Understanding medication abortion ineligibility due to gestational age among a cohort of patients in Southern California.

OBJECTIVE: Medication abortion (MAB) is safe and effective up to 77 days gestation. Limited data are available on how often patients are ineligible for MAB due to advanced gestational age and how many of those ineligible go on to receive procedural abortion. STUDY DESIGN: Retrospective analysis of electronic health records from Planned Parenthood of the Pacific Southwest (PPPSW) from January - December 2021. PPPSW has four procedural abortion sites and 15 MAB-only clinics that offered appointments only if last menstrual period-based GA was ≤70 days or unknown. Patients >70 days gestation by intake ultrasound at a MAB-only clinic were referred to a procedural center. RESULTS: Of 11,684 patients presenting for MAB at MAB-only sites 2224 (19%) did not receive a MAB; 3.8% (N = 444) presented past 70 days gestation and were thus ineligible due to gestational age limits. Of those ineligible (N = 444), 234 (53%) measured between 71-77 days of gestation. Three quarters (75.7%) of those ineligible went on to receive a procedural abortion at PPPSW after a mean wait time of 10 days. In multivariable analysis, no demographic factors were associated with higher odds of receiving a procedural abortion. CONCLUSIONS: Presenting for MAB past a gestational age limit was uncommon, supporting safety of no-test MAB protocols. A quarter of people ineligible for MAB due to gestational age did not receive a procedural abortion at PPPSW. If MAB were offered up to 77 days, half of patients who were denied MAB due to gestational age could have received MAB, expanding patient access. IMPLICATIONS: Being ineligible for MAB due to advanced gestational age was uncommon. Increasing MAB gestational age limits from 70 days to 77 days could further improve abortion access.

Preconception care utilization: Self-report versus claims-based measures among women with Medicaid.

The objective of this study is to compare self-reported preconception care utilization (PCU) among Medicaid-covered births to Medicaid claims. We identified all Medicaid-covered births to women ages 15-45 in 26 states in the year 2012 among the Pregnancy Risk Assessment and Monitoring System (PRAMS) survey and Medicaid Analytic eXtract (MAX) claims data, and identified preconception services in the latter using diagnosis codes published by Health and Human Services' Office of Population Affairs. We fit mixed-effects logistic regression models for the probability of PCU on sociodemographic factors (age, race, and ethnicity) and clinical diagnoses (depression, diabetes, or hypertension), separately for each dataset. Among 652,929 women delivering in MAX, 28.1% received at least one claims-based preconception service while an estimated 23.6% (95% CI 22.1-25.3) of PRAMS respondents reported receiving preconception care. Adjusting for age, chronic diseases, and state, PCU rates in both MAX and PRAMS were higher for non-Hispanic Black versus non-Hispanic White women (OR 1.51, 95% CI 1.49-1.54 and OR 2.05, 95% CI 1.60-2.62, respectively). Adjusting for differences in age, race and ethnicity, and state, PCU rates were higher for patients with diabetes (OR 1.34, 95% CI 1.29-1.40 and OR 1.82, 95% CI 1.16-2.85) or hypertension (OR 1.22, 95% CI 1.18-1.27 and OR 1.85, 95% CI 1.41-2.44). While Hispanic and Asian women were also more likely to report PCU than their non-Hispanic White counterparts (OR 2.07, 95% CI 1.53-2.80 and OR 3.37, 95% CI 2.28-4.98), they were less likely to have received it (OR 0.74, 95% CI 0.73-0.75 and OR 0.65, 95% CI 0.63-0.67). In conclusion, comparing self-report to claims measures of PCU, we found similar trends in the differences between non-Hispanic Black and White women, and between those with vs. without diabetes and hypertension. However, the two data sources differed in trends in other racial/ethnic groups (differences between Hispanic vs. non-Hispanic White women, and between Asian vs. non-Hispanic White women), and in those with vs. without depression. This suggests that while Medicaid claims can be a useful tool for studying preconception care, they may miss certain types of care among some sub-groups of the population or be subject to reporting differences that are hard to surmise. Both data sets have potential benefits and drawbacks as research tools.

Facilitators of and Barriers to Successful Implementation of the One Key Question® Pregnancy Intention Screening Tool.

Background: One Key Question® (OKQ) is a tool that embeds a patient-centered screening into routine visits with the goal of making pregnancy intention screening universal, but widespread implementation has not yet been adopted. We aimed to explore the barriers and facilitators of OKQ implementation to better understand how to best implement the tool across different settings. Methods: We invited staff and clinicians from one obstetrics and gynecology clinic and one family medicine clinic, which previously implemented OKQ, to complete surveys and qualitative interviews about their experiences with the tool. The interview guide and thematic analysis of the interview transcripts were informed by the Consolidated Framework for Implementation Research (CFIR). Main Findings: Major facilitators of OKQ implementation are the simplicity of the tool, engagement of clinic leadership, and compatibility between the perceived goals of the tool and those of practice staff and clinicians. Although participants indicated that OKQ had a minimal impact on clinic workflow during its implementation, preimplementation time concerns were a major barrier to implementation in both clinics. Barriers seen in the family medicine practice included OKQ distracting from the visit agenda, and concerns about the OKQ gold standard protocol of screening each patient at every visit. Participants even suggested asking OKQ only during annual check-up appointments. Conclusions: The perceived alignment between the tool's goals and those of clinic stakeholders was an important facilitator of OKQ implementation success. However, characteristics of the clinic setting, such as competing medical priorities and time constraints, influenced initial attitudes toward the feasibility of the intervention. Clinical Trial Registration Number: NCT03947788.

HIV Response Interventions that Integrate HIV Molecular Cluster and Social Network Analysis: A Systematic Review.

Due to improved efficiency and reduced cost of viral sequencing, molecular cluster analysis can be feasibly utilized alongside existing human immunodeficiency virus (HIV) prevention strategies. The goal of this paper is to elucidate how HIV molecular cluster and social network analyses are being integrated to implement HIV response interventions. We searched PubMed, Scopus, PsycINFO, and Cochrane Library databases for studies incorporating both HIV molecular cluster and social network data. We identified 32 articles that combined analyses of HIV molecular sequences and social or sexual networks. All studies were descriptive. Six studies described network interventions informed by molecular and social data but did not fully evaluate their efficacy. There is no current standard for incorporating molecular and social network analyses to inform interventions or data demonstrating its utility. More research must be conducted to delineate benefits and best practices for leveraging molecular data for network-based interventions.

RESUMEN: Debido a mejor eficiencia y costo reducido de la secuenciación viral, el análisis de complejos moleculares se puede utilizar de manera factible junto con las estrategias de prevención del virus de inmunodeficiencia humana (VIH) existentes. El objetivo de este repaso es de aclarar como integrar los análisis de las redes sociales y de los complejos moleculares del VIH para implementar intervenciones para controlar el VIH. Buscamos en las bases de datos de PubMed, Scopus, PsycINFO y Cochrane Library por estudios que incorporaran datos de redes sociales y grupos moleculares del VIH. Identificamos 32 estudios que combinaban análisis de secuencias moleculares del VIH y datos de redes sociales. Todos los estudios fueron descriptivos. Seis estudios describieron intervenciones informadas por datos moleculares y sociales, pero no evaluaron completamente su eficacia. No existe un estándar actual para incorporar análisis moleculares y sociales para informar intervenciones o datos que demuestren su eficacia. Se deben realizar más investigaciones para delinear los beneficios y las mejores prácticas de aplicar los datos moleculares y sociales para crear intervenciones del VIH.

Preconception care and severe maternal morbidity in the United States.

BACKGROUND: In the United States, approximately 52,000 women per year (accounting for 1.46% of births) experience severe maternal morbidity, which is defined as a complication that causes significant maternal harm or risk of death. It disproportionately affects women from racial or ethnic minorities, people with chronic diseases, and those with Medicaid or no insurance. Preconception care has been hailed as a strategy to improve pregnancy outcomes and reduce disparities, but its broad benefits for maternal outcomes have not been demonstrated. OBJECTIVE: Our objective was to measure the association between preconception care and the odds of severe maternal morbidity among women with Medicaid. STUDY DESIGN: This is a secondary analysis of Medicaid claims using the Medicaid Analytic Extract files (2010-2012). We used the International Classification of Diseases, Ninth Revision codes, published by the US Office of Population Affairs' Quality Family Planning program to define 7 domains of preconception care. The primary outcome was maternal death within 12 weeks of delivery or severe maternal morbidity during birth hospitalization, defined by the presence of any diagnosis or procedure on the severe maternal morbidity International Classification of Diseases, Ninth Revision code list from the Centers for Disease Control and Prevention. Because this list may overestimate severe maternal morbidity by counting any blood transfusion, our secondary outcome used the same code list but without transfusion. We reviewed care in the year before conception and used logistic regression to estimate the association between each domain and severe maternal morbidity for all births to women enrolled in Medicaid and aged 15 to 45 years with births during 2012. We performed a subgroup analysis for women with chronic disease (kidney disease, hypertension, or diabetes). RESULTS: Severe maternal morbidity or death occurred in 26,285 births (1.74%) when including blood transfusions and 9,481 births (0.63%) when excluding transfusions. Receiving contraceptive services in the year before conception was associated with decreased odds of severe maternal morbidity (adjusted odds ratio, 0.92; 95% confidence interval, 0.88-0.95) and pregnancy test services were associated with increased odds (adjusted odds ratio, 1.08; 95% confidence interval, 1.01-1.14). In the primary analysis, no significant associations were observed for other preconception care domains. Among those women with at least 1 chronic disease, contraceptive care (adjusted odds ratio, 0.84; 95% confidence interval, 0.75-0.95) and routine physical or gynecologic exams (adjusted odds ratio, 0.79; 95% confidence interval, 0.71-0.88) were associated with decreased odds of severe maternal morbidity. Similar associations were found for severe maternal morbidity when excluding blood transfusion. CONCLUSIONS: Contraceptive services in the year before conception and routine exams for women with chronic disease are associated with decreased odds of severe maternal morbidity or death for Medicaid enrollees.

Reproductive healthcare denials among a privately insured population.

This study aimed to quantify and examine reproductive healthcare denials experienced by individuals receiving employer-sponsored health insurance. We conducted a national cross-sectional survey using probability and non-probability-based panels from December 2019-January 2020. Eligible respondents were adults employed by any Standard and Poor's 500 company, who received employer-sponsored health insurance. Respondents (n = 1,001) reported whether anyone on their healthcare plan had been denied a reproductive healthcare service in the past five years and details about their denials. We conducted bivariate analyses and multiple logistic regression to estimate factors associated with denials. Eleven percent of respondents (14% of women; 10% of men) reported a denial. Compared to lower-income respondents, those with income ≥ $50,000/year were less likely to experience a denial (aOR = 0.53; 95% CI 0.29-0.97). Compared to respondents who were never married, being married (aOR = 2.33; 95% CI: 1.03-5.30) or cohabiting (aOR = 2.43; 95% CI: 1.03-5.72) significantly increased odds of experiencing a denial. In 38% of cases the patient learned of the denial at a scheduled visit, while 23% learned in an emergency setting, and 13% after the encounter. Individuals covered by employer-sponsored health insurance continue to be denied coverage of preventive services. Employers and insurers can facilitate access to reproductive healthcare by ensuring that their plans include comprehensive coverage and in-network providers offer comprehensive services.

Denial of tubal ligation in religious hospitals: Consumer attitudes when insurance limits hospital choice.

OBJECTIVES: Postpartum tubal ligation provides demonstrated benefits to women, but access to this procedure is threatened by restrictions at Catholic healthcare institutions. We aimed to understand how insured employees assign responsibility for postpartum sterilization denial and how it impacts their view of the quality of care provided. STUDY DESIGN: We conducted a nationally representative, cross-sectional survey of employees at Standard and Poor's (S&P) 500 companies utilizing a dual panel drawn from Amerispeak, a probability-based research panel, and a non-probability panel. Respondents answered questions about a scenario of a woman denied a tubal ligation due to Catholic hospital policy when her employer-sponsored insurance provided no other hospital choices. Of 1113 eligible panel members, 1001 (90%) completed the survey. Weighted analysis accounted for complex survey design. RESULTS: In response to the tubal ligation denial scenario, 42% of respondents rated hospital quality-of-care as poor or very poor. Sixty percent felt that something should have been done differently, with about half assigning responsibility to the religiously-affiliated hospital for not providing the procedure and half to the insurance company for not including secular hospitals in its network. Finding employers/insurance companies responsible was more common with higher education (RRR = 3.17; 95% CI: 1.58-6.33 some college; RRR = 4.26; 95% CI: 2.10-8.62 bachelor's or more) and less common among non-white respondents (RRR = 0.54; 95% CI: 0.31-0.97). Three quarters of respondents thought the employer should have intervened. CONCLUSIONS: The majority of insured employees do not think women should be denied postpartum tubal ligation. They assign hospitals, insurers, and employers responsibility to remove barriers to care. IMPLICATIONS: Most people who receive health insurance through a large employer disapprove of Catholic hospital restrictions when the patient's insurance restricts her hospital choice. To improve access to comprehensive reproductive care, employers and insurers should assure employees have in-network coverage of hospitals without religious restrictions.

Effects of clinic-level implementation of One Key Question® on reproductive health counseling and patient satisfaction.

OBJECTIVE: We evaluated the effect of clinic level implementation of the One Key Question (OKQ) intervention, including physician and staff training and workflow adjustments, on reproductive counseling and patient satisfaction in primary care and ob/gyn. STUDY DESIGN: We implemented the OKQ intervention in one primary care and one ob/gyn practice, while observing another primary care and ob/gyn practice that each provided usual care (control practices). We surveyed separate patient cohorts at two time points: 26 before and 33 after the primary care practice implemented OKQ, 38 before and 36 after the ob/gyn practice implemented OKQ, 26 and 37 at the primary care control practice, and 31 and 37 at the ob/gyn control practice. We used chi square tests to assess OKQ's effects on counseling rates and patient satisfaction, comparing intervention to control practices across time points. RESULTS: In primary care, from before to after implementation, the intervention practice did not significantly increase reproductive counseling (69-76%, p = 0.58), but increased patient satisfaction (81-97%, p = 0.04) while the control practice demonstrated a decrease in patient satisfaction over the same time periods. In the ob/gyn clinics, no significant change in reproductive counseling or patient satisfaction was seen in the intervention practice, while the control practice demonstrated a decrease in patient satisfaction. CONCLUSIONS: Implementing OKQ appears to increase patient satisfaction. Larger studies are needed to assess whether this clinic-level intervention may increase reproductive counseling. IMPLICATIONS: Further studies of the impact of clinic-level implementation of OKQ are needed.

How Should We Judge Whether and When Mission Statements Are Ethically Deployed?

Mission statements communicate health care organizations' fundamental purposes and can help potential patients choose where to seek care and employees where to seek employment. They offer limited benefit, however, when patients do not have meaningful choices about where to seek care, and they can be misused. Ethical implementation of mission statements requires health care organizations to be truthful and transparent about how their mission influences patient care, to create environments that help clinicians execute their professional obligations to patients, and to amplify their obligations to communities.

One Key Question® and the Desire to Avoid Pregnancy Scale: A comparison of two approaches to asking about pregnancy preferences.

OBJECTIVE: To facilitate assessment of patients' pregnancy preferences, we compared responses to One Key Question® with the validated Desire to Avoid Pregnancy (DAP) scale and assessed their relationships to patient-reported reproductive health behaviors. METHODS: In this after-visit survey in primary care and obstetrics-gynecology practices, women ages 18-49 (n = 177) answered "Would you like to become pregnant in the next year?" and the 14-item DAP scale. We performed one-way ANOVA to compare DAP scores (0-4 scale, 4 = highest preference to avoid pregnancy) across One Key Question® responses ("Yes," "Unsure," "Ok either way," "No but sometime in the future," "No never"). We used logistic regression to test association of One Key Question® and DAP with contraceptive and folic acid use. RESULTS: Most patients did not want to become pregnant in the next year, based on One Key Question® (7% "Yes," 4% "Unsure," 11% "Ok either way," 53% "In the future," 25% "Never"). The mean DAP score overall was 2.52 (SD = 1.03, Range: 0-4, Cronbach's α = 0.96). Scores differed by One Key Question® response ("Yes" mean DAP = 0.84, "Unsure" 1.64, "Ok" 1.42, "In the future" 2.94, "Never" 2.78, p < 0.001) yet varied markedly within each One Key Question® response group. Contraceptive use was lower among those who answered "Yes" (46%; OR = 0.14, 95% CI 0.04-0.48) vs. "No, future" (86%). Similarly, odds of contraceptive use increased with DAP score (OR = 1.69, 9% CI 1.18-2.42; predicted 51% for DAP = 0, 90% for DAP = 4). CONCLUSION: One Key Question® responses correlate with DAP scores, and contraceptive use correlates with not desiring pregnancy by both approaches. IMPLICATIONS STATEMENT: One Key Question® and the Desire to Avoid Pregnancy scale can both identify women wishing to avoid pregnancy to help clinicians address patients' contraceptive needs. Given the range of preferences associated with One Key Question® responses, clinicians who use it should proceed with further discussion to fully understand patients' feelings.

Pre-exposure Prophylaxis (PrEP) Awareness and Use Within High HIV Transmission Networks.

Improved implementation of pre-exposure prophylaxis (PrEP) should be a valuable tool within communities experiencing high HIV incidence, such as black men who have sex with men (MSM). Using baseline data from the Chicago arm of the Transmission Reduction Intervention Project (TRIP), we examined awareness and use of PrEP within HIV potential transmission networks. Transmission Reduction Intervention Project recruited participants ages 18-69 (N = 218) during 2014-2016 from networks originating from recently and chronically HIV-infected MSM and transgender persons. In total, 53.2% of participants had heard of PrEP, while 8 (6.5%) HIV-negative participants reported ever using PrEP. In multivariable regression, PrEP awareness was associated with identifying as gay, attending some college or higher, having an HIV test in the previous 6 months, and experiencing HIV-related social support. PrEP awareness was not associated with experiencing or observing HIV-related stigma. PrEP use was associated with participants knowing two or more other PrEP-users. These findings demonstrate moderate awareness, but low uptake of PrEP within HIV potential transmission networks in Chicago. Future research should explore how to increase PrEP use in these networks and investigate the social dynamics behind our finding that PrEP users are more likely to know other PrEP users.