- Email: [email protected]
Treatment patterns for early pregnancy failure among Michigan Medicaid participants
Abstracts / Contraception 74 (2006) 178 – 197
however, anxiety and fearfulness are strongly associated with higher pain scores. We aimed to evaluate the acceptability of sublingual (SL) lorazepam in combination with ibuprofen and cervical block for first-trimester uterine aspiration in a general gynecology outpatient setting. Materials and Methods: First-trimester ( b 12 weeks) uterine aspiration was performed in 131 women after premedication with 1–3 mg of SL lorazepam, 800 mg of oral ibuprofen and cervical block. Patient satisfaction, pain, anxiety and side effect scores were assessed by a questionnaire and a visual analog scale. Results: Maximum relaxation was achieved in 80% of patients, at a mean of 30 min, and required at least 1.5 mg of SL lorazepam. Thirty-three percent of patients who initially received 1 mg requested for another dose. SL lorazepam was well accepted: 84% reported acceptable pain control, 94% said they would recommend it to others and 87% said they would choose it again in the future. SL lorazepam was well tolerated: sleepiness, bad taste, dizziness and nausea were reported in 43%, 25%, 21% and 21%, respectively. Patients who reported having a generally low pain tolerance, compared to those reporting a high pain tolerance, experienced less pain during uterine aspiration after SL lorazepam (p = .04). Conclusions: The addition of at least 1.5 mg of SL lorazepam to ibuprofen and cervical block prior to first-trimester uterine aspiration provided acceptable pain control for the vast majority of women and significantly better pain ratings in the cohort reporting preprocedure low pain tolerance. 57 THE DETERMINANTS AND CIRCUMSTANCES OF THE USE OF EMERGENCY CONTRACEPTIVE PILLS IN FRANCE IN THE CONTEXT OF DIRECT PHARMACY ACCESS Moreau C, Trussell J, Bajos N. Introduction: In France, the 1999 introduction of a dedicated emergency contraceptive pill (ECP) that is available without a prescription has resulted in a 72% increase in its use over the past 5 years, especially in younger women (aged 15 – 24 years old). Materials and Methods: A population-based health survey conducted in 1999 and 2004 was used to examine changes in the determinants of lifetime ECP use among women aged 15–24 years (n = 743 in 1999; n = 1207 in 2004). We also explored the determinants and circumstances of the recent use of ECPs in 2004 among women aged 15 – 44 years who are at risk for unplanned pregnancy (n = 6084). Results: In 1999, 14.6% of women aged 15–24 years had ever used ECPs; this proportion rose to 31.7% in 2004. Results show consistent patterns of lifetime ECP use in 1999 and 2004, with greater use among women who are more highly educated, who live in large cities and who report a history of induced abortion. In 2004, 22% of women were not using contraceptives at the time they used ECPs, and 84% resumed use of a regular contraceptive after ECP use. However, 5.5% had unprotected intercourse after taking ECPs in the same menstrual cycle and in the next menstrual cycle. Conclusions: Despite direct pharmacy access, differences in ECP use, in terms of social and residence status, remain. ECPs were used as a backup method in case of contraceptive failure and did not impede the use of subsequent regular contraception.
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58 THE EFFECT OF THE PAPAYA WORKSHOP ON MEDICAL STUDENTS’ KNOWLEDGE ABOUT INTRAUTERINE CONTRACEPTION AND UTERINE ASPIRATION Steinauer J, Karasek D, Preskill F, Robertson P. Introduction: The effect of the Papaya Workshop on medical students’ knowledge about intrauterine contraception (IUC) and uterine aspiration (UA) was studied. Methods: Every 6 weeks, 10 medical students rotate through the University of California at San Francisco obstetrics/gynecology (OB/GYN) core clerkship, during which they gather for a 2-h Papaya Workshop to learn uterine anatomy and intrauterine surgical skills. Using patient cases, students discuss the indications, patient counseling components and procedures for IUC placement and UA, and practice them using papayas. The students complete surveys before the workshop, after the workshop and at the end of the OB/GYN rotation. These surveys include questions on knowledge and attitudes about IUC and UA and on comfort in counseling patients about both topics and procedures. Results: Seventy-eight students have participated in the workshop; of these, 99%, 95% and 91% completed the preworkshop, postworkshop and end-of-rotation survey, respectfully. A higher proportion of students correctly answered questions about IUC (64% vs. 89%, p b .001) and aspiration (56% vs. 89%, p b .001) after the workshop; these differences persisted to the end of the rotation (p b .001). Higher proportions of students were comfortable discussing these procedures with patients after the workshop (IUC: 45% vs. 96%, p b .001; UA: 17% vs. 81%, p b .001); this comfort level continued up to the end of the rotation (p b .001). Conclusion: The Papaya Workshop has a positive effect on medical students’ attitudes and comfort in counseling patients about IUC and UA. 59 TREATMENT PATTERNS FOR EARLY PREGNANCY FAILURE AMONG MICHIGAN MEDICAID PARTICIPANTS Dalton VK, Harris L, Cohn L, Clark S, Fendrick AM. Introduction: Contemporary treatment of early pregnancy failure (EPF) includes expectant, medical and surgical management. There are no population-based studies characterizing usual treatment patterns in the United States. Materials and Methods: To describe current treatment patterns, we conducted a retrospective review of EPF treatment among Michigan Medicaid participants between January 1, 2001, and December 31, 2004. Episodes were identified by the presence of a diagnostic code for EPF. Surgical treatment was distinguished from nonsurgical management through procedure codes. Facility charges, procedure and place of service codes were used to determine whether a procedure was performed in an operative suite versus an office. Cases without a claim for surgical uterine evacuation were examined for misoprostol pharmacy claim. Such cases were classified as medical management. Cases without a procedure or pharmacy claim were classified as expectant management. Results: A total of 21,311 episodes of EPF were analyzed. Overall, 16.6% of complete abortions, 34.9% of incomplete abortions and
196
Abstracts / Contraception 74 (2006) 178 – 197
45.7% of missed abortions were treated with surgical uterine evacuation. Of these, only 0.4% appeared to occur in an office, and this proportion did not change over the study period. The proportion of cases managed with misoprostol increased from 0.3% in 2001 to 1.4% in 2004 (p b .001). Caucasian race and age were both associated with surgical uterine evacuation (p b .001). The total number of visits will be compared between treatments. Patterns will also be examined by facility type and by location. Conclusions: EPF is mainly treated with expectant management or surgical evacuation; however, an increasing number of patients are being managed with misoprostol. 60 TRENDS IN ORAL CONTRACEPTIVE PRESCRIBING: A SURVEY OF OREGON WOMEN’S HEALTH PHYSICIANS Frederick C, Carlson N, Rosenberg K, Edelman A, Jensen J. Introduction: The attitudes, knowledge and prescribing habits of Oregon obstetrics and gynecology (OB/GYN) and family medicine (FM) physicians with regard to extended-use oral contraceptives (EOC) were examined. Whether geographic location or specialty influences these factors was determined. Materials and Methods: A cross-sectional survey of OB/GYN and FM members of the Oregon Medical Association was conducted from February to September 2005. Physicians with known e-mail addresses (n = 575) were sent a web-based survey, and a random sample without known e-mails (n = 138) received a paper survey through regular mail. Relationships between prescribing habits and geographic location, primary specialty, gender, knowledge and attitudes were examined using chi-square, Mann– Whitney U test and multiple logistic regression. Results: Of 713 providers surveyed, 233 completed the survey, for an overall response rate of 32.7%. The web-based survey achieved a response rate (26.3%) lower than that of the paper survey (59.4%). Subjects responding to the e-mail survey tended to be younger, female and more urban than the paper survey respondents (p N .05). Most respondents (211/233) indicated that they prescribe oral contraceptives. Of these, 73.8% prescribe EOC either often (31.0%) or sometimes (69.0%). A significant positive association exists between providers’ attitudes about medically induced amenorrhea and their willingness to prescribe EOC (odds ratio = 1.84; 95% confidence interval = 1.41, 2.42). After controlling for attitudes, other factors (geographic location, primary specialty, knowledge, gender and age) were not associated with prescribing habits. Conclusions: A positive physician attitude towards medically induced amenorrhea is the strongest factor influencing EOC prescription. 61 UNDERSTANDING ACCESS TO EMERGENCY CONTRACEPTION FOR LATINA YOUTH IN CALIFORNIA Sampson O, Miller S, Hearst N. Introduction: Emergency contraception (EC) has been available behind-the-counter at select pharmacies in California since 2002. Despite this service, use of EC remains low in certain communities in CA, particularly among Latina women. Given that Latina youth
account for two-thirds of California teen births, and that EC can help reduce unintended pregnancy, this mixed-methods study was designed to identify barriers to youth access to EC in selected counties in California. Materials and Methods: A dmystery-shopperT technique, where callers posed as either English- or Spanish-speaking, 15 or 18 years old adolescent females, was used to call all 119 EC-access pharmacies four times, in 9 California counties. Qualitative data were gathered from the callers and from interviews with a convenience sample of 25 providers and pharmacists. Results: Overall, 44.9% of English callers and of 25.2% of Spanish callers could obtain EC at the time of the call. Accessibility to EC by county was variable and influenced by the availability of the certified pharmacist, misinformation about time-effectiveness, and Spanish-language services. Analysis of qualitative interviews suggests that pharmacists and medical providers did not have a clear working relationship regarding EC provision, pharmacists found it challenging to counsel youth about EC, and that youth in certain communities seemed to utilize clinics over pharmacies for obtaining EC. Conclusions: Behind-the-counter EC provision by pharmacies in California, is not enhancing access for Latina youth. Understanding barriers for youth in different communities and attitudes of providers is important to medical and pharmacy education, best-practice guidelines, and opportunities for program improvement. 62 UNINTENDED PREGNANCY IN ACTIVE-DUTY WOMEN Chung-Park M. Introduction: This quasi-experimental study was performed to implement and to evaluate the effects of a reproductive health educational program in terms of knowledge, attitudes, decisional balance, self-efficacy, stages of change and contraceptive use, and to identify independent variables that are most likely to predict behavior change in the use of contraceptives among single activeduty women during the 4-month study period. Materials and Methods: Data were collected on three separate occasions at 2-month intervals over a 4-month period. The intervention for the experimental group consisted of two class sessions 2 months apart, while the control group received no intervention. Descriptive test, t test, analysis of variance, correlation and regression were used to analyze data from the sample of 198 Navy-enlisted females recruited from USS ships in California. Results: The program was effective in increasing and in retaining knowledge. A positive change in attitude, decisional balance and self-efficacy over time was seen in the experimental group, making subjects more accepting about contraception. Study variables such as attitude and stages of change correlated positively with contraceptive use (p b .05), while decisional balance and selfefficacy correlated with attitude and stages of change with knowledge, attitude and self-efficacy. Stages of change explained 93% (experimental group) and 73% (control group) of the variance in contraceptive use at the end of the program. There was a decrease in sexual activity and a greater use of contraceptive methods over time among sexually active individuals in the experimental group, leading to decreased unintended pregnancies (1 vs. 16 in the control group). Conclusion: Effective interventions to reduce unintended pregnancy are essential.
however, anxiety and fearfulness are strongly associated with higher pain scores. We aimed to evaluate the acceptability of sublingual (SL) lorazepam in combination with ibuprofen and cervical block for first-trimester uterine aspiration in a general gynecology outpatient setting. Materials and Methods: First-trimester ( b 12 weeks) uterine aspiration was performed in 131 women after premedication with 1–3 mg of SL lorazepam, 800 mg of oral ibuprofen and cervical block. Patient satisfaction, pain, anxiety and side effect scores were assessed by a questionnaire and a visual analog scale. Results: Maximum relaxation was achieved in 80% of patients, at a mean of 30 min, and required at least 1.5 mg of SL lorazepam. Thirty-three percent of patients who initially received 1 mg requested for another dose. SL lorazepam was well accepted: 84% reported acceptable pain control, 94% said they would recommend it to others and 87% said they would choose it again in the future. SL lorazepam was well tolerated: sleepiness, bad taste, dizziness and nausea were reported in 43%, 25%, 21% and 21%, respectively. Patients who reported having a generally low pain tolerance, compared to those reporting a high pain tolerance, experienced less pain during uterine aspiration after SL lorazepam (p = .04). Conclusions: The addition of at least 1.5 mg of SL lorazepam to ibuprofen and cervical block prior to first-trimester uterine aspiration provided acceptable pain control for the vast majority of women and significantly better pain ratings in the cohort reporting preprocedure low pain tolerance. 57 THE DETERMINANTS AND CIRCUMSTANCES OF THE USE OF EMERGENCY CONTRACEPTIVE PILLS IN FRANCE IN THE CONTEXT OF DIRECT PHARMACY ACCESS Moreau C, Trussell J, Bajos N. Introduction: In France, the 1999 introduction of a dedicated emergency contraceptive pill (ECP) that is available without a prescription has resulted in a 72% increase in its use over the past 5 years, especially in younger women (aged 15 – 24 years old). Materials and Methods: A population-based health survey conducted in 1999 and 2004 was used to examine changes in the determinants of lifetime ECP use among women aged 15–24 years (n = 743 in 1999; n = 1207 in 2004). We also explored the determinants and circumstances of the recent use of ECPs in 2004 among women aged 15 – 44 years who are at risk for unplanned pregnancy (n = 6084). Results: In 1999, 14.6% of women aged 15–24 years had ever used ECPs; this proportion rose to 31.7% in 2004. Results show consistent patterns of lifetime ECP use in 1999 and 2004, with greater use among women who are more highly educated, who live in large cities and who report a history of induced abortion. In 2004, 22% of women were not using contraceptives at the time they used ECPs, and 84% resumed use of a regular contraceptive after ECP use. However, 5.5% had unprotected intercourse after taking ECPs in the same menstrual cycle and in the next menstrual cycle. Conclusions: Despite direct pharmacy access, differences in ECP use, in terms of social and residence status, remain. ECPs were used as a backup method in case of contraceptive failure and did not impede the use of subsequent regular contraception.
195
58 THE EFFECT OF THE PAPAYA WORKSHOP ON MEDICAL STUDENTS’ KNOWLEDGE ABOUT INTRAUTERINE CONTRACEPTION AND UTERINE ASPIRATION Steinauer J, Karasek D, Preskill F, Robertson P. Introduction: The effect of the Papaya Workshop on medical students’ knowledge about intrauterine contraception (IUC) and uterine aspiration (UA) was studied. Methods: Every 6 weeks, 10 medical students rotate through the University of California at San Francisco obstetrics/gynecology (OB/GYN) core clerkship, during which they gather for a 2-h Papaya Workshop to learn uterine anatomy and intrauterine surgical skills. Using patient cases, students discuss the indications, patient counseling components and procedures for IUC placement and UA, and practice them using papayas. The students complete surveys before the workshop, after the workshop and at the end of the OB/GYN rotation. These surveys include questions on knowledge and attitudes about IUC and UA and on comfort in counseling patients about both topics and procedures. Results: Seventy-eight students have participated in the workshop; of these, 99%, 95% and 91% completed the preworkshop, postworkshop and end-of-rotation survey, respectfully. A higher proportion of students correctly answered questions about IUC (64% vs. 89%, p b .001) and aspiration (56% vs. 89%, p b .001) after the workshop; these differences persisted to the end of the rotation (p b .001). Higher proportions of students were comfortable discussing these procedures with patients after the workshop (IUC: 45% vs. 96%, p b .001; UA: 17% vs. 81%, p b .001); this comfort level continued up to the end of the rotation (p b .001). Conclusion: The Papaya Workshop has a positive effect on medical students’ attitudes and comfort in counseling patients about IUC and UA. 59 TREATMENT PATTERNS FOR EARLY PREGNANCY FAILURE AMONG MICHIGAN MEDICAID PARTICIPANTS Dalton VK, Harris L, Cohn L, Clark S, Fendrick AM. Introduction: Contemporary treatment of early pregnancy failure (EPF) includes expectant, medical and surgical management. There are no population-based studies characterizing usual treatment patterns in the United States. Materials and Methods: To describe current treatment patterns, we conducted a retrospective review of EPF treatment among Michigan Medicaid participants between January 1, 2001, and December 31, 2004. Episodes were identified by the presence of a diagnostic code for EPF. Surgical treatment was distinguished from nonsurgical management through procedure codes. Facility charges, procedure and place of service codes were used to determine whether a procedure was performed in an operative suite versus an office. Cases without a claim for surgical uterine evacuation were examined for misoprostol pharmacy claim. Such cases were classified as medical management. Cases without a procedure or pharmacy claim were classified as expectant management. Results: A total of 21,311 episodes of EPF were analyzed. Overall, 16.6% of complete abortions, 34.9% of incomplete abortions and
196
Abstracts / Contraception 74 (2006) 178 – 197
45.7% of missed abortions were treated with surgical uterine evacuation. Of these, only 0.4% appeared to occur in an office, and this proportion did not change over the study period. The proportion of cases managed with misoprostol increased from 0.3% in 2001 to 1.4% in 2004 (p b .001). Caucasian race and age were both associated with surgical uterine evacuation (p b .001). The total number of visits will be compared between treatments. Patterns will also be examined by facility type and by location. Conclusions: EPF is mainly treated with expectant management or surgical evacuation; however, an increasing number of patients are being managed with misoprostol. 60 TRENDS IN ORAL CONTRACEPTIVE PRESCRIBING: A SURVEY OF OREGON WOMEN’S HEALTH PHYSICIANS Frederick C, Carlson N, Rosenberg K, Edelman A, Jensen J. Introduction: The attitudes, knowledge and prescribing habits of Oregon obstetrics and gynecology (OB/GYN) and family medicine (FM) physicians with regard to extended-use oral contraceptives (EOC) were examined. Whether geographic location or specialty influences these factors was determined. Materials and Methods: A cross-sectional survey of OB/GYN and FM members of the Oregon Medical Association was conducted from February to September 2005. Physicians with known e-mail addresses (n = 575) were sent a web-based survey, and a random sample without known e-mails (n = 138) received a paper survey through regular mail. Relationships between prescribing habits and geographic location, primary specialty, gender, knowledge and attitudes were examined using chi-square, Mann– Whitney U test and multiple logistic regression. Results: Of 713 providers surveyed, 233 completed the survey, for an overall response rate of 32.7%. The web-based survey achieved a response rate (26.3%) lower than that of the paper survey (59.4%). Subjects responding to the e-mail survey tended to be younger, female and more urban than the paper survey respondents (p N .05). Most respondents (211/233) indicated that they prescribe oral contraceptives. Of these, 73.8% prescribe EOC either often (31.0%) or sometimes (69.0%). A significant positive association exists between providers’ attitudes about medically induced amenorrhea and their willingness to prescribe EOC (odds ratio = 1.84; 95% confidence interval = 1.41, 2.42). After controlling for attitudes, other factors (geographic location, primary specialty, knowledge, gender and age) were not associated with prescribing habits. Conclusions: A positive physician attitude towards medically induced amenorrhea is the strongest factor influencing EOC prescription. 61 UNDERSTANDING ACCESS TO EMERGENCY CONTRACEPTION FOR LATINA YOUTH IN CALIFORNIA Sampson O, Miller S, Hearst N. Introduction: Emergency contraception (EC) has been available behind-the-counter at select pharmacies in California since 2002. Despite this service, use of EC remains low in certain communities in CA, particularly among Latina women. Given that Latina youth
account for two-thirds of California teen births, and that EC can help reduce unintended pregnancy, this mixed-methods study was designed to identify barriers to youth access to EC in selected counties in California. Materials and Methods: A dmystery-shopperT technique, where callers posed as either English- or Spanish-speaking, 15 or 18 years old adolescent females, was used to call all 119 EC-access pharmacies four times, in 9 California counties. Qualitative data were gathered from the callers and from interviews with a convenience sample of 25 providers and pharmacists. Results: Overall, 44.9% of English callers and of 25.2% of Spanish callers could obtain EC at the time of the call. Accessibility to EC by county was variable and influenced by the availability of the certified pharmacist, misinformation about time-effectiveness, and Spanish-language services. Analysis of qualitative interviews suggests that pharmacists and medical providers did not have a clear working relationship regarding EC provision, pharmacists found it challenging to counsel youth about EC, and that youth in certain communities seemed to utilize clinics over pharmacies for obtaining EC. Conclusions: Behind-the-counter EC provision by pharmacies in California, is not enhancing access for Latina youth. Understanding barriers for youth in different communities and attitudes of providers is important to medical and pharmacy education, best-practice guidelines, and opportunities for program improvement. 62 UNINTENDED PREGNANCY IN ACTIVE-DUTY WOMEN Chung-Park M. Introduction: This quasi-experimental study was performed to implement and to evaluate the effects of a reproductive health educational program in terms of knowledge, attitudes, decisional balance, self-efficacy, stages of change and contraceptive use, and to identify independent variables that are most likely to predict behavior change in the use of contraceptives among single activeduty women during the 4-month study period. Materials and Methods: Data were collected on three separate occasions at 2-month intervals over a 4-month period. The intervention for the experimental group consisted of two class sessions 2 months apart, while the control group received no intervention. Descriptive test, t test, analysis of variance, correlation and regression were used to analyze data from the sample of 198 Navy-enlisted females recruited from USS ships in California. Results: The program was effective in increasing and in retaining knowledge. A positive change in attitude, decisional balance and self-efficacy over time was seen in the experimental group, making subjects more accepting about contraception. Study variables such as attitude and stages of change correlated positively with contraceptive use (p b .05), while decisional balance and selfefficacy correlated with attitude and stages of change with knowledge, attitude and self-efficacy. Stages of change explained 93% (experimental group) and 73% (control group) of the variance in contraceptive use at the end of the program. There was a decrease in sexual activity and a greater use of contraceptive methods over time among sexually active individuals in the experimental group, leading to decreased unintended pregnancies (1 vs. 16 in the control group). Conclusion: Effective interventions to reduce unintended pregnancy are essential.