Identifying Priority Strategies for Implementing Policies on - - PowerPoint PPT Presentation

Centers for Disease Control and Prevention

Identifying Priority Strategies for Implementing Policies on Immediate Postpartum Long-Acting Reversible Contraception in the United States

10th ANNUAL CONFERENCE ON THE SCIENCE OF DISSEMINATION AND IMPLEMENTATION IN HEALTH December 5, 2017 Charlan Kroelinger, PhD

Acting Chief Women’s Health and Fertility Branch Division of Reproductive Health National Center for Chronic Disease Prevention and Health Promotion

Unintended Pregnancy in the United States

• Almost half

(45%) of all pregnancies in the U.S. are unintended

Long-Acting Reversible Contraception (LARC)

• Most effective type of reversible birth

control

• Safe for most women and teens
• No effort after correct insertion
• Effective for 3-10 years
• High rates of satisfaction and

continuation

• Immediate return to fertility
• Nationally, use of LARC is low, but

increasing

• CDC. U.S. medical eligibility criteria for contraceptive use, 2010. MMWR Recomm Rep 2010;59(No. RR-4):1–86.

Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397–404. Boulet SL, D’Angelo DV, Morrow B, et al. Contraceptive Use Among Nonpregnant and Postpartum Women at Risk for Unintended Pregnancy, and Female High School Students, in the Context of Zika Preparedness — United States, 2011–2013 and 2015. MMWR Morb Mortal Wkly Rep. ePub: 2 August 2016. DOI: http://dx.doi.org/10.15585/mmwr.mm6530e2.

Despite Increases LARC Use Remains Low

Even though it appears to be a large increase, LARC methods are used by only 7.2% of women aged 15-44

Branum, AM and J Jones. Trends in Long-Acting Contraception Use Among U.S. Women Aged 15-44. 2015 NCHS Data Brief. No. 188.

Contraceptive Use in the US: Postpartum Women 2011-2013 PRAMS/MIHA

Surveillance System Population Percentage of Use by Effectiveness High

< 1%

Moderate

6% - 10%

Less

> 10%

None

PRAMS & MIHA – US Postpartum women at risk for unintended pregnancy 6.9% — 30.5% 25.8% — 42.7% 15.6% — 37.6% 3.5% — 15.3%

Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397–404. Boulet SL, D’Angelo DV, Morrow B, et al. Contraceptive Use Among Nonpregnant and Postpartum Women at Risk for Unintended Pregnancy, and Female High School Students, in the Context of Zika Preparedness — United States, 2011–2013 and 2015. MMWR Morb Mortal Wkly Rep. ePub: 2 August 2016.

Contraception Access During Health Care Engagement

• Immediate postpartum period

– Fewer insurance barriers – Safe and effective – Reduces risk of rapid repeat pregnancy – Continuation rates are similar to insertions at other times

• Association of State and Territorial Health Care Officials

(ASTHO) and CDC partnered with states to understand barriers to policy implementation for systems change

Hathaway, M., Torres, L., Vollett-Krech, J., & Wohltjen, H. (2014). Increasing LARC utilization: any woman, any place, any time. Clin Obstet Gynecol, 57(4), 718-730. Curtis, K. M., Tepper, N. K., Jatlaoui, T. C., Berry-Bibee, E., Horton, L. G., Zapata, L. B., . . . Whiteman, M. K. (2016). U.S. Medical Eligibility Criteria for Contraceptive Use,

• 2016. MMWR Recomm Rep, 65(3), 1-103.

Thiel de Bocanegra, H., Chang, R., Howell, M., & Darney, P. (2014). Interpregnancy intervals: impact of postpartum contraceptive effectiveness and coverage. Am J Obstet Gynecol, 210(4), 311 e311-318. Woo, I., Seifert, S., Hendricks, D., Jamshidi, R. M., Burke, A. E., & Fox, M. C. (2015). Six-month and 1-year continuation rates following postpartum insertion of implants and intrauterine devices. Contraception, 92(6), 532-535.

Immediate Postpartum LARC Learning Community

• State team engagement for policy

implementation – 13 states with policies – State Health Officials/Officers, Medicaid Medical Directors, Title V/Title X Directors, ACOG/Family Planning Provider, Hospital Administrators, Program Staff

• Identification of 8 domains
• Strategy development to address barriers and

leverage facilitators

• Peer-to-peer learning, shared resources,

technical assistance, virtual learning sessions

http://www.astho.org/Maternal-and-Child-Health/Long-Acting-Reversible-Contraception/LARC-Immediately-Postpartum-Learning-Community-Background/ Increasing Access to Contraception Learning Community: Nine Focus Areas for Success Fact Sheet. Association of State and Territorial Health Officials. http://www.astho.org/Maternal-and-Child-Health/Increasing-Access-to-Contraception/Learning-Community/Nine-Focus-Areas-for-Success/

Immediate Postpartum LARC Learning Community 8 Domains

Domain Description

Provider Training Implementing skill building for providers on immediate postpartum LARC insertion, training pharmacy staff

• n stocking and billing, and training administrative, pharmacy and clinical staff on billing and coding for

non-pharmacy use of LARC devices Pay Streams and Reimbursement Understanding how Title X family planning programs approach immediate postpartum LARC, the variability in how private insurers approach reimbursement services, the relationship of 1115 family planning waivers and state plan amendments with immediate postpartum LARC reimbursement under Medicaid, and the billing and coding process for Medicaid claims Informed Consent Defining timing and content of informed consent Stocking and Supply of Devices Providing concrete examples of device-stocking procedures and supply policies in both hospital pharmacies and clinics Outreach Recruiting advocates to develop and implement postpartum LARC policy by identifying effective strategies for contracting providers and policymakers , and providing examples of successful communication strategies to use with the public and clients Service Locations Differentiating strategies for rural settings including developing engagement strategies with federally qualified health centers, from least to most intense day amil on subject of the training y planning clinics, and the role of telehealth to reach providers in states Data, Monitoring and Evaluation Developing more information regarding appropriate quality assurance and improvement indicators for immediate postpartum LARC, measurement of uptake, and documentation on how to access existing data, particularly on safety monitoring and insertion rates Stakeholder Partnerships Identifying ways to engage national and federal partners on the issues of immediate postpartum LARC and determining which internal and external state partnerships are essential for successfully implementing policy

Methodology

• Qualitative, descriptive study
• Semi-structured key informant interviews with state teams (2015-2016)

– Interviews audio recorded and transcribed

• Excerpts identified and independently double-coded by strategy into the

eight areas of focus using Dedoose software – Strategies were reviewed and summarized – States implementing strategies in each domain counted

• Domains used by the most states identified, including cross-cutting domains

Kroelinger, CD, LF Waddell, DA Goodman, et al, Working with State Health Departments on Emerging Issues in Maternal and Child Health: Immediate Postpartum Long- Acting Reversible Contraceptives. J Women Health. 2015; 24.9:693-701. Rankin, KM, CD Kroelinger, CL DeSisto, et al, Application of Implementation Science Methodology to Immediate Postpartum Long-Acting Reversible Contraception Policy Roll-Out Across States. Matern Child Health J. 2016; 20:S173-S179. DeSisto, CL, C Estrich, CD Kroelinger, et al, Using a Multi-State Learning Community as an Implementation Strategy for Immediate Postpartum Long-Acting Reversible

• Contraception. Implemen Science. 2017; 12:138-147.

Results Health System Domains and Strategies: Cross-Cutting

STAKEHOLDER PARTNERSHIPS Facilitate partnerships among private and public insurers, device manufacturers, and state agencies

• Improve acquisition management
• Streamline service provision
• Increase efficiency in product

purchase

• Reduce per capita costs
• Identify champions

Our main clinical champion [is] our chair of the state ACOG [chapter], a professor, and the Medicaid medical director. She has great reach through those different professional streams.

Health Systems Domains and Strategies

Train healthcare providers on current insertion and removal techniques for LARC

• Support use of CDC’s evidence-based

contraceptive guidance, and provide quality family planning services

• Identify champions to promote best practices
• Promote contraceptive counseling
• Increase healthcare provider awareness on

appropriateness of LARC for most clients of all ages, and dispel myths

Making sure that residents and clinicians are well trained in LARC placement postpartum is something that we really want to focus on because of the connection with expulsion rates

• f LARC, and the experienced

providers or clinicians having lower expulsion rates.

Health Systems Domains and Strategies

Increase provider and consumer awareness of contraception

• Develop toolkits and resources

for providers, facilities, and clinics with resources on LARC

• Implement public/private

education campaigns and develop patient-friendly resources

• Develop social media campaigns
• Assess client satisfaction with

service delivery

One thing that we’re working

• n very closely with the valley

area, is what are the myths that surround LARCs and what can we do to address those and educate the population…we conducted a focus group…it was quite astonishing the myths that surround LARCs right now, and shows how much work we have to do.

Health Systems Domains and Strategies

Reimburse healthcare providers for the full range of contraceptive services, including

• Screening for pregnancy intention
• Client-centered contraceptive counseling
• Full cost of LARC device insertion, removal, and

replacement

• Device reinsertion and follow up

Offset patient out-of-pocket costs

• Demonstration and pilot projects

Train billing and coding administrative staff

• LARC toolkits

Our ACOG president [has] been sending

• ut bulletins and sort of spotlight on
• Medicaid. As soon as we finish this LARC
• ne-pager about how to order, what's

the reimbursement, what's the coding, what do the pharmacies buy, each of the five health plans...we’ll send it to every member. It’s just a lot for a provider to understand.

Discussion

• Stakeholder Partnerships – critical to policy

implementation in almost every other domain – Learning Community is a strategy – Networking across agencies/organizations/institutions

• Common strategies

– Champions – Pilot sites

• Data, Monitoring, and Evaluation

– Quality assurance/quality improvement – Administrative claims data analyses – economic methods

We recognized early on that our baseline data couldn’t be the number of IUDs and implants placed because we just weren’t there yet...Our approach was to collect on

• ther things that might show some sort of

progress or forward movement on that idea

• f implementing at the institutional level.

How many places have gotten through the pharmacy? What percentage of clinicians who can deliver at your institution have also received training? Similar kind of data point for nurses who are on L&D? What kind

• f other stakeholders will be directly

involved and need to have some elements

• f training? Those kinds of things.

Gaps in Strategy Development

• Logistical, Stocking, and Administrative Barriers

– Ensure device availability in all facilities and clinics – Remove clauses and restrictions for claims, and develop cost-sharing programs for device purchasing

• Frontier, Rural and Smaller Facilities, and Service Centers

– Train providers on service provision to most women of reproductive age, insertion techniques, and address gaps in provider knowledge, attitudes, and perceptions of LARC – Engage leadership to eliminate smaller reimbursements for services – Engage rural facilities to understand outpatient purchasing options

Gaps in Strategy Development Cont’d

• Client-centered Counseling and Appropriate Provision of Services for Special

Populations – Develop ethical, client-centered language on all contraceptive method

• ptions

– Develop informed consent processes in delivery facilities – Educate providers on confidentiality concerns of adolescents

• Target and Provide Services for Special Populations

– Develop resources and protocols for women with mental health issues, severe chronic conditions, addicted to illicit substances, are incarcerated, are undocumented, or are otherwise underserved – Obtain reimbursement for services among special populations of women

Limitations

• Data collected from a limited number of states
• Only one data collection point used in analysis
• Generalizability
• Evaluation of strategy impact

Conclusion

• Strategy development and implementation at the systems level takes time
• Peer-to-peer learning strategies may influence resource-sharing and cross-

state partnership

• Champions leverage resources, and pilot sites provide a micro-

environment for implementation that can provide data for scale-up statewide

For more information, contact CDC 1-800-CDC-INFO (232-4636) TTY: 1-888-232-6348 www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the

• fficial position of the Centers for Disease Control and Prevention.

Thank you!

If you have any questions please contact Charlan Kroelinger (ckroelinger@cdc.gov).