Prioritizing patient experience: Validation of the person-centered contraceptive counseling measure as a performance measure.

OBJECTIVE: A performance measure assessing how often patients experience patient-centered contraceptive counseling can inform quality improvement in contraceptive care and enable efforts to enhance equity in the provision of this care. We sought to test the validity and reliability of the Person-Centered Contraceptive Counseling (PCCC) measure as a performance measure, in preparation for application for endorsement from the National Quality Forum. STUDY DESIGN: We combined data from two research studies, a statewide quality improvement assessment, and a dedicated data collection effort at nine sites, all collected between 2009 and 2019 at 22 total sites in the United States, to evaluate the validity and reliability of the four-item PCCC measure aggregated at the provider and facility level. We scored the PCCC dichotomously as a "top-box" score of 20 versus less than 20. We assessed reliability using the Spearman-Brown coefficient, and validity by comparing scores on the PCCC to aggregated scores on single-item measures of patient satisfaction. RESULTS: We included 22 facilities and 34 providers in the analyses. The average PCCC top-box score by provider and facility was 81% and 79%, respectively. We found adequate reliability with panel sizes of 20-50. PCCC scores were strongly associated with the single-item measures of satisfaction. There were notable disparities by race/ethnicity and language (Spanish vs English) in PCCC scores. DISCUSSION: The PCCC is a valid and reliable performance measure for use at the provider and facility level. The development and use of the measures of patient experience, like the PCCC, is critical for prioritizing patient-centeredness in reproductive health care. IMPLICATIONS: The PCCC measure can facilitate the identification of gaps and disparities in patient-centered contraceptive counseling and enable quality improvement to promote quality, equitable contraceptive care. Using this measure provides the opportunity to enhance patient experience of care and build trust between contraceptive providers and the communities they serve.

Family Physicians' Barriers and Facilitators in Incorporating Medication Abortion.

PURPOSE: Medication abortion (MAB) provision by family physicians has the potential to expand abortion access. However, there are documented individual and structural barriers to provision. This study investigates how family physicians in the United States (US) navigate the barriers impeding abortion provision in primary care. METHODS: We conducted a qualitative study on the experiences of US family physicians with MAB in primary care. We recruited participants at national conferences and via professional networks. This analysis focuses on the experiences of the subset of participants who expressed interest in providing MAB. RESULTS: Forty-eight participants met inclusion criteria, with representation from all 4 regions of the US. Participants had diverse experiences related to abortion provision, training, and the environment in which they practice, with a third of participants working in states with hostile abortion policies. We categorized participants into 3 groups: (1) doctors who did not receive training and do not provide abortions (n = 11), (2) doctors who received training but do not provide abortions (n = 20), and (3) doctors who received training and currently provide abortions (n = 17). We found that training, administrative and community support, and internal motivation to overcome barriers help family physicians integrate MAB in primary care practices. Federal and state laws, absence of training, stigma around abortion provision, inaccurate or limited knowledge of institutional barriers, and administrative resistance all contributed to doctors excluding abortion provision from their scope of practice. CONCLUSION: Improving medication abortion provision by family physicians requires addressing the individual and system barriers family physicians encounter so they receive the education, training, and support to successfully integrate abortion care into clinical practice.

Development of the Person-Centered Contraceptive Counseling scale (PCCC), a short form of the Interpersonal Quality of Family Planning care scale.

OBJECTIVE: Person-centeredness is a critical component of quality in family planning. We previously validated an 11-item Interpersonal Quality of Family Planning (IQFP) scale. We sought to create a parsimonious version of the scale in preparation for testing its appropriateness as a patient-reported outcome performance measure. STUDY DESIGN: To explore clarity and importance of each of the 11 items, we conducted English and Spanish cognitive interviews with patients who received contraceptive counseling (n = 33) at 3 publicly funded California clinics. We triangulated these results with psychometric analysis of previously collected IQFP data (n = 1097) to assess validity and reliability of selected item combinations. RESULTS: The 11-item IQFP scale was reduced to a 4-item scale (the Person-Centered Contraceptive Counseling scale, or PCCC) that includes items evaluating provider performance regarding respect for patients, information provision, and eliciting and honoring patient preferences for birth control. Interview participants deemed the items included in the 4-item PCCC important and clear in both English and Spanish versions of the instrument. The 4-item PCCC retained the 11-item IQFP's psychometric properties, including internal consistency (Cronbach's alpha = 0.92 vs 0.97 for the PCCC and IQFP, respectively) and a consistent single factor analysis solution (factor loadings = 0.86-0.92 and 0.81-0.91). The 4-item PCCC additionally retained the construct and predictive validity of the IQFP. CONCLUSIONS: The 4-item PCCC is a valid and reliable as a measure of person-centered contraceptive counseling that reflects patients' perspectives on contraceptive counseling. IMPLICATIONS: Person-centered measures such as the 4-item PCCC can help inform efforts to improve health care quality. Future work will investigate the validity and reliability of the 4-item PCCC as a performance measure to determine the appropriateness of its use in the quality improvement context.

Birth Control Connect: A randomized trial of an online group to disseminate contraceptive information.

OBJECTIVE: We sought to test whether participation in an online group including IUD users influenced IUD-related knowledge, attitudes, and behavior among IUD non-users, as a proof-of-concept evaluation of information dissemination for less commonly used or novel contraceptives. STUDY DESIGN: We conducted a blinded, randomized controlled trial on the effect of online communication with IUD users within an online program called Birth Control Connect. Participants were women age 18-45 living in the United States who had never used an IUD. We invited participants randomized to the intervention to join two-week, nine-member discussion groups including four satisfied IUD users and five IUD non-users; we invited control participants to groups including nine IUD non-users. We performed chi-squared tests on IUD knowledge, information-seeking, informational support and use in immediate post-surveys, and t-tests comparing change in IUD attitudes and frequency of logins to discussion groups. RESULTS: We invited 488 IUD non-users and enrolled them into 70 groups between October 2015 and April 2016. We found increased positive attitudes towards the IUD in the intervention arm (0.65-point increase between pre- and post-surveys, versus 0.05 mean change for control arm, p = 0.03 for hormonal IUD, with a trend in the same direction for the non-hormonal IUD). Informational support also increased, with 70.3% of intervention arm participants self-reporting that they gained a better idea of what the IUD would be like, compared to 51.3% in control arm (p < 0.01). Of intervention participants, 63.3% versus 51.3% of control participants reported gaining new information from their group (p = 0.03). There were no differences in correct responses to knowledge items or information-seeking between groups. CONCLUSIONS: Online exposure to IUD users increased positive attitudes toward the IUD and informational support for decision-making about the IUD among non-users. IMPLICATIONS STATEMENT: Online spaces provide a promising environment for the exchange of accurate, useful contraceptive information based on real user experiences. Interventions aiming to harness social communication through structured online conversations (e.g., on existing social media platforms) about user experiences with lesser-known contraceptive methods such as the IUD may be worthwhile.

Cluster randomized trial of a patient-centered contraceptive decision support tool, My Birth Control.

BACKGROUND: Research suggests the need for improvement in the patient-centeredness and comprehensiveness of contraceptive counseling. My Birth Control is a tablet-based decision support tool designed to improve women's experience of contraceptive counseling and to help them select contraceptive methods that are consistent with their values and preferences. OBJECTIVE: The objective of this study was to evaluate the effect of My Birth Control on contraceptive continuation, experience of contraceptive care, and decision quality. STUDY DESIGN: Using a cluster randomized design, randomized at the provider level, patient participants interested in starting or changing contraception interacted with My Birth Control before their family planning visit (intervention) or received usual care (control). A postvisit survey assessed experience of care method satisfaction, decision quality, and contraceptive knowledge. Surveys at 4 and 7 months assessed the primary outcome of contraceptive continuation, along with method use, satisfaction, and unintended pregnancy. Mixed-effects logistic regression models with multiple imputation for missing data were used to examine the effect of treatment assignment. RESULTS: Twenty-eight providers participated and 758 patients enrolled between December 5, 2014, and February 5, 2016. Participants were racially/ethnically diverse; less than a quarter self-identified as white. No effect was found on 7-month continuation (56.6% and 59.6% for intervention and control group respectively, odds ratio, 0.89; 95% confidence interval, 0.65-1.22). However, assignment to the intervention group increased reporting of the greatest Interpersonal Quality of Family Planning score (66.0% vs 57.4%, odds ratio, 1.45; 95% confidence interval, 1.03-2.05), the greatest scores on the informed decision and uncertainty subscales of the Decisional Conflict Scale (50.5% vs 43.2%, odds ratio, 1.34; 95% confidence interval, 1.0-1.80 and 41.6% vs 33.3%, odds ratio, 1.45; 95% confidence interval, 1.03-2.05), and greater knowledge. CONCLUSION: My Birth Control had no effect on contraceptive continuation. The intervention did enhance the experience of contraceptive counseling and informed decision making, as well as contraceptive knowledge., The intervention's effect on patient experience is important, particularly given the personal nature of contraceptive decision making and the social and historical context of family planning care.

Side Effects and Health Benefits of Depot Medroxyprogesterone Acetate: A Systematic Review.

OBJECTIVE: Counseling about potential side effects and health benefits of contraceptive methods could facilitate continued method use and method satisfaction, yet no evidence-based compilation of side effects and benefits exists to aid such counseling. Among contraceptive methods in the United States, depot medroxyprogesterone acetate (DMPA) injectables have the highest discontinuation rates, and most discontinuation is attributable to side effects. This review examines the side effects and health benefits of DMPA to inform counseling. DATA SOURCES: We searched PubMed, POPLINE, EMBASE, Web of Science, Campbell Collaboration Library of Systematic Reviews, the Cochrane Database of Systematic Reviews, the Cochrane Center Register of Controlled Trials, and ClinicalTrials.gov. METHODS OF STUDY SELECTION: We included English-language studies published from 1985 to 2016 that enrolled healthy, nonbreastfeeding females aged 13-49 years at risk of unintended pregnancy, compared intramuscular or subcutaneous progestin-only injectables to a contemporaneous comparison group, and addressed at least one key question: 1) What side effects are associated with progestin-only injectable contraceptive use? 2) What health benefits are associated with progestin-only injectable contraceptive use? Study quality was assessed using criteria from the U.S. Preventive Services Task Force. TABULATION, INTEGRATION, AND RESULTS: Twenty-four studies met inclusion criteria. None were randomized controlled trials. There were 13 prospective cohort, five retrospective cohort, four case-control, and two cross-sectional studies. Studies of moderate or high risk of bias suggest an association between DMPA use and weight gain, increased body fat mass, irregular bleeding, and amenorrhea. Inconsistent evidence exists for an association between DMPA use and mood or libido changes. Limited evidence exists for an association between DMPA use and decreased risk of cancers and tubal infertility. CONCLUSION: Higher-quality research is needed to clarify DMPA's side effects and benefits. In absence of such evidence, patient-centered counseling should incorporate the available evidence while acknowledging its limitations and recognizing the value of women's lived experiences.

Client Preferences for Contraceptive Counseling: A Systematic Review.

CONTEXT: Providers can help clients achieve their personal reproductive goals by providing high-quality, client-centered contraceptive counseling. Given the individualized nature of contraceptive decision making, provider attention to clients' preferences for counseling interactions can enhance client centeredness. The objective of this systematic review was to summarize the evidence on what preferences clients have for the contraceptive counseling they receive. EVIDENCE ACQUISITION: This systematic review is part of an update to a prior review series to inform contraceptive counseling in clinical settings. Sixteen electronic bibliographic databases were searched for studies related to client preferences for contraceptive counseling published in the U.S. or similar settings from March 2011 through November 2016. Because studies on client preferences were not included in the prior review series, a limited search was conducted for earlier research published from October 1992 through February 2011. EVIDENCE SYNTHESIS: In total, 26 articles met inclusion criteria, including 17 from the search of literature published March 2011 or later and nine from the search of literature from October 1992 through February 2011. Nineteen articles included results about client preferences for information received during counseling, 13 articles included results about preferences for the decision-making process, 13 articles included results about preferences for the relationship between providers and clients, and 11 articles included results about preferences for the context in which contraceptive counseling is delivered. CONCLUSIONS: Evidence from the mostly small, qualitative studies included in this review describes preferences for the contraceptive counseling interaction. Provider attention to these preferences may improve the quality of family planning care; future research is needed to explore interventions designed to meet preferences. THEME INFORMATION: This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

Medication abortion failure in women with and without previous cesarean delivery.

OBJECTIVE: To investigate the association between previous cesarean delivery and medication abortion failure and the association between parity and failure. METHODS: Data were abstracted from 2035 consecutive charts of women who underwent medication abortion in 2011. All women were at 63 days gestation or less and received mifepristone 200mg orally and misoprostol 800 mcg buccally. We used multivariate logistic regression to assess the relationship between failure, defined as requiring either curettage or additional medication, and prior cesarean delivery. We also examined the relationship between failure and parity. RESULTS: Follow-up was available on 1609 (79%) patients. Overall, 4.5% of patients experienced failure. Neither cesarean delivery nor parity was associated with failure; 6.5% of women with prior cesarean delivery experienced failure, compared to 3.7% of nulliparous women [adjusted odds ratio (aOR), 1.79, 95% confidence interval (CI), 0.83-3.87]. With regard to parity, 4.7% of women with two or more previous births experienced failure, compared to 3.7% of nulliparous women (aOR, 1.07, 95% CI, 0.54-2.14). CONCLUSION: We did not find significant associations between prior cesarean delivery and failure or parity and failure. A previous study of patients who had received a less effective regimen reported significant associations between cesarean delivery and failure and parity and failure. While our results do not rule out the possibility of modest associations due to our limited statistical power, they are reassuring relative to previous findings. IMPLICATIONS: Our results suggest that if there are differences in women's odds of medication abortion failure by obstetric history, such differences are unlikely to be large. Providers and patients may factor this information into decision making about methods of pregnancy termination.