Maximizing LARC Availability: Bringing the Lessons of the CHOICE Project to Your Community

Transcription

1

2 Maximizing LARC Availability: Bringing the Lessons of the CHOICE Project to Your Community Reproductive Health 2012 September 21, 2012 David Turok, MD/MPH

3 Objectives Communicate to colleagues the reduction in unintended pregnancies with use of IUDs/implants. Communicate to patients the reduction in unintended pregnancies with use of IUDs/implants. Utilize 3 methods to improve access to IUDs and implants

4 Disclosure I receive research support from: Medicines 360 for the LNG 20 IUS study Teva for IUD research (& advisory council) Bioceptive for research on a novel IUD inserter Bayer Women s Health I am not involved in the CHOICE Project at all but I wish to thank those who are for the good work they ve done.

5 Unintended Pregnancy in the U.S. Intended 51% Unintended 49% Unintended births 23% Elective abortions 27% 1.3 million abortions/yr Fam Plann Perspect 1996;28: Perspect Sex Reprod Health. 2006;38:90-6 Finer and Zolna. Contraception 2011;84:

6 The Paradigm Shift is Happening Now We are a crucial part of it Supply side Demand side

7 Per 1,00 women Unintended Pregnancy Rate, U.S. women age fold difference fold difference Income below poverty level Income > 200% of poverty level Finer and Zolna. Contraception 2011;84:

8 LARC: Call it What You Like Contraception as effective as sterilization Lasts for at least 3 years following insertion Reversible Requires a medical provider to insert it LARC vs. HERC vs Our best chance to reduce unintended pregnancy

9 Highly Effective Reversible Contraception Copper T380A Hormone Free 12 yrs use LNG IUD 20mcg levonorgestrel released daily 5 years use Implanon Etonorgestrel 3 years use

10 The CHOICE Project 9,256 women in St. Louis Offered any reversible contraception Primary outcome: contraceptive failure No cost to participants Followed for 3 years Primary purpose is to promote LARC

11 What are the Barriers to Increasing LARC Access? Providers don t have time for counseling IUDs hurt, they re hard to get in, & expensive Too much irregular bleeding with the Implant Women discontinue the methods too quickly

12 Overcome Every Barrier to Providing LARC Methods Providers Uniform counseling on what works best Provide it NOW! No cost Lots of support

13 Start with Inform Women What Works Best Be aware of all contraceptive options Especially the most effective, reversible, longacting methods These methods include the IUD and the contraceptive Implant

14 CHOICE & Olympics Visualize the Olympic rings or your favorite Olympic moment

15 CHOICE Participants by Age (years)

16 CHOICE Participant Education

17 CHOICE is Representative of St. Louis

18 CHOICE Project Demographics Characteristic HS education or less 34 African American 47 Have trouble paying for basic needs % of Choice Population 40 Nulliparous 48 Had a prior unintended pregnancy 60 Had an abortion 40 Mean age of participants = 25 years old Peipert et al. Obstet Gynecol 2011;117:

19 Are CHOICE Patients Like Your Patients? Characteris tic CHOICE % NSFG % Absolute Difference Age Hispanic Black, non- Hispanic Married Education 12 th Grade Low Income Effect Size (Cohen s h) Kittur et al. Contraception 2011;83:479-85

20 CHOICE Project Prelim Results (1 yr) Method Starting n % Choosing Method % Continuing Method at 12 months % Very Satisfied LNG IUD 1,890 45% 87.5% 70.4% Copper IUD % 84.0% 65.6% Implant % 83.3% 54.8% Depo 313 8% 56.5% 42.3% OCPs % 55.1% 41.0% Ring % 54.2% 46.6% Peipert et al. Obstet Gynecol 2011;117:

21 Contraceptive Method Initiated

22 IUD vs. Implant Use by Age Group

23 LARC Users Continued Use at Higher Rates

24 Pregnancy Rates Winner et al. NEJM 2012:366:

25 16 X

26 Contraceptive Continuation Rates

27 Real World OCP Refill Rates 2 studies of prescription databases Almost 2 million women included OCP prescription refill rates: 1 month 59-75% 3 months 48-64% 12 months 16-35% Murphy P, Brixner D. Contraception 2008;77: Nelson AL, Westhoff C, Schnare SM. Obstet Gynecol 2008;112:782-7

28 12 Month Prospective Hormonal Contraception Continuation Raine, Obstet Gynecol 2011;117:363 71

29 Why Do Women Discontinue Hormonal Contraception? Raine, Obstet Gynecol 2011;117:363 71

30 CHOICE Users Rx Refills Analysis of late refills 619 women 6,435 Rxs for Pill, Patch, or Ring Pittman et al. Contraception 2011;83:

31 CHOICE Users Rx Refills 619 women 6,435 Rxs for Pill, Patch, or Ring 30% never missed a refill 31% had 1 late refill 39% had 2 or more late refills 55% were still using these methods at 1 year Pittman et al. Contraception 2011;83:

32 Acknowledge the Imperfections Not everyone is satisfied with these methods Expect failed insertions & higher rates of expulsion/removal Keep your eye on the prize Increasing their use has the potential to dramatically decrease unintended pregnancies

33 100 New Contraceptors: CHOICE vs. Your Clinic CHOICE 75 women choose LARC No insertion failures 86% continue at 1 year 65 LARC users at 1 year YOFPC 50 women choose LARC 60% continue at 1 year 5 can t get it inserted 5 expulsions 15 removals 25 LARC users at 1 year

34 What Else Will CHOICE Teach Us? Fertility after IUD discontinuation Relationship between STIs & IUDs

35 Take Home Points IUP & Implant users have lowest risk of UIP Start contraceptive counseling with Provide it NOW! Minimize patient costs* (ACA will help a lot) Lots of support