Virtual Music Therapy for Substance Use Disorders in a Federally Qualified Health Center.

BACKGROUND: Music therapy (MT) is an effective adjunctive treatment for substance use disorders (SUD), which is primarily available in inpatient treatment centers and rarely provided in outpatient primary care. METHODS: We evaluated the feasibility and acceptability of a virtual group MT program for SUD in a Federally Qualified Health Center (FQHC), and secondarily assessed patient perceptions of its effect. Feasibility was measured by implementation-related process measures, attendance and use of technology. Qualitative interviews eliciting participant perceptions were conducted to evaluate acceptability and effect. Mood scores, substance use and craving were measured before and after the intervention. RESULTS: Onboarding of the music therapist took 3.5 months. All MT sessions were attended by 1 to 5 individuals out of 6. Participants reported that group MT was "soothing" and "calming," gave them tools to treat cravings and stress, and created a sense of community. They reported that during sessions their cravings decreased. Anxiety and depression scores trended down, as did the number of days of substance use. They all stated they would seek out MT again. DISCUSSION: Our results suggest that remote group MT is feasible and acceptable to our FQHC patients with SUD. Patients reported an improvement in mood and their ability to manage stress, and a decrease in substance use. CONCLUSION: We wish to build on the results of this study to enhance our understanding of the effects of MT in the outpatient setting, and broaden our patients' access to MT in primary care.

Patient's experience and satisfaction with self-administered subcutaneous depot medroxyprogesterone acetate use during the first year of COVID-19.

OBJECTIVES: Self-administered subcutaneous (SC) depot medroxyprogesterone acetate (DMPA) can improve contraception access by eliminating a health center visit for administration. For patients at our New York City health centers who were offered a switch to self-administered DMPA-SC at the onset of the coronavirus 2019 (COVID-19) pandemic, we sought to understand their experience of choosing to switch, of accessing and using the method, and their method satisfaction. STUDY DESIGN: Individual interview study of 22 patients using intramuscular DMPA prior to the start of the pandemic. All had a telehealth visit to discuss switching to self-administered DMPA-SC and received a DMPA-SC prescription during the first months of COVID-19. We used a grounded theory analysis approach. RESULTS: Respondents viewed switching to self-administered DMPA-SC as a decision they had to make if they wanted to continue DMPA. Most respondents experienced logistical challenges acquiring DMPA-SC from their pharmacy. Issues around convenience were important to respondents; however what respondents found convenient varied. Despite all this, respondents appreciated having the option of DMPA-SC and felt it to be overall empowering. CONCLUSIONS: This study exploring patients' experience with self-administered DMPA-SC during the initial year of the COVID-19 pandemic found that, notwithstanding initial hesitation about self-administered injections and logistical challenges getting the SC formulation, many found the experience of trying self-administered DMPA-SC to be empowering and appreciated having this option. Thus, self-administered DMPA-SC should be included in clinicians' routine contraception counseling and provision, insurance companies should cover DMPA-SC without requiring prior authorization, and pharmacies should consistently stock DMPA-SC. IMPLICATIONS: Self-administered DMPA-SC is an acceptable contraception option that provides an opportunity to maintain contraception access while eliminating need for an in-person visit. Thus, self-administered DMPA-SC should be included in clinicians' routine contraception counseling and provision, insurance companies need to cover this contraceptive without need for prior authorization, and pharmacies should consistently stock DMPA-SC.

US clinicians' perspectives on how mifepristone regulations affect access to medication abortion and early pregnancy loss care in primary care.

OBJECTIVE: Protocols including mifepristone are the most effective medication regimens for medication abortion and early pregnancy loss (EPL) management. Both can be safely and effectively offered in primary care settings. Despite mifepristone's excellent safety record, the United States (US) Food and Drug Administration (FDA) heavily regulates provision. This exploratory study examines US primary care clinicians' perspectives on the effects of mifepristone restrictions, including FDA regulations, on access to medication abortion and EPL management in primary care. STUDY DESIGN: In 2019, we conducted an online qualitative survey of US primary care clinicians recruited from six reproductive health-focused listservs. Open-ended questions queried about barriers to providing mifepristone and effects on patients when unable to access mifepristone in primary care. We iteratively coded and analyzed qualitative data using inductive thematic analysis. RESULTS: Of our analytic sample of 113 respondents, one-third had mifepristone available in their current primary practice setting. Key barriers to provision stemmed from the FDA rule to stock and dispense mifepristone onsite, including logistical difficulties and resistance from health center leadership. Clinicians believed that lack of mifepristone in primary care resulted in negative patient experiences, including disrupted continuity of care, medically-unnecessary appointments, and undesired aspiration procedures. CONCLUSIONS: FDA regulations that inhibit mifepristone provision in primary care create structural barriers to provision. This may result in physical, emotional, and financial burdens for patients. IMPLICATIONS: When mifepristone is unavailable in primary care, some patients in need of abortion or EPL care may experience physical, emotional, and financial harms. Removing FDA restrictions is a critical step in reducing primary care barriers to mifepristone provision and improving access to timely, patient-centered medication abortion and EPL care.

Barriers and Enablers to Family Physicians' Provision of Early Pregnancy Loss Management in the United States.

BACKGROUND: Early pregnancy loss (EPL) is a common experience. Treatment options include expectant management, medication, and uterine aspiration. Although family physicians can offer comprehensive EPL treatment in their office-based settings, few actually do. This study explored the postresidency provision of EPL management and factors that inhibit or enable providing this care among family physicians trained in early abortion during residency. METHODS: Using an exploratory sequential mixed-methods design, we studied a sample of family physicians trained in early abortion during residency. We initially interviewed a subset trained in uterine aspiration during residency, then surveyed the entire sample. Interview transcripts were coded and analyzed using grounded theory; results informed survey development. On survey responses, we used Pearson χ2 to examine the association between certain variables and provision of EPL care options. RESULTS: Most of the 15 interview and 231 survey respondents provided expectant management of EPL. Of the survey respondents, 47.2% provided medication management and 11.4% manual vacuum aspiration. Key challenges and facilitators involved referral, training, ultrasound access, and managing systems-level issues. In bivariate analyses, providing prenatal care, offering abortion care, access to ultrasound, and competency were positively associated with providing EPL management options (p < .05). CONCLUSIONS: Clinical training alone is insufficient to expand access to comprehensive EPL care in family medicine office-based settings. Supporting family physicians during and after residency with training and technical assistance to address barriers to care may strengthen their abilities to champion practice change and expand access to comprehensive EPL management options.

Effectiveness of clinical decision support to enhance delivery of family planning services in primary care settings.

PURPOSE: There is a need to improve delivery of family planning services, including preconception and contraception services, in primary care. We assessed whether a clinician-facing clinical decision support implemented in a family medicine staffed primary care network improved provision of family planning services for reproductive-aged female patients, and differed in effect for certain patients or clinical settings. METHODS: We conducted a pragmatic study with difference-in-differences design to estimate, at the visit-level, the clinical decision support's effect on documenting the provision of family planning services 52 weeks prior to and after implementation. We also used logistic regression with a sample subset to evaluate intervention effect on the patient-level. RESULTS: 27,817 eligible patients made 91,185 visits during the study period. Overall, unadjusted documentation of family planning services increased by 2.7 percentage points (55.7% pre-intervention to 58.4% intervention). In the adjusted analysis, documentation increased by 3.4 percentage points (95% CI: 2.24, 4.63). The intervention effect varied across sites at the visit-level, ranging from a -1.2 to +6.5 percentage point change. Modification of effect by race, insurance, and site were substantial, but not by age group nor ethnicity. Additionally, patient-level subset analysis showed that those exposed to the intervention had 1.26 times the odds of having family planning services documented after implementation compared to controls (95% CI: 1.17, 1.36). CONCLUSIONS: This clinical decision support modestly improved documentation of family planning services in our primary care network; effect varied across sites. IMPLICATIONS: Integrating a family planning services clinical decision support into the electronic medical record at primary care sites may increase the provision of preconception and/or contraception services for women of reproductive age. Further study should explore intervention effect at sites with lower initial provision of family planning services.

Intention to provide abortion upon completing family medicine residency and subsequent abortion provision: a 5-year follow-up survey.

OBJECTIVE: Among family physicians who graduated from residencies with abortion training, we explore the association between intention to provide abortion at the end of residency and abortion provision 5 years postresidency. STUDY DESIGN: We invited 2009-2012 graduates from US family medicine residency programs with a required opt-out abortion training rotation or elective abortion training opportunities, and who had completed a baseline end-of-residency survey (N=477) to take our follow-up survey 5 years postresidency (2014-2017). We used logistic regression to examine the association between intention to provide abortion postresidency and abortion provision 5 years later. RESULTS: One hundred and seventy-two of 477 (36.1%) family physicians responded to our survey. More responders compared to nonresponders had intended to provide uterine aspiration and medication abortion at baseline (p≪.01) and attended residency in states considered hostile and middle ground toward abortion rights (p=.03). Of the 155 eligible respondents for analysis, 27.1% offered some type of abortion care in their practice. Of those that provided abortion, 100% provided medication abortion and 71.4% uterine aspiration. Most respondents that provided uterine aspiration abortion did so in abortion/family planning clinics or in sites that already established routine abortion care. Those who had intended to provide any abortion care at baseline had 4.03 times the odds of providing any abortion care 5 years later (95% confidence interval: 1.72-9.47). Administrative and systems-level barriers to integrate abortion were mentioned most frequently compared to personal beliefs or safety factors to explain why respondents did not provide abortion. CONCLUSIONS: We found an association between intention to provide abortion after residency and providing abortion in practice 5 years later. However, only 27.1% of respondents provided some abortion care. Factors beyond intention to provide care appear to inhibit or facilitate family physicians' abilities to practice abortion in primary care. IMPLICATIONS: Supporting family physicians who express intention to provide abortion after residency with additional training and technical assistance may contribute toward expanding access and availability of abortion care.

Feasibility study of family planning services screening as clinical decision support at an urban Federally Qualified Health Center network.

OBJECTIVE: The objective was to assess the feasibility of an intervention introducing family planning services screening clinical decision support to improve provision of contraception and/or preconception services for women of reproductive age in our primary care Federally Qualified Health Center (FQHC) network. STUDY DESIGN: We implemented a family planning services screening prompt for support staff to ask women 13-44 years at nonobstetric visits at specified time intervals. The response was displayed in the electronic medical record for the provider to review, linked to a documentation tool. We evaluated staff comfort with the screening before and after rollout at all seven FQHC sites. At the pilot site, we examined implementation feasibility by assessing screening rate and the outcome measure of family planning (contraception and/or preconception) documentation during visits by women 13-44 years before and during the intervention's first year. RESULTS: At baseline, support staff reported high level of comfort (60% very, 25% somewhat) in asking the family planning services screening question; this increased to 80% reporting they were "very comfortable" in the postsurvey (p = <.01). From mid-December 2016-mid-January 2018, the screening question was displayed for 1503 visits at the pilot site, of which 96% had a documented response. Family planning documentation rate at the pilot site showed a 6% increase from 64% during the preintervention period to 70% during the 13-month intervention period (p<.01). Time series analysis demonstrated more positive upward trend attributed to the intervention period (intervention R2=0.15 vs. preintervention R2=0.01). CONCLUSION: Our study demonstrated high staff acceptability of the intervention at all sites and a high screening rate with a significant increase in family planning documentation rate at the pilot site during the intervention period. This suggests that this family planning services screening decision support intervention is feasible in an FQHC setting. IMPLICATIONS: Implementation of a family planning services screening decision support intervention is feasible in an FQHC setting. Further evaluation of performance at multiple sites, accounting for variable site characteristics, is needed.

A data extraction algorithm for assessment of contraceptive counseling and provision.

BACKGROUND: Contraception counseling and provision is an essential preventative service. Real-time assessment of these services is critical for quality improvement and comparative study. Direct observation is not feasible on a large scale, so indirect measures (such as chart review) have been determined to be acceptable tools for this assessment. Computer-aided chart review has significant benefits over manual chart review as far as greater efficiency and ease of repeated measurements. The wide use of electronic medical records provides an opportunity to create a data extraction algorithm for computer-aided chart review that is sharable among institutions. We provide a useful schema for others who use electronic medical record systems and are interested in real-time assessment of contraception counseling and provision for the purposes of baseline assessment of services and quality improvement. OBJECTIVE: The purpose of this study was to create a comprehensive and accurate data extraction algorithm that is useful in the assessment of contraception counseling and provision rates in the outpatient setting. STUDY DESIGN: We included all visits between August 2015 and May 2016 at 8 outpatient clinics that are affiliated with a large, urban academic medical center in which nonpregnant women who were 14-45 years old were seen by a nurse practitioner, physician's assistant, or physician. Contraception-related prescriptions, International Classification of Diseases codes, current procedural terminology codes, and search-term capture were extracted with the use of structured query language from electronic medical record data that were stored in a relational database. The algorithm's hierarchy was designed to query prescription data first, followed by International Classification of Diseases and current procedural terminology codes, and finally search-term capture. Visits were censored when the first positive evidence of contraceptive service was obtained. Search terms were selected based on group discussion of investigators and providers. This algorithm was then compared with manual chart review and refined 3 times until high sensitivity and specificity, when compared with manual chart review, were achieved. RESULTS: There were 22,134 visits of reproductive-aged women who our inclusion criteria. Electronic medical record evidence of contraception counseling or provision was found in 56.9% of these visits. Of these, 21.3% were captured by prescriptions; 8.9% were captured by International Classification of Diseases codes, and 69.7% were captured by search-term capture with the use of our algorithm. Among visits with evidence of contraception counseling without provision, 15.7% were captured by diagnosis codes and 84.3% were captured by search-term capture. When compared with manual chart review, sensitivity and specificity improved from 0.79 and 0.85 to 0.99 and 0.98, respectively, over the 3 rounds of testing and revision. CONCLUSION: Data extraction algorithms can be used effectively for computer-aided chart review of contraception counseling and provision measures, but testing and refinement are extremely important. Search-term capture from unstructured data is a critical component of a comprehensive algorithm, especially for the capture of instances of contraception counseling without provision. The algorithm that we developed here could be used by others with an electronic medical record system who are interested in real-time assessment, quality improvement, and comparative study of the delivery of contraceptive services. The ease of execution of this algorithm also allows for its repeated use for ongoing assessments over time.

Beyond the Surface: Care Seeking Among Patients Initiating Contraceptive Implant in an Urban Federally Qualified Health Center Network.

PURPOSE: To describe rates of and reasons for follow-up among adolescents and adults receiving contraceptive implants in a Federally Qualified Health Center (FQHC). METHODS: Retrospective comparison of patient-initiated implant-related contacts during the 6 months postinsertion among adolescents (110) and adults (154) who had implants placed at a FQHC network. RESULTS: Forty percent of adolescents and 26% of adults initiated follow-up ( P = .016). Bleeding changes and discussing removal were the most common reasons for follow-up for both groups. Adolescents (5.5%) and adults (9.0%) had similar removal rates ( P = .348). However, among patients who discussed implant removal, adults were more likely to have removals compared with adolescents ( P = .002). CONCLUSIONS: Other FQHCs may anticipate a similar experience to ours, where adolescents may be more likely than adults to initiate implant-related follow up, with removal rates of less than 10% at 6 months. Further study of physician decision making and patient autonomy regarding implantable contraception removal requests is warranted.

Louisiana and Mississippi Family Physicians' Contraception Counseling for Adolescents with a Focus on Intrauterine Contraception.

STUDY OBJECTIVE: The adolescent pregnancy rate in Louisiana (LA) and Mississippi (MS) is one of the highest in the United States. One approach to decrease that rate is to increase contraceptive use. We sought to characterize LA and MS family physicians' (FPs) contraception counseling for adolescents with a focus on the intrauterine contraceptive device (IUD). DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Online survey of resident and practicing physician members of the LA and MS Academy of FPs. RESULTS: Three hundred ninety-eight of 1616 invited FPs responded; 244 were included in our analysis. When counseling adolescents about contraception, respondents "frequently discussed" oral contraceptives and condoms 87.5% (210/240) and 83.8% (202/241) of the time, respectively. Newer and more highly effective contraceptives such as the ring, patch, IUD, and implant were "frequently discussed" only 34.6% (82/237)-39.3% (92/234) of the time. In the previous 6 months, 56% (136/243) of respondents ever discussed an IUD with an adolescent. Respondents were more likely to have discussed IUDs if they learned IUD insertion during residency, had on-site access to IUD inserters, believed they were competent and/or comfortable with IUD counseling. In 5 clinical scenarios asking whether the respondent would recommend an IUD to a 17- or a 27-year-old patient (in all scenarios patients were eligible for an IUD), respondents were restrictive overall and significantly fewer would recommend an IUD for the adolescent. CONCLUSION: Our results suggest that there are missed opportunities for full-scope contraception counseling by LA and MS FPs. When these FPs counsel adolescents about contraception they less frequently discuss newer methods and more highly effective methods. Additionally many LA and MS FPs use overly restrictive eligibility criteria when considering IUDs.

US family physicians' intrauterine and implantable contraception provision: results from a national survey.

OBJECTIVE: Establish a current cross-sectional national picture of intrauterine device (IUD) and implant provision by US family physicians and ascertain individual, clinical site and scope of practice level associations with provision. STUDY DESIGN: Secondary analysis of data from 2329 family physicians recertifying with the American Board of Family Medicine in 2014. RESULTS: Overall, 19.7% of respondents regularly inserted IUDs, and 11.3% regularly inserted and/or removed implants. Family physicians provided these services in a wide range of clinical settings. In bivariate analysis, almost all of the individual, clinical site and scope of practice characteristics we examined were associated with provision of both methods. In multivariate analysis, the scope of practice characteristics showed the strongest association with both IUD and implant provision. For IUDs, this included providing prenatal care with [adjusted odds ratio (aOR) 3.26, 95% confidence interval (95% CI)=1.93-5.49] or without (aOR=3.38, 95% CI=1.88-6.06) delivery, performance of endometrial biopsies (aOR=16.51, 95% CI=11.97-22.79) and implant insertion and removal (aOR=8.78, 95% CI=5.79-13.33). For implants, it was providing prenatal care and delivery (aOR=1.77, 95% CI=1.15-2.74), office skin procedures (aOR=3.07, 95% CI=1.47-6.42), endometrial biopsies (aOR=3.67, 95% CI=2.41-5.59) and IUD insertion (aOR=8.58, 95% CI=5.70-12.91). CONCLUSIONS: While a minority of family physicians regularly provided IUDs and/or implants, those who provided did so in a broad range of outpatient settings. Individual and clinical site characteristics were not largely predictive of provision. This connotes potential for family physicians to increase IUD and implant access in a variety of settings. Provision of both methods was strongly associated with scope of practice variables including performance of certain office procedures as well as prenatal and/or obstetrical care. IMPLICATIONS: These data provide a baseline from which to analyze change in IUD and implant provision in family medicine, identify gaps in care and ascertain potential leverage points for interventions to increase long-acting reversible contraceptive provision by family physicians. Interventions may be more successful if they first focus on sites and/or family physicians who already provide prenatal care, obstetrical care, skin procedures and/or endometrial biopsies.

Urban Adolescents' and Young Adults' Decision-Making Process around Selection of Intrauterine Contraception.

STUDY OBJECTIVE: To examine adolescent and young adults' priorities, values, and preferences affecting the choice to use an intrauterine contraceptive device (IUD). DESIGN: Qualitative exploratory study with analysis done using a modified grounded theory approach. SETTING: Outpatient adolescent medicine clinic located within an academic children's hospital in the Bronx, New York. PARTICIPANTS: Twenty-seven women aged 16 to 25 years of age on the day of their IUD insertion. INTERVENTIONS AND MAIN OUTCOME MEASURES: We conducted semistructured interviews exploring participant's decision making process around selecting an IUD. We were specifically interested in elucidating factors that could potentially improve IUD counseling. RESULTS: We identified 4 broad factors affecting choice: (1) personal; (2) IUD device-specific; (3) health care provider; and (4) social network. Most of the participants perceived an ease with a user-independent method and were attracted by the high efficacy of IUDs, potential longevity of use, and the option to remove the device before its expiration. Participants described their health care provider as being the most influential individual during the IUD decision-making process via provision of reliable, accurate contraceptive information and demonstration of an actual device. Of all people in their social network, mothers played the biggest role. CONCLUSION: Adolescents and young women who choose an IUD appear to value the IUDs' efficacy and convenience, their relationship with and elements of clinicians' contraceptive counseling, and their mother's support. Our results suggest that during IUD counseling, clinicians should discuss these device-specific benefits, elicit patient questions and concerns, and use visual aids including the device itself. Incorporating the factors we found most salient into routine IUD counseling might increase the number of adolescents and young women who choose an IUD as a good fit for them.

Counseling Adolescents About the Intrauterine Contraceptive Device: A Comparison of Primary Care Pediatricians With Family Physicians and Obstetrician-Gynecologists in the Bronx, New York.

BACKGROUND: The intrauterine device (IUD) is a highly effective contraceptive, yet not all primary care providers (PCPs) counsel adolescents about IUDs. We sought to describe PCPs' frequency of counseling adolescents about IUDs and identify whether different factors are associated with frequent counseling by pediatricians compared with family physicians and gynecologists. METHODS: Surveyed PCPs affiliated with a Bronx, New York academic institution. MAIN OUTCOME: Frequent counseling of female adolescents about IUDs. RESULTS: Frequent counseling was lower in pediatricians compared with family physicians and gynecologists (35.8% and 81.6%, respectively, P < .001). Among all PCP types, frequent counseling was associated with feeling more competent counseling and managing expected IUD side effects (P < .001). Other significant variables included inserting IUDs themselves (P < .001, family physicians and gynecologists) or having access to an inserter in their office (P = .04, pediatricians). CONCLUSIONS: Correlates of frequent IUD counseling differed according to PCP specialty. Our results suggest that interventions to increase IUD counseling should focus on improving PCPs' competency around counseling and side effect management as well as increasing access to IUD inserters.

Intrauterine devices at six months: does patient age matter? Results from an urban family medicine federally qualified health center (FQHC) network.

BACKGROUND: Federally qualified health centers (FQHCs) can address high rates of unintended pregnancy among adolescents in the United States by increasing access to intrauterine devices (IUDs) in underserved settings. Despite national guidelines endorsing adolescent use of IUDs, some physicians remain concerned about IUD tolerance and safety in adolescents. Therefore we compared adolescents and adults in a family physician staffed FQHC network with regard to (1) IUD postinsertion experience, (2) device discontinuation, and (3) sexually transmitted infection (STI) rates. METHODS: We conducted a retrospective cohort study among women <36 years old who had an IUD inserted in 2011 at a New York City FQHC staffed by family physicians. RESULTS: We included 684 women (27% adolescents, 73% adults). During the 6-month postinsertion period, 59% of adolescents and 43% of adults initiated IUD-related clinical contact after insertion, most commonly for bleeding changes and pelvic or abdominal pain. There were no significant differences between groups in IUD expulsion or removal or STI rates. CONCLUSIONS: Urban FQHC providers may anticipate that, compared with their adult IUD users, adolescents will initiate more clinical follow-up visits after insertion. Both groups will, however, have similar clinical concerns about, reasons for, and rate of device discontinuation and low STI rates.

Fear of intrauterine contraception among adolescents in New York City.

OBJECTIVE: The intrauterine contraceptive device (IUD) is one of the most effective contraceptive methods, but it remains underutilized, especially among adolescents. Little is known about how adolescents perceive IUDs. The objective of this study is to explore urban, minority female adolescents' attitudes and beliefs about IUDs and to identify barriers to IUD use. STUDY DESIGN: Qualitative semistructured interviews were conducted with 21 adolescents aged 14 to 21 years who had heard about the IUD but never used one personally. Participants were recruited from two urban school-based health clinics and one community health center. Individual interviews were audiotaped and transcribed. Themes were identified by two independent researchers through line-by-line analysis of interview transcripts. RESULTS: Fear of the IUD predominated. Respondents related fears about pain, expulsion, foreign body and the potential for physical harm. Common themes in support of the IUD included the IUD's superior efficacy compared to other contraceptive methods and the ability to use this method long term. Despite identifying IUD benefits, most respondents did not appear to think the method would be well suited for them. CONCLUSION: Though the IUD is safe and effective for adolescents, we found that urban female adolescents have many device-related concerns which must be addressed to make this method more acceptable. IMPLICATIONS: Understanding urban, minority adolescents' perspective on IUDs and their specific concerns about IUD method use can help clinicians provide targeted and relevant contraceptive counseling.