the clinician-health educator team and counseling for · pdf filethe clinician-health educator...

The clinician-health educator team and

counseling for LARC

Presented to the ARHP annual meeting September 2013

Kirsten M. Thompson, MPH Lisa Stern, MSN, APRN Marsha Gelt, MPH J. Joseph Speidel, MD MPH Cynthia C. Harper, PhD

Department of Obstetrics, Gynecology and Reproductive

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Objectives

•  Identify common barriers to client LARC access

•  Describe how this study intervention changed patient care

•  Name strategies to address barriers


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Disclosures

•  Kirsten Thompson, Marsha Gelt, Joseph Speidel, and Cynthia Harper have no financial relationships to disclose.

•  Lisa Stern has received research funding from Teva and Bayer for an unrelated project.


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Tell us about your practice

•  How do you feel about your team’s current LARC provision?

•  What is getting in the way of improving client access to LARC?


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Formative research

•  Common barriers to LARC access across practice settings

–  High cost to clients

–  Clinic flow issues

–  No recent provider training

Thompson KM et al. Contraception 2011. Morse J et al. Perspect Sex Reprod Health 2012.

Harper CC et al. Family Medicine 2012.


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Study design

•  Cluster randomized controlled trial with Planned Parenthood clinics

•  Research question: Can we improve LARC access with an in-service training?

•  Intervention: 4-hour CME-accredited in-service training on LARC

•  Ethical approval from UCSF & Allendale IRBs


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Clinic sample

•  40 eligible Planned Parenthood clinics: –  ≥ 400 clients per year

–  No shared staff with other study sites

–  No private funds for free contraceptives


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•  Eligible staff: –  Worked at participating clinics

–  Conducted contraceptive education with clients

•  Surveys assessed LARC knowledge, attitudes, and counseling practices

•  Issued at baseline (n=410) & 12 months post-training (n=463)

•  42% of staff changed between surveys

Staff sample & methods


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•  Use of evidence-based LARC eligibility criteria

•  Counseling in order of typical use effectiveness

•  Routinely discussing IUDs & implants with contraceptive clients

What were we trying to change?

WHO et al. Family Planning: A Global Handbook for Providers. 2007.


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Evidence-based eligibility criteria

•  Would you consider an IUD for a… Teenager? Nullipara? Unmarried client? Smoker? Obese client?

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No Yes Arm 0 57% 43% Arm 1 58% 42%

Baseline proportion of staff with evidence-based LARC eligibility criteria, by study arm

p = 0.8


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Differences between team members

•  A higher proportion of clinicians had evidence-based views compared to health educators

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No Yes Clinician 18% 82% Health educator

76% 24%

Baseline proportion of staff with evidence-based LARC eligibility criteria, by staff position

p < 0.001


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Counseling in order of effectiveness

•  How often do you discuss contraception in such a way that you mention the most effective methods before the least effective methods?

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No Yes Arm 0 26% 74% Arm 1 37% 63%

Baseline proportion of staff who counsel in order of effectiveness, by study arm

p = 0.02


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Routinely discuss IUDs

•  Among female clients seeking contraception, how frequently do you discuss IUDs?

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No Yes Arm 0 24% 76% Arm 1 29% 71%

Baseline proportion of staff who routinely discuss IUDs, by study arm

p = 0.3


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Routinely discuss implant

•  Among female clients seeking contraception, how frequently do you discuss the implant?

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No Yes Arm 0 42% 58% Arm 1 42% 58%

Baseline proportion of staff who routinely discuss implants, by study arm

p = 0.9


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Training audience included…

•  Clinicians •  Medical assistants •  Health educators •  Front desk staff •  Clinic manager •  Billing specialists

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Intervention training •  Self-assessment for LARC biases •  Videos showing:

–  peers’ positive experiences with integrating LARC –  young women’s experiences of using methods

•  Providers’ role in LARC access •  Evidence-based eligibility criteria •  Counseling techniques •  Common client concerns •  Concurrent practica for health educators &

clinicians


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Videos

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Case Study: Mari

•  18 years old, no children

•  Forgets to take the Pill

•  Had PID two years ago

•  Wants to finish college before having children

•  Requests an IUD

Would your clinic give her a LARC?


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Do IUDs increase PID or infertility?

•  No, IUDs do not increase risk of PID •  No, IUDs do not decrease future fertility

CASE STUDY

Hubacher D et al. N Engl J Med. 2001. Grimes D. Lancet. 2000.

Farley T et al. Lancet. 1992. Toivonen J et al. Obstet Gynecol. 1991.


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Can women with a history of PID use an IUD?

•  Yes, women with PID history can use IUDs •  Active PID is contraindication

CASE STUDY

ACOG Practice Bulletin. Obstet Gynecol. 2005. Skjeldestad F et al. Contraception. 1996.

Centers for Disease Control. MMWR. 2010.

CDC Medical Eligibility for Initiating Contraception

Condition LNG-IUS or Copper IUD

Pelvic inflammatory disease

Past PID, subsequent pregnancy 1

Past PID, no subsequent pregnancy 2

Current PID 4


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Can women who have no children use an IUD?

•  Yes, IUDs are appropriate for women with no children

CASE STUDY

Veldhuis H. Eur J Gen Pract. 2004. Suhonen S et al. Contraception. 2004.

Thonneau P et al. Human Reprod. 2006. ACOG Committee Opinion 539. Obstet Gynecol. 2012.


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Can women with a history of STIs use an IUD?

•  Yes. Past infections are not a contra-indication to any method of contraception.

CASE STUDY

ACOG Practice Bulletin. Obstet Gynecol. 2005. Skjeldestad F et al. Contraception. 1996.

Centers for Disease Control. MMWR. 2010.

CDC Medical Eligibility for Initiating Contraception

Condition LNG-IUS or Copper IUD

Sexually Transmitted Infections

Current vaginitis 2

Current chlamydia, gonorrhea, or purulent cervicitis

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STI screening and IUD insertion

•  Women at high personal risk à screen before IUD placement

•  Same-day screening and placement if:

–  Patient can be reached for treatment

–  Clinic flow allows for longer visit

•  Women at low personal risk for STIs may safely use IUDs without screening tests

ACOG Practice Bulletin. Obstet Gynecol. 2005. MacIsaac L and Espey E. Obstet Gynecol Clin N Am. 2007.

Sufrin CB et al. Obstet Gynecol. 2012.

CASE STUDY


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Implementing changes

•  Sites had time to make changes •  Optional training for implants •  Packet for new staff, feedback form, and lots of

other communication with sites •  Staff surveyed again 12 months after training

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Evidence-based eligibility criteria

•  Use of evidence-based eligibility criteria for LARC increased in Arm 1

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Baseline Endline No Yes No Yes

Arm 0 57% 43% 55% 45% Arm 1 58% 42% 42% 58%

Endline proportion of staff who counsel in order of effectiveness, by arm

p = 0.01


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Differences between team members

•  Health educator knowledge increased, but difference persisted

•  42% staff turnover, mostly health educators in both study arms

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Clinician 18% 82% 19% 81% Health educator

76% 24% 61% 39%

Endline proportion of staff with evidence-based LARC eligibility criteria, by staff position

p < 0.001


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Counseling in order of effectiveness

•  Large increase in Arm 1 staff counseling in order of typical use effectiveness

•  Largest change among health educators

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Arm 0 26% 74% 30% 70% Arm 1 37% 63% 17% 83%

Endline proportion of staff who counsel in order of effectiveness, by arm

p = 0.001


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Routinely discuss IUDs

•  Increase in routine IUD counseling in both arms; significantly higher in Arm 1

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Arm 0 24% 76% 19% 81% Arm 1 29% 71% 13% 87%

Endline proportion of staff who discuss implants, by arm

p = 0.05


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School of Medicine

Routinely discuss implants

•  Increase in routine IUD counseling in both arms; significantly higher in Arm 1

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Arm 0 42% 58% 30% 70% Arm 1 42% 58% 21% 79%

Endline proportion of staff who discuss implants, by arm

p = 0.04


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Take home points

•  A 4-hour training can change patient care! Best practices: •  Get buy in from staff at all levels •  Ensure all team members have training

appropriate to their roles •  Same-day provision should be standard care •  Patient education materials in waiting areas •  Evaluate progress

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Team involvement

•  What changes would be most helpful to increase LARC access at your practice?

–  front desk changes

–  counseling changes

–  screening simplifications

–  clinical or protocol changes

–  paperwork changes

–  clinic flow changes


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Resources

•  Where to find the MEC •  UCSF trainings •  ACOG LARC program: coding guide, practice

guidelines •  Patient assistance programs

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Thank you!

[email protected]

[email protected]

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