National Partnership for Women & Families

Monthly Women's Health Research Review

Study compares follow-up care conducted at office, via phone after medication abortion

Summary of "Comparing office and telephone follow-up after medical abortion," Chen et al., Contraception, April 18, 2016.

"The main purpose of follow-up after [medication] abortion is to detect ongoing pregnancies," according to Melissa Chen of the Department of Obstetrics and Gynecology at the University of California-Davis (UC-Davis) and colleagues.

The researchers noted that methods for follow-up include in-office exams using "ultrasonography and/or clinical examination, serum human chorionic gonadotropin (hCG) measurements, telephone assessment with urine pregnancy test (UPT), and self-assessment with UPT." According to the researchers, "Both office evaluation and serum hCG measurements require the patient to present to a facility for assessment, which incurs additional costs, time and travel, and poses a risk of loss to follow-up."

However, "telephone follow-up with a home UPT eliminates an in-person visit." Further, according to the researchers, studies have shown that home UPTs -- including high-sensitivity, low-sensitivity and semi-quantitative tests -- "all appear effective in detecting ongoing pregnancies." In addition, the researchers wrote "the high-sensitivity UPT is commercially available" in the United States "and can be integrated into clinical practice."

The researchers offered women presenting for medication abortion at UC-Davis Medical Center the option to follow up with an in-office visit or a phone call and then "compare[d] proportion lost to follow-up after [medication] abortion in women who choose office versus telephone-based evaluation." They also "compare[d] successful abortion rates between the follow-up methods and describe[d] staff effort required to complete follow-up."

Materials and methods

The researchers conducted the study using data on women presenting for abortion care at UC-Davis Medical Center between August 2012 and August 2015. According to the researchers, the study period marked the first three years of a new medication abortion program at the facility.

The researchers wrote that women who had a medication abortion at the facility took 200 mg mifepristone orally at the office and then could choose between taking 800 mcg of misoprostol by mouth between 24 and 72 hours later or vaginally up to 72 hours later.

According to the researchers, women who opted for office-based follow up received an ultrasound one to two weeks after the abortion. Women who opted for telephone follow up received a phone call one week after the medication abortion and a second phone call four weeks after the medication abortion to discuss the results of an at-home UPT. The researchers noted that if a patient or provider "was unsure whether the pregnancy passed after the first telephone evaluation or if the patient reported a positive UPT at four weeks, then the clinician scheduled the patient for an office evaluation."

The researchers wrote, "Women in the office follow-up group were considered to have completed all follow-up if they attended an office visit." According to the researchers, women who opted to follow up by phone were considered to have completed follow up if they completed both phone calls or if they alternatively completed an in-office visit.

The researchers also tracked how many medication abortion procedures were successful and assessed "staff effort to complete follow up as measured by the number of missed office visits that required rescheduling in the office group and additional attempts required to complete telephone follow-up."

Among women who had more than one medication abortion over the study period, the researchers only considered the first. In addition, the researchers categorized women by the initial method of follow-up selected, even if they switched follow-up methods later.

Results

The final sample included 176 medication abortion patients. According to the study, 105 women chose office-based follow-up, while 71 chose telephone follow-up. The researchers found that while "women who chose office evaluation were more likely to complete all follow-up (94.3% vs 84.5% ...), the proportion lost to follow-up was similar in both groups (4.8% vs 5.6% ...)."

The researchers noted that nine women (8.6 percent) in the office-based group switched to telephone follow-up, and two women (2.8 percent) switched from the telephone group to the office group. Ten women in the telephone follow-up group were asked to come into the office, and all of them complied. According to the researchers, two patients (1.9 percent) in the office group and four (5.6 percent) in the telephone group visited the emergency department.

Medication abortion efficacy was similar among both groups, at 94 percent for the office group and 92.5 percent for the telephone group, the researchers wrote. They found that the two ongoing pregnancies that occurred during the study were both detected in the office group. Overall, "[p]roviders performed nine suction aspirations for incomplete abortions."

In terms of staff effort, the researchers found that staff rescheduled appointments for 15 percent of patients in the office group. In the telephone follow-up group, 43.9 percent of patients received more than one call attempt at one week, while 69.4 percent received more than one call attempt at four weeks. The researchers noted that "[s]taff did not call 5.7% of patients at one week and 12.5% of patients at four weeks for follow-up evaluation."

Discussion

The researchers said the low rate of women lost to follow up in both groups could "be attributed to women being able to choose their preferred method of follow-up." According to the researchers, previous studies have found "lost to follow-up rates" of between 18 and 45 percent when office-based follow up was the only option, and between 13 and 30 percent when telephone follow up with UPT was the only option. The researchers also noted relatively high rates of undetected pregnancy in prior research examining "medical abortion outcomes with a self-assessment and low-sensitivity UPT or a semi-quantitative UPT," which "provid[e] support for telephone assessment by a clinician in addition to home UPT."

The researchers wrote that while "the [medication] abortion efficacy rates were similar in both groups, the overall efficacy is lower (93.4%) compared to what [the researchers] expected."

In addition, the researchers noted that while "the ongoing pregnancy rate of 1.2% is similar to previous studies ... , the incomplete abortion rate in this study was higher." They hypothesized that "the incomplete abortion rate may reflect the abortion service being new to our teaching institution and providers potentially addressing symptoms with aspiration rather than expectant management or a second dose of misoprostol."

According to the researchers, "Staff effort appears higher in the telephone group compared to the office group, which may pose a barrier to implementation of telephone-based evaluation for some practices." They noted, however, that "[w]hile staff effort appears higher for telephone follow-up, the staff effort associated with a missed office visit can also be considerable given the staff time already allotted for the missed visit and the need to call patients to reschedule."

In addition, they wrote that it is not clear whether "women who required more than one telephone call to complete follow-up would have been lost to follow-up if [the researchers] only offered office evaluation." According to the researchers, "significant staff resources may also be required to call and reschedule patients if office follow-up had been the only option offered."

The researchers wrote that the "study is the first to assess outcomes in clinical practice with telephone evaluation as compared to office follow-up in the United States." They concluded, "By having alternative methods of follow-up available after [medication] abortion, patients can choose the option that is more comfortable and convenient for them, which may increase patient adherence to follow-up."