Required examinations and tests before initiating contraception: Provider practices from a national cross-sectional survey

Objective(s)We estimated the prevalence of requiring specific examinations or tests before providing contraception in a nationwide survey of family planning providers.Study DesignWe conducted a cross-sectional survey of public-sector health centers and office-based physicians providing family planning services across the United States in 2019 (n = 1395). We estimated the weighted proportion of providers (or their health center or practice) who required blood pressure measurement, pelvic examination (bimanual examination and cervical inspection), Papanicolaou (Pap) smear, clinical breast examination (CBE), and chlamydia and gonorrhea (CT/GC) screening before initiating hormonal or intrauterine contraception (IUC) for healthy women. We performed multivariable regression to identify factors associated with pelvic examination practices aligned with clinical recommendations; these recommendations classify examinations and tests as recommended or unnecessary before initiation of specific contraceptive methods.ResultsThe overall response rate was 51%. Most providers required blood pressure measurement before initiating each method. Unnecessary CBE, Pap smears, and CT/GC screening were required by 14% to 33% of providers across methods. Fifty-two to 62% of providers required recommended pelvic examination before IUC placement; however, 16% to 23% of providers required unnecessary pelvic examinations before non-intrauterine hormonal method initiation. Factors associated with recommendation-aligned pelvic examination practices included having a higher proportion of patients using public funding (Medicaid or other assistance) and more recently completing formal clinical training.ConclusionsAlmost half (47%) of providers did not require necessary pelvic examination before placing IUC. Conversely, many providers required unnecessary examinations and tests before contraception initiation for patients.ImplicationsMost providers required the few recommended examinations and tests for safe contraceptive provision. Reduction of unnecessary examinations and tests may reduce barriers to contraceptive access. There are also opportunities to increase use of recommended examinations, as up to 48% of providers did not require recommended pelvic examination before IUC.     

Obstetrician-gynecologists’ beliefs on the importance of pelvic examinations in assessing hormonal contraception eligibility

Objective

To describe obstetrician-gynecologists’ beliefs regarding the importance of pelvic examination (including external genitalia inspection, speculum examination, bimanual examination) in assessing hormonal contraception eligibility.

Methods

In a national probability survey, 1020 obstetrician-gynecologists drawn from the American Medical Association’s Physician Masterfile rated importance of the examination in four categories: very, moderately, a little and not important.

Results

The response rate was 62% (n= 521). Seventy-nine percent considered at least one exam component to be of some importance (very, moderately, or a little importance). Bimanual examination was rated more often than external examination in each level of importance (p<.001). Physicians who believed no component of the examination was important were more likely to be younger, female and in practice settings other than private practice.

Conclusions

Despite guidelines stating that pelvic examinations are unnecessary in assessing hormonal contraception eligibility, most obstetrician-gynecologists believe that they are of some importance. These attitudes may pose a barrier to contraception provision.     

Utilization of Health Services in Physician Offices and Outpatient Clinics by Adolescents and Young Women in the United States: Implications for Improving Access to Reproductive Health Services

PurposeWe examined utilization patterns of adolescents and young women as they seek general and reproductive health services in physician offices and hospital outpatient clinics.MethodsWe analyzed physician office visits in the 2003–2006 National Ambulatory Medical Care Surveys, and hospital outpatient clinic visits in the National Hospital Ambulatory Medical Care Surveys, to examine utilization patterns of females aged 9–26 years by 2-year age intervals and other characteristics such as physician specialty or clinic type.ResultsThe number of visits to primary care physician offices increased with age, from 4.9 million for ages 9–10 years to 9.0 million for ages 25–26 years. The proportion of visits made to obstetrician-gynecologists and family practitioners increased with age, and by ages 15–16 years fewer than half of all visits to primary care providers were made to pediatricians. The proportion of visits to family practitioners increased from 25% at ages 9–10 years to 30% at ages 25–26 years. By ages 17–18 years, a larger proportion of visits were made to obstetrician-gynecologists (33% of 7.0 million visits) and to family practitioners (34%) than to pediatricians (23%). The proportion of visits for reproductive health services peaked at 53% of 7.5 million physician visits at ages 20–21 years. Similar utilization patterns were observed for the 11.0 million hospital outpatient visits to primary care providers.ConclusionsBecause adolescents and young women most commonly utilize healthcare services provided by obstetrician-gynecologists and family practitioners, these specialties should be priority targets for interventions to improve the quality and availability of reproductive health services.     

A Survey of College Women's Experiences with and Attitudes toward Pelvic Examinations

A questionnaire assessing college women's experiences with and attitudes towards pelvic examinations was mailed to every 20th woman registered at Colorado State University in 1977. The response rate was, 76% (N = 254). Of the respondents, 17% had never had a pelvic examination, and most of these women expressed apprehension about the exam. Of those with examination experience, most respondents had had fewer than five exams (mean age at first exam = 17.95 years), were sexually active, were now obtaining examinations routinely, and had had their first examination for preponderantly nonpathologic reasons. Attitudes towards the examination were mixed, with respondents disagreeing on their preference for particular elements of the examination situation. These results are presented in the context of attacks on gynecologic practice offered by the women's health movement, women practitioners, sexual counselors, lesbians, and some gynecologists. It is argued that objective data regarding experiences and attitudes must be collected before recommendations for change can be made. The present data suggest a great need for disseminating information concerning the pelvic examination to young women.     

Psychological aspects of the pelvic exam: individual needs and physician involvement

Many women are traumatized by pelvic examinations, resulting in reactions ranging from mild anxiety and embarrassment to avoiding the exam altogether. Studies which surveyed how women feel about pelvic exams are discussed and analyzed as are projects utilizing the educational pelvic exam approach. The concept of psychological preparation for pelvic exams is presented incorporating the importance of personal control. The main theme is the proposal that preparation for pelvic exams should be tailored to each individual patient. The role of the examiner is also discussed, stressing physician education and sexual conflicts involved in the performance of pelvic exams.     

Well-woman care and HPV vaccination rates in women with Rett syndrome

BackgroundLifespan has increased in individuals with Rett syndrome (RTT), but little is currently known about the provision of well-woman care to these individuals.ObjectiveTo collect data on well-woman examinations and human papillomavirus (HPV) vaccination rates in women with RTT to understand the current state of women’s healthcare in individuals with RTT.MethodsA retrospective cross-sectional chart review and prospective survey of 77 patients with Rett syndrome who were cared for at a single specialty clinic over five years was conducted to collect data on women’s health examinations and HPV vaccination rates.ResultsThe following percentages represent women with RTT who have met the recommendations of ACOG for well-woman examinations: breast examinations- 40.3%, pelvic examinations- 51.2%, mammograms- 75.0%, external genitourinary examinations ?31.6%. Many of these women also had delayed exams. 22.9% of women who were eligible for the HPV vaccine have received it.ConclusionsMany women with RTT do not undergo well-woman examinations and HPV vaccinations as recommended by ACOG. Since these women are not usually sexually active, many guardians believe the HPV vaccine is unnecessary. However, like other women with disabilities, RTT females are at risk for sexual abuse and disparities in access to women’s health services, so these topics should be discussed with caretakers.     

A Stimulus Control Intervention in the Gynecological Exam with Sexual Abuse Survivors

ABSTRACT

The effectiveness of a new examination gown, as a stimulus control intervention designed to reduce distress during the pelvic exam, was investigated in a sample of sexual abuse survivors and women without abuse histories. Sixty-nine participants from a women's health ambulatory center and a private practice in gynecology were randomly assigned to the experimental gown condition or the paper drape control group. One-third of the sample reported a history of childhood sexual abuse. Survivors reported higher anxiety during exams than did women without abuse histories. Women who wore the experimental gown reported more positive emotional and physical experiences of the exam. Further research is required to examine the trend showing that survivors who wore the experimental gown reported less anxiety during the examination than survivors who wore the control drape.     

Obstetrician-gynecologist and patient factors associated with intimate partner violence screening in a clinical setting

ABSTRACT

Screening for intimate partner violence is recommended by the medical community. This study investigated obstetrician-gynecologists’ intimate partner violence screening patterns and physician and patient factors associated with screening. Four hundred obstetricians-gynecologists completed the Physician Readiness to Manage Intimate Partner Violence Survey between December 2014 and July 2015. Their patients completed the Patient Safety and Satisfaction Survey. Hierarchical generalized linear modeling analyzed physician and patient variables related to the likelihood of being screened. Forty-four physicians responded. The viable patient response rate was 81.3 percent (n = 894) of patients from included physicians. Less than half (43.2 percent) of physicians reported screening during annual exams. There was a statistically significant difference for patient race/ethnicity (p < .03) and the number of previous doctor visits (p < .03) with not being screened. These patient-level variables accounted for approximately 68.3 percent of the variance screening odds. There was no significant difference (p < .10) between physicians’ perceived preparation, knowledge, and attitudes for not being screened. The hierarchical generalized linear modeling analysis showed a trend for physicians with a high-perceived preparation for screening was related to initial visits. This study identified that obstetrician-gynecologists do not routinely screen for IPV and race/ethnicity and number of visits are factors in screening for intimate partner violence.     

Importantes diferencias entre facultades de medicina. Implicaciones para la medicina de familia y comunitaria

ObjectiveTo determine if there are significant differences between universities in the proclivity to choose Family and Community Medicine (FCM), given the constraints imposed by the number of choice. To test the hypothesis that the Schools of Medicine that have the FCM as a compulsory subject in the degree (3 of 27) had the highest preference for this specialty.DesignObservational study on the data file of all the individuals taking the MIR examination between 2003 and 2011.LocationSpain.ParticipantsAll those who sat the examinations called by MIR 2003-2011.Main measurementsPosition in the ranking of each candidate, elected position (specialty and center), post code of residence, sex, nationality and university in which they studied, and post code location for the residence chosen.ResultsThe percentage electing FCM is highly correlated with the position in the ranking: 8% of graduates for the ‘best’ college, 46% for the worst. Very noticeable and consistent differences in the preparation for the MIR among the 27 medical schools. Ranking in the exam, female and foreigner, help predict the choice of FCM. The FCM compulsory curriculum from three universities does not seem to exert any influence.ConclusionsThe convenient yardstick competition between the schools of medicine, FCM in their curriculum and the emphasis on the most attractive attributes of the specialty can contribute to the necessary renewal of FCM.     

Are Adolescents Being Screened for Emotional Distress in Primary Care?

PurposeTo assess primary care providers’ rates of screening for emotional distress among adolescent patients.MethodsSecondary data analysis utilizing data from: (1) well visits in pediatric clinics within a managed care plan in California, and (2) the 2003 California Health Interview Survey (CHIS), a state population sample. The Pediatric clinic sample included 1089 adolescent patients, ages 13 to 17, who completed a survey about provider screening immediately upon exiting a well visit. The CHIS sample included 899 adolescents, ages 13 to 17, who had a routine physical exam within the past 3 months. As part of the survey, adolescents answered a question about whether they had talked with their provider about their emotions at the time of the exam. Logistic regressions, controlling for age, gender, race/ethnicity, and adolescent depressive symptoms were performed.ResultsAbout one-third of adolescents reported a discussion of emotional health. Females were significantly more likely to be screened than males (36% vs. 30% in clinic; 37% vs. 26% in CHIS); as were older and Latino adolescents in the clinic sample. Although 27% of teens endorsed emotional distress, distress was not a significant predictor of talking to a provider about emotions.ConclusionsPrimary care clinicians/systems need to better utilize the primary care visit to screen adolescents for emotional health.     

Provider Practices and Young Women's Experiences with Provider Self-disclosure during Emergency Contraceptive Visits

BackgroundResearch on the impact of providers disclosing personal contraceptive experiences with patients is limited. In this study, we examine patient and provider perspectives about provider self-disclosure (PSD) of personal contraceptive experiences and its effects on contraceptive decision making and the provider–patient relationship.MethodsWe conducted 18 one-on-one telephone interviews with clinicians who provide contraceptive services to young women and 17 patients seeking emergency contraception from three Bay Area community-based, youth-friendly clinics regarding their contraceptive counseling practices and experiences, respectively. After transcribing and coding all interviews, we summarized structural codes related to contraceptive counseling and PSD.ResultsAlthough providers noted that PSD could help to build rapport and increase patient comfort, most did not report self-disclosing their contraceptive experiences, primarily owing to concerns that it might cross professional boundaries or compromise patient autonomy. All patients held positive attitudes toward and welcomed PSD practices, with many noting that it increased their comfort and trust in their provider.ConclusionsThere were notable differences between patient and provider attitudes toward PSD of contraceptive method use, with patients expressing more positive feelings about the practice than providers. Community-based providers should consider that many young women welcome self-disclosure of provider contraceptive experiences and that more research is needed to understand the effects of PSD practices around contraception on the patient–provider relationship and autonomous contraceptive decision making.     

TRICARE Extended Care Health Option Program: Prevalence of pediatric ECHO enrollees and healthcare service utilization in the Military Health System

BackgroundThe Extended Care Health Option (ECHO) Program is a TRICARE program aimed at reducing the disabling effects of chronic medical conditions for beneficiaries of the Department of Defense (DoD) healthcare program. However, little is known about military-connected children enrolled in the program.Objective/HypothesisThe aim of this study was to examine the demographic makeup of pediatric ECHO beneficiaries and their healthcare claims data. This is the first study to evaluate healthcare utilization of this subset of military dependents.MethodsA cross-sectional study was performed evaluating ECHO enrolled pediatric beneficiaries and their health service utilization during 2017–2019. TRICARE claims and military treatment facility (MTF) encounter data were utilized to evaluate health service utilization and identify the most frequently reported ICD-10-CM and CPT codes associated with care for this population.ResultsOf the 2,001,619 dependents aged 0–26 years who received medical care in the Military Health System (MHS) during 2017–2019, 21,588 individuals (1.1%) were enrolled in ECHO. The majority of encounters (65.4%) were provided in the MTFs. Inpatient visits, therapeutic services, and in-home nursing care were the top utilized private sector care services. Outpatient visits encompassed 94.8% of healthcare encounters, and neurodevelopmental disorders were the top principal diagnoses among ECHO beneficiaries.ConclusionsWith the increasing prevalence of children with medical complexity and developmental delay, the pediatric TRICARE beneficiaries eligible for ECHO will likely continue to rise. Improving services and supports for military children with special healthcare needs is needed to maximize their developmental trajectory.     

Inefficiencies of electronic medical record use by surgical healthcare providers

ObjectivesElectronic medical records (EMRs) are intended to reduce healthcare costs and improve quality of care. Nevertheless, usability issues common to EMRs have been noted. Given the time demands of a clinic and surgery schedule, as well as the association between EMR usage and burnout, continued investigation into the utility of EMRs is important. We investigated the number of login encounters and time expended on EMRs by surgeons and advanced practice providers (APPs) across several surgical specialties.MethodsA one-year retrospective study was conducted at a tertiary pediatric hospital utilizing EMR data for surgeons and surgical APPs. Encounters and hours expended on EMR were calculated and stratified into three categories: within working hours, after-hours during the work week, and during the weekend. The mean hours expended per provider were calculated and compared between provider types and surgical specialty.ResultsMean time spent on EMR within working hours and after-hours during the work week was significantly less for surgeons than surgical APPs (1.76 hours/day vs. 2.10 hours/day, p<0.0001; 0.272 hours/day vs. 0.299 hours/day, p = 0.0173, respectively). Orthopedic surgery providers spent the most time logged into EMRs during working hours (2.33 hours/day), while neurosurgery expended the least time (1.42 hours/day). A high volume of encounters occurred within and outside working hours for all providers.ConclusionsRegardless of provider type or surgical specialty, substantial time was still universally expended navigating EMRs. This single institution study suggests that opportunities to optimize utility of EMR should be further explored to improve provider work-life balance.     

Telemedicine for contraceptive counseling: An exploratory survey of US family planning providers following rapid adoption of services during the COVID-19 pandemic

ObjectiveDuring the COVID-19 pandemic, many clinicians started offering telemedicine services. The objective of this study is to describe the experience of US family planning providers with the rapid adoption of telemedicine for contraceptive counseling during this period.Study designThis is a cross-sectional web-based survey of family planning providers practicing in the United States.ResultsA total of 172 providers completed the survey (34% response rate). Of these, 156 (91%) provided telemedicine services in the 2 months preceding the survey. Most (78%) were new to telemedicine. About half (54%) referred less than a quarter of contraception patients for in-person visits, and 53% stated that the most common referral reason was long-acting reversible contraceptive (LARC) insertion. A majority of providers strongly agree that telemedicine visits are an effective way to provide contraceptive counseling (80%), and that this service should be expanded after the pandemic (84%). If asked to provide telemedicine visits after the pandemic, 64% of providers would be very happy about it. Many providers used personal phones or smartphones to conduct telemedicine visits but stated that ideal devices would be work-issued computers, tablets, or phones. More than half (59%) of providers prefer video over phone visits.ConclusionsFamily planning clinicians in the United States reported a positive experience with telemedicine for contraceptive counseling during the early stage of the COVID-19 pandemic and believe that this service should be expanded. Clinicians seem to prefer using work-issued devices and conducting video rather than phone visits.ImplicationsTelemedicine is a promising option for providing contraceptive counseling even beyond the COVID-19 pandemic. An investment in hospital or clinic-issued devices that allow for video conferencing may optimize clinicians’ telemedicine experience.     

Continuing social disparities despite upward trends in sexual and reproductive health service use among young women in the United States

BackgroundBuilding upon previous work describing declining rates and socioeconomic disparities in sexual and reproductive health (SRH) service use among young women in the United States, we reexamined patterns and determinants of SRH service use in 2006–2010.Study DesignWe used the latest data from the National Survey of Family Growth to evaluate SRH service use including contraceptive, sexually transmitted infection (STI) and other gynecological exam services among 3780 women ages 15–24 years. We compared proportions of service use across survey years and employed multiple logistic regression to estimate the influence of time and women's sociodemographic characteristics on the likelihood of SRH service use.ResultsThe proportion of women using SRH services increased from 50% (2006–2007) to 54% (2007–2008) and 57% (2008–2010) [all year odds ratios (ORs) 1.4, p values<.03]. Among sexually experienced women, the proportions using SRH and contraceptive services were unchanged, while STI service use increased from 22% (2006–2007) to 33% (2008–2009) (OR 1.7, confidence interval 1.1–2.4, p=.009). Differentials in service use existed across sociodemographic groups, largely with lower proportions of service use among women of social disadvantage.ConclusionsOur results suggest a reversal of negative trends but continuing social disparities in young women's use of SRH services in the United States.     

Postpartum Contraception Use by Urban/Rural Status: An Analysis of the Michigan Pregnancy Risk Assessment Monitoring System Data

ObjectiveWe sought to examine rural/urban differences in postpartum contraceptive use, which are underexplored in the literature.MethodsWe analyzed phase 5 (2004–2008) of the Michigan Pregnancy Risk Assessment Monitoring System (PRAMS) survey. Using Rural–Urban Commuting Area codes and weighted multinomial logistic regression, we examined the association between self-reported postpartum contraceptive method and rural/urban residence among postpartum women not desiring pregnancy (n = 6,468).ResultsPostpartum (mean, 16.5 weeks after delivery), 14.4% of respondents were using sterilization, 6.7% long-acting reversible contraception (LARC), 37.3% moderately effective hormonal methods, 38.4% less effective methods or no method, and 3.2% abstinence. Multivariable analysis yielded sporadic geographic patterns. Odds of method use varied significantly by age, parity, body mass index, and breastfeeding status. Not discussing contraception with a prenatal healthcare provider decreased odds of postpartum LARC use (odds ratio, 0.52; 95% CI, 0.36–0.75). Number of prenatal visits and weeks since delivery were not associated with postpartum contraception method.ConclusionsWe did not observe strong variation in postpartum contraceptive use based on geography. Low uptake of highly effective contraception across rural and urban areas suggests a need for education and outreach regarding these methods.