www.sandyford.org

Increasing the Proportion of Women using Long Acting Reversible Contraception (LARC) within a Geographical Area in

Scotland

Dr Audrey Brown

www.sandyford.org

Greater Glasgow and Clyde

www.sandyford.org

Long-acting reversible contraception

• National Institute for Clinical Health and Excellence (NICE) 2005– Women should be offered a choice of all methods

including LARC. – All LARC methods are more cost effective than the

combined oral contraceptive pill even at 1 year of use.– IUDs, IUS and implants are more cost effective than

the injectable contraceptives.– Increasing the use of LARC will reduce unwanted

pregnancies

www.sandyford.org

Scotland 2004/5 Uptake intra-uterine device, intra-uterine system,

contraceptive implantper 1000 women aged 15-44

Rate per 1000 women

within Scotland

Rate per 1000 women

within GGC

23 17

www.sandyford.org

vLARC rate per 1000 women 2004/05

0 5 10 15 20 25 30 35 40 45

Greater Glasgow & Clyde

Lanarkshire

Lothian

Fife

Forth Valley

Scotland

Grampian

Tayside

Dumfries and Galloway

Ayrshire & Arran

Borders

Islands

Highland

www.sandyford.org

GGC – time for action• Target set to increase from

17/1000 to 85/1000 in 5 years

www.sandyford.org

National Drivers

• Key Clinical Indicator (KCI) on LARC – Information and Statistics Division – annual reporting of uptake by board area

• Quality Improvement Scotland (QIS) – standard on intrauterine and implantable methods of contraception

• National LARC awareness campaign

www.sandyford.org

Key Clinical Indicators for Sexual Health: Population Based Indicator

Termination of Pregnancy Sterilisation Long Acting Reversible Contraception

Chlamydia HIV Therapy

www.sandyford.org

QIS LARC standardEssential Criteria

• Women requiring contraception are given information about, and offered a choice of, all methods of contraception including intra-uterine and implantable contraceptives

• 60 or more females per 1000 of reproductive age per year are prescribed intrauterine and implantable contraceptives

• Contraceptive providers who do not provide intrauterine and implantable contraceptives have an agreed mechanism in place for referring women

• A consultation appointment with a service providing intrauterine and implantable contraceptives is available within 5 working days

Desirable criterion

• 100 or more females per 1000 of reproductive age per year are prescribed intrauterine and implantable contraceptives by the end of 2011

www.sandyford.org

• Media launch• Retail outlets• Cinemas• Gym changing rooms• Bar toilets

www.sandyford.org

Local action:• Raise awareness through distribution of LARC

resource pack• Contraceptive prescribing guidance for primary

care• Improve access to free training, especially for

nursing staff, both primary care and acutes• Reimburse primary care practitioners for

provision of LARC in general practice• Locality mapping to drive local planning• Improve access to LARC at Sandyford

www.sandyford.org

LARC Resource PackThis resource pack is designed to support both CHPs and specialist sexual health services in planning developments and implementation of local LARC (Long Acting Reversible

Contraception) services.

Section 1 – National LARC Policy & Perspective Major documents supporting the rationale of increasing the use of LARC methods will reduce rates of unintended pregnancy in a cost effective manner

Comparative rates of effectiveness of different contraceptive methods

Section 2 – An Overview of LARC Usage Levels at National, Board & CHP LevelAn overview of LARC usage for the national board-wide and CHP perspective including local mapping reports.

Section 3 – LARC Protocols & Guidance DocumentsProtocols and Clinical Guidance documents supporting provision of LARC

GP Contraceptive Prescribing Guidance Faculty of Sexual & Reproductive Healthcare Guidance on LARC

Section 4 – GP Income & Local PaymentsQOF Agreement for LARC 2009/10

Enhanced Service Agreements

Section 5A – LARC TrainingFaculty of Sexual & Reproductive Healthcare training package CDs for fitting Implants, IUD/IUS and EHC provisionn

Faculty Information re obtainment of Letters of Competence Nurse training documentation – RCN & West MCN Guidance, PGDs

Information on how to access training locally through Sandyford

Section 5B – LARC Education Useful websites & online resources

Available meetings & coursesResources available refer to sections 6 & 7

Section 6 – LARC Patient PerspectivePatient/Client perspective

2 Articles from Peer Review Journals (article D Mansour et all European Journal of Contraception 13.4.2008) RAGS article WISH Report

National Sexual Health Awareness Campaign materials

Section 7 – Patient Resources for LARCPatient/Client Information

Information on how to access written leaflets and posters locallyUseful websites

Examples of patient information leaflets (FPA, Health Scotland )Sandyford materials for signposting/referring patients to local services.

Section 8 – Templates & Tools for Local LARC Planning, Audit & Implementation.This section contains some examples of templates that can be adapted and supported at a local CHP level.

Some examples have been included:Needs Assessment Audits

Implementation/Action Plans

www.sandyford.org

CONTRACEPTIVE PRESCRIBING IN PRIMARY CARE

Patient requests contraception

Take full medical and sexual history Check BP and smear status Offer STI screening Discuss contraceptive choices taking into account the above and

patient preference

Consider long-acting reversible contraception (LARC) as first line option as this is the most effective way to avoid pregnancy

LONG-ACTING REVERSIBLE CONTRACEPTION (LARC)See Nice CG30 (Long-acting Reversible Contraception – Oct 2005)

Progesterone-only implant (Implanon®) - Lasts 3 years Copper IUD (TT380 Slimline®) - Lasts 10 years Progestogen-only IUS (Mirena®) - Lasts 5 years

•Useful if menorrhagia present Progestogen-only depot (Depo-Provera®)

•Given every 12 weeks NB: The effectiveness of LARC preparations containing hormones, such as

Implanon® may be affected by interacting medicines. Refer to individual SPC or BNF for guidance

Consider appropriateness of COC or POP taking into account patients age, medical history, risk factors and patient

preferences

COC appropriatePOP appropriate

Micronor® or Femulen®

Should be considered 1st line POPs

Cerazette® should only be considered in women who cannot tolerate or have contraindications to oestrogen containing contraceptives

Cerazette® may also have advantages in women with a history of poor compliance

1st line choice should be a standard strength 2nd generation such as Microgynon 30® or Loestrin 30®

If patient suffers from acne, consider Marvelon®

Adverse effects, poor cycle control or poor compliance may dictate

further options

www.sandyford.org

Local Enhanced ServiceNational Enhanced Service

Contraceptive Implant

• In 2009-10 each practice contracted to provide the contraceptive implant service will receive a £25.81 insertion fee and £51.61 removal fee per patient

IUD/IUS

• In 2009-10 each practice contracted to provide the IUD/IUS service will receive a £79.92 insertion fee per patient.

www.sandyford.org

www.sandyford.org

Capturing termination of pregnancy population

• Over 3000 TOPs annually in GGC• Over 1 in 4 are repeat TOP• Two thirds performed medically• Local training programme for gynaecology

nurses to train in implant insertion

www.sandyford.org

GGC women undergoing MTOP in 2007 and 2010

Contraceptive method chosen at time of assessment clinic in 2007 and 2010

0

5

10

15

20

25

30

35

COCPPOP

Impla

nt

IUD/IU

S

DMPA

Barrie

r

Nil/und

ecide

d

pe

rce

nta

ge

of

all

wo

me

n

% requesting method in 2007 % requesting method in 2010

www.sandyford.org

GGC women undergoing MTOP in 2007 and 2010

Contraceptive method supplied on day of abortion in 2007 and 2010

0

5

10

15

20

25

30

35

40

45

COCPPOP

Impla

nt

IUD/IU

S

DMPA

Barrie

r

Nil/und

ecide

d

pe

rce

nta

ge

of

all

wo

me

n

% supplied with method in 2007 % supplied with method in 2010

www.sandyford.org

MTOP and STOP women

Method of contraception provided on day of TOPJul-Sept 2010 TOPAR clients

0

5

10

15

20

25

30

coc pop depo impl iud ius nil

Method

% % receiving method on day

www.sandyford.org

Improving access to LARC at Sandyford

• Redesign of Sandyford Central drop-in services Sept 2009

• Increase drop-in registration hours from 2 hour window to 5 hour window

• Offer LARC fitting at drop-in

www.sandyford.org

• IUD/IUS insertion or reinsertion

– Jan - Aug 09

• 103

– Sept 09 – Feb10

• 152

0

20

40

60

80

100

120

140

160

Insertion only IUD/IUS check Not Recorded Procedure abandoned Removal only Removal/insertion

2009 32009 42009 52009 62009 72009 82009 92009 102009 112009 122010 12010 22010 3

Cou

nt o

f Pro

cedu

res

IUD/IUS Procedure Type by Month

www.sandyford.org

• Implant insertion or reinsertion– Jan – Aug 09

• 86

– Sept 09 – Feb 10• 180

0

20

40

60

80

100

120

140

160

180

Implant Insertion Implant Removal Implant Removal and Insertion Not Recorded

2009 32009 42009 52009 62009 72009 82009 92009 102009 112009 122010 12010 22010 3

Cou

nt o

f Pro

cedu

res

Implant Procedure Type by Month

www.sandyford.org

Activity in 2004/05 vs 2009/10 in GGC

1° Care 2°Care Total

Impl 257 1259 1516

IUD/

IUS

1384 2483 3867

vLARC 1641 3742 5383

1° Care 2°Care Total

Impl 2964 7883 10847

IUD/

IUS

1854 8431 10285

vLARC 4818 16314 21132

www.sandyford.org

5 years on…..Rate per 1000 women

within Scotland

Rate per 1000 women

within GGC

2004/5 23 17

2005/6 30 31

2006/7 34 37

2007/8 41 46

2008/9 47 53

2009/10 57 69

www.sandyford.org

vLARC rate per 1000 women 2009/10

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0

Lanarkshire

Fife

Forth Valley

Lothian

Borders

Grampian

Scotland

Tayside

Ayrshire & Arran

Western Isles

Shetland Islands

Highland

Greater Glasgow & Clyde

Dumfries and Galloway

Orkney Islands

NHS board area

www.sandyford.org

Abortions performed in Scotland, 1968-2009p

-

2 000

4 000

6 000

8 000

10 000

12 000

14 000

16 000

19

68

19

69

19

70

19

71

19

72

19

73

19

74

19

75

19

76

19

77

19

78

19

79

19

80

19

81

19

82

19

83

19

84

19

85

19

86

19

87

19

88

19

89

19

90

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

Year

Nu

mb

er

1 Refers to therapeutic abortions notified in accordance with the Abortion Act 1967. p Provisional.Source : Notifications (to the Chief Medical Officer for Scotland) of abortions performed under the Abortion Act 1967

www.sandyford.org

Summary• Uptake of LARC in GGC has increased from

17/1000 women to 69/1000 women over 5 years• Increase in uptake in GGC has outperformed

that in Scotland as a whole• A combination of national and local drivers are

likely to have contributed• We did not meet our own target of a 5 fold

increase in uptake in 5 years• But we did meet the essential QIS target of 60

per 1000 women being prescribed LARC