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A mystery shopper study identifying practice-level barriers to adolescent IUD access in western Pennsylvania
Journal Pre-proofs Brief Research Article A Mystery Shopper Study Identifying Practice-Level Barriers to Adolescent IUD Access in Western Pennsylvania Sarah E. Lim, Colleen M. Krajewski PII: DOI: Reference:
S0010-7824(19)30445-7 https://doi.org/10.1016/j.contraception.2019.10.011 CON 9349
To appear in:
Contraception
Received Date: Revised Date: Accepted Date:
30 June 2018 28 October 2019 30 October 2019
Please cite this article as: S.E. Lim, C.M. Krajewski, A Mystery Shopper Study Identifying Practice-Level Barriers to Adolescent IUD Access in Western Pennsylvania, Contraception (2019), doi: https://doi.org/10.1016/ j.contraception.2019.10.011
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2019 Published by Elsevier Inc.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Title: A Mystery Shopper Study Identifying Practice-Level Barriers to Adolescent IUD Access in Western Pennsylvania Author names and affiliations: Sarah E. Lima Colleen M. Krajewskib aUniversity
of Pittsburgh School of Medicine 3550 Terrace St, Pittsburgh, PA 15213 USA [email protected] (corresponding author) bUniversity
of Pittsburgh Department of Obstetrics, Gynecology & Reproductive Science 300 Halket Street, Pittsburgh PA 15213 USA Word count of abstract: 92 Word count of manuscript text: 1014 Tables: 1 Figures: 0 Appendices: 1
24
Abstract:
25
Objective(s): To identify practice-level barriers that adolescents experience when
26
seeking a hormonal intrauterine device (IUD).
27
Study design: We secret-shopped gynecological practices within a health system using a
28
script targeting potential practice-level barriers.
29
Results: We assessed 50 of a targeted 50 practices; only 8 (16%) would schedule a
30
contraceptive appointment that permitted same-day IUD placement. Twenty-eight (56%)
31
respondents stated a parent must accompany the adolescent.
32
Conclusion: Practice-level barriers to adolescent IUD access exist that are inconsistent
33
with best-practice guidelines and Pennsylvania state law.
34
Implications: Practice staff and providers need more medical and legal education
35
regarding IUD provision to adolescents.
36
Keywords: Adolescent; intrauterine device; contraception; mystery shopper;
37
Pennsylvania; barriers
38
39 40
1. Introduction The American College of Obstetricians and Gynecologists, American Academy of
41
Pediatrics, and American Academy of Family Physicians support intrauterine devices
42
(IUDs) as first-line contraceptive methods for adolescents based on efficacy,
43
acceptability, and safety data. [1-4] Adolescent decision-making regarding long-acting
44
reversible contraceptive use is influenced by clinical operations issues such as requiring a
45
2-day IUD insertion protocol, lack of insurance benefit and cost information, and failure
46
to assure consent and confidentiality. [5] Evidence-based practice supports removing
47
barriers to IUD access such as placing an IUD in asymptomatic patients on the same day
48
as sexually transmitted disease screening when infection is not present on exam. [6]
49
In 2013, 2.8% of U.S. teens aged 15-19 years reported using an intrauterine
50
device for contraception at Title X service sites; in Pennsylvania, the rate was 1.2%. [7]
51
We aimed to identify practice-level barriers that may account for this lower rate of
52
adolescent IUD utilization.
53
2. Materials and Methods
54
We used the University of Pittsburgh Medical Center (UPMC) directory to search
55
for gynecology providers and grouped 155 providers to 56 practices based on duplicate
56
addresses. We used practice addresses to determine their county, and whether they shared
57
an address with a hospital or were freestanding.
58
One author (SL) telephoned practices, identified as a nulliparous, sixteen-year-
59
old female seeking information about obtaining a hormonal intrauterine device. We
60
initiated a script [Appendix A] with the first person answering the phone and if an
61
automated option was available, selected to speak with the highest level of clinical staff.
62
We did not attempt the script with practices who did not provide IUDs.
63
We primarily assessed if practices were willing to schedule a contraceptive
64
appointment which included IUD placement at that appointment. We asked practices who
65
answered “No” why they would be unable to place an IUD at the first visit. We also
66
assessed practices for the availability of after-school appointments; ability to provide a
67
specific IUD information resource; ability to provide cost and insurance information; and
68
whether parental presence was required. We made three attempts to contact practice
69
managers after our primary data accrual was complete to confirm whether a practice was
70
willing to schedule a contraceptive appointment which included IUD placement at that
71
appointment and whether parental presence was required at contraceptive appointments.
72
We entered data at the time of the call on a secure web application, RedCAP
73
(www.ctsiredcap.pitt.edu). The University of Pittsburgh Institutional Review Board
74
approved this study.
75
3. Results
76
We contacted fifty-six practices; five did not provide IUDs and one did not
77
provide IUDs for self-referred patients. The 50 practices included 38 (76%) private and
78
21 (24%) hospital-affiliated. We spoke with many levels of staff, including medical
79
assistants, registered nurses, and nurse practitioners at practices within twelve counties.
80
Table 1 summarizes practice response frequencies for the targeted potential
81
practice-level barriers. Eight (16%) practices said they could provide IUD insertion at the
82
first contraceptive visit; 38 (76%) answered "No" or "Not usually" and 4 (8%) said it
83
depended on the provider. Most gave several reasons for saying “No” or “Not usually”,
84
such as practice policy (n=14), requiring negative STI test results or normal pap test
85
(n=10), requiring an examination (n=3), requiring insertion timing with menses (n=14),
86
and needing time to order the IUD (n=5) or verify insurance coverage (n=16).
87
Of the 30 (60%) practices that offered a specific source of information about the
88
IUD, the information was typically a product website or offering to mail a company
89
promotional pamphlet. The 20 (40%) practices that did not offer information told the
90
patient to search online or wait for the appointment.
91
We successfully contacted 38 (76%) practice managers. The majority (n=29,76%)
92
confirmed staff responses regarding the primary outcome and the question of parental
93
presence at the contraceptive appointment, but there were discrepancies reported. Two
94
managers said their staff incorrectly answered “Yes” when asked if an adolescent
95
could receive an IUD insertion at the first contraceptive visit. With regards to the
96
question of required parental presence, four managers said their staff incorrectly
97
answered “No” and four others said their staff incorrectly answered “Yes.”
98
4. Discussion
99
This study assessed an aspect of the adolescent patient experience that occurs
100
prior to meeting a provider, which could impact the patient-provider experience or
101
prevent an appointment from being scheduled. All but one practice had practice-level
102
barriers to adolescent IUD access. Many follow policies inconsistent with recommended
103
standards of care, such as requiring two visits, negative STI testing prior to IUD
104
insertion, or an insertion timed with menses. [6] Twenty-eight (56%) practices required
105
parental presence for a contraceptive appointment, even though Pennsylvania supports
106
the right to consent to contraceptive care for individuals above age fourteen. [8]
107
Strengths of this study include high practice response rate and outcomes derived
108
from realistic encounters under standardized conditions. The diversity of practices
109
spanning 12 counties and including hospital and community-based sites emphasizes the
110
pervasive nature of the barriers identified.
111
This study is limited by sampling error characteristic of secret-shopper studies.
112
We interacted with clinical staff of different levels of training and were only able to
113
contact 76% of practice managers to verify the primary outcome and the question of
114
parental presence at the contraceptive appointment.
115
The confirmation of information by practice mangers, though limited by a
116
suboptimal response rate, does raise two important points– first, managers confirmed that
117
over half (56%) of practices require parental presence for IUD provision which is
118
contrary to the state law that they practice in, and second that only 3 out of 4 callers were
119
given correct information regarding key practice policies. Information given to the
120
mystery shopper may not reflect the clinical practice of IUD providers, but an adolescent
121
would be reasonable to conclude that they do and make contraceptive decisions
122
accordingly.
123
We identified practice-level barriers among gynecology practices of a large
124
Pennsylvania health care system that may contribute to low rates of IUD uptake in
125
adolescents. Identified barriers include policies and practices inconsistent with
126
professional guidelines and state law. We clearly need continued education in all levels of
127
practice staff to reduce barriers to care. Further research assessing the extent to which
128
these barriers and others limit IUD uptake may guide improvement efforts.
129
130 131 132 133 134
Acknowledgements: We would like to thank Jeanine Buchanich, PhD, M.Ed of the
135
University of Pittsburgh School of Public Health for her assistance with our data
136
analyses. We would like to thank Christy Boraas, MD of the University of Minnesota
137
with her assistance in preparing this manuscript.
138 139
Funding: This research did not receive any specific grant from funding agencies in the
140
public, commercial, or not-for-profit sectors.
141 142 143
Conflicts of interest: The authors have no conflicts of interest to disclose.
144
References
145
[1] Adolescents and long-acting reversible contraception: implants and intrauterine
146
devices. Committee Opinion No. 735. American College of Obstetricians and
147
Gynecologists. Obstet Gynecol 2018;131:e130–9.
148 149 150 151 152 153 154
[2] Klein DA, Arnold JJ, Reese ES. Provision of Contraception: Key Recommendations from the CDC. Am Fam Physician 2015;91:625–33. [3] Contraception for Adolescents. Committee on Adolescence. American Academy of Pediatrics. Pediatrics 2014:134:e1244-56. [4] Counseling adolescents about contraception. Committee Opinion No. 710. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e74–80. [5] Pritt NM, Norris AH, Berlan ED. Barriers and facilitators to adolescents’ use of long-
155
acting reversible contraceptives. J Pediatr Adolesc Gynecol 2017;30:18–22.
156
[6] Long-acting reversible contraception: implants and intrauterine devices. Practice
157
Bulletin No. 186. American College of Obstetricians and Gynecologists. Obstet
158
Gynecol 2017;130:e251–69.
159
[7] Romero L, Pazol K, Warner L, Gavin L, Moskosky S, Besera G, et al. Vital Signs:
160
Trends in Use of Long-Acting Reversible Contraception Among Teens Aged 15–19
161
Years Seeking Contraceptive Services — United States, 2005–2013. MMWR
162
2015;64:363–9.
163
[8] American Civil Liberties Union of Pennsylvania. “Do you have to tell my mom?”
164
Minors, Health Care & the Law, https://www.aclupa.org/our-work/duvall-
165
reproductive-freedom-project/minorsaccesstoconfidential/minors-health-care-and-the-
166
law.
S0010-7824(19)30445-7 https://doi.org/10.1016/j.contraception.2019.10.011 CON 9349
To appear in:
Contraception
Received Date: Revised Date: Accepted Date:
30 June 2018 28 October 2019 30 October 2019
Please cite this article as: S.E. Lim, C.M. Krajewski, A Mystery Shopper Study Identifying Practice-Level Barriers to Adolescent IUD Access in Western Pennsylvania, Contraception (2019), doi: https://doi.org/10.1016/ j.contraception.2019.10.011
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2019 Published by Elsevier Inc.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Title: A Mystery Shopper Study Identifying Practice-Level Barriers to Adolescent IUD Access in Western Pennsylvania Author names and affiliations: Sarah E. Lima Colleen M. Krajewskib aUniversity
of Pittsburgh School of Medicine 3550 Terrace St, Pittsburgh, PA 15213 USA [email protected] (corresponding author) bUniversity
of Pittsburgh Department of Obstetrics, Gynecology & Reproductive Science 300 Halket Street, Pittsburgh PA 15213 USA Word count of abstract: 92 Word count of manuscript text: 1014 Tables: 1 Figures: 0 Appendices: 1
24
Abstract:
25
Objective(s): To identify practice-level barriers that adolescents experience when
26
seeking a hormonal intrauterine device (IUD).
27
Study design: We secret-shopped gynecological practices within a health system using a
28
script targeting potential practice-level barriers.
29
Results: We assessed 50 of a targeted 50 practices; only 8 (16%) would schedule a
30
contraceptive appointment that permitted same-day IUD placement. Twenty-eight (56%)
31
respondents stated a parent must accompany the adolescent.
32
Conclusion: Practice-level barriers to adolescent IUD access exist that are inconsistent
33
with best-practice guidelines and Pennsylvania state law.
34
Implications: Practice staff and providers need more medical and legal education
35
regarding IUD provision to adolescents.
36
Keywords: Adolescent; intrauterine device; contraception; mystery shopper;
37
Pennsylvania; barriers
38
39 40
1. Introduction The American College of Obstetricians and Gynecologists, American Academy of
41
Pediatrics, and American Academy of Family Physicians support intrauterine devices
42
(IUDs) as first-line contraceptive methods for adolescents based on efficacy,
43
acceptability, and safety data. [1-4] Adolescent decision-making regarding long-acting
44
reversible contraceptive use is influenced by clinical operations issues such as requiring a
45
2-day IUD insertion protocol, lack of insurance benefit and cost information, and failure
46
to assure consent and confidentiality. [5] Evidence-based practice supports removing
47
barriers to IUD access such as placing an IUD in asymptomatic patients on the same day
48
as sexually transmitted disease screening when infection is not present on exam. [6]
49
In 2013, 2.8% of U.S. teens aged 15-19 years reported using an intrauterine
50
device for contraception at Title X service sites; in Pennsylvania, the rate was 1.2%. [7]
51
We aimed to identify practice-level barriers that may account for this lower rate of
52
adolescent IUD utilization.
53
2. Materials and Methods
54
We used the University of Pittsburgh Medical Center (UPMC) directory to search
55
for gynecology providers and grouped 155 providers to 56 practices based on duplicate
56
addresses. We used practice addresses to determine their county, and whether they shared
57
an address with a hospital or were freestanding.
58
One author (SL) telephoned practices, identified as a nulliparous, sixteen-year-
59
old female seeking information about obtaining a hormonal intrauterine device. We
60
initiated a script [Appendix A] with the first person answering the phone and if an
61
automated option was available, selected to speak with the highest level of clinical staff.
62
We did not attempt the script with practices who did not provide IUDs.
63
We primarily assessed if practices were willing to schedule a contraceptive
64
appointment which included IUD placement at that appointment. We asked practices who
65
answered “No” why they would be unable to place an IUD at the first visit. We also
66
assessed practices for the availability of after-school appointments; ability to provide a
67
specific IUD information resource; ability to provide cost and insurance information; and
68
whether parental presence was required. We made three attempts to contact practice
69
managers after our primary data accrual was complete to confirm whether a practice was
70
willing to schedule a contraceptive appointment which included IUD placement at that
71
appointment and whether parental presence was required at contraceptive appointments.
72
We entered data at the time of the call on a secure web application, RedCAP
73
(www.ctsiredcap.pitt.edu). The University of Pittsburgh Institutional Review Board
74
approved this study.
75
3. Results
76
We contacted fifty-six practices; five did not provide IUDs and one did not
77
provide IUDs for self-referred patients. The 50 practices included 38 (76%) private and
78
21 (24%) hospital-affiliated. We spoke with many levels of staff, including medical
79
assistants, registered nurses, and nurse practitioners at practices within twelve counties.
80
Table 1 summarizes practice response frequencies for the targeted potential
81
practice-level barriers. Eight (16%) practices said they could provide IUD insertion at the
82
first contraceptive visit; 38 (76%) answered "No" or "Not usually" and 4 (8%) said it
83
depended on the provider. Most gave several reasons for saying “No” or “Not usually”,
84
such as practice policy (n=14), requiring negative STI test results or normal pap test
85
(n=10), requiring an examination (n=3), requiring insertion timing with menses (n=14),
86
and needing time to order the IUD (n=5) or verify insurance coverage (n=16).
87
Of the 30 (60%) practices that offered a specific source of information about the
88
IUD, the information was typically a product website or offering to mail a company
89
promotional pamphlet. The 20 (40%) practices that did not offer information told the
90
patient to search online or wait for the appointment.
91
We successfully contacted 38 (76%) practice managers. The majority (n=29,76%)
92
confirmed staff responses regarding the primary outcome and the question of parental
93
presence at the contraceptive appointment, but there were discrepancies reported. Two
94
managers said their staff incorrectly answered “Yes” when asked if an adolescent
95
could receive an IUD insertion at the first contraceptive visit. With regards to the
96
question of required parental presence, four managers said their staff incorrectly
97
answered “No” and four others said their staff incorrectly answered “Yes.”
98
4. Discussion
99
This study assessed an aspect of the adolescent patient experience that occurs
100
prior to meeting a provider, which could impact the patient-provider experience or
101
prevent an appointment from being scheduled. All but one practice had practice-level
102
barriers to adolescent IUD access. Many follow policies inconsistent with recommended
103
standards of care, such as requiring two visits, negative STI testing prior to IUD
104
insertion, or an insertion timed with menses. [6] Twenty-eight (56%) practices required
105
parental presence for a contraceptive appointment, even though Pennsylvania supports
106
the right to consent to contraceptive care for individuals above age fourteen. [8]
107
Strengths of this study include high practice response rate and outcomes derived
108
from realistic encounters under standardized conditions. The diversity of practices
109
spanning 12 counties and including hospital and community-based sites emphasizes the
110
pervasive nature of the barriers identified.
111
This study is limited by sampling error characteristic of secret-shopper studies.
112
We interacted with clinical staff of different levels of training and were only able to
113
contact 76% of practice managers to verify the primary outcome and the question of
114
parental presence at the contraceptive appointment.
115
The confirmation of information by practice mangers, though limited by a
116
suboptimal response rate, does raise two important points– first, managers confirmed that
117
over half (56%) of practices require parental presence for IUD provision which is
118
contrary to the state law that they practice in, and second that only 3 out of 4 callers were
119
given correct information regarding key practice policies. Information given to the
120
mystery shopper may not reflect the clinical practice of IUD providers, but an adolescent
121
would be reasonable to conclude that they do and make contraceptive decisions
122
accordingly.
123
We identified practice-level barriers among gynecology practices of a large
124
Pennsylvania health care system that may contribute to low rates of IUD uptake in
125
adolescents. Identified barriers include policies and practices inconsistent with
126
professional guidelines and state law. We clearly need continued education in all levels of
127
practice staff to reduce barriers to care. Further research assessing the extent to which
128
these barriers and others limit IUD uptake may guide improvement efforts.
129
130 131 132 133 134
Acknowledgements: We would like to thank Jeanine Buchanich, PhD, M.Ed of the
135
University of Pittsburgh School of Public Health for her assistance with our data
136
analyses. We would like to thank Christy Boraas, MD of the University of Minnesota
137
with her assistance in preparing this manuscript.
138 139
Funding: This research did not receive any specific grant from funding agencies in the
140
public, commercial, or not-for-profit sectors.
141 142 143
Conflicts of interest: The authors have no conflicts of interest to disclose.
144
References
145
[1] Adolescents and long-acting reversible contraception: implants and intrauterine
146
devices. Committee Opinion No. 735. American College of Obstetricians and
147
Gynecologists. Obstet Gynecol 2018;131:e130–9.
148 149 150 151 152 153 154
[2] Klein DA, Arnold JJ, Reese ES. Provision of Contraception: Key Recommendations from the CDC. Am Fam Physician 2015;91:625–33. [3] Contraception for Adolescents. Committee on Adolescence. American Academy of Pediatrics. Pediatrics 2014:134:e1244-56. [4] Counseling adolescents about contraception. Committee Opinion No. 710. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e74–80. [5] Pritt NM, Norris AH, Berlan ED. Barriers and facilitators to adolescents’ use of long-
155
acting reversible contraceptives. J Pediatr Adolesc Gynecol 2017;30:18–22.
156
[6] Long-acting reversible contraception: implants and intrauterine devices. Practice
157
Bulletin No. 186. American College of Obstetricians and Gynecologists. Obstet
158
Gynecol 2017;130:e251–69.
159
[7] Romero L, Pazol K, Warner L, Gavin L, Moskosky S, Besera G, et al. Vital Signs:
160
Trends in Use of Long-Acting Reversible Contraception Among Teens Aged 15–19
161
Years Seeking Contraceptive Services — United States, 2005–2013. MMWR
162
2015;64:363–9.
163
[8] American Civil Liberties Union of Pennsylvania. “Do you have to tell my mom?”
164
Minors, Health Care & the Law, https://www.aclupa.org/our-work/duvall-
165
reproductive-freedom-project/minorsaccesstoconfidential/minors-health-care-and-the-
166
law.