Accessibility of long-acting reversible contraceptives (LARCs) in Federally Qualified Health Centers (FQHCs)

Contraception 89 (2014) 91 – 96

Original research article

Accessibility of long-acting reversible contraceptives (LARCs) in Federally Qualified Health Centers (FQHCs)☆ Tishra Beeson⁎, Susan Wood, Brian Bruen, Debora Goetz Goldberg, Holly Mead, Sara Rosenbaum Department of Health Policy, The George Washington University School of Public Health and Health Services, Washington, DC 2006, USA Received 29 April 2013; revised 24 September 2013; accepted 24 September 2013

Abstract Objective(s): This study examines the on-site availability of long-acting reversible contraception (LARC) methods, defined here as intrauterine devices and contraceptive implants, at Federally Qualified Health Centers (FQHCs). We also describe factors associated with onsite availability and specific challenges and barriers to providing on-site access to LARC as reported by FQHCs. Study design: An original survey of 423 FQHC organizations was fielded in 2011. Results: Over two thirds of FQHCs offer on-site availability of intrauterine devices yet only 36% of FQHCs report that they offer on-site contraceptive implants. Larger FQHCs and FQHCs receiving Title X Family Planning program funding are more likely to provide on-site access to LARC methods. Other organizational and patient characteristics are associated with the on-site availability of LARC methods, though this relationship varies by the type of method. The most commonly reported barriers to providing on-site access to LARC methods are related to the cost of stocking or supplying the drug and/or device, the perceived lack of staffing and training, and the unique needs of special populations. Conclusion: Our findings indicate that patients seeking care in small FQHC organizations, FQHCs with limited dedicated family planning funding and FQHCs located in rural areas may have fewer choices and limited access to LARC methods on-site. Implications: Despite the presumed widespread coverage of contraceptives for women as a result of provisions in the Affordable Care Act, there is a limited understanding of how FQHCs may redesign their practices to provide on-site availability of LARC methods. This study sheds light on the current state of practice and challenges related to providing LARC methods in FQHC settings. © 2014 Elsevier Inc. All rights reserved. Keywords: Long-acting reversible contraceptives; Community health centers; LARC

1. Introduction Long-acting reversible contraceptives (LARCs) are a highly effective, long-term contraceptive option for women [1,2]. LARCs are considered more effective in the prevention of unintended pregnancies during typical use than other methods because they require only a single insertion for long-term use, and they minimize the role of user adherence in contraceptive effectiveness [3]. The evidence base for contraception suggests that access to a range of contraceptive methods, particularly LARC, may

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Conflicts of Interest: The authors report no conflicts of interest. ⁎ Corresponding author. Tel.: + 1 202.994.4238. E-mail address: [email protected] (T. Beeson).

0010-7824/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.contraception.2013.09.014

increase contraceptive use and reduce unintended pregnancies [4,5]. Although low-income underserved women in the United States face disproportionately higher rates of unintended pregnancy, LARCs continue to be underutilized, likely because of the relatively high costs of these devices [6,7]. A recent study of over 9000 underserved women showed that, when cost barriers were removed, 75% of women chose a LARC method as their contraceptive method of choice. The same study demonstrated a significant reduction in indicators of unintended pregnancy among the population as a whole, such as rates of abortions, repeat abortions and teenage births, as a result of providing contraceptives at no cost to women [8]. Making LARC methods available on-site eliminates the challenge of patients needing a referral, acquiring the device on their own, or having to make an appointment elsewhere for

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insertion, and may improve the use of these highly effective methods among medically underserved populations. However, significant barriers to the provision of LARC methods continue to persist. In fact, a recent study of on-site availability of contraceptive methods in office-based practices and Title-X-funded clinics demonstrated that up to one third of these clinic settings referred patients out for LARC methods [4]. Prior literature reveals that financial cost, funding sources, clinician-level factors (such as provider type, attitudes, training and skills) and practice settings can be important factors in the provision of LARC methods [9–13]. Our study was designed to explore some of these factors with respect to the on-site availability of LARC methods in Federally Qualified Health Centers (FQHCs). FQHCs comprise one of the largest primary health care systems for the medically underserved, and by virtue of their federal designation, they are required to provide voluntary family planning services to all patients [14,16]. Despite FQHCs’ major role in providing this care, the scope and delivery of family planning services, including LARC, vary greatly across the FQHC system [17]. With this in mind, the Jacobs Institute of Women’s Health and the Geiger Gibson Program in Community Health Policy explored how FQHCs meet the family planning needs of the nearly 20 million patients they serve — including 5.6 million women of childbearing age — through an original survey on the scope and delivery of family planning services in FQHCs [15]. In 2011, approximately 1128 FQHCs were in operation; over 20 million patients received care at one of more than 8100 primary care delivery sites, and total patient visits exceeded 80 million [15,18]. Their mission is to furnish comprehensive primary health care to medically underserved communities whose populations experience elevated health risks and shortages of primary health care professionals. Notable patterns in the accessibility of contraceptive methods emerged from our survey findings, particularly with respect to the on-site availability of LARC methods in FQHC settings. We defined on-site availability as the provision or delivery of a particular contraceptive method directly at the responding FQHC’s largest primary care site without the need for referral or obtaining the method through an external source. We also explored FQHC participation in the Title X Family Planning program — a federal grant program that provides funding for family planning services to a network of 4400 community-based clinics, including some FQHCs [19]. 2. Materials and methods 2.1. Data sources We developed a survey of FQHC organizations in 2011. The purpose of the survey was to gather detailed information from FQHCs regarding the reproductive health services they offer, including family planning, and to explore the organization and delivery of these services both on-site and

through referral arrangements. FQHCs were also asked to report whether or not they had certain providers on staff at their largest clinical site, including Obstetrician/Gynecologists (OB/GYNs), Certified Nurse Midwives and family planning educators. The survey was modified and extended from existing Guttmacher Institute surveys of publicly funded family planning clinics and adapted for the setting and services provided by FQHCs [20]. For the purposes of this paper, we reference the results pertaining to the provision of LARC methods by prescription only, on-site or through referral arrangements. Among a universe of 1128 FQHC organizations in 2011, we had contact information for 959 FQHCs. We sent the survey via email to both the chief executive officers and the chief medical officers of these 959 FQHCs. Weighting adjustments were utilized to account for the size (small, medium and large) and regional distribution of FQHC respondents by Census region (West, South, Midwest and East) [21]. This survey was reviewed and approved by the Institutional Review Board at the George Washington University. More information on the general methods and findings on the scope and organization of family planning services provided in FQHC settings have been published elsewhere [17,22]. We hypothesized that FQHCs receiving Title X funding, those that serve a larger volume of patients and those that employ OBGYN providers would be more likely to have on-site availability of LARC methods at their largest primary care sites. Our study measured the association of these important factors with the on-site availability of LARC methods at FQHCs in the United States. 2.2. Variables of interest For this analysis, we defined LARC methods according to the Centers for Disease Control and Prevention definition that includes the levonorgestrel-releasing intrauterine device (LNG-IUD), the copper IUD and the contraceptive implant [4]. In order to explore which contraceptive methods were available at the clinical site level, we asked FQHCs to identify their largest primary care site as the unit of analysis and to indicate whether LARC methods were available through prescription only, available on-site or available by referral. In a follow-up question, we asked FQHCs to identify their processes in the event of a LARC method only being available by prescription. For the purposes of multivariate regression analysis, we collapsed the two types of IUDs into one variable, noting that IUDs were available if the FQHC provided one or the other, or both onsite. FQHCs were also asked to identify the location of their largest primary care site as urban, suburban or rural. We defined large FQHCs as those that served 20,000 or more patients in the preceding calendar year, while medium FQHCs represent those serving 10,000–19,999 patients and small FQHCs represent those serving less than 10,000 patients annually. Staffing characteristics were treated as dichotomous variables, indicating either the presence or

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absence of an OB/GYN, Certified Nurse Midwife or family planning educator on staff. 2.3. Data analysis Our analysis of LARC availability in FQHC settings includes a descriptive summary of the number of FQHCs’ largest sites that provide these contraceptive methods and the mechanisms by which these methods are provided. We categorized the provision of LARC methods at FQHCs’ largest primary care site into three separate categories: (a) by prescription only, (b) on-site availability and (c) by referral. We grouped both referrals to external providers or clinics and referrals to other primary care sites within the FQHC organization in this third category to account for any circumstances in which a patient might not have on-site and timely access to readily available LARC methods. Our study also includes bivariate analysis using χ 2 tests of independence to determine if any significant differences in the on-site availability of LARC methods were observed between FQHCs of differing sizes and between FQHCs that receive Title X funding and those that do not. Our multivariate logistic regression explores the probability of an FQHC’s largest primary care site providing LARC methods on-site, given a set of organizational characteristics and population demographics. Approximately 414 FQHC respondents provided complete data on IUD availability, and 392 respondents provided complete data on the provision of contraceptive implants for the purposes of the multivariate regression analysis. Our models also include a separate control for the state of California because of the disproportionately high share of responses we received from that state. We also conducted Hosmer–Lemeshow goodness-of-fit tests for each of our models. All analyses were conducted using STATA version 11 [23]. Finally, we used thematic content analysis to assess key themes from an open-ended survey question on perceived barriers and challenges FQHCs face in providing family planning services. A team of two researchers conducted qualitative coding by reading all responses and conducting open coding for the development of key themes relating to barriers and challenges. The two researchers compared codes until consensus was achieved. Any discrepancies in the researchers’ coding selections served as interpretive discussion among the larger team of investigators.

3. Results

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graphics between respondent FQHCs and nonrespondent FQHCs and observed that respondents were not significantly different from nonrespondents on most characteristics except size (respondents tended to be larger than nonrespondents) and geographic distribution. FQHCs responding to our survey represented more than 1900 primary care delivery sites across the United States, and virtually all reported that they provide at least one contraceptive method (99.8%) [17]. While these FQHCs provide at least one contraceptive method, the availability of LARC methods at their largest clinical sites varies greatly across three mechanisms: through prescription only, on-site availability or by referral arrangement. Although the majority of FQHCs’ largest clinical sites provide on-site availability of both types of IUD methods (56% for LNG-IUD and 52% for copper IUD), slightly more than one third of FQHCs make referrals to provide these services. Only 36% of FQHCs’ largest clinical sites offer on-site delivery of contraceptive implants, suggesting that patients at most centers would have to seek this method outside of the FQHC (Table 1). When LARC methods were reported to be only available by prescription, approximately one third of FQHCs reported that the patient was responsible for obtaining the method or device elsewhere and then returning to the FQHC for insertion. Approximately 30% of FQHCs reported this prescription-only process for IUDs, and 27% of FQHCs described this process for the contraceptive implant. 3.2. Availability of LARC by FQHC size and receipt of Title X funding Our findings suggest that access to LARC methods at FQHCs’ largest clinical sites is highly correlated with both the size of the health care organization and the receipt of dedicated family planning funding through the Title X Family Planning program. A higher proportion of large FQHCs offered on-site availability of each LARC method category when compared with small or medium FQHCs. Similarly, a higher proportion of FQHCs receiving Title X family planning funding offered on-site delivery at their largest primary care site for each LARC method category compared with FQHCs not receiving this dedicated funding. These differences were statistically significant at an alpha of 0.05 (Table 2). 3.3. Factors associated with on-site availability of LARC Our multivariate analyses indicate that some common factors are significantly associated with the on-site availability of LARC at FQHCs’ largest clinical site (Table 3).

3.1. Summary of descriptive findings The survey had a 44% response rate (n= 423) during a 6month survey fielding period. FQHCs were categorized as small (34% of respondents), medium (29% of respondents) or large (37% of respondents) based on the annual patient volume reported in the Uniform Data System [15]. We compared organizational characteristics and patient population demo-

Table 1 Availability of LARCs, all FQHCs

LNG-IUD Copper IUD Implant

Prescription only

On-site

Referral or other

9% 9% 7%

56% 52% 36%

35% 39% 57%

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Table 2 On-site availability of LARCs, by size and receipt of Title X funds FQHC size a

LNG-IUD Copper IUD Implant a

Title X funding

Small or medium

Large

p value

Non-Title X recipient

Title X recipient

p value

56% 50% 33%

71% 72% 55%

b .01 b .01 b .01

55% 50% 35%

79% 80% 56%

b.01 b.01 b.01

Organizational size is defined as follows: small, b10,000 patients per year; medium, 10,000–19,999 patients per year; large, ≥ 20,000 patients per year.

First, FQHC size continues to have a strong association with ability to provide on-site delivery of LARC, with large FQHCs being over twice as likely to provide IUDs on-site at their largest primary care site compared to small FQHCs. They are also 3.3 times more likely than small FQHCs to provide the contraceptive implant on-site. Similar patterns occurred for medium-sized clinics compared to small clinics. These results confirmed our hypothesis that FQHCs serving larger volumes of patients would be more likely to offer onsite availability of LARC methods. FQHCs with Title X funding are also over three times as likely as FQHCs that do not receive such funding to provide on-site access to IUDs and almost twice as likely to provide on-site availability of contraceptive implants, further confirming our stated hypotheses. We also found that FQHCs that employed an OB/GYN provider on staff at their largest primary care site were more likely to have contraceptive implants available on-site, which confirmed our earlier hypothesis that staffing arrangements, particularly the presence of an OB/GYN, are associated with on-site availability of LARC even when controlling for the size of the FQHC organization. Another strongly associated factor for both IUDs and the contraceptive implant was location in a Western state; our adjustment for overrepresentation in the state of California actually tempered the Western state effect in both models, although this was not statistically significant in the model on contraceptive implants. Compared to FQHCs located in urban areas, rural FQHCs were less than half as likely to report providing contraceptive implants onsite. In addition, the percentage of Medicaid patients and the percentage of uninsured patients in an FQHC’s payer mix appear to be positively correlated with the on-site availability of contraceptive implants, although this relationship does not hold true for IUDs. Both models exhibited goodness-of-fit tests at satisfactory significance levels. 3.4. Challenges and barriers to providing LARC methods at FQHCs Among our 423 respondents, over half (57%) of FQHCs reported at least one barrier to meeting the family planning needs of their patient population. Among the open-ended responses related to the provision of LARC methods, there were 44 unique references to IUDs, contraceptive implants or LARC methods in general. Among responses that were specifically attributable to the provision of a given contraceptive method, FQHCs reported more challenges in

providing IUDs and implants compared to any other method. Among the few respondents who offered qualitative comments, the most commonly reported challenges were related to the cost of stocking IUD devices and implant supplies, poor reimbursement for IUD insertion, the cost burden for patients related to purchasing IUD or implant devices, the need for training staff for IUD and implant insertion, and specific challenges related to providing LARC methods to special populations such as adolescents and undocumented immigrants. One respondent FQHC’s comments highlight the challenges related to the cost of providing LARC, noting that the “cost of IUDs and lack of reimbursement prevent us from stocking IUDs. Patients have to bring devices for insertion on-site,” while another indicated, “costs are always a barrier especially for our uninsured patients. LARC methods remain the best contraception to offer but are prohibitively costly to provide to uninsured clients.” Another FQHC respondent commented, “financial pressures are always a concern. It has been a great challenge to purchase [implants] and also to expend the time, effort and financial resources to provide training to our licensed personnel.” 4. Discussion Our findings indicate that both the receipt of Title X family planning funding and the size of the FQHC are strongly correlated with a higher probability of LARC methods being available on-site at FQHCs. These results suggest that direct and on-site availability of such methods may be influenced by financing mechanisms, particularly by the receipt of Title X funding. Our findings also demonstrate that regional variation exists with respect to the on-site delivery of LARC, particularly exhibited by the high degree of on-site availability of LARC at FQHCs in the West region. We also found evidence of poorer on-site availability of contraceptive implants in FQHCs that identified their largest primary care site as being located in a rural area. These findings indicate that patients seeking care in small FQHC organizations, FQHCs with limited dedicated family planning funding and FQHCs located in rural areas may have fewer choices and limited access to LARC methods on-site. We also found a positive but small correlation between the presence of an OB/GYN on staff and the on-site availability of contraceptive implants, which confirms prior research findings that indicate resources for family planning services,

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Table 3 Factors associated with on-site availability of LARC methods

Organizational characteristics Small size a (reference group) Medium size Large size Non-Title X (reference group) Title X Number of sites Region Northeast (reference group) West South Midwest Urbanicity Urban (reference group) Rural Suburban Staffing OB/GYN on staff Certified Nurse Midwife on staff Family planning educator on staff Patient characteristics Percent privately/other insured (reference group) Percent Medicaid Percent uninsured Oversampling adjustment for California Goodness-of-fit test a

IUDs

Implants

n=414

n= 392

Odds ratio

(95% CI)

p value

Odds ratio

(95% CI)

p value

– 1.95 2.12 – 3.12 1.01

– (1.2–3.16) (1.14–3.95) – (1.8–5.50) (0.94–1.09)

– b.01 .02 – b.01 .76

– 2.49 3.25 – 1.93 0.99

– (1.48–4.19) (1.73–6.12) – (1.23–3.04) (0.92–1.07)

– b .01 b .01 – b .01 .83

– 4.48 0.60 1.47

– (1.64–12.27) (0.27–1.33) (0.60–3.63)

– b0.01 .21 .40

– 5.09 1.78 2.34

– (1.95–13.26) (0.81–3.90) (0.96–5.72)

– b .01 .15 .06

– 0.81 0.91

– (0.41–1.59) (0.59–1.41)

– .55 .68

– 0.41 1.24

– (0.110–0.84) (0.81–1.91)

– .02 .32

1.14 1.19 1.13

(0.97–1.34) (0.94–1.50) (0.73–2.19)

.12 .16 .41

1.35 1.04 1.45

(1.15–1.60) (0.85–1.26) (0.89–2.35)

b .01 .71 .14

– 1.03 1.01 0.40 1.59

– (0.87–1.22) (0.94–1.09) (0.17–0.93)

– .73 .71 .03 .12

– 1.25 1.10 0.57 0.40

– (1.05–1.50) (1.01–1.20) (0.27–1.20)

– .01 .04 .14 .93

Organizational size is defined as follows: small, b 10,000 patients per year; medium, 10,000–19,999 patients per year; large, N 20,000 patients per year.

practice setting characteristics and provider-level factors are associated with better access to LARC methods [9–12]. 4.1. Limitations FQHCs self-reported their practices regarding the on-site availability of certain contraceptive methods, including LARC. We did not conduct any other observational method to verify whether these contraceptive methods were indeed provided on-site, by prescription or through referral arrangements. This analysis also does not account for any patient-level factors that may influence the ability to access LARC methods, including patient need or preferences regarding LARC method use. We are also not able to assess through this analysis any differential access to LARC methods by subpopulation, which limits our findings to the general FQHC population and not to any subgroups of patients that may be in greater need of LARC methods. Prior research has found that low-income and medically underserved women tend to use different contraceptive methods, are less likely to use contraception at all and are more likely to experience contraceptive failure compared to higherincome women, putting them at higher risk of an unintended pregnancy [24–28]. Understanding the roles of patient preferences and utilization across the range of contraceptive methods, including LARC, would identify opportunities for

targeted interventions aimed at improving delivery and onsite availability of LARC methods. Future research efforts should also emphasize underserved patients’ experiences in accessing such methods to confirm the findings of this study and to explore patient-level challenges and barriers to accessing LARC methods at FQHCs. The implications of this research are increasingly important, especially in light of the expansion of coverage through Medicaid and health insurance exchanges by 2014. Furthermore, the required health plan coverage guidelines regarding women’s preventive services name all FDAapproved contraceptive methods among the required services that qualifying health plans must cover with zero-cost sharing by patients [29,30]. The presumed widespread coverage of contraceptive methods for women including LARCs ameliorates some of the previously identified cost barriers to providing LARC methods in FQHC settings. Given that FQHCs anticipate providing care for up to 40 million patients by 2019, many of whom will gain coverage as a result of the Affordable Care Act, the full complement of contraceptive methods should be more readily available to the majority of patients seeking care in an FQHC setting in order to improve the likelihood that women will be able to easily access their preferred contraceptive method. Despite increased access to these methods through expanded insurance coverage, on-site availability of LARC methods

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may require significant efforts on behalf of FQHCs to redesign their practices to accommodate the delivery of LARC methods on-site. Our findings underscore the reality that, in many cases, FQHCs still face challenges in providing on-site access to the full range of LARC methods due to barriers to acquiring and stocking certain devices, staffing and training issues, and other reasons. References [1] Increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy. [Internet] Washington, DC: Committee on Gynecologic Practice, ACOG; 2009 [cited 2013 April 18]. Available from: http://www.acog.org/~/media/Committee%20Opinions/ Committee%20on%20Gynecologic%20Practice/co450.pdf?dmc= 1&ts=20130418T1404380086. [2] Finer LB, Jerman J, Kavanaugh ML. Changes in use of long-acting contraceptive methods in the United States, 2007–2009, fertility and sterility. Available from: http://www.guttmacher.org/pubs/journals/j. fertnstert.2012.06.027.pdf 2012. [3] Winner B, Peipert JF, Zhao Q, Buckel C, Madden T, Allsworth JE, et al. Long-acting reversible contraception: a practical solution to reduce unintended pregnancy. N Engl J Med 2012 May;366(21): 1998–2007. [4] Centers for Disease Control and Prevention (CDC). Contraceptive methods available to patients of office-based physicians and Title X clinics — United States, 2009–2010. MMWR Weekly 2011;60(1):1–4. [5] Speidel JJ, Harper CC, Shields WC. The potential of long-acting reversible contraception to decrease unintended pregnancy. Contraception 2008 Sep;78:197–200. [6] Eisenberg D, McNicholas C, Peipert JF. Cost as a barrier to long-acting reversible contraceptive (LARC) use in adolescents. J Adolescent Health 2013;52:s59–63. [7] Rose SB, Cooper AJ, Baker NK, Lawton B. Attitudes toward longacting reversible contraception among young women seeking abortion. J Womens Health 2011 Nov;20(11):1729–35. [8] Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 2012;120(6):1291–7. [9] Harper CC, Henderson JT, Raine TR, Goodman S, Darney PD, Thompson KM, et al. Evidence-based IUD practice: family physicians and obstetrician–gynecologists. Fam Med 2012;44(9):637–45. [10] Morse J, Freedman L, Speidel JJ, Thompson KM, Stratton L, Harper CC. Postabortion contraception: qualitative interviews on counseling and provision of long-acting reversible contraceptive methods. Perspect Sex Repro H 2012;44(2):100–6. [11] Vaaler ML, Kalanges LK, Fonseca VP, Castrucci BC. Urban–rural differences in attitudes and practices toward long-acting reversible contraceptives among family planning providers in Texas. Women's Health Iss 2012;22(2):e157–62. [12] Blumoff Greenberg K, Makino KK, Coles MS. Factors associated with provision of long-acting reversible contraception among adolescent health care providers. J Adolescent Health 2013;52:372–4. [13] Thompson KM, Speidel JJ, Saporta V, Waxman NJ, Harper CC. Contraceptive policies affect post-abortion provision of long-acting reversible contraception. Contraception 2011;83(1):41–7.

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