The Contraceptive CHOICE Project

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Objectives

• Describe the study design and methods• Review key findings from Pre-CHOICE surveys• Review important findings from CHOICE• Discuss dissemination and translation of

results into practice

Unintended Pregnancy in the U.S.

• Over 3 million unintended pregnancies– 59% mistimed– 39% unwanted

• 1.2 million abortions• 367,752 births to teens 15-19 years• Contraception

– 52% non-use– 43% incorrect use

Finer Contraception 2011; Hamilton NCHS 2012; Frost Guttmacher Inst 2008

Long-acting Reversible Contraception (LARC)

LNG-IUS• 99% effective• 20 mcg

levonorgestrel/day• Up to 5 years

Copper T IUD• 99% effective• Copper ions

• Up to 10 years

Subdermal Implant• 99% effective• 60 mcg

etonogestrel/day• Up to 3 years

Study Primary Objectives

• To increase the acceptance and use of long-acting reversible contraceptive (LARC) methods among women of childbearing age

• To measure acceptability, satisfaction, side-effects, and rates of continuation across a variety of reversible contraceptive methods, including long-acting reversible methods

Study Hypotheses

• Increase IUD use– Sentinel clinics from <2% to 6% or more– Post-abortion insertion <1% to 10% or more

• Increase implant use to 3% or more• Observe higher 12-month continuation rates for

LARC vs. other methods• Population outcomes

– Teen pregnancy decline by 10%– Repeat abortion decline by 10%

Study Design: Prospective CohortE

LIG

IBL

E

Exposure Outcome2–3 y

LNG-IUSCu-IUDImplantDMPAPills

PatchRing

Other

Unintended pregnancy

Teen pregnancyRepeat abortion

AbortionContinuationSatisfaction

STI

Study Inclusion Criteria

• 14-45 years• Primary residency in STL City or County• Sexually active with male partner

(or soon to be)• Does not desire pregnancy during next 12

months• Desires reversible contraception• Willing to try a new contraceptive method

Study Timeline

Screening & Enrollment

Introduce study

Eligibility screenLARC Blurb

Offer participation

Enroll participant!

Eligible

Agrees

• Contraceptive Counseling• Informed Consent • Contact Information• Medical Record Authorization• Clinical Forms and

Evaluation• Baseline STI• Baseline Survey• Method Allocation

Contraceptive Counseling• P000001• Development and training included

– Counseling Framework– Standard Script– Contraception 101 Lecture– Counseling and Medical History Forms– Testing & Observation

• Provided by 53 research staff & volunteers– 37 staff, 14 medical, 1 graduate and 1 undergraduate students

• Additional resource for managing patient calls

Madden Contraception 2012

Contraceptive “Menu of Options”

Study Recruitment

Aug 07Dec 07

Dec 08Dec 09

Dec 10Sep 11

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

Location 9,256

2 Abortion clinics 17%

8 Community clinics 14%

University-based research clinic• Word-of-mouth• Provider referrals

69%

Study Follow-Up Rates

6 12 24 36

98% 94% 87% 81%

Survey

Pre-CHOICE Survey Results

STL Population Survey• Objective: Survey knowledge and attitudes about

IUDs among women in St. Louis area• Methods:

– 8-page written survey– Mailed to 12,500 randomly selected households

• One adult female in household asked to complete survey• 1,665 of 7,722 (22%) deliverable and eligible surveys returned

– Measures:• Obstetric & contraceptive history• Knowledge regarding method effectiveness• Knowledge regarding appropriate candidates, side effects, and

myths of IUD

Hladky Obstet Gynecol 2011

STL Population Survey Results• Respondents overall:

– Mean age = 31.9– 57% white– 82% had insurance (83% private)– 70% greater than high school education– 18% history of abortion

• 127 (8%) were currently using or had used IUD– Slightly older (mean age = 32.4)– More likely to be parous– More likely to be receiving public assistance

Hladky Obstet Gynecol 2011

MYTHS Regarding IUDs• 50% of women surveyed believe IUD is SAFE• Common safety concerns:

– Pelvic Pain 36% – Infertility 30%– Cancer 14%– STDs 11%

• 61% underestimate the effectiveness

Hladky Obstet Gynecol 2011

Knowledge About IUDs

STL Population Survey Results

STL Provider Survey

• Objective: Survey knowledge and attitudes about IUD among providers in St. Louis area

• Methods:– Written self-administered survey– Mailed to 250 providers

• Medical directories and electronic searches• 137/186 (73.7%) delivered and eligible surveys returned

– Measures:• Demographic characteristics• Graduate medical training• Contraceptive patients seen and willingness to insert IUD

Madden Contraception 2010

STL Provider Survey Results• 99% physicians• 85% white, 4% black, 10% other• Residency training:

– 44% completed before 1989– 41% 1989-1999– 16% after 1999

• 56% completed residency at a Catholic institution• Contraceptive patients each week

– 35%: 0–25 – 50%: 26-50 – 15%: 50+

Madden Contraception 2010

STL Provider Survey Results• 36% not trained in IUD insertion during residency

or clinical training• Discussed IUD with patients

– 18% “always”– 75% “most or some of the time”

• 66% reported inserted >10 IUD in past year• GC/CT testing prior to IUD insertion

– 40% always – 52% sometimes

Madden Contraception 2010

STL Provider Survey Results• Appropriate candidates for IUDs

– 62% nulliparous– 31% adolescent– 45% STI in past 2 years– 37% PID in past 5 years– 37% non-monogamous relationship

• Offer IUD– 98% if 35 y.o., married, with 3 children– 50% if unmarried 17 y.o., monogamous, and one child– 19% if unmarried 17 y.o., never been pregnant

Madden Contraception 2010

CHOICE Project Results

CHOICE Study Participants

Peipert Obstet Gynecol 2012

Baseline Chosen Method%

LNG-IUS 46.0Copper IUD 11.9Implant 16.9DMPA 6.9Pills 9.4Ring 7.0Patch 1.8Other <1.0

75%

Peipert Obstet & Gynecol 2012

Choice of LARC Methods among Adolescents

Mestad Contraception 2011

12-Month ContinuationMethod Continuation Rate (%)

LNG-IUS 87.5

Copper IUD 84.1

Implant 83.3

Any LARC 86.2

DMPA 56.2

OCPs 55.0

Ring 54.2

Patch 49.5

Non-LARC 54.7

Peipert Obstet Gynecol 2011

12-month Continuation: Adolescents Compared to Older Women

Rosenstock Obstet Gynecol 2012

Unintended Pregnancy by Contraceptive Method

1 2 30%

2%

4%

6%

8%

10%

12%LARC DMPA PPR

Year

Parti

cipa

nts

with

Con

trac

eptiv

e Fa

ilure

(%) HRadj = 22.3

95% CI 14.0, 35.4

Winner NEJM 2012

Method Failure by Age

Winner NEJM 2012

Repeat Abortion in St. Louis Region

• Data obtained from MO DHHS– Represents women who reside in Missouri at time of

abortion• Repeat abortion measured as ever had a

previous abortion• Compared to Kansas City & non-metro MO

– KC: One abortion clinic– KC: Similar demographic characteristics to STL

Repeat Abortion 2006 - 2010

2006 2007 2008 2009 201025%

30%

35%

40%

45%

50%

55%

St. Louis City/CountyKansas CityNon-Metro Missouri

Perc

ent o

f rep

eat a

borti

ons

Peipert Obstet Gynecol 2012

Test of Trend 2006-2010: STL, p=.002; KC, p=.003; Non-metro MO, p=.18

CHOICE Compared to U.S.• Teen birth rate (age 15-19 years)

– 6.3 per 1,000 teens (first year use rate)– 16.3 per 1,000 teens (average annual rate)– Compared to 34.3 per 1,000 nationally

• Abortion rate (women ages 15-44)– 6.0 per 1,000 women (average annual rate)– Compared to 19.6 per 1,000 nationally

• Unintended pregnancy rate– 15.0 per 1,000 women (average annual rate)– Cumulative: 35.0 per 1,000 women– Compared to 52.0 per 1,000 nationally

Peipert Obstet Gynecol 2012

Main Findings from CHOICE

• Women overwhelmingly choose LARC• LARC methods associated with higher

continuation & satisfaction than shorter-acting methods– Regardless of age

• LARC methods associated with lower rates of unintended pregnancy

• Increasing LARC use can decrease unintended pregnancy in the population

Dissemination & Translating Research into Practice

The Secret: 3 Key Ingredients

• Education regarding all methods, especially LARC– Reframe the conversation to start with the most

effective methods• Access to providers who will offer & provide LARC

– Dispel myths and increase the practice of evidence-based medicine

• Affordable contraception– Institute of Medicine recommendation, Affordable

Care Act, Medicaid Expansion

Successful Implementation of CHOICE Model

Key Element Barrier Facilitator

EducationLimited time for contraceptive counseling during appointment

Counseling provided by non-clinician trained in tiered-based counseling

Access Outdated myths regarding teens as LARC candidates

Identify local “champion clinician” who is LARC proficient, trusted, and can dispel myths

Cost

Lack of reimbursement for contraceptive method, insertion & removal

Network with clinics that have identified how best to manage cost issue through effective billing or payer mix

Up-front cost of stocking LARC methods for same-day insertions

Investigate ways to purchase a few methods that serve as temporary supply

Dissemination Strategies• Create online Resource Center to disseminate

CHOICE materials LARC First– The Evidence– Contraceptive Counseling– Advanced Practitioner Resources– Patient Management– Effective Staffing & Management

• Provide technical assistance to end users– >100 national & international requests

• Evaluate how CHOICE materials are adopted and adapted for successful use– PCORI Funding

40

Online Resource Center

Examples of Dissemination

Courtesy of Mary Alexander, Healthy Start Indianapolis

Dissemination Strategies• National forums & grand rounds• Community presentations & festivals/events

Dissemination Strategies• Website transitioned from recruitment to

resource guide

• Social media

• Lay Press

• Short videos

Open the Dialog Video

http://www.youtube.com/watch?v=VAsdg7f7M7w

Pathway to Choice Video

http://www.youtube.com/watch?v=cd46pXtMHOo

What method is right for you?

http://www.youtube.com/watch?v=u9SHoy1C3tU

To Learn More Visit

www.choiceproject.wustl.edu

www.facebook.com/choiceproject

http://www.youtube.com/user/WUSTLChoiceProject

https://twitter.com/WUSTLChoice