Challenges in translating evidence to practice: the provision of intrauterine contraception.

OBJECTIVE: Intrauterine contraception is used by many women worldwide, however, it is rarely used in the United States. Although available at no cost from the state family planning program for low-income women in California, only 1.3% of female patients obtain intrauterine contraceptives annually. This study assessed knowledge and practice patterns of practitioners regarding intrauterine contraception. METHODS: We conducted a survey among physicians, nurse practitioners, and physician assistants (n=1,246) serving more than 100 contraceptive patients per year in the California State family planning program. The response rate was 65% (N=816). We used multiple logistic regression to measure the association of knowledge with clinical practice among different provider types. RESULTS: Forty percent of providers did not offer intrauterine contraception to contraceptive patients, and 36% infrequently provided counseling, although 92% thought their patients were receptive to learning about the method. Regression analyses showed younger physicians and those trained in residency were more likely to offer insertions. Fewer than half of clinicians considered nulliparous women (46%) and postabortion women (39%) to be appropriate candidates. Evidence-based views of the types of patients who could be safely provided with intrauterine contraception were associated with more counseling and method provision, as well as with knowledge of bleeding patterns for the levonorgestrel-releasing intrauterine system and copper devices. CONCLUSION: Prescribing practices reflected the erroneous belief that intrauterine contraceptives are appropriate only for a restricted set of women. The scientific literature shows intrauterine contraceptives can be used safely by many women, including postabortion patients. Results revealed a need for training on updated insertion guidelines and method-specific side effects, including differences between hormonal and nonhormonal devices. LEVEL OF EVIDENCE: III.

Number of oral contraceptive pill packages dispensed, method continuation, and costs.

OBJECTIVE: To estimate the effect of the number of cycles of oral contraceptive pills (OCPs) dispensed per visit on method continuation, pill wastage, use of services, and health care costs. METHODS: We used paid claims data for 82,319 women dispensed OCPs through the California Family PACT (Planning, Access, Care, and Treatment) Program in January 2003 to examine contraceptive continuation and service use. RESULTS: Women who received 13 cycles at their first visit in January 2003 received 14.5 cycles over the course of 2003 compared with 9.0 cycles among women receiving three cycles at first visit. When client characteristics are controlled, women who received 13 cycles were 28% more likely to have OCPs on hand and twice as likely to have sufficient OCP cycles for 15 months of continuous use compared with women who received three cycles. Oral contraceptive pill wastage was higher among women initially dispensed 13 cycles (6.5% of the cycles dispensed) than among women who received three cycles (2% of cycles). Despite having one fewer clinician visit, women dispensed 13 cycles were more likely to receive Pap and Chlamydia tests and less likely to have a pregnancy test than women initially dispensed fewer cycles. Over the course of the year, Family PACT paid 99 US dollars more for women who received three cycles and 44 US dollars more for women who received only one cycle than it did for women who received 13 cycles at their first visits of 2003. CONCLUSION: Dispensing a year's supply of OCP cycles to women is associated with higher method continuation and lower costs than dispensing fewer cycles per visit. LEVEL OF EVIDENCE: II-2.

Comparison of adherence to chlamydia screening guidelines among Title X providers and non-Title X providers in the California Family Planning, Access, Care, and Treatment Program.

BACKGROUND: Annual chlamydia screening is recommended for adolescent and young adult females and targeted screening is recommended for women ≥26 years based on risk. Although screening levels have increased over time, adherence to these guidelines varies, with high levels of adherence among Title X family planning providers. However, previous studies of provider variation in screening rates have not adjusted for differences in clinic and client population characteristics. METHODS: Administrative claims from the California Family Planning, Access, Care, and Treatment (Family PACT) program were used to (1) examine clinic and client sociodemographic characteristics by provider group-Title X-funded public sector, non-Title X public sector, and private sector providers, and (2) estimate age-specific screening and differences in rates by provider group during 2009. RESULTS: Among 833 providers, Title X providers were more likely than non-Title X public sector providers and private sector providers to serve a higher client volume, a higher proportion of clients aged ≤25 years, and a higher proportion of African American clients. Non-Title X public providers were more likely to be located in rural areas, compared with Title X grantees and private sector providers. Title X providers had the largest absolute difference in screening rates for young females vs. older females (10.9%). Unadjusted screening rates for young clients were lower among non-Title X public sector providers (54%) compared with private sector and Title X providers (64% each). After controlling for provider group, urban location, client volume, and percent African American, private sector providers had higher screening rates than Title X and non-Title X public providers. CONCLUSIONS: Screening rates for females were higher among private providers compared with Title X and non-Title X public providers. However, only Title X providers were more likely to adhere to screening guidelines through high screening rates for young females and low screening rates for older females.

Enhancing service delivery through title x funding: findings from California.

CONTEXT: The federal Title X grant program provides funding for family planning services for low-income women and men. In California, all clinics receiving Title X funds participate in the state's family planning program, Family PACT, along with other public and private providers. The relative extent to which Title X-funded clinics and other Family PACT providers have incorporated enhancements beyond their core medical services has never been studied. METHODS: In 2010, a survey was sent to public- and private-sector Family PACT clinicians to assess whether funding streams were associated with the availability of special services: extended clinic hours, outreach to vulnerable populations, services for clients not proficient in English and use of advanced clinic-based technologies. Bivariate and logistic regression analyses controlling for potentially confounding factors were conducted. RESULTS: Greater proportions of Title X-funded clinics than of other public and private providers had Spanish-speaking unlicensed clinical staff (89% vs. 71% and 58%, respectively) and Spanish-language signs (95% vs. 85% and 82%). Title X-funded providers were more likely than other public providers to offer extended clinic hours, provide outreach to at least three vulnerable or hard-to-reach populations, and use three or more advanced technologies (odds ratios, 2.0-2.9). CONCLUSIONS: Compared with other Family PACT providers, clinics that receive Title X funding have implemented greater infrastructure enhancements to promote access and improve the quality of service for underserved populations. This may be because Title X-funded providers have more financial opportunities to provide the array of services that best respond to their clients' needs.

Quality of reproductive health services to limited English proficient (LEP) patients.

BACKGROUND: Medical patients with limited English proficiency (LEP) frequently receive health care services of suboptimal quality. METHODS: We explored whether clients served with staff interpreters (language-discordant, LDI) receive reproductive health care of lower quality than clients seen by a bilingual clinician (language concordant, LC). We conducted a medical record review of 1,589 reproductive health visits of female and male LEP clients. RESULTS: Multivariate analyses showed that LDI visits were significantly less likely than LC visits to contain documentation of the provision of education and counseling services and less likely to have documentation of sexually transmitted infection (STI) risk assessment among new female clients. Female clients in LDI and LC visits were equally likely to be tested for Chlamydia. CONCLUSIONS: Quality improvement activities should target family planning providers who must use interpreters when serving LEP clients. Medical charts should document the use of interpreters and bilingual clinicians to monitor quality of care.

Correlates of receiving reproductive health care services among U.S. men aged 15 to 44 years.

Men have a significant role in reproductive health decision making and behavior, including family planning and prevention of sexually transmitted diseases (STDs).Yet studies on reproductive health care of men are scarce. The National Survey of Family Growth 2006-2008 provided data that allowed assessment of the predisposing, enabling, and need factors associated with men's receipt of reproductive health services in the United States. Although more than half (54%) of U.S. men received at least one health care service in the 12 months prior to the survey, far fewer had received birth control counseling/methods, including condoms (12%) and STD/HIV testing/STD treatment (12%). Men with publicly funded health insurance and men who received physical exam were more likely to receive reproductive health services when compared with men with private health insurance and men who did not receive a physical exam. Men who reported religion was somewhat important were significantly more likely to receive birth control counseling/ methods than men who stated religion was very important. The pseudo-R (2) (54%), a measure of model fit improvement, suggested that enabling factors accounted for the strongest association with receiving either birth control counseling/ methods or STD/HIV testing/STD treatment.

Race, ethnicity and differences in contraception among low-income women: methods received by Family PACT Clients, California, 2001-2007.

CONTEXT: The extent to which racial and ethnic differences in method choice are associated with financial barriers is unclear. Understanding these associations may provide insight into how to address racial and ethnic disparities in unintended pregnancy. METHODS: Claims data from the California Family PACT program, which provides free family planning services to low-income residents, were used to determine the proportions of women receiving each type of contraceptive method in 2001-2007. Bivariate and multivariate analyses were performed to identify associations between women's race and ethnicity and the primary contraceptive method they received in 2007. RESULTS: Compared with white women, blacks and Latinas were less likely to receive oral contraceptives (odds ratios, 0.4 and 0.6, respectively) and the contraceptive ring (0.7 and 0.5), and more likely to receive the injectable (1.6 and 1.4) and the patch (1.6 and 2.3). Black women were less likely than whites to receive the IUD (0.5), but more likely to receive barrier methods and emergency contraceptive pills (2.6); associations were similar, though weaker, for Latinas. Racial and ethnic disparities in receipt of effective methods declined between 2001 and 2005, largely because receipt of the patch (which was introduced in 2002) was higher among minority than white women. CONCLUSION: Although Family PACT eliminates financial barriers to method choice, the methods women received differed substantially by race and ethnicity in this low-income population. The reduction in racial and ethnic disparities following introduction of the patch suggests that methods with novel characteristics may increase acceptability of contraceptives among minority women.

Estimating the fertility effect of expansions of publicly funded family planning services in California.

OBJECTIVE: To estimate the number of unintended pregnancies averted through the provision of family planning services to low income women in Family PACT, California's Medicaid waiver program. STUDY DESIGN: We use a Markov model to estimate the number of pregnancies in the absence of Family PACT based on the contraceptive method mix used before program enrollment, and pregnancies in the presence of the program, based on method dispensing claims. RESULTS: Nearly 1 million (998,084) women were provided with contraceptives in Family PACT in 2007. Contraceptive services averted over an estimated 286,700 unintended pregnancies including 122,000 abortions, 133,000 unintended births, and over 40,000 births among teens. CONCLUSION: This conservative measure of the effect of Family PACT on unintended pregnancies indicates the benefit of expanding access to contraceptive services, an example for other states considering expanding access to family planning services through a state plan amendment under health care reform.

Barriers to adolescents' getting emergency contraception through pharmacy access in California: differences by language and region.

CONTEXT: In California, emergency contraception is available without a prescription to females younger than 18 through pharmacy access. Timely access to the method is critical to reduce the rate of unintended pregnancy among adolescents, particularly Latinas. METHODS: In 2005-2006, researchers posing as English- and Spanish-speaking females-who said they either were 15 and had had unprotected intercourse last night or were 18 and had had unprotected sex four days ago-called 115 pharmacy-access pharmacies in California. Each pharmacy received one call using each scenario; a call was considered successful if the caller was told she could come in to obtain the method. Chi-square tests were used to assess differences between subgroups. In-depth interviews with 22 providers and pharmacists were also conducted, and emergent themes were identified. RESULTS: Thirty-six percent of all calls were successful. Spanish speakers were less successful than English speakers (24% vs. 48%), and callers to rural pharmacies were less successful than callers to urban ones (27% vs. 44%). Although rural pharmacies were more likely to offer Spanish-language services, Spanish-speaking callers to these pharmacies were the least successful of all callers (17%). Spanish speakers were also less successful than English speakers when calling urban pharmacies (30% vs. 57%). Interviews suggested that little cooperation existed between pharmacists and clinicians and that dispensing the method at clinics was a favorable option for adolescents. CONCLUSIONS: Adolescents face significant barriers to obtaining emergency contraception, but the expansion of Spanish-language services at pharmacies and greater collaboration between providers and pharmacists could improve access.

PTSD, depression, prescription drug use, and health care utilization of Chinese workers affected by the WTC attacks.

This study assessed the impact of the World Trade Center (WTC) attacks on emotional problems, prescription drug usage, and utilization of medical and mental health services within the Chinese community in lower Manhattan. We administered a survey to 148 randomly selected Chinese workers affected by the WTC attacks in March 2003. Although nearly half of the respondents had elevated PTSD and/or elevated depression scores, only a few (4.4%) had talked to a counselor. However, nearly all (86%) reported having visited a physician at least once since September 11, 2001. Individuals with elevated PTSD scores were significantly more likely to have gone to a physician after 9/11. They were also more likely to have received prescription drugs and to indicate an interest in counseling after 9/11 than individuals with low PTSD scores. The findings highlight the role of the primary care physician as gatekeeper for mental health symptoms after a disaster. They further suggest that primary care physicians should use screening tools for depression and posttraumatic stress after a major disaster and that they should be sensitive to potential emotional problems that are associated with somatic complaints.