Contraception Initiation after Early Abortion in a Family Medicine Setting: A Retrospective Chart Review.

OBJECTIVES: Early abortion increasingly is provided in the primary care setting, allowing improved access, continuity of care, and contraception, if desired. We aimed in this retrospective chart review to describe postabortion contraception provision in a family medicine office. METHODS: Participants were those patients who obtained an induced abortion during an 11-year period at a family medicine office. We documented contraception provision within 30 days of abortion and used simple proportions, Fisher exact tests, and χ2 tests to describe differences in contraceptive provision by type of abortion and continuity status. RESULTS: Most of the patients who underwent abortions (254/353, 72%) had documentation of a contraceptive method within 30 days of abortion, which was similar for patients who had either a medication (124/166, 75%) or an aspiration abortion (130/187, 70%, P = 0.71). The most common contraceptives were contraceptive pills (104/353, 29%) or intrauterine devices (68/353, 19%). Patients who chose a tier 1 method were more likely to have a procedure abortion (50/87, 57%), whereas patients who chose a tier 2 method were likely to have a medication abortion (83/160, 52%). Fewer than half (45%, 158/353, P = 0.0002) were continuity patients and established patients in the primary care office. Most tier 1 contraceptive users were continuity patients (49/87, 60%), whereas most patients without a contraceptive method were noncontinuity patients (72/99, 73%). CONCLUSIONS: The primary care setting is uniquely equipped for providing early abortion and postabortion contraception. Although the providers offered all contraceptive options to eligible patients, continuity patients were more likely to receive more effective contraception in their primary care office.

Bacterial Vaginosis Treatment Patterns, Associated Complications, and Health Care Economic Burden of Women With Medicaid Coverage in the United States.

BACKGROUND: Bacterial vaginosis (BV) is a highly prevalent vaginal infection. OBJECTIVES: Primary objectives of this study were to examine treatment patterns among female patients with Medicaid coverage who were diagnosed with incident BV, the frequency of BV-associated complications, and health care resource utilization (HCRU) and associated costs of incident BV and its recurrence. Secondary objectives were to identify predictors of total all-cause health care costs and number of treatment courses. METHODS: Female patients aged 12-49 years with an incident vaginitis diagnosis and ≥1 pharmacy claim for a BV medication were selected from the Merative MarketScan Medicaid database (2017-2020). Additional treatment courses were evaluated during a ≥12-month follow-up period, in which new cases of BV-associated complications and HCRU and the associated costs were also measured. Generalized linear models were used to identify baseline predictors of total all-cause health care costs and number of treatment courses. RESULTS: An incident vaginitis diagnosis and ≥1 BV medication claim were present in 114 313 patients (mean age: 28.4 years; 48.6% black). During the follow-up, 56.6% had 1 treatment course, 24.9% had 2, 10.2% had 3, and 8.3% had ≥4; 43.4% had BV recurrence. Oral metronidazole (88.5%) was the most frequently prescribed medication. Nearly 1 in 5 had a new occurrence of a BV-associated complication; most (76.6%) were sexually transmitted infections (STIs). Total all-cause and BV-related costs averaged $5794 and $300, respectively, per patient; both increased among those with more treatment courses. Older age, pregnancy, comorbidity, any STIs, postprocedural gynecological infection (PGI), and infertility were predictive of higher total all-cause health care costs, while race/ethnicity other than white was predictive of lower costs. Older age, black race, any STIs, pelvic inflammatory disease, and PGI were predictive of >1 treatment courses. CONCLUSION AND RELEVANCE: The high recurrence of BV represents an unmet need in women's health care and better treatments are necessary.

Hospice Capacity to Provide General Inpatient Care: Emergency Department Utilization and Live Discharge Among Cancer Patients.

General inpatient (GIP) hospice care is used only minimally for hospice patients, and more than a quarter of Medicare hospice facilities do not provide GIP care. To determine the impact of hospices' capacity to provide on emergency department use during hospice enrollment and live discharge from hospice, we used Surveillance, Epidemiology, and End Results-Medicare linked data and CMS Provider of Services data from 2007 to 2013 from ten states and two metropolitan regions. Grouping hospices into three GIP care provision categories: 1) no-GIP; 2) GIP-contract; and 3) GIP-IHF where hospices directly provide GIP care in their own inpatient hospice facility (IHF), we built a multilevel logistic model that accounted for unobserved hospice characteristics. Nearly 9% of the study sample received GIP care, of which 82% received such care in the last week of discharge. GIP-IHF hospices had lower live discharge rates than no-GIP hospices (AOR: .61; 95% CI: .47-.79; P < .001) and GIP-contract hospices (AOR: .84; 95% CI: .70-1.00; P < .05). Similarly, GIP-contract hospices were also associated with a decreased risk of live discharge, compared to no-GIP hospices (AOR: .76; CI: .62-.92; P < .05). There was no difference in emergency department use between no-GIP hospices and hospices with such capacity. Our results suggest that hospices capable of providing GIP care have lower live discharge rates than their counterparts. However, the fact that GIP care tends to be provided too close to death limits its effectiveness in preventing avoidable emergency department use.

Treatment patterns and economic burden of bacterial vaginosis among commercially insured women in the USA.

Aim: Bacterial vaginosis (BV) is a common vaginal dysbiosis associated with adverse clinical sequelae, most notably, increased risk of sexually transmitted infections (STIs). The aims of this study were to estimate the frequency of BV recurrence, treatment patterns, other gynecological (GYN) conditions, and the associated healthcare resource utilization (HCRU) and costs among commercially insured patients in the USA. Patients & methods: Female patients aged 12-49 years with an incident vaginitis diagnosis and ≥1 pharmacy claim for a BV medication (fungal treatment only excluded) were selected from the Merative™ MarketScan commercial database (2017-2020). During a minimum 12-month follow-up, additional treatment courses, treatment patterns, frequency of other GYN conditions, and HCRU and costs were assessed. Generalized linear models were used to identify baseline predictors of total all-cause healthcare costs and number of treatment courses. Results: The study population included 140,826 patients (mean age: 31.5 years) with an incident vaginitis diagnosis and ≥1 BV medication claim. During the follow-up, 64.2% had 1 treatment course, 22.0% had 2, 8.1% had 3, and 5.8% had ≥4; 35.8% had a BV recurrence (≥2 BV medication claims). The most commonly prescribed BV medication was oral metronidazole (73.6%). Approximately 12% (n = 16,619) of patients had a new diagnosis of another GYN condition in the follow-up; 8.2% had a new STI, which were more common among patients with ≥4 treatment courses (12.9%). During follow-up, total all-cause healthcare costs averaged $8987 per patient per year (PPPY) of which $470 was BV-related. BV-related healthcare costs increased from $403 PPPY among those with 1 treatment course to $806 PPPY among those with ≥4 with nearly half the costs attributed to outpatient office visits. Conclusion: BV recurrence among this population represented a substantial clinical and healthcare economic burden warranting improvements in women's healthcare.

Barriers to and Facilitators of Contraceptive Implant Training in New Jersey Family Medicine Residencies: A Qualitative Study.

BACKGROUND AND OBJECTIVES: The aim of this study was to examine experiences of New Jersey family medicine residents and preceptors with the etonogestrel subdermal contraceptive implant and to explore barriers to and facilitators of training. METHODS: In this qualitative study, we conducted semistructured individual interviews to explore residents' and preceptors' experiences with contraceptive implant procedural training. We invited residents and preceptors from programs with high (5.2-10.9) and low (0.0-0.1) implant procedures per resident to participate. Participants discussed factors that supported or inhibited implant training and provision. We transcribed, coded, and analyzed interviews on a rolling basis. We used memoing to reflect on the data and identify saturation. We developed and refined our codebook using a collaborative, iterative process. We analyzed interviews using deductive and inductive techniques to identify themes. RESULTS: We interviewed 25 subjects: 14 residents and 11 preceptors from four family medicine residency programs with the highest and lowest implant training numbers. Common barriers included lack of hands-on experience with the procedure, lack of teaching with the procedure, and difficulty scheduling patients. Facilitators included formal training and inclusion of contraception in residency curricula, preceptors' comfort with the procedure, office sessions dedicated to procedures or gynecology visits, and patient familiarity with the implant. CONCLUSIONS: Family medicine residencies provide unique opportunities to impact provision of long-acting reversible contraception (LARC). We identified potential interventions, including formal implant training sessions, dedicated procedure office sessions, stocking of devices in the office, and staff focused on reproductive health that can aid in scheduling, obtaining devices, and setup.

Intrauterine device self-removal practices during the COVID-19 pandemic among family planning clinics.

OBJECTIVES: To explore the prevalence of intrauterine device self-removal practices before and during the COVID-19 pandemic among family planning clinics. STUDY DESIGN: This is a secondary analysis of data from a descriptive, longitudinal study using a clinic-based convenience sample from the Abortion Clinical Research Network assessing baseline and pandemic-adaptive family planning practices. RESULTS: Of the 63 sites that provided contraception, 5 (7.9%) reported providing guidance on intrauterine device self-removal at baseline. Sixteen sites (25.4%) provided guidance on self-removal by the end of the study period. Self-removal counseling was associated with being an academic center and reporting a median lower number of monthly contraceptive encounters. CONCLUSIONS: Endorsement of IUD self-removal increased to one-quarter of sites by the final timepoint. IMPLICATIONS: Twenty-five percent of family planning clinics reported provision of intrauterine device self-removal guidance by eight months into the COVID-19 pandemic, a three-fold increase from baseline; these findings suggest clinician support for patient autonomy in contraceptive self-management and limited concern for safety issues with self-removal during a public health emergency.

Dilation and evacuation with an abdominal cerclage at 21 weeks gestation: A case report.

This case demonstrates a successful dilation and evacuation (D&E) at 21 weeks gestation for a patient with abdominal cerclage without initial advanced dilation. We followed a 2-day protocol with placement of 5 laminaria and mifepristone for cervical preparation without complication.

Exploring the experience of IUD self-removal in the United States through posts on internet forums.

OBJECTIVE: Some intrauterine devices (IUD) users self-remove their IUDs, and these experiences are not well understood. This study examines what IUD users post in internet forums about their experience, as well as advice and questions shared among IUD users about self-removal. STUDY DESIGN: This study uses qualitative analysis of internet health and parenting forum postings about IUD self-removal identified from an internet search engine. We analyzed the data using inductive and deductive content analyses. RESULTS: Twenty-eight sites, containing 1742 posts by 1197 unique users, satisfied our eligibility criteria. Users reported successful IUD self-removal attempts as "quick," "easy," and "painless"; it was rare to encounter IUD users describing complications of their self-removal attempts. Users described unsuccessful attempts as failure to find or grasp strings. Many IUD users described their successful removal techniques and gave advice to other users who were struggling with self-removal. Users frequently utilized the forum to ask questions about IUD self-removal methods and timing, pain, when to seek medical intervention, and the effects on future fertility. CONCLUSIONS: Posts describing successful IUD self-removal report positive experiences. IUD users who have difficulty with self-removal may utilize internet forums to learn from others' experiences. IMPLICATIONS: Exploring IUD users' experiences with and questions about self-removal may inform strategies to develop better resources for those who desire self-removal.

Investigating Barriers to Completion of Postpartum Tubal Ligation: A Retrospective Chart Review.

OBJECTIVES: To identify the completion rate for postpartum tubal ligation (PPTL) and predictors of noncompletion of PPTL in a central New Jersey population. METHODS: We conducted a retrospective chart review at a tertiary care center in New Jersey for patients delivering during an 18-month period. We used the electronic medical record to identify all of the patients who had documented desire for a PPTL at the time of admission. We calculated the rate of PPTL completion and identified predictors of completion and risk factors for noncompletion. We recorded any documented reasons for cancellation and choice of contraception after noncompletion. RESULTS: Of 626 women who requested PPTL on admission, 508 (81.2%) procedures were performed. The most common reasons for noncompletion were patient changing her mind (38.1%) and unknown/not documented (22.9%). Cesarean delivery was the strongest predictor of completion, with 93.4% completion among cesarean deliveries compared with 65.6% among vaginal deliveries (P < 0.01). Lack of insurance also was associated with noncompletion (P < 0.01). There was no difference in body mass index (P = 0.75), gravidity (P = 0.99), parity (P = 0.72), or high-risk status (P = 0.47) between completed and noncompleted PPTL. CONCLUSIONS: Cesarean delivery is a strong predictor of PPTL completion, most likely because of easier availability of the operating room, anesthesia, and ancillary staff. Body mass index, gravidity, and parity are not associated with PPTL completion. Future research should focus on exploring whether this association is system, provider, or patient dependent.

"$231 to pull a string!!!" American IUD users' reasons for IUD self-removal: An analysis of internet forums.

OBJECTIVE: The perspectives and experiences of intrauterine device (IUD) users who consider IUD self-removal are largely unknown. This study describes the reasons for IUD self-removal as documented in internet forums by IUD users discussing self-removal. STUDY DESIGN: This qualitative study used an internet search strategy to document IUD users' reasons for self-removal in the United States. We employed a content analysis of online data using inductive and deductive qualitative techniques to examine the reasons why IUD users consider self-removal. RESULTS: Search results initially identified 235 websites, of which 28 had online health or parenting forums with content related to IUD self-removal. Individual websites contained between 1 and 637 posts by between 1 and 454 individual users. IUD users described a variety of reasons for IUD discontinuation including undesired symptoms or side effects as well as planning for pregnancy. IUD users discussed difficulties accessing provider-removal because of cost or lack of appointment availability. IUD users also discussed how reading about others' successful self-removal experiences or approval by medical providers made self-removal a feasible or acceptable option. CONCLUSIONS: Some IUD users utilize online forums for advice about IUD removal, and attempt IUD self-removal due to side effects or because they desire pregnancy. Lack of access to a provider led some patients to attempt self-removal who may have preferred provider-removal. IMPLICATIONS: For those who prefer self-removal, anticipatory counseling from a clinician regarding self-removal might be useful and reassuring. Improving access to self-removal may help preserve reproductive autonomy for those who face barriers to IUD removal in the clinical setting.

Access to IUD removal: Data from a mystery-caller study.

OBJECTIVE: This study describes access and barriers to intrauterine device (IUD) removal appointments in 10 mid-sized cities in the United States. STUDY DESIGN: This mystery caller study utilized a sampling frame of health centers in 10 mid-sized cities gathered from 3 search engines. We gathered data about the timing of the next available appointment, the requirements for additional appointments prior to IUD removal, and the out-of-pocket cost. We used descriptive statistics to describe the availability and cost of IUD removal visits, and compared results between primary care clinics and family planning or gynecology clinics. Any additional information regarding why a visit was not available or other requirements for IUD removal that was provided to the researcher was also recorded. RESULTS: Of 229 clinics included for analysis, 60.7% could offer an IUD removal appointment to the mystery caller, and the majority of these could provide an initial appointment within 2 weeks (61.2%), with a median of 10 days. Of clinics offering IUD removal, 17.3% required more than one visit before removing the IUD, and 43.2% confirmed that IUD removal would occur at the first visit. Five clinics (5.6%) reported that they would not remove an IUD that was not placed at their clinic. Sliding scale fees were offered at 16.3% of clinics. For the clinics that cited an out-of-pocket cost and did not offer sliding scale fees, the median cost of the IUD removal was $262, with a range of $50 to over $1000. Neither appointment availability nor cost differed between primary care and family planning or gynecology clinics. CONCLUSIONS: Overall, timely IUD removal appointments were available at the clinics we sampled, but both financial and clinic policy barriers to IUD removal were documented, including the need for multiple appointments and the total out-of-pocket costs. IMPLICATIONS: In our current climate focused on improving access to IUDs, it is essential to address and reduce barriers to IUD removal when desired, in order to preserve reproductive autonomy.

Providing Abortion Services in the Primary Care Setting.

Patients commonly present with unintended pregnancy in the primary care setting, and 1 in 4 women has an abortion in her lifetime. Early abortion services can be safely provided in the primary care setting. Abortion options provided in primary care settings include both medication abortion and early uterine aspiration abortion. Medication abortion, provided up to 10 weeks' gestational age, includes mifepristone (a progestin antagonist) and misoprostol (a prostaglandin). Uterine aspiration can be provided via manual or electronic vacuum in the first trimester.

Taking the provider "out of the loop:" patients' and physicians' perspectives about IUD self-removal.

OBJECTIVE: This study describes the perspectives of patients and providers about intrauterine device (IUD) self-removal. STUDY DESIGN: This qualitative study is a subanalysis of two datasets from a single project, which included semistructured individual interviews with 15 patients and 12 physicians. We derived the data for this analysis from portions of the interviews pertaining to IUD self-removal and provider removal. We analyzed data using deductive and inductive techniques to perform content and thematic analyses. RESULTS: The majority of patients and physicians cited both concerns about and potential benefits of IUD self-removal. Patients cited concerns about safety as the reason they did not wish to remove their own IUD, but physicians did not share these concerns; instead, physicians were apprehensive about not being involved in the discussion to remove the IUD. Both patients and physicians valued having the provider "in the loop" and reported fears about hasty or coerced removal. CONCLUSIONS: IUD self-removal is an option that some patients may be interested in. Addressing concerns about safety may make self-removal more appealing to some patients. Addressing physicians' concern about "hasty" removal may require additional training so that providers are better able to support patients' decision making around contraceptive use. IMPLICATIONS: The option of self-removal could have a positive impact on reproductive autonomy and patient decision making.

"I wish they could hold on a little longer": physicians' experiences with requests for early IUD removal.

OBJECTIVE: This study describes the perceptions and experiences of family physicians when women request early intrauterine device (IUD) removal. STUDY DESIGN: This qualitative study included semistructured individual interviews with 12 physicians who encountered patients seeking early IUD removal. We identified eligible participants via chart review. We analyzed interviews using deductive and inductive techniques to identify content and themes. RESULTS: Physicians consistently referred to IUDs as the "best" or their "favorite" method, and several joked that they tried to "sell" the IUD during contraceptive counseling. Most reported having mixed or negative feelings when patients opted to remove the IUD. Most encouraged their patients to continue the IUD, hoping to delay removal until symptoms resolved so that removal was not needed. Some physicians reported feeling guilty or as if they had "failed" when a patient wanted the IUD removed. Many providers reported a conflict between valuing patient autonomy and feeling that early removal was not in the patient's best interest. CONCLUSIONS: Physicians have complex and contradictory feelings about early IUD removal. While most providers acknowledged the need for patient autonomy, they still reported encouraging IUD continuation based on their own opinion about the IUD. IMPLICATIONS: While IUDs are highly effective and well-liked contraceptives, providers' responses to IUD removal requests have implications for both reproductive autonomy as well as the doctor-patient relationship. More work is needed to ensure that providers remove a patient's IUD when requested.

"She just told me to leave it": Women's experiences discussing early elective IUD removal.

OBJECTIVE: The objective of this study is to describe the thoughts and experiences of women who report discussing intrauterine device (IUD) removal within 9 months of insertion. STUDY DESIGN: This is a qualitative study, consisting of semistructured individual interviews with 16 women who considered early elective IUD removal. We identified eligible participants via chart review. We analyzed interviews using a modified grounded theory approach. RESULTS: While pain and bleeding were prominent reasons for removal, women also discussed many other symptoms and concerns. Most women reported a strong desire to have a successful IUD experience, and all reported waiting for symptoms to resolve prior to their visit. Some women reported that providers supported their choice, while others reported that providers preferred that they continue the IUD despite symptoms and concerns. Some women reported providers' resistance or refusal to remove the IUDs. The women who reported that their providers were neutral about IUD removal more frequently expressed satisfaction with the visit. When the provider resisted removal, women felt frustrated, even as they acknowledged their doctor's good intentions. In several cases, this may have hurt the doctor-patient relationship. CONCLUSIONS: When physicians resist early elective IUD removal, it may impact patient satisfaction and even jeopardize the doctor-patient relationship. IMPLICATIONS: Though IUDs are highly effective and well-liked contraceptives, some patients choose to discontinue the method. Because provision of patient-centered contraceptive care includes IUD removal when requested, providers must ensure that their counseling is unbiased and that they do not place perceived or real barriers to IUD removal.

Providing Long-Acting Reversible Contraception in an Academic Family Medicine Center.

BACKGROUND AND OBJECTIVES: Providing long-acting reversible contraception (LARC), which includes the intrauterine device (IUD) and the implant, falls within the scope of family medicine. The study objective was to describe 12-month rates of LARC continuation, LARC elective removal, and IUD expulsion in an academic family medicine center in New Jersey. METHODS: We conducted a retrospective electronic chart review of 219 LARC insertions that occurred from June 2009--May 2012. Life table analyses were used to determine 12-month rates of LARC continuation, elective removal, and IUD expulsion. To explore differences in outcomes based upon training level (faculty versus trainees), we conducted Cox proportional hazard models. RESULTS: Of 219 LARC insertions, faculty performed 100 (45.7%), and trainees (residents and students) performed 119 (54.3%). The 12-month continuation rate for all devices was 78%. The elective removal rate at 12 months was 17%; trainee-placed devices were more likely to be electively removed than faculty-placed devices (HR 2.43, 95% CI=1.05--5.62). The IUD expulsion rate at 12 months was 7.0%; expulsion rates did not differ by level of training. CONCLUSIONS: These data provide support for the fact that family physicians in an academic setting can provide LARC with continuation, elective removal, and IUD expulsion rates similar to those observed in outpatient specialist clinics without resident training. Potential causes for the higher removal rate associated with trainee-inserted devices should be further explored.

Music for surgical abortion care study: a randomized controlled pilot study.

BACKGROUND: The study objective was to explore the effect of music as an adjunct to local anesthesia on pain and anxiety during first-trimester surgical abortion. Secondary outcomes included patient satisfaction and coping. STUDY DESIGN: We conducted a randomized controlled pilot study of 26 women comparing music and local anesthesia to local anesthesia alone. We assessed pain, anxiety and coping with 11-point verbal numerical scales. Patient satisfaction was measured via a 4-point Likert scale. RESULTS: In the music group, we noted a trend toward a faster decline in anxiety postprocedure (p=.065). The music group reported better coping than the control group (mean±S.D., 8.5±2.3 and 6.2±2.8, respectively; p<.05). Both groups reported similarly high satisfaction scores. There were no group differences in pain. CONCLUSIONS: Music as an adjunct to local anesthesia during surgical abortion is associated with a trend toward less anxiety postprocedure and better coping while maintaining high patient satisfaction. Music does not appear to affect abortion pain.