 to 2020 was examined. Interrupted time series regression analysis was used to assess changes in the use of intrauterine devices (IUDs) and contraceptive implants between 2012 and 2016 and 2017 and 2020. Analyses were conducted for all women and stratified by age groups.

RESULTS

Long-acting reversible contraception use increased from 8.5% during the pre-Choose Well period to 10.9% during the Choose Well period (p < .001), with IUD use increasing from 4.3% to 5.2% (p < .001) and implant use increasing from 4.6% to 6.0% (p < .001). The interrupted time series analysis found a significant positive change in the average level of monthly IUD use after Choose Well began (0.493 percentage points; 95% confidence interval, 0.311-0.675). The effect was stronger among women 20 to 25 years of age. Choose Well significantly increased the trend in IUD use among all women by a positive 0.013 percentage points (95% confidence interval, 0.006-0.020) per month beyond expected values.

CONCLUSIONS

At the mid-point of the Choose Well Evaluation, the use of IUD methods increased significantly beyond what would be expected had pre-Choose Well trends continued. This was particularly evident among women 20 to 25 years of age. These findings suggest that Choose Well succeeded in reducing barriers to the use of IUDs.

Increases in IUD Provision at Alabama Department of Public Health Clinics From 2016 to 2019

The Alabama Department of Public Health (ADPH) began allocating Title X funding to intrauterine device (IUD) provision at family planning clinics in 2019, instated more training opportunities, and expanded nurse practitioner scope of practice to include IUD placements. We assessed IUD provision and protocols at ADPH Title X clinics in 2016 and 2019 before and after ADPH policy changes. Generalized binomial regression models assessed differences between years. The proportion of ADPH clinics reporting offering any IUD on-site increased by 61.6 percentage points ( P < .001), stockpiling IUDs on-site increased by 85.9 percentage points ( P < .001), IUD placement/removal training increased by 71.4 percentage points ( P < .001), and same-visit IUD placement trainings increased by 64.1 percentage points ( P < .001). Advanced practice nurses were significantly more likely to place IUDs in 2019 compared with 2016 ( P < .001). These findings highlight the positive impact of policy changes related to Title X funding allocation and scope of practice on provision of a full range of contraceptive methods. These changes in policies and practices at the state and local levels within ADPH have expanded the availability of the full range of contraceptive options across the state of Alabama. This expanded access to contraceptive options is especially important given the rapid changes in reproductive health policies occurring in Alabama and across the United States.

North Carolina Pharmacists' Support for Hormonal Contraception Prescription Status Change

BACKGROUND

Pharmacist-prescribed hormonal contraception (HC) may offer additional avenues of access for patients; however, it is unknown whether pharmacists would support over-the-counter access to contraception over pharmacist-prescribed models.

OBJECTIVE

The objective of this study was to understand how North Carolina (NC) pharmacists believed HC should be classified and how pharmacist and pharmacy characteristics were associated with those beliefs.

METHODS

This study was a secondary analysis of a cross-sectional, anonymous, online survey completed by 587 licensed NC pharmacists. The primary outcome of interest was how pharmacists believed HC should be classified: prescription-only, pharmacist-prescribed, behind-the-counter, or over-the-counter. Multinomial bivariate and multivariable regression analyses were conducted to describe the association between pharmacist and pharmacy characteristics with the outcomes of interest through odds ratios and adjusted odds ratios, respectively. Chi-square tests were used to examine the association of geographic location with distribution of attitudes toward HC classification.

RESULTS

Fifty-one percent of NC pharmacists supported classification of HC as pharmacist-prescribed, while 23% supported non-prescription (behind- or over-the-counter) classification. Controlling for pharmacist demographics and pharmacy characteristics, completing residency training was significantly associated with supporting pharmacist-prescribed vs prescription-only classification (adjusted odds ratio (aOR) = 2.55, P = .02). Pharmacists had higher odds of supporting pharmacist-prescribed vs prescription-only HC if they agreed that they were well trained to do so (aOR = 3.14, P < .01). Distribution of attitudes about classification of HC did not significantly differ by geographic location (P = .14).

CONCLUSIONS

Most NC pharmacists support deviating from the current prescription-only classification of HC, with more support for pharmacist-prescribed classification. Continuing education programs should focus on training pharmacists to feel more confident prescribing HC.