Development and testing of an iOS waiting room "app" for contraceptive counseling in a Title X family planning clinic.

OBJECTIVE: Long-acting reversible contraceptive (LARC) methods, such as the intrauterine device and implant, are highly effective but used by less than 10% of US women. The objective of our study was to improve LARC interest by enhancing clinic counseling. STUDY DESIGN: A quality improvement methodology was used to evaluate intrauterine device service delivery in 3 Chicago Title X clinics. To address identified barriers, we developed a theory-based iOS application (app) for patients to use in the clinic waiting room using human-centered design. The final prototype was tested in a randomized controlled trial in a Title X clinic with sexually active females (79% African American) under age 30 years. Our sample of 60 was chosen to detect an increase from 10% (baseline) to 45% (app intervention) in the proportion of patients expressing interest in discussing a LARC method during their clinic visit with 80% power and two-sided α = 0.05. After completing demographic and baseline knowledge questionnaires, participants were randomized 1:1 to intervention (app) or standard care arms. App users also completed a posttest. Our primary outcome was expressed interest in discussing a LARC method during the clinic visit. Secondary outcomes were contraceptive knowledge and LARC selection. RESULTS: App testers (n = 17) preferred interactive, visually appealing design and video testimonials. In the pilot randomized controlled trial (n = 52), app users had a significantly higher knowledge of contraceptive effectiveness (P = .0001) and increased interest in the implant (7.1-32.1%, P = .02) after the intervention. Users were highly satisfied with the app. Staff reported no problems using the app in the clinic. CONCLUSION: Use of a theory-based counseling app offers a novel method to optimize wait time while minimizing clinic flow disruption. Preliminary data demonstrate that app use was associated with improvements in patients' contraceptive knowledge and interest in the implant.

Daily context matters: predictors of missed oral contraceptive pills among college and graduate students.

OBJECTIVE: The purpose of this study was to understand the relationship between daily contextual factors and oral contraceptive (OC) adherence among students who attend college or graduate school. STUDY DESIGN: Data on OC adherence, demographics, contextual factors, and side-effects were collected as part of the acceptability of the NuvaRing (Merck & Co, Whitehouse Station, NJ) vs OC study, in which students were assigned randomly to the contraceptive vaginal ring or to a low-dose OC. We performed bivariate and multivariable analyses to create an explanatory model for nonperfect OC adherence (missed at least 1 pill during 3 months of use). RESULTS: In a multivariable predictive model, missing a pill was associated positively with high perceived stress (odds ratio [OR], 3.16; P = .007), having ≥10 hours per week of paid employment (OR, 2.13; P = .075), and living with a partner (OR, 9.92; P = .040). CONCLUSION: Stressful and hectic lives contribute to poor OC adherence. When counseling women about contraception, clinicians should consider the influence of daily life on contraceptive adherence.

Novel measures of heart rate variability predict cardiovascular mortality in older adults independent of traditional cardiovascular risk factors: the Cardiovascular Health Study (CHS).

UNLABELLED: Novel HRV Predicts CV Mortality in the Elderly. BACKGROUND: It is unknown whether abnormal heart rate turbulence (HRT) and abnormal fractal properties of heart rate variability identify older adults at increased risk of cardiovascular death (CVdth). METHODS: Data from 1,172 community-dwelling adults, ages 72 +/- 5 (65-93) years, who participated in the Cardiovascular Health Study (CHS), a study of risk factors for CV disease in people >or=65 years. HRT and the short-term fractal scaling exponent (DFA1) derived from 24-hour Holter recordings. HRT categorized as: normal (turbulence slope [TS] and turbulence onset [TO] normal) or abnormal (TS and/or TO abnormal). DFA1 categorized as low (1). Cox regression analyses stratified by Framingham Risk Score (FRS) strata (low = <10, mid = 10-20, and high >20) and adjusted for prevalent clinical cardiovascular disease (CVD), diabetes, and quartiles of ventricular premature beat counts (VPCs). RESULTS: CVdths (N = 172) occurred over a median follow-up of 12.3 years. Within each FRS stratum, low DFA1 + abnormal HRT predicted risk of CVdth (RR = 7.7 for low FRS; 3.6, mid FRS; 2.8, high FRS). Among high FRS stratum participants, low DFA1 alone also predicted CVdth (RR = 2.0). VPCs in the highest quartile predicted CVdth, but only in the high FRS group. Clinical CV disease predicted CVdth at each FRS stratum (RR = 2.9, low; 2.6, mid; and 1.9, high). Diabetes predicted CVdth in the highest FRS group only (RR = 2.2). CONCLUSIONS: The combination of low DFA1 + abnormal HRT is a strong risk factor for CVdth among older adults even after adjustment for conventional CVD risk measures and the presence of CVD.

A motivational interviewing-based counseling intervention to increase postabortion uptake of contraception: A pilot randomized controlled trial.

OBJECTIVE: To determine if a counseling intervention using the principles of motivational interviewing (MI) would impact uptake of long-acting reversible contraception (LARC) after abortion. METHODS: We conducted a pilot randomized controlled trial comparing an MI-based contraception counseling intervention to only non-standardized counseling. Sixty women 15-29 years-old were randomized. PRIMARY OUTCOME: uptake of LARC within four weeks of abortion. SECONDARY OUTCOMES: uptake of any effective contraceptive, contraceptive use three months after abortion and satisfaction with counseling. Bivariate analysis was used to compare outcomes. RESULTS: In the intervention arm, 65.5% of participants received a long-acting method within four weeks compared to 32.3% in the control arm (p=0.01). Three months after the abortion, differences in LARC use endured (60.0% vs. 30.8%, p=0.05). Uptake and use of any effective method were not statistically different. More women in the intervention arm reported satisfaction with their counseling than women in the control arm (92.0% vs. 65.4%, p=0.04). CONCLUSION: Twice as many women in the MI-based contraception counseling intervention initiated and continued to use LARC compared to women who received only non-standardized counseling. PRACTICE IMPLICATIONS: A contraception counseling session using the principles and skills of motivational interviewing has the potential to impact LARC use after abortion.

Postplacental insertion of the levonorgestrel intrauterine device after cesarean delivery vs. delayed insertion: a randomized controlled trial.

OBJECTIVE: This trial was designed to compare levonorgestrel intrauterine device (LNG-IUD) use at 1 year after delivery between women randomized to postplacental insertion at the time of cesarean delivery and delayed insertion 4-8 weeks after delivery. STUDY DESIGN: This randomized controlled trial was conducted at two urban medical centers. Eligible pregnant women with planned cesarean deliveries were randomized to immediate postplacental insertion during cesarean or delayed insertion after 4-8 weeks. We used intention-to-treat analysis for the primary outcome of LNG-IUD use 12 months after delivery. RESULTS: Forty-two women were randomized, 20 into the postplacental group and 22 in the delayed group. Although confirmed use of the LNG-IUD 12 months after delivery was higher in the postplacental group (60.0% vs. 40.9%, p=.35), this difference was not statistically significance. Expulsion was significantly more common in the postplacental group (20.0% vs. 0%, p=.04). There were significant differences between the two sites in baseline population characteristics, follow-up and expulsion. The trial did not answer the intended question as it was halted early due to slow enrollment. CONCLUSIONS: Our results show higher expulsion after postplacental insertion compared to delayed insertion but suggest similar IUD use at 12 months. Moreover, it provides valuable lessons regarding a randomized controlled trial of postplacental LNG-IUD placement due to the challenges of estimating effect size and the nature of the population who might benefit from immediate insertion. IMPLICATIONS: Postplacental insertion of an IUD may improve use of highly effective contraception during the postpartum period. While our results suggest higher expulsion after postplacental insertion compared to delayed insertion and similar IUD use at 12 months, our trial was insufficient to definitively test our hypothesis.

Impact of a revised appointment scheduling script on IUD service delivery in three Title X family planning clinics.

OBJECTIVE: The objective was to study a redesigned call script for intrauterine device (IUD) appointment scheduling. STUDY DESIGN: The script for a Title X call center was redesigned. Pre- and postintervention data were collected. RESULTS: For women with a scheduled IUD visit (n=99, pre n=57, post n=42), the preintervention IUD insertion rate was 47%; the postintervention insertion rate was 60% (p=.23). Among women ≤25 years old, the preintervention rate was 41% and the postintervention rate was 68% (p=.05). No-show rates decreased (40.4% vs. 23.8%, p=.08), particularly for younger women (n=51; 46.9% vs. 15.8%, p=.04). CONCLUSION: A revised IUD appointment scheduling script improved long-acting reversible contraceptive uptake. IMPLICATIONS: Revising an appointment scheduling call script is a simple and scalable intervention to decrease administrative and clinical barriers to family planning services. As many clinics in the United States move toward computerized and centralized call centers, improving patient communication during the scheduling process may have a broad impact on clinical efficiency.

A systematic approach to improving intrauterine device services in family planning clinics.

OBJECTIVES: To improve the quality of intrauterine device (IUD) services at Title X clinics. STUDY DESIGN: Failure Modes Effects and Criticality Analysis (FMECA) is a step-by-step approach, adopted for healthcare, in which team members evaluate the systems and processes of a specific type of clinical care (e.g., IUD care) in order to identify practices that contribute to poor quality, unsafe, unreliable, or inefficient care. These weaknesses are termed "failures." The FMECA uses qualitative (e.g., meetings) and quantitative (e.g., clinical operations) data to determine failure frequency and impact in order to prioritize the parts of a clinical care system or process to be redesigned and improved. An FMECA was conducted in three community-based Title X family planning clinics on the South and West Sides of Chicago, IL with all care team members; IUD clients were also interviewed regarding their visit. Clinic administrative data was also assessed to determine the frequency and impact of the identified failures. RESULTS: After combining the FMECA and clinical operations data, "critical" areas across all three clinics were: (1) client does not show up for or cancels appointment; (2) client is ineligible for an IUD insertion due to unprotected intercourse; and (3) limited time for counseling, informing, and placing IUDs. As most insertions were successful, failed IUD insertion was not considered a high-risk failure. CONCLUSIONS: This process revealed that the failures most in need of improvement and redesign were the scheduling and intake processes and the lack of time for counseling during certain types of visits. IMPLICATIONS: A systematic assessment of the underlying problems in IUD-care revealed three important issues across three clinics: (1) client does not show up for appointment or cancels appointment; (2) client recently had unprotected intercourse; and (3) limited time for counseling, informing, and placing IUDs.