Download - Provision of Long Acting Reversible Contraception by Rural Primary Care Physicians in IL and WI
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Britt Lunde, MD MPHThe Mount Sinai School of Medicine
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Goal: increase proportion of intended pregnancies by 10%
(from 51% to 56%)
www.healthypeople.gov/2020
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Finer, 2011
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• For Women• Adequate Prenatal care• Smoking• Domestic violence• Depression
• And babies • Birth defects• Birth weight• Childhood health• Educational attainment
CDC MMWR 2007Cheng, Contracept 2009Logan, Child Trends 2007
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CCooppppeerr IIUUDD 00..66 %% 00..88 %%
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SSppeerrmmiicciiddeess 1188 %% 2299 %%
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Pre
gnan
cy r
ate
in f
irst
year
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use
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• Majority of rural physicians practice primary care
• IUD provision associated with gynecologist on site
• Patient recommendations vary by specialty• 1995 rural Idaho majority providing LARC
COGME 18th Report, Sept 2007Cope, J Gen Inter Med 2006Rosenblatt, Am J Public Health 1995
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• Rural Primary Care Physicians• Current provision of LARC• Perceived barriers to provision• Opportunities for further support and education
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• Cross sectional survey of physicians• Family Medicine and Internal Medicine• RUCA code ≥4 for practice zip code in IL
and WI• Development of survey
• WI Research and Education Network• UIC Survey Research Lab• Pilot interviews with rural physicians
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• Physicians have low response rates• Web surveys have low response rates• Survey literature on mixed-mode:
Kellerman, Am J Prev Med, 2001Millar M, Public Opinion Quarterly, 2011
Mode 1st response
2nd response
Final response
Web 42.3% 7.8% 50.2%
Mail 51.3 1.9 53.2
Choice 47.7 4.6 52.3
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Web(n = 538)
Paper(n = 324)
Total(n = 862)
Response rate, % 23.3 14.0 37.3
Age, years ±SD* 46.8 ±10.5 50.9 ±11.2 48.3 ±11.0
Insert IUDs, %* 38.7 27.9 34.6
Insert Implant, %*
10.8 5.4 8.7
Interview, %* 22.7 2.2 15.1
Gender, specialty no significant difference
* p<0.05
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All respondents
Place IUDs Adjusted OR
Total sample n=599
34.6
Female (%)Male
34.264.8
50.726.1
2.2 (1.3 – 3.7)ref
Age, mean ±SD 48.3 ±11.0 45.8 ± 10.6 ns
Family Medicine (%)Internal Medicine
80.616.9
42.21.8
4.0 (0.8 – 20.2)ref
Practice Ob (%) 28.3 72.5 7.4 (4.3 – 12.7)
Training post residency (%) in residency
8.250.9
69.455.7
2.1 (1.0 – 4.5)ref
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All respondents
Place Implant Adjusted OR
Total sample n=599 8.7
Female (%)Male
34.264.8
14.15.8
1.7 (0.5 – 5.4)ref
Age(mean ± SD)
48.3 ±10.9 43.8 ±10.2 2.3 (1.3 – 4.3)/10 years ↓
Family Medicine (%)Internal Medicine
80.616.9
10.30.9
2.6 (0.2 – 34.4)ref
Practice Ob (%) 28.5 19.9 9.8 (2.8 – 34.3)
Training post residency (%) in residency
9.43.7
71.439.1
9.2 (2.0 – 42.7)ref
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Family Medicine(n=483)
Internal Medicine
(101)
Eligible Response rate, %*
29.7 20.9
% female physicians* 36.4 23.8
Prescribe OCPs in practice, %*
93.4 59.4
Referral for IUD, %* Primary care MD Gynecologist
25.557.9
6.177.8
Distance to referral, % in same office <25 miles
49.838.6
57.336.7
* p<0.05
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% of Physicians
*=p <0.05
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Distance, miles*=p<0.05
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• More likely to provide LARC• Female• Practice OB• Training post-residency
• Providers’ perceived barriers• Patient interest and knowledge• Not physician’s practice pattern
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Thank you!
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• Centers for Disease Control and Prevention. Preconception and interconception health status of women who recently gave birth to a live-born infant—pregnancy risk assessment monitoring system (PRAMS), United States, 26 Reporting Areas, 2004. MMWR Weekly. 2007 Dec 14;56(SS-10):1-40.
• Cheng D, Schwarz E, Douglas E, Horon I. Unintended pregnancy and associated maternal preconception, prenatal and postpartum behaviors. Contracept 2009;79(3):194-8.
• Cope JR, Yano EM, Lee ML, Washington Dl. Determinants of contraceptive availability at medical facilities in the Department of Veterans Affairs. J Gen Intern Med. 2006 Mar;21 Suppl 3:S33-9.
• Council on Graduate Medical Education (COGME). Eighteenth report: new paradigms for physician training and improving access to health care. September 2007.
• Finer LB and Zolna MR. Unintended pregnancy in the United States: incidence and disparities. Contracept 2011; 84(5):478–85.
• Kellerman SE, Herold J. Physician response to surveys; a review of the literature. Am J Prev Med 2001;20(1):61-67.
• Logan C, Holcombe E, Manlove J, et al. The consequences of unintended childbearing: A white paper [Internet]. Washington: Child Trends, Inc.; 2007 May.
• Millar M and Dillman D. Improving response to web and mixed-mode surveys. Public Opinion Quarterly 2011;75(2):249-269.
• Rosenblatt R, Mattis R, and Hart LG. Abortions in rural Idaho: physicians’ attitudes and practices. Am J Public Health 1995;85:1423-5.
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Method Rural (%) Urban (%)
Sterilization Female Male
47.29.6
35.68.8
IUDImplant
5.00.3
4.90.3
Oral contraceptivesInjectable
24.34.0
24.53.0
Condoms 9.3 15.9
Withdrawal 3.8 4.8
None 8.2 11.8
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Adjusted OR
Rural no hs degreeRural hs degreeUrban no hs degreeUrban hs degreeRural and urban, >hs degree
7.9 (4.3 – 14.5)3.4 (2.0 – 5.8)2.0 (1.3 – 3.0)1.8 (1.2 – 2.8)ref
Income <100% of FPL 100-199% ≥200%
1.8 (1.0 – 3.0)1.5 (1.0 – 2.3)ref
Insurance Public None Private
0.8 (0.5 – 1.2)0.8 (0.5 – 1.2)ref
Adjusted for age, parity, relationship status