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The Contraceptive CHOICE Project
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Objectives
• Describe the study design and methods
• Review key findings from Pre-CHOICE surveys
• Review important findings from CHOICE
• Discuss dissemination and translation of
results into practice
Unintended Pregnancy in the U.S.
• Over 3 million unintended pregnancies
– 59% mistimed
– 39% unwanted
• 1.2 million abortions
• 367,752 births to teens 15-19 years
• Contraception
– 52% non-use
– 43% incorrect use
Finer Contraception 2011; Hamilton
NCHS 2012; Frost Guttmacher Inst 2008
Long-acting Reversible
Contraception (LARC)
LNG-IUS
• 99% effective
• 20 mcg
levonorgestrel/day
• Up to 5 years
Copper T IUD
• 99% effective
• Copper ions
• Up to 10 years
Subdermal Implant
• 99% effective
• 60 mcg
etonogestrel/day
• Up to 3 years
Study Primary Objectives
• To increase the acceptance and use of long-acting
reversible contraceptive (LARC) methods among
women of childbearing age
• To measure acceptability, satisfaction, sideeffects, and rates of continuation across a variety
of reversible contraceptive methods, including
long-acting reversible methods
Study Hypotheses
• Increase IUD use
– Sentinel clinics from <2% to 6% or more
– Post-abortion insertion <1% to 10% or more
• Increase implant use to 3% or more
• Observe higher 12-month continuation rates for
LARC vs. other methods
• Population outcomes
– Teen pregnancy decline by 10%
– Repeat abortion decline by 10%
Study Design: Prospective Cohort
Exposure
Outcome
ELIGIBLE
2–3 y
LNG-IUS
Cu-IUD
Implant
DMPA
Pills
Patch
Ring
Other
Unintended
pregnancy
Teen pregnancy
Repeat abortion
Abortion
Continuation
Satisfaction
STI
Study Inclusion Criteria
• 14-45 years
• Primary residency in STL City or County
• Sexually active with male partner
(or soon to be)
• Does not desire pregnancy during next 12
months
• Desires reversible contraception
• Willing to try a new contraceptive method
Study Timeline
Screening & Enrollment
Introduce study
Enroll participant!
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•
•
•
•
Eligibility screen
LARC Blurb
Eligible
Offer participation
Agrees
Contraceptive Counseling
Informed Consent
Contact Information
Medical Record Authorization
Clinical Forms and
Evaluation
• Baseline STI
• Baseline Survey
• Method Allocation
Contraceptive Counseling
• P000001
• Development and training included
–
–
–
–
–
Counseling Framework
Standard Script
Contraception 101 Lecture
Counseling and Medical History Forms
Testing & Observation
• Provided by 53 research staff & volunteers
– 37 staff, 14 medical, 1 graduate and 1 undergraduate
students
• Additional resource for managing patient calls
Madden Contraception 2012
Contraceptive “Menu of Options”
Study Recruitment
10,000
Location
2 Abortion clinics
8 Community clinics
University-based
research clinic
• Word-of-mouth
• Provider referrals
9,256
17%
14%
69%
9,000
8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
Study Follow-Up Rates
Survey
98% 94%
6
12
87%
81%
24
36
Pre-CHOICE Survey Results
STL Population Survey
• Objective: Survey knowledge and attitudes about
IUDs among women in St. Louis area
• Methods:
– 8-page written survey
– Mailed to 12,500 randomly selected households
• One adult female in household asked to complete survey
• 1,665 of 7,722 (22%) deliverable and eligible surveys
returned
– Measures:
• Obstetric & contraceptive history
• Knowledge regarding method effectiveness
• Knowledge regarding appropriate candidates, side effects,
and myths of IUD
Hladky Obstet Gynecol 2011
STL Population Survey Results
• Respondents overall:
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–
–
–
–
Mean age = 31.9
57% white
82% had insurance (83% private)
70% greater than high school education
18% history of abortion
• 127 (8%) were currently using or had used IUD
– Slightly older (mean age = 32.4)
– More likely to be parous
– More likely to be receiving public assistance
Hladky Obstet Gynecol 2011
MYTHS Regarding IUDs
• 50% of women surveyed believe IUD is SAFE
• Common safety concerns:
– Pelvic Pain
– Infertility
– Cancer
– STDs
36%
30%
14%
11%
• 61% underestimate the effectiveness
Hladky Obstet Gynecol 2011
Knowledge About IUDs
STL Population Survey Results
STL Provider Survey
• Objective: Survey knowledge and attitudes about IUD
among providers in St. Louis area
• Methods:
– Written self-administered survey
– Mailed to 250 providers
• Medical directories and electronic searches
• 137/186 (73.7%) delivered and eligible surveys returned
– Measures:
• Demographic characteristics
• Graduate medical training
• Contraceptive patients seen and willingness to insert IUD
Madden Contraception 2010
STL Provider Survey Results
• 99% physicians
• 85% white, 4% black, 10% other
• Residency training:
– 44% completed before 1989
– 41% 1989-1999
– 16% after 1999
• 56% completed residency at a Catholic institution
• Contraceptive patients each week
– 35%: 0–25
– 50%: 26-50
– 15%: 50+
Madden Contraception 2010
STL Provider Survey Results
• 36% not trained in IUD insertion during
residency or clinical training
• Discussed IUD with patients
– 18% “always”
– 75% “most or some of the time”
• 66% reported inserted >10 IUD in past year
• GC/CT testing prior to IUD insertion
– 40% always
– 52% sometimes
Madden Contraception 2010
STL Provider Survey Results
• Appropriate candidates for IUDs
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62% nulliparous
31% adolescent
45% STI in past 2 years
37% PID in past 5 years
37% non-monogamous relationship
• Offer IUD
– 98% if 35 y.o., married, with 3 children
– 50% if unmarried 17 y.o., monogamous, and one child
– 19% if unmarried 17 y.o., never been pregnant
Madden Contraception 2010
CHOICE Project Results
CHOICE Study Participants
Peipert Obstet Gynecol 2012
Baseline Chosen Method
%
LNG-IUS
Copper IUD
Implant
DMPA
Pills
Ring
Patch
Other
46.0
11.9
16.9
6.9
9.4
7.0
1.8
<1.0
75%
Peipert Obstet & Gynecol 2012
Choice of LARC Methods
among Adolescents
Mestad Contraception 2011
12-Month Continuation
Method
Continuation Rate (%)
LNG-IUS
87.5
Copper IUD
84.1
Implant
83.3
Any LARC
86.2
DMPA
56.2
OCPs
55.0
Ring
54.2
Patch
49.5
Non-LARC
54.7
Peipert Obstet Gynecol 2011
12-month Continuation: Adolescents
Compared to Older Women
Rosenstock Obstet Gynecol 2012
Unintended Pregnancy by
Contraceptive Method
Participants with Contraceptive
Failure (%)
LARC
DMPA
PPR
12%
10%
8%
HRadj = 22.3
95% CI 14.0, 35.4
6%
4%
2%
0%
1
2
Year
3
Winner NEJM 2012
Method Failure by Age
Winner NEJM 2012
Repeat Abortion in St. Louis Region
• Data obtained from MO DHHS
– Represents women who reside in Missouri at time of
abortion
• Repeat abortion measured as ever had a
previous abortion
• Compared to Kansas City & non-metro MO
– KC: One abortion clinic
– KC: Similar demographic characteristics to STL
Repeat Abortion 2006 - 2010
Percent of repeat abortions
55%
50%
45%
St. Louis City/County
40%
Kansas City
Non-Metro Missouri
35%
30%
25%
2006
2007
2008
2009
2010
Test of Trend 2006-2010: STL, p=.002; KC, p=.003; Non-metro MO, p=.18
Peipert Obstet Gynecol 2012
CHOICE Compared to U.S.
• Teen birth rate (age 15-19 years)
– 6.3 per 1,000 teens (first year use rate)
– 16.3 per 1,000 teens (average annual rate)
– Compared to 34.3 per 1,000 nationally
• Abortion rate (women ages 15-44)
– 6.0 per 1,000 women (average annual rate)
– Compared to 19.6 per 1,000 nationally
• Unintended pregnancy rate
– 15.0 per 1,000 women (average annual rate)
– Cumulative: 35.0 per 1,000 women
– Compared to 52.0 per 1,000 nationally
Peipert Obstet Gynecol 2012
Main Findings from CHOICE
• Women overwhelmingly choose LARC
• LARC methods associated with higher
continuation & satisfaction than shorter-acting
methods
– Regardless of age
• LARC methods associated with lower rates of
unintended pregnancy
• Increasing LARC use can decrease unintended
pregnancy in the population
Dissemination &
Translating Research into Practice
The Secret: 3 Key Ingredients
• Education regarding all methods, especially LARC
– Reframe the conversation to start with the most
effective methods
• Access to providers who will offer & provide LARC
– Dispel myths and increase the practice of evidencebased medicine
• Affordable contraception
– Institute of Medicine recommendation, Affordable
Care Act, Medicaid Expansion
Successful Implementation of
CHOICE Model
Key
Element
Barrier
Facilitator
Education
Limited time for contraceptive
counseling during appointment
Counseling provided by non-clinician
trained in tiered-based counseling
Outdated myths regarding
teens as LARC candidates
Identify local “champion clinician”
who is LARC proficient, trusted, and
can dispel myths
Lack of reimbursement for
contraceptive method,
insertion & removal
Network with clinics that have
identified how best to manage cost
issue through effective billing or
payer mix
Access
Cost
Up-front cost of stocking LARC Investigate ways to purchase a few
methods for same-day
methods that serve as temporary
insertions
supply
Dissemination Strategies
• Create online Resource Center to disseminate
CHOICE materials LARC First
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The Evidence
Contraceptive Counseling
Advanced Practitioner Resources
Patient Management
Effective Staffing & Management
• Provide technical assistance to end users
– >100 national & international requests
• Evaluate how CHOICE materials are adopted and
adapted for successful use
– PCORI Funding
40
Online Resource Center
Examples of Dissemination
Courtesy of Mary Alexander, Healthy Start Indianapolis
Dissemination Strategies
• National forums & grand rounds
• Community presentations & festivals/events
Dissemination Strategies
• Website transitioned from recruitment to
resource guide
• Social media
• Lay Press
• Short videos
Open the Dialog Video
http://www.youtube.com/watch?v=VAsdg7f7M7w
Pathway to Choice Video
http://www.youtube.com/watch?v=cd46pXtMHOo
What method is right for you?
http://www.youtube.com/watch?v=u9SHoy1C3tU
To Learn More Visit
www.choiceproject.wustl.edu
www.facebook.com/choiceproject
http://www.youtube.com/user/WUSTLChoiceProject
https://twitter.com/WUSTLChoice