BRIEF REPORTS. Providing Long-Acting Reversible Contraception in an Academic Family Medicine Center Jennifer Amico, MD, MPH; Justine Wu, MD, MPH

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1 Providing Long-Acting Reversible Contraception in an Academic Family Medicine Center Jennifer Amico, MD, MPH; Justine Wu, MD, MPH 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 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= ). 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. (Fam Med 2015;47(9): ) Long-acting reversible contraceptives (LARC) are the most effective reversible contraceptive methods 1-3 and include the intrauterine device (IUD) and the implant. The American Academy of Family Physicians recognizes LARC provision as a skill that falls within the scope of family medicine, 4,5 yet a recent national, randomized survey of family physicians revealed that only 24% had inserted an IUD in the last 12 months. 6 To our knowledge, no prior studies have documented clinical outcomes associated with LARC provision in an academic family medicine setting. The aim of this retrospective chart review was to determine 12-month rates of device continuation, elective removal, and IUD expulsion in an academic family medicine center (FMC). An exploratory study objective was to compare clinical outcomes by training level (faculty versus trainee). Methods This retrospective chart review included 209 women who received 219 LARC devices at an FMC in central New Jersey from June 2009 May During the analysis period, all patients received grant-provided devices at no cost, including the levonorgestrel intrauterine system (LNG-IUS), the copper IUD, and the etonogestrel implant. Patients were still responsible for the insertion cost by using their insurance benefits or paying out of pocket (a discounted fee of $122 $218). Faculty supervised all trainees (residents and medical students) involved in any LARC procedures. All providers used the same practice-wide consent forms, which also guided counseling regarding LARC benefits and possible side effects and risks. The FMC LARC Log, which documents all patients who have received a grant-funded device, was used to identify records for review. A single investigator (JA) abstracted data from the university-wide electronic medical record (EMR) From the Department of Family and Community Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ (Dr Amico); and Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI (Dr Wu). FAMILY MEDICINE VOL. 47, NO. 9 OCTOBER

2 that includes progress notes, phone notes, laboratory results, and radiology reports from all outpatient sites and the Emergency Department; all documents were reviewed from the date of the LARC insertion up to the date of the chart review. Demographic data that may influence clinical outcomes based upon previous literature 7-9 were obtained: age at the time of insertion, marital status, parity, history of vaginal deliveries, history of elective abortions, and body mass index (BMI) on the day of LARC insertion. Devices were considered to still be in place unless otherwise indicated in the EMR. We determined the clinician level of training by reviewing the procedure note, including the electronic signature. Using SPSS (version 20), we conducted life table analyses to estimate the 12-month continuation rate. To explore differences in continuation, removal, and expulsion rates between faculty and trainees, we plotted Kaplan-Meier survival curves and compared the curves with logrank tests. To adjust for potential confounders, we estimated Cox proportional hazards models and included all demographics noted previously (a=0.05). To check the assumptions of the proportional hazards models, we plotted the log-log of survival probability. The Robert Wood Johnson Medical School Institutional Review Board approved the study. Results We reviewed 225 visits for LARC insertions, of which 219 devices were successfully inserted (97.3%) (Table 1). Women 20 years comprised 12% of the total group; 43% of patients were nulliparous. Patient demographics did not differ significantly between faculty insertions and trainee insertions. LNG-IUS devices comprised the majority of devices (75.8%), followed by the copper IUD (15.5%) and the implant (8.7%) (Table 2). Table 1: Patient Demographics, by Physician Type (Faculty Versus Trainees), n=219 Insertions Demographics Total n=219 (%) Trainees n=119 (54.3%) Faculty n=100 (45.7%) P Value Age (12.8) 18 (15.1) 10 (10.0) (52.5) 63 (52.9) 52 (52.0) (22.3) 27 (22.7) 22 (22.0) (12.3) 11 (9.2) 16 (16.0).15 Marital status a Single 137 (69.9) 78 (65.5) 59 (59.0).33 Married 59 (30.1) 31 (26.1) 28 (28.0).76 Parity b Nulliparous 89 (43.2) 52 (43.7) 37 (37.0).34 Parous 117 (56.8) 62 (52.1) 55 (55.0).67 Previous vaginal delivery c Yes 70 (38.5) 33 (27.7) 37 (37.0).15 No 112 (61.5) 68 (57.1) 44 (44.0).06 Previous elective abortion d Yes 70 (36.3) 41 (34.5) 29 (29.0).47 No 123 (63.7) 65 (54.6) 58 (58.0).68 Body Mass Index b <25 kg/m 2 95 (46.1) 51 (44.3) 44 (48.4) kg/m 2 55 (26.7) 32 (27.8) 23 (25.3) kg/m 2 56 (27.2) 32 (27.8) 24 (26.4).88 a n=196, b n=206, c n=182, d n=193 Note: BMI was calculated and categorized per the World Health Organization: <25.0 kg/m 2 (normal weight/underweight), kg/m 2 (overweight), 30.0 kg/m 2 (obese). Note: Demographics do not include six encounters during which devices were not inserted: four women required two visits for insertion (one patient changed her mind during insertion, for three patients provider unable to pass uterine sound), two women did not have devices inserted (one patient changed her mind during insertion, one perforation identified during uterine sounding, the patient was observed and did not experience any untoward effects). 728 OCTOBER 2015 VOL. 47, NO. 9 FAMILY MEDICINE

3 Table 2: Successful LARC Insertions by Type of Device and Physician Type (Faculty Versus Trainees), n=219 Insertions Type of Device Total n=219 (%) Trainees n=119 (54.3%) Faculty n=100 (45.7%) LNG-IUS 166 (75.8) 95 (79.8) 71 (71) Copper IUD 34 (15.5) 20 (16.8) 14 (14) Implant 19 (8.7) 4 (3.4) 15 (15) LNG-IUS levonorgestrel intrauterine system The 12-month continuation rate was 78 per 100 woman-years for all devices (Figure 1). The continuation rate for faculty-inserted devices was higher than trainee-inserted devices (87 and 70 per 100 woman years, respectively, P<.05). The 12-month elective removal rate was 17 per 100 woman years (Figure 2); trainee-inserted devices were 2.43 times more likely to be removed than faculty-inserted devices (95% CI= ). The 12-month IUD expulsion rate was 7 per 100 woman years; the difference in the expulsion rate for faculty-inserted versus traineeinserted IUDs approached, but did not meet, statistical significance (HR 1.80, 95% CI= , P=.053). The majority of documented expulsions occurred within the first 12 months of insertion (46.7% of expulsions occurred within 3 months, 26.7% from 3 6 months, 8.3% from 6 12 months). The most common reasons devices were electively removed prior to the end of the manufacturer-approved Figure 1: Kaplan-Meier Survival Curves of LARC Continuation, Comparing Trainee-Inserted Devices to Faculty-Inserted Devices Log-rank test, P<.01 Median time from device insertion to date of chart review: 17.4 months LARC long-acting reversible contraceptive time period were undesired bleeding (46.2%) and pain (28.2%). Discussion The rates of LARC continuation, elective removal, and IUD expulsion at this academic FMC were similar to national estimates. 1,7,8,10,11 We also observed a significantly higher removal rate of devices placed by trainees compared to faculty. One possible reason for this finding is that trainees may be more likely to place IUDs in the lower uterine segment, which could lead to more pain and bleeding. This finding is consistent with a prior study reporting more removals for pain and bleeding for IUDs placed by less experienced providers. 12 Our 12-month IUD expulsion rate was 7.0%, which falls within the range of 2% 10% as reported previously. 1,7,8 The difference in expulsion rates between faculty and trainees approached but did not reach statistical significance. Larger, adequately powered studies are necessary to confirm this finding. One strength of our study is the inclusion of a high proportion of nulliparous women (43%) compared to studies in other settings, 7,9 which likely reflects a practice-wide acceptance that nulliparous women are appropriate IUD candidates. 13 There were several study limitations. If women sought care for device-related problems at clinical sites not captured by our EMR, we may have overestimated the LARC continuation rate. We reviewed charts from only one academic FMC with a robust reproductive health program; these data may not be generalizable to programs with less collective FAMILY MEDICINE VOL. 47, NO. 9 OCTOBER

4 Figure 2: Kaplan-Meier Hazard Curves of LARC Removals (A) and IUD Expulsion (B), Comparing Trainee-Inserted Devices to Faculty-Inserted Devices Notes: Faculty is referent group. HR 2.43, 95% CI= (trainees compared to faculty) Log-rank test, P=.030 Notes: Faculty is referent group. HR 1.80, 95% CI= (trainees compared to faculty) Log-rank test, P=.053 LARC long-acting reversible contraceptive experience. We were unable to reliably determine the primary care provider (PCP) for each patient based on the data available and therefore could not explore the potential influence of PCP versus non-pcp clinician on continuation rates. This study contributes new evidence that LARC provision in an academic family medicine setting, with a high proportion of nulliparous women receiving IUDs, is associated with acceptable continuation, removal, and expulsion rates. Adequately powered, prospective studies should be done to investigate the higher rate of removal among devices placed by trainees and mechanisms by which this may occur. ACKNOWLEDGMENTS: Preliminary data from this study have been presented as a poster at the 2012 Society of Teachers of Family Medicine Annual Spring Conference, Seattle, WA, and at the 2012 New Jersey Academy of Family Physicians Conference, Atlantic City, NJ. Disclosures: Justine Wu is a Nexplanon trainer for Merck. Jennifer Amico has no conflicts of interest to disclose. 730 OCTOBER 2015 VOL. 47, NO. 9 FAMILY MEDICINE

5 CORRESPONDING AUTHOR: Address correspondence to Dr Amico, Rutgers-Robert Wood Johnson Medical School, Department of Family and Community Medicine, 1 Robert Wood Johnson Place, MEB 262, New Brunswick, NJ Fax: amicojr@rwjms.rutgers.edu. References 1. Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart F. Contraceptive technology, 19th edition. New York: Ardent Media, Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med 2012;366(21): Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 2012;120(6): American Academy of Family Physicians. American Academy of Family Physicians Recommended Curriculum Guidelines for Family Medicine Residents: Women s Health medical_education_residency/program_directors/reprint282_women.pdf. Accessed December 18, American Academy of Family Physicians. American Academy of Family Physicians Recommended Curriculum Guidelines for Family Medicine Residents: Maternity and Gynecologic Care documents/medical_education_residency/ program_directors/reprint261_maternity.pdf. Accessed December 18, Rubin SE, Fletcher J, Stein T, Segall-Gutierrez P, Gold M. Determinants of intrauterine contraception provision among US family physicians: a national survey of knowledge, attitudes, and practice. Contraception 2011;83(5): Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol 2011;117(5): Garbers S, Haines-Stephan J, Lipton Y, Meserve A, Spieler L, Chiasson MA. Continuation of copper-containing intrauterine devices at 6 months. Contraception 2013;87(1): Dickerson LM, Diaz VA, Jordan J, et al. Satisfaction, early removal, and side effects associated with long-acting reversible contraception. Fam Med 2013;45(10): Blumenthal PD, Voedisch A, Gemzell-Danielsson K. Strategies to prevent unintended pregnancy: increasing use of long-acting reversible contraception. Human Reproduction Update 2011;17(1): Grunloh DS, Casner T, Secura GM, Peipert JF, Madden T. Characteristics associated with discontinuation of long-acting reversible contraception within the first 6 months of use. Obstet Gynecol 2013 Dec;122(6): Zhang J. Factors associated with copper T IUD removal for bleeding/pain: a multivariate analysis. Contraception 1993;48(1): Peterson HB, Cates W. Evidence-based medicine in action: the United States Selected Practice Recommendations for Contraceptive Use. Contraception 2013;87(5): FAMILY MEDICINE VOL. 47, NO. 9 OCTOBER