Long-acting Reversible Contraception Placement Research Articles

Rates of Female Sterilization, Vasectomy, and LARC Placement Before and After the Dobbs Decision: A Retrospective Cohort Study [ID 2683404

INTRODUCTION: Immediately after the Dobbs decision in Ohio, abortion was restricted after detection of a fetal heartbeat. The objective of this study was to characterize changes in utilization of long-acting reversible contraception (LARC) and permanent sterilization (PS) after the abrupt enactment of restrictive abortion legislation. METHODS: We conducted a retrospective cohort study of female and male patients aged 15–55 who underwent permanent sterilization (tubal ligation, salpingectomy, vasectomy) or LARC placement (IUD, contraceptive implant) at a large Northeast Ohio hospital system from January 1, 2022 to December 31, 2022; 6 months before and after Dobbs. Contraception procedure volumes were compared, and patient characteristics were assessed. RESULTS: Pre-Dobbs, 4,247 procedures were identified among females, including 725 (17.1%) PS and 7,449 (81.3%) LARC. Post-Dobbs, the total number of female procedures increased by 15.5% (4,916) and there was a significant increase in the proportion of PS procedures, representing 20.1% of all female procedures (P<.001). Males showed a similar trend, with vasectomies rising from 1,193 to 1,590 procedures. Post-Dobbs, patients undergoing procedures were younger (women, 30.9 years [24.5, 36.8] versus 31.5 [25.2, 36.9]; P=.011; men, 36.6 years [32.9, 39.6] versus 37.2 [34.2, 40.4]; P<.001). Among patients undergoing procedures post-Dobbs, the proportion that reported single relationship status significantly increased for women (57.4% versus 55.9%; P=.028) and men (23.0% versus 18.1%; P=.002). CONCLUSION: This study demonstrates increased utilization of LARC and PS following the Dobbs decision. This rise in PS and demographic changes implies concerns about abortion access, especially among younger reproductive-aged patients. Further research is warranted to understand the driving factors behind these trends.

Permanent and long-acting reversible contraception volumes at a multihospital system in Ohio before and after Dobbs

ObjectivesImmediately following the Dobbs decision, Ohio prohibited abortion after the detection of fetal cardiac activity. We aimed to characterize changes in the uptake of long-acting reversible contraception (LARC) and permanent contraception following the abrupt enactment of restrictive abortion legislation. Study designWe conducted a retrospective cohort study using electronic medical record data of patients aged 15 to 55 who underwent permanent contraception (tubal ligation, vasectomy) or LARC placement (intrauterine device, contraceptive implant) at a multihospital system in northeast Ohio from January 1, 2022 to Decemeber 31, 2022, 6 months before and after Dobbs. We compared procedure volumes and patient characteristics. ResultsWe identified 4247 tubal ligation and LARC procedures pre-Dobbs, including 725 (17.1%) permanent contraception and 3522 (82.9%) LARC. Post-Dobbs, the total number of tubal ligation and LARC procedures increased by 15.8% (4916), and there was a significant increase in the proportion of permanent contraception, (p < 0.001). Vasectomy volume increased by 33.3% post-Dobbs, from 1193 to 1590 procedures. Compared to pre-Dobbs, patients undergoing contraceptive procedures post-Dobbs were younger (tubal ligation and LARC, 30.9 median years [24.5, 36.8] vs 31.5 [25.2, 36.9], p = 0.011; vasectomy, median 36.6 years [32.9, 39.6] vs 37.2 [34.2, 40.4], p < 0.001) and more likely to report single relationship status (57.4% vs 55.9% for tubal ligation and LARC, p = 0.028% and 23.0% vs 18.1% for vasectomy, p = 0.002). ConclusionsThis study demonstrates increased uptake of contraceptive procedures following the Dobbs decision. This rise in permanent contraception suggests a relationship between abortion policy and contraceptive decision-making, especially among younger patients. ImplicationsIncreased permanent and long-acting reversible contraception procedures following Dobbs reveal shifting contraceptive choices, particularly among younger individuals, indicating a connection between abortion policy and reproductive decisions.

Association of Medicaid Reimbursement Policies with Provision of Long-Acting Reversible Contraception in the Postpartum Period, 2012-2018.

Background: To address reimbursement challenges associated with long-acting reversible contraception (LARC) in the postpartum period, state Medicaid programs have provided additional payments ("carve-outs"). Implementation has been heterogeneous, with states providing separate payments for the device only, procedure only, or both the device and procedure. Methods: Claims data were drawn from 210,994 deliveries in the United States between 2012 and 2018. Using generalized estimating equations, we assess the relationship between Medicaid carve-out policies and the likelihood of LARC placement at (1) 3 days postpartum, (2) 60 days postpartum, and (3) 1 year postpartum, in Medicaid and commercially insured populations. Results: Among Medicaid beneficiaries, the likelihood of receiving LARC was higher in states with any carve-out, compared with states without carve-outs, at 3 days (adjusted odds ratio [aOR] 1.49 [95% confidence interval: 1.33-1.67], p < 0.001), 60 days (aOR: 1.40 [95% CI: 1.35-1.46], p < 0.001), and 1 year postpartum (aOR: 1.15 [95% CI: 1.11-1.20], p < 0.001). Adjustments were made for geographic region, seasonality, and patient age. Heterogeneity was observed by carve-out type; device carve-outs were consistently associated with greater likelihood of postpartum LARC placement, compared with states with no carve-outs. Similar trends were observed among commercially insured patients. Conclusion: Findings support the effectiveness of Medicaid carve-outs on postpartum LARC provision, particularly for device carve-outs, which were associated with increased postpartum LARC placement at 3 days, 60 days, and 1 year postpartum. This outcome suggests that policies to address cost-related barriers associated with LARC devices may prove most useful in overcoming barriers to immediate postpartum LARC placement, with the overarching aim of promoting reproductive autonomy.

The Impact of COVID-19 and Policy Changes on Immediate Postpartum Contraception and Permanent Contraception at an Urban Hospital: A Retrospective Cohort Study.

Objective: At the onset of the COVID-19 pandemic, in addition to increased use of telemedicine visits and a temporary suspension of interval tubal ligations, providers at the University of Maryland Medical Center were encouraged to counsel patients interested in long-acting reversible contraception (LARC) about immediate postpartum placement. We assessed immediate postpartum contraception uptake following these policy changes. Materials and Methods: In this retrospective cohort study, we compared patients who delivered a live born infant(s) before the pandemic ("pre-COVID cohort," December 16, 2019-March 1, 2020) and at the beginning of the pandemic ("during-COVID cohort," March 16-May 31, 2020). We collected electronic medical record data, including sociodemographic characteristics and contraception choices antenatally and through 1 year postpartum for 631 patients (321 pre-COVID, 310 during-COVID). Results: Odds of immediate postpartum LARC use in the during-COVID cohort were 33% higher than in the pre-COVID cohort, but this was not statistically significant (adjusted odds ratio 1.33, 95% confidence interval: 0.81-2.19). We found no difference in numbers of patients who received immediate postpartum tubal ligation (10% pre-COVID vs. 11% during-COVID). No patients in the during-COVID cohort obtained interval tubal ligations within 6 months of delivery. Contraceptive choices differed at postpartum visits (p = 0.03), with a decrease in delayed postpartum LARC placement in the during-COVID cohort (15% pre-COVID vs. 8% during-COVID). Conclusions: When COVID-19-related hospital policies prompted increased counseling on immediate postpartum LARC and suspension of interval tubal ligations, patients tended to be more likely to choose immediate postpartum LARC. Situational resource restrictions and targeted counseling may influence patient choices and access to desired contraceptive methods.

Single-Visit Long-Acting Reversible Contraception Initiation Among Adolescents Before and During COVID-19

PurposeSingle-visit long-acting reversible contraception (LARC) is cost-effective and convenient. Our objective was to compare incidence of single-visit LARC placement and associated factors during the year before the COVID-19 pandemic (March 15, 2020) and the first year of the pandemic. MethodsThis retrospective cohort study analyzed electronic health records from a large healthcare system. Eligible adolescents were aged 10–19 years and received outpatient LARC from March 15, 2019 to March 14, 2021. Logistic regression models determined the relationship of patient and provider characteristics on single-visit LARC before and during COVID-19. ResultsOne thousand six adolescents initiated LARC during the study period. Fewer adolescents received single-visit LARC during COVID-19 (289/506, 57.1%) compared to before (315/500, 63.0%), although changes in odds of single-visit LARC were not statistically significant. Concordance between county of patient residence and the location of the LARC placement facility was associated with single-visit LARC before (adjusted odds ratio [aOR] = 2.75) and during (aOR = 1.74) the pandemic (both p < .05). During the pandemic, a few factors were associated with reduced odds of single-visit LARC: (1) public insurance (aOR = 0.49, p < .01), (2) nonobstetricians/nongynecologists providers (pediatrics [aOR = 0.35, p < .01], family medicine [aOR = 0.53, p < .01], or internal medicine [aOR = 0.14, p < .05]), and (3) advanced practice practitioners (aOR = 0.49, p < .01). DiscussionIncidence of single-visit LARC was similar before and during the pandemic. Certain factors were associated with lower odds of single-visit LARC insertion, suggesting differential access during the pandemic for subgroups of adolescents. Our findings may guide policy and programmatic interventions to improve access to single-visit LARC for all adolescent populations.

Postpartum long-acting reversible contraception among privately insured: U.S. National analysis 2007–2016, by term and preterm birth

ObjectivesTo investigate postpartum long-acting reversible contraception (LARC) use among privately insured women, with specific consideration of use after preterm delivery. Study designWe used the national IBM MarketScan Commercial Database to identify singleton deliveries from 2007 to 2016, spontaneous preterm birth, and follow-up ≤12 weeks postpartum. We assessed ≤12-week postpartum LARC placement overall and after spontaneous preterm deliveries, across study years. We examined timing of placement, rates of postpartum follow-up, and state-level variation in postpartum LARC. ResultsAmong 3,132,107 singleton deliveries, 6.6% were spontaneous preterm. Over the time period, total postpartum LARC use increased 4.8% to 11.7% for intrauterine devices (IUDs), 0.2% to 2.4% for implants. In 2016, those who experienced a spontaneous preterm birth were less likely to initiate postpartum IUDs compared to their peers (10.2% vs 11.8%, p < 0.001), minimally more likely to initiate implants (2.7% vs 2.4%, p = 0.04) and more likely to present for postpartum care (61.7% vs 55.9%, p < 0.001). LARC placement prior to hospital discharge was rare (preterm: 8 per 10,000 deliveries vs all others: 6.3 per 10,000 deliveries, p = 0.002). State-level analysis showed wide variation in postpartum LARC (range 6%–32%). ConclusionsWhile postpartum LARC use increased among the privately insured 2007–2016, few received LARC prior to hospital discharge. Those experiencing preterm birth were no more likely to receive inpatient LARC. Postpartum follow-up remained low and regional variation of LARC was high, highlighting the need for efforts to remove barriers to inpatient postpartum LARC for all who desire it—public and privately insured alike. ImplicationsAmong the half of U.S. births that are privately insured, postpartum LARC is increasing after both term and preterm births, yet exceedingly few (<0.1%) received LARC prior to hospital discharge.

The Impact of the COVID-19 Pandemic on Postpartum LARC: A Retrospective Cohort Study [A20

INTRODUCTION: At the onset of the COVID-19 pandemic, providers were encouraged to counsel patients interested in long-acting reversible contraception (LARC) about immediate postpartum placement to decrease in-person postpartum visits. We assessed the impact of this COVID-related hospital policy on postpartum LARC uptake. METHODS: In this retrospective cohort study, we compared patients who delivered a live born infant(s) during two periods, one immediately prior to the COVID pandemic (“pre-COVID cohort” (December 16, 2019 to March 1, 2020)), and one at the onset of the pandemic (“COVID cohort” (March 16-May 31, 2020)). We collected electronic medical record data, including sociodemographic characteristics and contraception choices, in the antenatal and postpartum periods for 649 patients. Odds ratios were adjusted for age and race. RESULTS: We found an increase in immediate postpartum LARC use during COVID (13% vs. 9%, P=.12, aOR 1.44, CI 0.87-2.39). The etonogestrel implant was the most placed form of immediate postpartum LARC in both cohorts (67% and 71% in pre- and during COVID cohorts, respectively). In general, contraceptive choices at discharge differed between the cohorts (P=.01), with fewer patients desiring LARC placement at the postpartum visit during COVID (13% vs. 6% in pre- and during COVID cohorts). There was no difference between the average number of postpartum visits attended in each cohort (OR 0.93, CI 0.68-1.28). CONCLUSION: Changes in contraceptive counseling during COVID were accompanied by differences in postpartum contraceptive choices at discharge. Targeted contraceptive counseling can influence patient choices in the setting of expected barriers to routine postpartum care.

Timing of postpartum long acting, reversible contraception was not associated with 12-month removal rates in a large Medicaid sample

ObjectiveTo determine whether the timing of placement of long acting, reversible contraception (LARC) methods postpartum (immediate postpartum (IPP) or interval (within 6 months postpartum) is associated with higher removal rates by 12 months postpartum. Study DesignWe conducted a retrospective cohort study using linked Medicaid claims and birth certificate data (n = 313,849) from Oregon and South Carolina from January 1, 2010 to December 31, 2018. Our primary outcome was LARC (intrauterine device (IUD) or implant) removal by 12 months postpartum. We compared crude proportions and rates of removal and used a multivariable survival analysis to compare removal over 12 months between IPP and interval LARC placement controlling for sociodemographic and clinical factors and clustered at the woman level. ResultsOur sample included 313,849 births to 247,884 women; a majority did not receive any postpartum contraception (207,058 [66.0%]). Out of the 54,018 (17.2%) of births followed by an immediate postpartum or interval LARC placement, 11.8% discontinued by 12 months. In multivariable analyses, births followed by IPP LARC were 10% more likely to experience discontinuation at any point up to 12 months compared with interval LARC (HR: 1.10, 95% CI: 1.00–1.22), but this was not statistically significant. ConclusionIPP LARC devices are removed at similar rates as LARC placed within 6 months postpartum. ImplicationsTiming of postpartum long acting reversible contraception- interval or immediately postpartum- was not associated with 12 month removal rates.

Long-Acting Reversible Contraception: Placement, Continuation, and Removal Rates at an Inner-City Academic Medical Center Clinic.

Long-Acting Reversible Contraception (LARCs) has the potential to decrease unintended pregnancies but only if women can easily access a requested method. Retrospective electronic chart review identified women desiring LARC placement over a one-year period ending 31 December 2016. Most of the 311 insertions were for family planning, with 220 new insertions and 60 replacements. Delays occurred in 38% (n = 118) of patients, averaged 5 ± 5 weeks, and 47% received interval contraception. Reasons included absence of qualified provider (n = 44, 37%), pending cultures (n = 31, 26%), and Mirena availability. Teenage LARC use favored Nexplanon whereas older women preferred Mirena (p < 0.01). Of the 11% choosing early LARC removal, a significant number were African Americans (p = 0.040) or teenagers (p = 0.048). Retention time varied by device type; most patients switched to other contraceptives. No patients experienced IUD expulsion. Understanding barriers, attempting to remedy them, and addressing the side effects associated with LARC use is of importance in this inner-city patient population in the United States.

Attendance of an Initial Follow-up Visit after Long-Acting Reversible Contraception Insertion and Method Continuation Among Adolescents and Young Adults: A Retrospective Study.

To assess attendance of an initial follow-up visit after long-acting reversible contraception (LARC) insertion and whether follow-up was associated with a higher likelihood of method continuation in adolescents and young adults (AYAs). Retrospective chart review including patients receiving LARC (etonogestrel 68mg implant, levonorgestrel 52mg intrauterine device, or copper intrauterine device) between January 1, 2014, and August 1,2017. An urban adolescent center providing primary care and reproductive health services. A total of 331 patients 13-28years of age. Attendance of a follow-up visit 4-8weeks after LARC insertion. Follow-up was defined as visits addressing LARC method or routine physical examinations in the adolescent center or affiliated school-based health clinics. Continuation and discontinuation were defined as documented presence or removal, respectively, of device at various time points. Descriptive analyses, χ2 test, Fisher exact test, t test, and survival analysis were used. Approximately one-third (29.3%) of the patients attended a follow-up visit. Follow-up was associated with a higher likelihood of LARC removal in the first year (hazard ratio [HR]=2.10, 95% confidence interval [CI] 1.33-3.32). At 500days post-insertion and beyond, there was no difference in LARC continuation between AYAs who followed-up and those who did not (HR=1.07, 95% CI 0.67-1.71). Few AYAs attended an initial follow-up visit after LARC placement. These visits were associated with an increased likelihood of LARC removal in the first year; however, this association was not observed long term. More information is needed to determine how to approach follow-up this population.

Evaluation of Contraception Access within the Indianapolis Metropolitan Area

Background: Access to family planning care and the full-spectrum of contraception, including same-day access to long acting reversible contraception (LARC) is critical to reduce unintended pregnancy and maternal/infant mortality. However, access remains variable for many women in Indiana. We sought to examine access to various contraceptive practices within the Indianapolis metropolitan area. &#x0D; &#x0D; Methods: A telephone survey of clinic managers was conducted between June-July 2020 of all identified IU Health, Eskenazi, and HealthNet primary care and OB/GYN providers in the Indianapolis metropolitan area. The 27-question survey gathered information regarding contraceptive practices (e.g. contraceptive method availability, same-day LARC insertion/removal, pregnancy intention screening, educational materials, and parental consent policies). The data was compared based on type of medical provider (OB/GYN, Family Medicine, and Pediatrics). &#x0D; &#x0D; Results: In total, 82 sites were identified, 58 surveys (70.7%) were completed. Oral contraception is the most commonly offered contraception (91.4%), followed by depot medroxyprogesterone acetate (DMPA) injection (84.5%), and the contraceptive patch (81.0%). LARC placement is available in 51.7% of all clinics, but only 34.5% offer same-day placements. Routine pregnancy intention screening is offered in 43.1% and educational materials in 74.1% of practices. OB/GYN clinics provide the most comprehensive access, 69.2% provide same-day LARC insertion (84.6% LARC removals). Family medicine practices are variable regarding contraceptive choices: over 91% offer oral contraception and DMPA injections, but only 20.8% place LARCs and 41.7% remove LARCs. Half (50%) of pediatric clinics provide oral contraception, while 50% do not provide any contraceptives. Parental consent for minors to obtain contraception provision is highly variable. &#x0D; &#x0D; Conclusion: Contraceptive practices vary among primary care and OB/GYN providers in the Indianapolis area. This variability in access leads to barriers for use, particularly for young women. Efforts to ensure comprehensive, same-day access to all forms of contraception (including LARCs), pregnancy intention screening, and contraceptive educational materials are needed.

Time Trends in Massachusetts Adolescents' Postabortion Contraceptive Uptake

PurposeThe purpose of the study was to assess uptake of postabortion contraception across changes in insurance regulations and insurance type used on the day of abortion, accounting for demographic characteristics and consent type (parental vs. judicial) for abortion among Massachusetts adolescents. MethodsWe conducted a retrospective record review of 1,375 minors (≤17 years) presenting for their first lifetime surgical abortion at a statewide network of abortion clinics between 2010 and 2016. Postabortion contraceptive method was defined as long-acting reversible contraception (LARC) placed onsite, short-acting reversible contraception (SARC) provided onsite, or no method received. ResultsThe proportion of minors leaving with no method dropped from 38% in 2010 to 21% in 2016, while LARC placement increased from 19% to 45%. No difference was observed by consent type. Both LARC and SARC were more prevalent among minors with Medicaid or private insurance compared to those not using insurance on the day of abortion. In a multinomial regression model accounting for consent type and demographic characteristics, minors who received care during the final epoch of the study (relative risk ratio [RRR] = 3.30; 95% confidence interval [CI]: 2.23–4.88) or used private insurance (RRR = 3.91; 95% CI: 2.24–6.84) or Medicaid (RRR = 5.54; 95% CI: 3.37–9.11) on the day of service had significantly higher relative risk of receiving LARC versus no method (p < .001), with similar results for LARC versus SARC. ConclusionsPostabortion contraceptive uptake changed over time. Disparately low LARC uptake among minors not using insurance to pay for their abortions highlights a need to ensure equitable access to all methods, regardless of ability to pay.

The Impact of Medicaid Reimbursement on Rates of Postpartum LARC Uptake [27J

INTRODUCTION: There are many barriers to immediate postpartum long acting reversible contraception (LARC) placement, including lack of knowledge, restrictive placement criteria, inadequate reimbursement, and policies banning reimbursement for placement during an inpatient hospitalization. We aimed to determine the impact of a policy change by Missouri Medicaid in October of 2016 allowing reimbursement of immediate postpartum LARC placement. METHODS: We completed a retrospective cohort study comparing patients who delivered at Barnes Jewish Hospital (BJH) one year before (September, 2015-September 2016) and after (November, 2016-November, 2017) the Medicaid LARC immediate postpartum reimbursement policy change. Patients who had a contraindication to LARC placement were excluded. The primary outcome was immediate postpartum LARC placement. Demographic characteristics were compared using chi-square and Fisher’s exact test, as appropriate. Pertinent confounders were controlled for using logistic regression and the analysis was stratified by insurance type. RESULTS: A total of 6,233 women were included with 3,105 delivering before the postpartum LARC policy change and 3,128 delivering after. Immediate postpartum LARC uptake increased from 0.5% (n=16) to 7.3% (n=229) after the policy change (adjusted odds ratio (aOR) 15.4; 95% CI 9.3-25.8). In stratified analysis, postpartum LARC uptake increased in both women enrolled in Medicaid (0.7% to 9.6%; aOR 14.8; 95% CI 8.6-25.9) and private insurance (0.2% to 2.9%; aOR 13.3; 95% CI 3.2-55.9). CONCLUSION: Medicaid reimbursement for inpatient postpartum LARC is associated with an increased uptake among women with both Medicaid and private insurance. This policy change is an important step in reducing the burden of unintended pregnancies.

Postpartum LARC Among the Privately Insured—Use After Preterm and Term Births [23J

INTRODUCTION: Sub-optimal interpregnancy interval (IPI) and prior preterm delivery are risk factors for preterm birth. Provision of long acting reversible contraception (LARC) in the postpartum period may optimize IPI and thereby decrease the risk of a subsequent preterm birth. However, postpartum LARC uptake has not been investigated among those with a prior preterm delivery who are privately insured. METHODS: We used the national IBM MarketScan® Commercial Database to identify singleton deliveries from 2007-2016, spontaneous preterm birth, and follow up within 12 weeks postpartum. We compared LARC placement after preterm and term deliveries across years and by state. RESULTS: Among 3,132,107 singleton deliveries, 6.6% were preterm. Over the time period, postpartum LARC use more than doubled: 4.8% to 11.5% for intrauterine devices (IUDs), 0.1% to 2.3% for implants. In 2016, compared to term cohort, the preterm cohort was less likely to receive IUDs (10.1% vs 11.7%, P&lt;.0001), as likely to receive implants (2.5% vs 2.3%, P=.15) and more likely to present for postpartum care (62% vs 56%, P&lt;.0001). Placement of LARC prior to hospital discharge was exceedingly rare in both cohorts (preterm: 8 per 10,000 deliveries vs term: 7 per 10,000 deliveries, P=.05). State level analysis showed postpartum LARC use widely varied, by state (range 6%-32%). CONCLUSION: While postpartum LARC is increasing among the privately insured, exceedingly few receive LARC prior to hospital discharge. Postpartum follow-up is alarmingly low, highlighting the importance of inpatient LARC access. Variable state-level uptake and private reimbursement warrant ongoing surveillance and efforts to remove barriers to postpartum LARC for all.

The Impact of an Adolescent Gynecology Provider on Intrauterine Device and Subdermal Contraceptive Implant Use Among Adolescent Patients.

To assess how the addition of a pediatric and adolescent gynecologist (PAG) in an area where one has not previously been available affects the use of long-acting reversible contraception (LARC) among adolescent and adult women 13-24years of age. Retrospective chart review. Academic practice including 12 general practice obstetric/gynecologists (GP) and 1 PAG, and Title X clinics in 3 neighboring counties in West Virginia. Patients receiving an intrauterine device (IUD) or implant during 2010-2016. Subject charts were reviewed for age and date at insertion, provider (GP, PAG, and Title X), device type, parity, discontinuation, and sequential LARC placement. Frequencies of LARC and relative risks (RR) with 95% confidence intervals were calculated for the 13- to 17-year and 18- to 24-year age groups and compared between provider type. The frequency of LARC increased over time for all providers for participants age 13-24; the PAG had the highest frequency of LARC among participants aged 13-17years. The RR for IUD provision for the PAG provider among those aged 13-17years was 3.1 and 32.5 times greater compared to GP and Title X (P<.001). Title X providers were 2.9 (2.27, 3.79) and 2.8 (2.06, 3.81) times more likely to provide implants to patients aged 13-17years compared to PAG and GP, respectively (P<.001). A PAG provider can have a positive impact on LARC uptake among adolescents in a community where this specialist has not previously been available. This is most noted among 13- to 17-year-old patients receiving IUDs.

Cost Minimization Analysis of Same-Day Long-Acting Reversible Contraception for Adolescents

Long-acting reversible contraception (LARC) is considered first-line contraception for adolescents but often requires multiple clinic visits to obtain. To analyze Indiana Medicaid's cost savings associated with providing adolescents with same-day access to LARC. An economic evaluation of cost minimization from the payer's (Medicaid) perspective was performed from August 2017 through August 2018. The cost model examined the anticipated outcome of providing LARC at the first visit compared with requiring a second visit for placement. The costs and probabilities of clinic visits, devices, device insertions and removals, unintended pregnancy, and births, according to previously published sources, were incorporated into the model. The participants were payers (Medicaid). The outcomes were the cost of same-day LARC placement vs LARC placement at a subsequent visit in US dollars, and rates of unintended pregnancy and abortion. One-way sensitivity analysis was done. Same-day LARC placement was associated with lower overall costs ($2016 per patient over 1 year) compared with LARC placement at a subsequent visit ($4133 per patient over 1 year). Compared with the return-visit strategy, same-day LARC was associated with an unintended pregnancy rate of 14% vs 48% and an abortion rate of 4% vs 14%. Providing same-day LARC could save costs for Medicaid, largely by preventing unintended pregnancy. Expected cost savings could be used to implement policies that make this strategy feasible in all clinical settings.

Follow-Up Care and 6-Month Continuation Rates for Long-Acting Reversible Contraceptives in Adolescents and Young Adults: A Retrospective Chart Review.

Describe follow-up care patterns and continuation rates during the first 6months after initiating a long-acting reversible contraceptive (LARC) device among adolescent and young adult women. Retrospective chart review among patients who had an intrauterine device (IUD) or subdermal implant placed between January 2015 and December2016. Urban adolescent specialty care clinic. Women ages 13-23years. Follow-up encounters were defined as scheduled and unscheduled phone calls, outpatient clinic visits, or emergency department visits during the 6months after device placement. Continuation was defined as not having the device removed or expelled during the 6months after initiation. Frequencies were calculated, and logistic regression was used to determine predictors of follow-up encounters and continuation. Among the 177 patients, 180 LARC devices were placed. Most were 13-17years of age (56%), non-Hispanic black (64%), publicly insured (57%), and had an IUD placed (57%). Most (86%) had 1 or more clinical encounters during the 6months: 70% attended a scheduled encounter and 53% had an unscheduled encounter. Approximately half (45%) attended the scheduled 2-week office visit; only 6% attended the 6-month office visit. The 6-month LARC continuation rate was 92% (n=166), with most discontinuations among IUD users (n=12; 7%). LARC continuation rates were high in our study population. Most adolescent and young adult women have at least 1 follow-up encounter in the 6months after LARC placement. Clinical practices should be prepared to address issues that arise during follow-up encounters, whether in person or by phone.

Cost Sharing and Utilization of Postpartum Intrauterine Devices and Contraceptive Implants Among Commercially Insured Women.

Cost sharing may impede postpartum contraceptive use. We evaluated the association between out-of-pocket costs and long-acting reversible contraceptive (LARC) insertion among commercially insured postpartum women. Using the ClinformaticsData Mart, we examined out-of-pocket costs for LARC insertions at 0 to 3 and 4-60days postpartum among women in employer-sponsored health plans from 2013 to 2016. Patient costs were estimated by summing copayment, coinsurance, and deductible payments for LARC services (device+placement). Multivariable logistic regression evaluated the association between plan cost sharing for LARC services (at least one beneficiary with >$200 cost share) and LARC insertion by 60days postpartum (yes/no). We identified 396,073 deliveries among women in 51,797 employer-based plans. Overall, LARC placement by 60days postpartum was observed after 5.2% (n=20,604) of deliveries. Inpatient LARC insertion (n=233; 0.06% of deliveries) was less common than outpatient LARC insertion (n=20,375; 5.14% of deliveries). Cost sharing was observed in 23.4% of LARC insertions (inpatient IUD: median, $50.00; range, $0.93-5,055.91; inpatient implant: median, $11.91; range, $2.49-650.14; outpatient IUD: median, $25.00; range, $0.01-3,354.80; outpatient implant: median, $27.20; range, $0.18-2,444.01). Among 5,895 plans with at least one LARC insertion and after adjusting for patient age, poverty status, race/ethnicity, region, and plan type, women in plans with cost sharing of more than $200 demonstrated lower odds of LARC use by 60days postpartum (odds ratio, 0.74; 95% confidence interval, 0.71-0.77). Cost sharing for postpartum LARC is associated with use, suggesting that out-of-pocket costs may impede LARC access for some commercially insured postpartum women. Reducing out-of-pocket costs for the most effective forms of contraception may increase use.

Factors Associated With and Barriers to Receiving Inpatient Long-Acting, Reversible Contraception [1C

INTRODUCTION: Factors associated with inpatient long-acting, reversible contraception (LARC) placement and potential barriers to inpatient LARC placement during the immediate postpartum period are largely unknown. The objective of this study was to determine factors associated with LARC placement and barriers to LARC placement during the post-partum hospitalization. METHODS: We identified 3072 deliveries at an urban, academic hospital between January 1, 2017 and July 31, 2018. We randomly selected 218 cases that received a LARC and 218 controls that did not receive a LARC. We excluded 68 patients <18 years of age or in a system requiring outpatient contraception planning. We look at bivariate relationships between patient characteristics and inpatient LARC placement. Chi-square tests and Fisher's Exact tests were used to assess statistical significance. RESULTS: Recipients of LARC were younger (mean age of 28 versus 29.5, p<0.01). Admission by Family Medicine providers (OR 0.10, 95% CI 0.02-0.45), lack of recorded prior contraception plan (OR 0.25, 95% CI 0.17-0.39), and delivery complications (OR 0.48, 95% CI 0.32-0.71) were associated with lower odds of receiving LARC placement. Single marital status was associated with higher odds of receiving LARC placement (OR 1.50, 95% CI 1.03-2.19). CONCLUSION: Findings suggest that provider specialty, which may be confounded by prior procedural training, and lack of prior contraception planning present significant barriers to immediate LARC placement.

Postpartum Long-Acting Reversible Contraception Is Associated With a Decrease in Recurrent Preterm Birth [3R

INTRODUCTION: A history of preterm birth is a major risk factor for subsequent preterm birth. The purpose of this study was to compare the rate of recurrent preterm birth in women who received postpartum long-acting reversible contraception (LARC) to those who did not receive postpartum LARC. METHODS: This is a retrospective cohort study of women with singleton gestations who delivered prior to 37 weeks between January 2011 and January 2015. The study was approved by the local IRB, and protected health information was de-identified. The rate of recurrent preterm birth was compared between women who received a LARC method within 12 weeks postpartum and those who did not receive LARC. Chi square analysis and multivariate logistic regression were performed controlling for maternal age, BMI, education, employment, race, ethnicity and insurance type. Interpregnancy interval was investigated as a secondary outcome. RESULTS: Of 355 subjects with preterm birth, 110 (31%) received postpartum LARC. The rate of recurrent preterm birth was 10.6% in the LARC group vs 23.4% in the non-LARC group (P=.006). After adjusting for potential confounders, subjects with postpartum LARC were 58% less likely to have a recurrent preterm birth as compared to subjects without postpartum LARC (adjusted 95% CI 0.20 - 0.86). The mean interpregnancy interval was 11.2 months longer in the LARC group as compared to the non-LARC group (P=.003). CONCLUSION: LARC placement within 12 weeks following a preterm birth is associated with a decreased risk of recurrent preterm birth. Contraceptive counseling in women with preterm birth should address this risk-reducing intervention.