Summary of "Incorporating Long-acting Reversible Contraception Into Primary Care: A Training and Practice Innovation," Pace et al., Women's Health Issues, Nov. 2, 2015.
"As the Affordable Care Act (ACA) reduces cost sharing as a barrier to long-acting reversible contraceptive (LARC) use, attention has turned to other barriers that limit LARC's availability to patients," according to Lydia Pace of Brigham and Women's Hospital's divisions of general internal medicine and women's health, and colleagues. According to the authors, "Two key barriers are the limited availability of on-site LARC services at primary care clinics, and inadequate numbers of providers trained in LARC insertion and removal, particularly among non-obstetrician-gynecologists."
"Across specialties, many outpatient primary care practices do not offer LARC and require patients seeking LARC to be referred elsewhere," the authors wrote, nothing that in 2011, "only 56% of office-based obstetricians/gynecologists, family practitioners, and adolescent medicine specialists offered on-site IUDs; only 32% offered implants." They added that LARC training is "uncommon among generalist primary care providers," and in "national surveys of family practitioners, only 42% and 11% of family practitioners were comfortable inserting an IUD and implant, respectively.
Further, "facility-level barriers, including upfront costs and logistics complicate the incorporation of LARC into outpatient clinics," and primary care facilities that do not commonly provide ob-gyn services likely have a particularly hard time providing LARCs, the authors noted.
The authors proposed "a clinical innovation to foster on-site LARC provision in the general internal medicine practice at" Brigham and Women's Hospital. According to the authors, clinicians at the facility "routinely provide contraceptive counseling and prescriptions, [but] before this project, patients requesting LARC were referred to obstetricians/gynecologists."
The model aims to "1) to train general internists to competence in IUD and implant placement, 2) develop a systems-level protocol to provide LARC services onsite, and 3) build the foundation for comprehensive internal medicine resident training in LARC."
Planning and Implementing the Training
For their project, the authors had one clinic faculty member coordinate "intensive training of one or two attending physicians." Those providers could then "develop an on-site LARC practice where other internists could refer patients, creating consistent volume to maintain provider skills, and ultimately provide internal resident training opportunities."
To provide a "high-volume ... repetitive and efficient procedural experience" for trainees, ob-gyns first trained internists on IUD insertion using a model and then advanced them to post-abortion IUD insertion. Then, internists trained for "7 half-days ... placing 10 IUDs under supervision" in the facility's general gynecology clinic. The authors cited coordinating the schedules of ob-gyns, trainees and patients as the "most challenging aspect of LARC training."
Planning and Implementing the LARC Clinic
The authors coordinated their project with the hospital's supervisors and its pharmacy to secure IUDs and implants, as well as with nurses, laboratory services and administrative staff for logistics.
The internist developed referral templates in the facility's electronic health record system "[t]o educate colleagues and generate buy-in" that "guid[ed] referring physicians in patient selection and counseling." The internist also "led teaching conferences for faculty and residents updating them in LARC, candidate selection, and the new referral templates and protocols."
According to the authors, "a twice monthly LARC clinic [then] began in our primary clinic." The LARC clinic had 24 referrals in 8 months, and "most were referred by other clinicians within the practice." Of the 24 patients:
- 11 received an IUD, one of whom expelled the device five months after placement;
- Six received an implant, two of which were placed by a certified resident under supervision;
- Four had previously placed IUDs removed; and
- Three requested IUDs but were referred to an ob-gyn because of "procedural difficulties."
The authors cited "a no-show rate of about 40%" among patients as their biggest challenge in implementation.
Recommendations for LARC Provision in Primary Care
According to the authors, the "project demonstrates that LARC training and provision in general internal medicine and other primary care settings are feasible though [they] require strong commitment from trainees, obstetrician/gynecologist partners, clinic staff, and practice directors." They offered five guidelines for "primary care practices interested in LARC provision":
- Engaging leadership to secure financial and logistical support;
- Tailoring training guidelines based on primary care providers' "perspectives and skills";
- Developing flexible systems that balance "provider competence and patient access while maintaining clinic productivity," such as arranging LARC days at a clinic or ensuring convenient and prompt referrals when same-day LARC insertion is not feasible; and
- Training all primary care physicians in contraceptive counseling for LARC, "regardless of on-site LARC availability."
The authors stated that their "next steps include strategies to reduce no-shows and increase referrals"; formally evaluating patient satisfaction; and "offer[ing] LARC training during ambulatory rotations for internal medicine residents in the residency program's primary care track."
Conclusions
"Provision of comprehensive contraceptive care by primary care providers is essential to realize the ACA's promise to increase access to essential women's preventive services," the authors said. They noted that "it could make accessible, highly effective contraception a reality for more patients, particularly those with chronic conditions."
The authors urged "primary care practice leaders to strongly consider offering [LARC] services in the context of comprehensive preventive care, and urge primary care residencies to explore how to include LARC in training programs."
