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Factors Associated With Provision of Long-Acting Reversible Contraception Among Adolescent Health Care Providers
Journal of Adolescent Health 52 (2013) 372 374
www.jahonline.org Adolescent health brief
Factors Associated With Provision of Long-Acting Reversible Contraception Among Adolescent Health Care Providers Katherine Blumoff Greenberg, M.D. a, *, Kevin K. Makino b, and Mandy S. Coles, M.D., M.P.H. a a b
Division of Adolescent Medicine, University of Rochester Medical Center, Rochester, New York Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
Article history: Received August 2, 2012; Accepted November 6, 2012 Keywords: Adolescent; Contraception; Contraceptive implant; Health care provider; Intrauterine device; Long acting reversible contraception
See Related Editorial p. 255
A B S T R A C T
Purpose: To identify provider and practice characteristics associated with long acting reversible contraception (LARC, either progesterone contraceptive implants or intrauterine devices [IUDs]) provision among adolescent health care providers. Methods: We used data from a previously conducted survey of US providers on reproductive health to predict provision of any form of LARC as well as progesterone contraceptive implants or IUDs specifically using Chi square and multivariate logistic regressions. Results: One third of providers reported any LARC provision. In logistic regressions, residency training in obstetrics/gynecology or family medicine (rather than internal medicine/pediatrics) was the strongest predictor of LARC provision, particularly for IUDs. Conclusions: A minority of providers reported offering IUDs or contraceptive implants, most of whom had received procedural women’s health training. Increasing the number of providers offering this type of contraception may help to prevent adolescent pregnancies and may be most easily accomplished via training in contraceptive implant provision. Ó 2013 Society for Adolescent Health and Medicine. All rights reserved.
Adolescent pregnancy is associated with increased risk of suboptimal health outcomes for mother and child, and continues to be more common in the United States than in most developed nations [1]. Much of the recent decline in American adolescent pregnancies may be attributed to improved contra ceptive use, especially of more effective methods [2]. Long acting reversible contraceptive (LARC) methods such as * Address correspondence to: Katherine Blumoff Greenberg, M.D., 601 Elmwood Avenue, Box 690, Rochester, NY 14642. E-mail address: [email protected] (K.B. Greenberg).
IMPLICATIONS AND CONTRIBUTION
Increased long acting re versible contraception (LARC) use may help miti gate the ongoing problem of unintended adolescent pregnancy. This study imp lies that the limited number of physicians offering LARC to teens poses a barrier to adolescents’ access and utilization. Procedural women’s health training predicted LARC provision, suggesting provider training improves adoles cents’ access to LARC services.
contraceptive implants and intrauterine devices (IUDs) are the most effective pregnancy prevention options for women of all ages [3]. However, adolescents do not routinely use LARC methods [4]; reasons for this are not well understood. In a recent study, more than 60% of adolescents chose LARC (63% with contraceptive implants and 37% with IUDs) after receiving evidence based contraceptive counseling and in the absence of financial barriers [5], suggesting that provider counseling and access barriers contribute to low use. Lack of clinician training and comfort in placing these devices for adolescent patients may also perpetuate underutilization [4].
1054-139X/$ see front matter Ó 2013 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2012.11.003
K.B. Greenberg et al. / Journal of Adolescent Health 52 (2013) 372 374
Although IUD training is not specifically required in non obstetric/gynecologic training programs, physicians are more likely to offer LARC in practice if they provided LARC during training [6]. The Institute of Medicine has identified expanding young women’s access to LARC as a promising strategy to address their national priority of preventing unintended preg nancy [7]. Our study reports the prevalence of self reported LARC provision among a group of adolescent health care providers, and identifies provider and practice characteristics predictive of adolescent LARC provision. Methods We analyzed data from an online survey that evaluated adolescent medicine providers on a variety of reproductive health topics. The survey was administered to medical provider members of the Society for Adolescent Health and Medicine (SAHM)da self identified group dedicated to the care of adolescents who work in a wide range of clinical settings and have varied training backgrounds. The data collection methods for this survey are described in detail elsewhere.[8] Our study explored respondents’ self reported provision of either contraceptive implant or IUD insertion as part of routine clinical service. We excluded nurse practitioners (for whom we did not have procedural women’s health training information), physicians whose residency training was in psychiatry or emer gency medicine, and providers who denied offering any contra ceptive services in their regular practice. We explored LARC provision with respect to provider and practice characteristics using Chi square analyses. Providers were dichotomized into two groups based on their presumed procedural women’s health training. With the exception of one respondent who reported post residency family planning training, these groups differentiated between providers whose residency training typically include procedural women’s health care training (obstetrics/gynecology and family medicine [OB/FM]) and those whose residencies typically do not (internal medicine, pediatrics, and combined medicine pediatrics [IM/Peds]) [9]. We then conducted multivariate logistic regres sion analyses to identify factors that predicted any LARC provi sion as well as provision of contraceptive implants or IUDs specifically. Last, we performed sensitivity analyses to assess whether the association of provider training with LARC provision was stable across those who completed residency before and after Food and Drug Administration approval of Implanon in 2006. All data analyses were done with STATA 11.0. The Univer sity of Rochester Research Subjects Review Board approved this study. Results Of the 917 U.S. clinician members of SAHM with email addresses, 87% (n 797) received the survey invitation, and 54% (n 430) participated in the survey. Respondent character istics are reported in a prior publication [8], and demographics can be seen in Table 1. By primary residency, our sample was 77% pediatrics trained (n 291), 5% medicine trained (n 20), 6% medicine pediatrics trained (n 23), 10% family medicine trained (n 36), and 2% obstetrics and gynecology trained (n 8). Thirty two percent (124/385) of our analytic sample reported providing either form of LARC. Among the OB/FM trained group,
373
Table 1 Provider and practice characteristic (Chi-square analyses)
Provider characteristics Female Age (years) 24 39 40 49 50 59 60 or older Race White Black Asian Other Latino/Hispanic Residency training OB/FM IM/Peds Practice characteristics Practice location Urban Suburban Rural Primary clinical site Private practice Academic medical center Hospital-based clinic Other
Analytic sample (n 385)
LARC providers (n 124)
n (%)
n (%)
260 (67.89)
85 (69.67)
113 100 122 50
(29.35) (25.97) (31.69) (12.99)
39 37 35 13
(31.45) (29.84) (28.23) (10.48)
306 37 27 14 18
(79.69) (9.64) (7.03) (3.54) (4.71)
100 13 5 5 6
(81.30) (10.57) (4.07) (4.07) (4.96)
p value
.609 .407
.414
45 (11.90) 333 (88.10)
35 (28.69) 87 (71.31)
286 (74.48) 78 (20.31) 20 (5.21)
109 (87.20) 11 (8.80) 5 (4.00)
.877 <.001
<.001
.004 54 125 135 71
(14.03) (32.47) (35.06) (18.44)
6 42 50 27
(4.80) (33.60) (40.00) (21.60)
Analytic sample includes providers who met inclusion and exclusion criteria. Cells may not add to overall sample number because of variation in response rates to various questions. IM/Peds internal medicine, pediatrics, and combined medicine-pediatrics; LARC long-acting reversible contraception; OB/FM obstetrics/gynecology and family medicine.
88% (35/45) reported providing some form of LARC compared with 26% (87/333) in the IM/Peds group. Forty seven percent (21/45) of the OB/FM group reported placing contraceptive implants compared with 24% (79/333) of the IM/Peds group (data not shown). In logistic regression models (Table 2), presumed exposure to procedural women’s health training was the strongest predictor of LARC provision for both contraceptive implants and IUDs. Practice location was also associated with LARC provision, but not completion of adolescent fellowship training. Results were not sensitive to the timing of respondents’ residency completion. Discussion Only one third of our sample reported providing any LARC services, although rates were much higher among providers with procedural women’s health training. Exposure to this training was the strongest predictor of any type of LARC provision. However, striking differences emerged between the provision of contraceptive implants and IUDs. OB/FM providers were somewhat more likely to provide contraceptive implants but considerably more likely to provide IUDs than their IM/ Peds peers. The skills and equipment necessary to insert IUDs may explain some of this difference, because they can present real barriers to providers who lack procedural gynecologic training or who practice in settings with few resources [10]. Contraceptive implants, in contrast, require minimal instruc tion beyond the Food and Drug Administrationemandated
374
K.B. Greenberg et al. / Journal of Adolescent Health 52 (2013) 372 374
Table 2 Factors associated with LARC provision (logistic regressions)
Characteristics Residency training OB/FM (referent: IM/Peds) Practice location Suburban (urban) Rural (urban)
Any LARC method
Contraceptive implants
IUDs
OR (95% CI)
OR (95% CI)
OR (95% CI)
19.40 (5.58 67.37)a
4.46 (1.72 11.54)b
83.83 (15.31 458.97)a
.20 (.07 .57)b .15 (.17 1.28)
.27 (.10 .73)b .17 (.18 1.69)
.08 (.01 .57)b .21 (.16 2.60)
Other variables included in the logistic regression model and not significant include: provider gender, age, race, ethnicity, clinic setting, and adolescent medicine fellowship completion. CI confidence interval; IM/Peds internal medicine, pediatrics, and combined medicine-pediatrics; IUD intrauterine device; LARC long-acting reversible contraception; OB/FM obstetrics/gynecology and family medicine; OR odds ratio. a p < .001. b p < .05.
manufacturer training and no special materials beyond the implant inserters themselves. Limitations of this survey’s findings have been discussed previously [8] and include lack of generalizability to non SAHM members, who provide the majority of reproductive health services to adolescents. Specific limitations to these analyses include the small sample size of OB/FM trained clinicians and our use of residency type to reflect procedural women’s health training. One third of the providers in our sample reported providing LARC services, and provider residency training appears to be a significant factor in the provision of both contraceptive implants and IUDs. Our results further suggest that exposure to procedural women’s health training has a larger impact on insertion of IUDs than for contraceptive implants. Reported contraceptive implant placement is lower overall than we might have expected, suggesting an underutilization of implants by SAHM member providers. Because these implants require few procedural skills, it may be easier to increase provider training in contraceptive implants than in IUDs. We acknowledge that even widespread training will not guarantee an increase in LARC use. However, increasing the number of providers offering the contraceptive implant would improve LARC access and may have broad reaching consequences for adolescent pregnancy prevention, particularly given young teens expressed preference for implants over IUDs. Acknowledgments The first draft of this manuscript was written by K.B.G., who did not receive honorarium, grant, or other payment for the production of this manuscript. This project was funded by a grant from the Society for Family Planning and supported in part by the Rochester MCH Leadership Education in Adolescent Health
T71MC00012 11 01. K.M. is a trainee in the Medical Scientist Training Program funded by NIH T32 GM07356 and was also supported in part by NIH Grant Number UL1 RR024160. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Society for Family Planning, Maternal and Child Health Bureau, National Institute of General Medical Sciences, or the National Institutes of Health. At the time of submission to the Journal of Adolescent Health, this research was also been submitted for consideration as a scientific presentation at the Society for Adolescent Health and Medicine 2013 annual meeting. References [1] Klein JD. Adolescent pregnancy: Current trends and issues. Pediatrics 2005; 116:281 6. [2] Santelli JS, Lindberg LD, Finer LB, Singh S. Explaining recent declines in adolescent pregnancy in the United States: The contribution of abstinence and improved contraceptive use. Am J Public Health 2007;97:150 6. [3] Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med 2012;366:1998 2007. [4] Yen S, Saah T, Hillard PJ. IUDs and adolescents an under-utilized opportunity for pregnancy prevention. J Pediatr Adolesc Gynecol 2010;23:123 8. [5] Mestad R, Secura G, Allsworth JE, et al. Acceptance of long-acting reversible contraceptive methods by adolescent participants in the Contraceptive CHOICE Project. Contraception 2011;84:493 8. [6] Rubin SE, Fletcher J, Stein T, et al. Determinants of intrauterine contraception provision among US family physicians: A national survey of knowledge, attitudes and practice. Contraception 2011;83:472 8. [7] National Academies Press. Initial National Priorities for Comparative Effectiveness Research. Washington DC: National Academies Press; 2009. [8] Coles MS, Makino KK, Phelps R. Knowledge of medication abortion among adolescent medicine providers. J Adolesc Health 2012;50:383 8. [9] Accreditation Council for Graduate Medical Education (ACGME). Program Requirements for Residencies in Family Medicine, Obstetrics/Gynecology, Internal Medicine, and Pediatrics. Available at: http://www.acgme.org/ acWebsite/home/home.asp. Accessed November 3, 2012. [10] Harper CC, Blum M, de Bocanegra HT, et al. Challenges in translating evidence to practice: The provision of intrauterine contraception. Obstet Gynecol 2008;11:1359 69.
www.jahonline.org Adolescent health brief
Factors Associated With Provision of Long-Acting Reversible Contraception Among Adolescent Health Care Providers Katherine Blumoff Greenberg, M.D. a, *, Kevin K. Makino b, and Mandy S. Coles, M.D., M.P.H. a a b
Division of Adolescent Medicine, University of Rochester Medical Center, Rochester, New York Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
Article history: Received August 2, 2012; Accepted November 6, 2012 Keywords: Adolescent; Contraception; Contraceptive implant; Health care provider; Intrauterine device; Long acting reversible contraception
See Related Editorial p. 255
A B S T R A C T
Purpose: To identify provider and practice characteristics associated with long acting reversible contraception (LARC, either progesterone contraceptive implants or intrauterine devices [IUDs]) provision among adolescent health care providers. Methods: We used data from a previously conducted survey of US providers on reproductive health to predict provision of any form of LARC as well as progesterone contraceptive implants or IUDs specifically using Chi square and multivariate logistic regressions. Results: One third of providers reported any LARC provision. In logistic regressions, residency training in obstetrics/gynecology or family medicine (rather than internal medicine/pediatrics) was the strongest predictor of LARC provision, particularly for IUDs. Conclusions: A minority of providers reported offering IUDs or contraceptive implants, most of whom had received procedural women’s health training. Increasing the number of providers offering this type of contraception may help to prevent adolescent pregnancies and may be most easily accomplished via training in contraceptive implant provision. Ó 2013 Society for Adolescent Health and Medicine. All rights reserved.
Adolescent pregnancy is associated with increased risk of suboptimal health outcomes for mother and child, and continues to be more common in the United States than in most developed nations [1]. Much of the recent decline in American adolescent pregnancies may be attributed to improved contra ceptive use, especially of more effective methods [2]. Long acting reversible contraceptive (LARC) methods such as * Address correspondence to: Katherine Blumoff Greenberg, M.D., 601 Elmwood Avenue, Box 690, Rochester, NY 14642. E-mail address: [email protected] (K.B. Greenberg).
IMPLICATIONS AND CONTRIBUTION
Increased long acting re versible contraception (LARC) use may help miti gate the ongoing problem of unintended adolescent pregnancy. This study imp lies that the limited number of physicians offering LARC to teens poses a barrier to adolescents’ access and utilization. Procedural women’s health training predicted LARC provision, suggesting provider training improves adoles cents’ access to LARC services.
contraceptive implants and intrauterine devices (IUDs) are the most effective pregnancy prevention options for women of all ages [3]. However, adolescents do not routinely use LARC methods [4]; reasons for this are not well understood. In a recent study, more than 60% of adolescents chose LARC (63% with contraceptive implants and 37% with IUDs) after receiving evidence based contraceptive counseling and in the absence of financial barriers [5], suggesting that provider counseling and access barriers contribute to low use. Lack of clinician training and comfort in placing these devices for adolescent patients may also perpetuate underutilization [4].
1054-139X/$ see front matter Ó 2013 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2012.11.003
K.B. Greenberg et al. / Journal of Adolescent Health 52 (2013) 372 374
Although IUD training is not specifically required in non obstetric/gynecologic training programs, physicians are more likely to offer LARC in practice if they provided LARC during training [6]. The Institute of Medicine has identified expanding young women’s access to LARC as a promising strategy to address their national priority of preventing unintended preg nancy [7]. Our study reports the prevalence of self reported LARC provision among a group of adolescent health care providers, and identifies provider and practice characteristics predictive of adolescent LARC provision. Methods We analyzed data from an online survey that evaluated adolescent medicine providers on a variety of reproductive health topics. The survey was administered to medical provider members of the Society for Adolescent Health and Medicine (SAHM)da self identified group dedicated to the care of adolescents who work in a wide range of clinical settings and have varied training backgrounds. The data collection methods for this survey are described in detail elsewhere.[8] Our study explored respondents’ self reported provision of either contraceptive implant or IUD insertion as part of routine clinical service. We excluded nurse practitioners (for whom we did not have procedural women’s health training information), physicians whose residency training was in psychiatry or emer gency medicine, and providers who denied offering any contra ceptive services in their regular practice. We explored LARC provision with respect to provider and practice characteristics using Chi square analyses. Providers were dichotomized into two groups based on their presumed procedural women’s health training. With the exception of one respondent who reported post residency family planning training, these groups differentiated between providers whose residency training typically include procedural women’s health care training (obstetrics/gynecology and family medicine [OB/FM]) and those whose residencies typically do not (internal medicine, pediatrics, and combined medicine pediatrics [IM/Peds]) [9]. We then conducted multivariate logistic regres sion analyses to identify factors that predicted any LARC provi sion as well as provision of contraceptive implants or IUDs specifically. Last, we performed sensitivity analyses to assess whether the association of provider training with LARC provision was stable across those who completed residency before and after Food and Drug Administration approval of Implanon in 2006. All data analyses were done with STATA 11.0. The Univer sity of Rochester Research Subjects Review Board approved this study. Results Of the 917 U.S. clinician members of SAHM with email addresses, 87% (n 797) received the survey invitation, and 54% (n 430) participated in the survey. Respondent character istics are reported in a prior publication [8], and demographics can be seen in Table 1. By primary residency, our sample was 77% pediatrics trained (n 291), 5% medicine trained (n 20), 6% medicine pediatrics trained (n 23), 10% family medicine trained (n 36), and 2% obstetrics and gynecology trained (n 8). Thirty two percent (124/385) of our analytic sample reported providing either form of LARC. Among the OB/FM trained group,
373
Table 1 Provider and practice characteristic (Chi-square analyses)
Provider characteristics Female Age (years) 24 39 40 49 50 59 60 or older Race White Black Asian Other Latino/Hispanic Residency training OB/FM IM/Peds Practice characteristics Practice location Urban Suburban Rural Primary clinical site Private practice Academic medical center Hospital-based clinic Other
Analytic sample (n 385)
LARC providers (n 124)
n (%)
n (%)
260 (67.89)
85 (69.67)
113 100 122 50
(29.35) (25.97) (31.69) (12.99)
39 37 35 13
(31.45) (29.84) (28.23) (10.48)
306 37 27 14 18
(79.69) (9.64) (7.03) (3.54) (4.71)
100 13 5 5 6
(81.30) (10.57) (4.07) (4.07) (4.96)
p value
.609 .407
.414
45 (11.90) 333 (88.10)
35 (28.69) 87 (71.31)
286 (74.48) 78 (20.31) 20 (5.21)
109 (87.20) 11 (8.80) 5 (4.00)
.877 <.001
<.001
.004 54 125 135 71
(14.03) (32.47) (35.06) (18.44)
6 42 50 27
(4.80) (33.60) (40.00) (21.60)
Analytic sample includes providers who met inclusion and exclusion criteria. Cells may not add to overall sample number because of variation in response rates to various questions. IM/Peds internal medicine, pediatrics, and combined medicine-pediatrics; LARC long-acting reversible contraception; OB/FM obstetrics/gynecology and family medicine.
88% (35/45) reported providing some form of LARC compared with 26% (87/333) in the IM/Peds group. Forty seven percent (21/45) of the OB/FM group reported placing contraceptive implants compared with 24% (79/333) of the IM/Peds group (data not shown). In logistic regression models (Table 2), presumed exposure to procedural women’s health training was the strongest predictor of LARC provision for both contraceptive implants and IUDs. Practice location was also associated with LARC provision, but not completion of adolescent fellowship training. Results were not sensitive to the timing of respondents’ residency completion. Discussion Only one third of our sample reported providing any LARC services, although rates were much higher among providers with procedural women’s health training. Exposure to this training was the strongest predictor of any type of LARC provision. However, striking differences emerged between the provision of contraceptive implants and IUDs. OB/FM providers were somewhat more likely to provide contraceptive implants but considerably more likely to provide IUDs than their IM/ Peds peers. The skills and equipment necessary to insert IUDs may explain some of this difference, because they can present real barriers to providers who lack procedural gynecologic training or who practice in settings with few resources [10]. Contraceptive implants, in contrast, require minimal instruc tion beyond the Food and Drug Administrationemandated
374
K.B. Greenberg et al. / Journal of Adolescent Health 52 (2013) 372 374
Table 2 Factors associated with LARC provision (logistic regressions)
Characteristics Residency training OB/FM (referent: IM/Peds) Practice location Suburban (urban) Rural (urban)
Any LARC method
Contraceptive implants
IUDs
OR (95% CI)
OR (95% CI)
OR (95% CI)
19.40 (5.58 67.37)a
4.46 (1.72 11.54)b
83.83 (15.31 458.97)a
.20 (.07 .57)b .15 (.17 1.28)
.27 (.10 .73)b .17 (.18 1.69)
.08 (.01 .57)b .21 (.16 2.60)
Other variables included in the logistic regression model and not significant include: provider gender, age, race, ethnicity, clinic setting, and adolescent medicine fellowship completion. CI confidence interval; IM/Peds internal medicine, pediatrics, and combined medicine-pediatrics; IUD intrauterine device; LARC long-acting reversible contraception; OB/FM obstetrics/gynecology and family medicine; OR odds ratio. a p < .001. b p < .05.
manufacturer training and no special materials beyond the implant inserters themselves. Limitations of this survey’s findings have been discussed previously [8] and include lack of generalizability to non SAHM members, who provide the majority of reproductive health services to adolescents. Specific limitations to these analyses include the small sample size of OB/FM trained clinicians and our use of residency type to reflect procedural women’s health training. One third of the providers in our sample reported providing LARC services, and provider residency training appears to be a significant factor in the provision of both contraceptive implants and IUDs. Our results further suggest that exposure to procedural women’s health training has a larger impact on insertion of IUDs than for contraceptive implants. Reported contraceptive implant placement is lower overall than we might have expected, suggesting an underutilization of implants by SAHM member providers. Because these implants require few procedural skills, it may be easier to increase provider training in contraceptive implants than in IUDs. We acknowledge that even widespread training will not guarantee an increase in LARC use. However, increasing the number of providers offering the contraceptive implant would improve LARC access and may have broad reaching consequences for adolescent pregnancy prevention, particularly given young teens expressed preference for implants over IUDs. Acknowledgments The first draft of this manuscript was written by K.B.G., who did not receive honorarium, grant, or other payment for the production of this manuscript. This project was funded by a grant from the Society for Family Planning and supported in part by the Rochester MCH Leadership Education in Adolescent Health
T71MC00012 11 01. K.M. is a trainee in the Medical Scientist Training Program funded by NIH T32 GM07356 and was also supported in part by NIH Grant Number UL1 RR024160. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Society for Family Planning, Maternal and Child Health Bureau, National Institute of General Medical Sciences, or the National Institutes of Health. At the time of submission to the Journal of Adolescent Health, this research was also been submitted for consideration as a scientific presentation at the Society for Adolescent Health and Medicine 2013 annual meeting. References [1] Klein JD. Adolescent pregnancy: Current trends and issues. Pediatrics 2005; 116:281 6. [2] Santelli JS, Lindberg LD, Finer LB, Singh S. Explaining recent declines in adolescent pregnancy in the United States: The contribution of abstinence and improved contraceptive use. Am J Public Health 2007;97:150 6. [3] Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med 2012;366:1998 2007. [4] Yen S, Saah T, Hillard PJ. IUDs and adolescents an under-utilized opportunity for pregnancy prevention. J Pediatr Adolesc Gynecol 2010;23:123 8. [5] Mestad R, Secura G, Allsworth JE, et al. Acceptance of long-acting reversible contraceptive methods by adolescent participants in the Contraceptive CHOICE Project. Contraception 2011;84:493 8. [6] Rubin SE, Fletcher J, Stein T, et al. Determinants of intrauterine contraception provision among US family physicians: A national survey of knowledge, attitudes and practice. Contraception 2011;83:472 8. [7] National Academies Press. Initial National Priorities for Comparative Effectiveness Research. Washington DC: National Academies Press; 2009. [8] Coles MS, Makino KK, Phelps R. Knowledge of medication abortion among adolescent medicine providers. J Adolesc Health 2012;50:383 8. [9] Accreditation Council for Graduate Medical Education (ACGME). Program Requirements for Residencies in Family Medicine, Obstetrics/Gynecology, Internal Medicine, and Pediatrics. Available at: http://www.acgme.org/ acWebsite/home/home.asp. Accessed November 3, 2012. [10] Harper CC, Blum M, de Bocanegra HT, et al. Challenges in translating evidence to practice: The provision of intrauterine contraception. Obstet Gynecol 2008;11:1359 69.