Six percent (61/1,000) of sites were found to be invalid as a result of closures (n=10), disenrollment (n=6), administrative (n=4), duplicate (n=9) or wrong (n=32) address, and did not serve female Family PACT clients in fiscal year 2009–2010 (n=6), leaving a final sample of 939 eligible sites. After three follow-up mailings, one follow-up telephone call, and up to six e-mail reminders for those with an available e-mail address, 636 of the 939 eligible sites completed the survey for a response rate of 68% (Fig. 1). Responding sites served a greater average number of Family PACT clients (1,794 compared with 931; P<.001) than nonresponders. Four surveys that could not be linked to the administrative database and 49 nonadvanced practice clinician respondents were excluded from all analyses, leaving a final sample of 587 for analysis. Most participants chose to complete the mail-in survey (75%), 22% completed the survey online, and on request, 3% completed the survey through a telephone interview with the lead author.
Respondent and site characteristics are presented in Table 1. Seventy-two percent of study respondents were physicians, 15% were nurse practitioners, 5% were physician assistants, and 2% were certified nurse midwives. More than half (62%) were site medical directors (n=362), 6% (n=34) were chiefs of obstetrics–gynecology or pediatrics, and the remaining respondents were assistant or associate medical directors, clinic managers, or other clinic staff (32%, n=184). Nearly half (45%) completed their clinical training between 1985 and 1999.
The median number of women provided a Family PACT service in fiscal year 2009–2010 was 919 ranging from 28 to 15,888 women per site (Table 1). Nearly half (44%) of sites experienced an increase in the number of Family PACT clients dispensed an IUD according to claims; more than one fourth (26%) experienced an increase in the number of clients dispensed an implant. Three fourths (74%) of respondents discussed IUDs and 49% discussed the implant routinely with many or most contraceptive patients (Table 1). Approximately 69% (395/573) of respondents reported that their site offered IUDs onsite, whereas 62% (363/587) had Family PACT claims for IUDs (not shown). Forty percent (218/544) of site respondents said the contraceptive implant was available onsite and 30% (175/587) had a paid claim for the implant (not shown). When self-report and administrative claims data were combined, most sites offered the hormonal (65%, n=382) and copper (66%, n=389) IUD onsite. Forty-one percent (n=241) of sites offered the contraceptive implant onsite. According to this combined measure, 72% (421/587) offered at least one of the three LARC methods onsite.
Respondents considered more types of women suitable for the implant than for IUDs (P<.001). They were least likely to consider women with a history of pelvic inflammatory disease suitable for IUDs followed by nulliparous women, with a history of ectopic pregnancy, and teenagers (Table 2). Respondents were most likely to consider smokers (16%) and women with a history of hypertension (14%) inappropriate for the contraceptive implant.
Most respondents agreed (93%) that the IUD is safe. Approximately half correctly agreed that an IUD can be inserted immediately postabortion (56%) or immediately postpartum (43%; Table 3). Three fourths (76%) felt that a follow-up visit is necessary after an IUD insertion, 41% correctly disagreed that IUDs cause an abortion, one third (33%) felt that IUDs increase the risk of pelvic inflammatory disease, 57% disagreed that a patient with pelvic inflammatory disease needs to have her IUD removed to treat for pelvic inflammatory disease, 11% incorrectly believed that antibiotic prophylaxis is indicated at the time of IUD insertion, and 11% felt that an IUD is more likely to lead to lawsuits.
Most respondents viewed the implant as safe (80%) and 19% reported no opinion on safety. Sixty-one percent agreed that the implant can be inserted at any time in the menstrual cycle, 72% agreed that little pain is experienced at the site of placement, and 50% erroneously agreed that a follow-up visit is necessary after implant insertion (Table 3). In bivariate analyses, all respondent and practice characteristics were significantly associated with both outcome variables (Table 4).
According to multivariable logistic regression general estimation equation models, respondents representing community health centers were significantly more likely to offer the IUC onsite (odds ratio [OR] 3.84, 95% confidence interval [CI] 2.10–7.03) than private practice respondents. Respondents trained in IUD insertion (OR 9.15, CI 5.16–16.23) and who held beliefs that favor IUD provision (OR 2.03, CI 1.25–3.25) were more likely to represent a site that offers IUDs onsite than those without such training and less favorable beliefs.
Similar variables were significantly associated with onsite implant provision in multivariable analyses. When compared with private practice respondents, those from Planned Parenthood, community health centers, and county or city clinic sites were more likely to offer implants onsite. The unusually high OR for Planned Parenthood sites is the result of the limited variability among this group with all but one health care provider offering implants onsite. Respondents with implant insertion training (OR 7.71, CI 4.79–12.41) and who held more favorable beliefs about the implant (OR 1.91, CI 1.34–2.74) were more likely to represent a site with onsite implant provision.
These findings suggest increased provision and understanding about LARC among California health care providers. This sample represents an ideal scenario for LARC provision because the patient barrier of cost is removed through Family PACT reimbursement. Nearly all respondents (93%) viewed the IUD as safe, a proportion similar to the previous Family PACT and other surveys and higher than a national survey of health care providers where three fifths described IUDs as safe.9,16 When compared with the prior Family PACT IUD survey, assessments of appropriate candidates for the IUD expanded on all measures, particularly on perceptions of the suitability of IUDs for nulliparous women and women with a history of ectopic pregnancy.5 The vast majority of respondents in this study were aware that antibiotic prophylaxis and a follow-up visit are unnecessary for IUD care and few were concerned about lawsuits stemming from the provision of IUDs.
However, these results demonstrate that there is still need for practices and beliefs that favor LARC provision. Approximately one fifth of respondents would not recommend IUDs for teenagers, nulliparous women, or women with a history of pelvic inflammatory disease, ectopic pregnancy, or sexually transmitted Infections. A sizeable proportion did not believe that IUDs should be inserted postabortion or postpartum; approximately one third or more also believed that IUDs cause abortion. Such beliefs may lead to limited contraceptive choices for women and a greater burden on patients and health care providers by unnecessarily requiring additional visits and procedures. These findings point to the need to further strengthen and incorporate professional guidelines into health care provider education efforts so as to ensure that women are offered all the contraceptive choices available to them. Office of Family Planning training efforts have already shown success in changing IUD attitudes among Family PACT attendees.17
A considerable minority of respondents expressed no opinion regarding the safety or appropriate clinical protocols for the contraceptive implant. Those familiar with the contraceptive implant held a fairly expansive view of the patients considered suitable for this method, particularly when compared with the patients considered suitable for IUDs. On average, less than one patient type was considered inappropriate for the implant, yet one fifth of health care providers stated they had “no opinion” regarding the implant's safety, insertion timing, whether a follow-up visit is necessary, or whether placement is painful, suggesting that a good level of understanding about this relatively new method has not yet been achieved.
Interestingly, although respondents held more expansive views about the implant than IUDs, fewer offer the implant than the IUD onsite. Nearly three fourths offer IUDs onsite compared with only 41% offering implants onsite, possibly a reflection of insufficient trained health care providers because only half reported training in this area. Health care providers may not be sufficiently skilled or knowledgeable about how to best provide the implant, low patient demand, or both may be influencing the lower level of implant compared with IUD provision.
Family PACT’s diverse provider network is a valued component of the program, giving clients greater flexibility when choosing the health care provider that best suits their needs. Onsite insertion of LARC is also clearly an advantage to women, precluding them from having to seek care over several visits and potentially from different sites. However, the findings from this study show that inherent in this array of health care providers are diverse LARC beliefs and practices that in turn may shape and influence the options women are offered. Understanding the strategies implemented by the best performing health care providers could help design future interventions. Tailored training approaches for health care providers at sites not offering LARC methods would help reach the health care providers who may benefit most from such training.
This study must be viewed in light of its limitations. Our data are mostly based on self-report, which may not be an accurate measure of the extent of LARC counseling that takes place in each practice. Although we attempted to improve the reliability of our onsite LARC provision variable by creating a measure that included both self-report and billing data, both may be inaccurate. The respondent may not be fully aware of the types of methods available at their practice and claims data can include billing errors. In addition, each respondent represented the views of their entire site, which does not take into account the diversity of beliefs and practices that likely exist within each site. By choosing the medical director or senior clinician who oversees family planning services at each site, we hope to have captured the prevailing views that may influence the entire practice.
Furthermore, our scales and indices have not been validated and do not capture the complexity of an individual patient's profile, which may determine whether a clinician finds it appropriate to discuss and offer a particular method to its clients. Many respondents held “no opinion” on several items in our LARC beliefs scales, potentially limiting their validity. We chose to code “no opinion” as neutral but its meaning may vary for different items and respondents. Use of a different scoring methodology would have likely changed our results.
In our sampling strategy, the probability of selecting a Family PACT site was proportional to the number of female Family PACT clients served at the site. This method was used to ensure that our findings would be generalizable to the Family PACT provider population to whom the typical female client is exposed. Sites that served few female Family PACT clients are not well represented and their site directors likely hold different views and practices than those who responded to this survey.
Use of LARC services among Family PACT clients has increased significantly in recent years, surpassing that of national estimates.12,18 These changes in LARC provision and use are likely the result of an array of factors including changing recommendations, increased training, and the changing, more favorable views of LARC presented in this study, yet many clinicians from sites offering family planning services have not kept pace with recent professional guidelines, suggesting the need for continued work aimed at informing health care providers of current recommendations.
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© 2014 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.
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