Medical Eligibility Research Articles

Committee Opinion No. 577

The U.S. Selected Practice Recommendations for Contraceptive Use, 2013 (U.S. SPR), issued by the Centers for Disease Control and Prevention is a companion piece to the Centers for Disease Control and Prevention's U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. The U.S. Medical Eligibility Criteria for Contraceptive Use, 2010, provides guidance for which contraceptive methods are safe for women with selected characteristics and medical conditions, whereas the U.S. SPR offers guidance on how to use these methods most effectively. The American College of Obstetricians and Gynecologists endorses the U.S. SPR and encourages its use by Fellows; providers should always consider the specific clinical situation when applying these guidelines to individual clinical care.

Counseling and provision of long-acting reversible contraception in the US: National survey of nurse practitioners

ObjectiveNurse practitioners (NPs) provide frontline care in women's health, including contraception, an essential preventive service. Their importance for contraceptive care will grow, with healthcare reforms focused on affordable primary care. This study assessed practice and training needs to prepare NPs to offer high-efficacy contraceptives — intrauterine devices (IUDs) and implants. MethodA US nationally representative sample of nurse practitioners in primary care and women's health was surveyed in 2009 (response rate 69%, n=586) to assess clinician knowledge and practices, guided by the CDC US Medical Eligibility Criteria for Contraceptive Use. ResultsTwo-thirds of women's health NPs (66%) were trained in IUD insertions, compared to 12% of primary care NPs. Contraceptive counseling that routinely included IUDs was low overall (43%). Nurse practitioners used overly restrictive patient eligibility criteria, inconsistent with CDC guidelines. Insertion training (aOR=2.4, 95%CI: 1.10 5.33) and knowledge of patient eligibility (aOR=2.9, 95%CI: 1.91 4.32) were associated with IUD provision. Contraceptive implant provision was low: 42% of NPs in women's health and 10% in primary care. Half of NPs desired training in these methods. ConclusionNurse practitioners have an increasingly important position in addressing high unintended pregnancy in the US, but require specific training in long-acting reversible contraceptives.

Motivation for a Health-Literate Health Care System—Does Socioeconomic Status Play a Substantial Role? Implications for an Irish Health Policymaker

In this article, the authors argue that the association between socioeconomic status and motivation for a health-literate health care system has implications for health policymakers. As Ireland now undergoes health care reform, the authors pose the question, “Should policymakers invest in health literacy as predominately a health inequalities or a public health issue?” Data from 2 cohorts of the Survey of Lifestyle, Attitudes and Nutrition (1998 and 2002) were used to construct a motivation for a health-literate health care system variable. Multivariate logistic regressions and concentration curves were used in the analyses of this variable. Of the 12,513 pooled respondents, 46% sought at least 1 attribute on a health-literate health care system. No discernible trend emerged from the main independent variables—social class grouping, medical card eligibility, level of education, and employment—in the regression analyses. The concentration curve, for 2002 data, graphically showed that the motivation for a health-literate health care system is spread equally across the income distribution. This analysis and more recent data suggest that health literacy in Ireland should be viewed predominately as a public health issue with a policy focus at a system level.

LARC First: What the General Pediatrician Needs to Know about IUDs and Contraceptive Implants

Despite a steady decline during the past 20 years teen pregnancy remains a significant public health issue in the United States the overwhelming majority (80%) of which is unintended. Long-acting reversible contraceptives (LARCs) such as intrauterine devices (IUDs) and contraceptive implants are the most effective methods of reversible contraception and are recommended as first-line contraception for teens by adolescent medicine and reproductive health specialists. The Centers for Disease Control (CDC) Medical Eligibility Criteria a comprehensive summary of recommendations regarding contraceptive safety for a wide array of medical conditions supports the use of IUDs and contraceptive implants for females younger than 20 years old. However only 4.5% of teens who use birth control currently use a LARC method. Available data suggest that general practitioners who feel under-informed about LARC methods are less likely to counsel their patients about these options. The goal of this article is to provide a review of LARC methods to help increase general pediatricians’ comfort in discussing these highly effective methods during all contraception counseling sessions with their teen and young adult patients.

Postpartum contraception

Postpartum contraception is an integral part of women's reproductive healthcare that poses many challenges to both the new mother and her practitioner. These challenges are associated with having a newborn, breastfeeding, maternal medical comorbidities, as well as socioeconomic barriers. While we provide contraception counseling in the postpartum period during their hospital stay, 10���44% of women are at risk of an unplanned pregnancy in the first 12 months postpartum. This session will focus on understanding the medical eligibility criteria for providing contraception in both breastfeeding and non-breastfeeding women, as well as how to provide the most effective method of contraception as soon after delivery as possible. The audience will participate in a discussion regarding overcoming the challenges of post-placental IUD placement and implant placement prior to hospital discharge. Also, affecting a change in scheduling the postpartum visit earlier, as the current tradition is out of date, will be addressed.

Innovative approaches in postpartum contraception

The aim of this study was to describe the implications of recurrent unintended pregnancy and barriers to postpartum contraception provision; explain the benefits and procedures for providing Long Acting Reversible Contraception (LARC) immediately postpartum and explain the CDC medical eligibility criteria and the evidence regarding the effects on lactation of postpartum hormonal contraception.

Inappropriate Use of Combined Hormonal Contraceptives for Birth Control Among Women of Reproductive Age in the United States

To describe the extent of inappropriate use of combined hormonal contraceptives (CHC) according to the United States Medical Eligibility Criteria (U.S. MEC). We analyzed Kantar Health's 2010 U.S. National Health and Wellness Survey data, which is an annual population-based survey of 75,000 U.S. adults via internet. A stratified random sampling framework was used to construct a sample that reflects the U.S. census by age, gender, and ethnicity. The analysis included nonpregnant females aged 18-44 years who used CHC, including oral, patch, or vaginal rings in the past 6 months. Women classified into category 3 (theoretical or proven risks usually outweigh the advantages of using the method) or 4 (unacceptable health risk) according to the U.S. MEC were defined as having high-risk conditions, or inappropriate CHC use. The proportions of women who had inappropriate CHC use were then projected to the U.S. population by diseases/conditions and demographic characteristics incorporating sampling weights. We identified 2963 adult females of reproductive age (mean 29.3±6.0) (i.e., 20.4% of all adult females of reproductive age in the database) as being CHC users. Among them, 23.7% (95% CI: 22.8%-24.5%) had at least one high-risk condition and 9.3% (95% CI: 9.2%-9.4%) had at least one condition of unacceptable risk. The three most common high-risk conditions were migraine (12.7%), multiple risk factors for arterial cardiovascular disease (9.3%), and hypertension (6.1%). Women with relatively higher proportions of inappropriate CHC use were age ≥35, not finished college, and Medicaid recipients. A large portion of women used CHC inappropriately. Hormone-free and progestin-only contraceptives are available options with potentially less risk for them.

Global survey of healthcare practitioners’ beliefs and practices around intrauterine contraceptive method use in nulliparous women

BackgroundDespite the efficacy and safety of intrauterine contraceptive methods (IUCs), healthcare providers (HCPs) are sometimes reluctant to recommend their use, particularly in nulliparous women. This study sought to understand the global practitioner perceived impediments to IUC provision. Study DesignWe developed an online survey for HCPs administered across 4 regions comprising 15 countries. We sought their attitudes to IUC provision; their perceived barriers to IUC use, particularly in nulliparous women; as well as their knowledge of the World Health Organization Medical Eligibility Criteria (WHO MEC) for contraceptive use. ResultsWe received 1862 responses from HCPs in 15 countries grouped into 4 regions, with an average country response rate of 18%. For analysis, the results were grouped into these regions: Latin America, 402 (21.6%); USA, 156 (8.4%); Europe and Canada, 1103 (59.2%); and Australia, 201 (10.8%). The two most frequently identified perceived barriers to IUC use in nulliparous women were difficulty of insertion (56.6%) and pelvic inflammatory disease (PID) (49.2%), but responses differed by region and HCP type. Only 49.7% recognized the correct WHO MEC category for IUC use in nulliparous women. DiscussionThe results of this survey confirm that, across the four regions, the two main barriers to IUC provision for nulliparous women are concern about the difficulty of insertion and PID. Providers’ knowledge of the WHO MEC was lacking universally. A global effort is required to improve understanding of the evidence and knowledge of available guidelines for IUC use.

AB0326 Severity index for rheumatoid arthritis and its association with healthcare costs and biologic therapy use in turkey

ObjectivesTo apply a validated claims-based severity index for rheumatoid arthritis (SIFRA) to prevalent RA groups in Turkey to determine the effects of RA severity on healthcare costs and biologic use.MethodsUsing...

The Workforce Wellness Index

To devise a methodology to create a single health risk-cost score that can be applied to health risk assessment survey data and account for the medical costs associated with modifiable risks. We linked person-level health risk assessment data with medical benefit eligibility and claims data for 341,650 workers for the period 2005 to 2010 and performed multivariate analyses to estimate costs associated with high risks. We used the estimated costs and risk prevalence rates to create a composite Workforce Wellness Index (WWI) score. Increasing obesity rates among employees was found to be the most important contributor to increased health care spending and the main reason the WWI score worsened over time. Employers that address employees' health risk factors may be able to reduce their medical spending and achieve an improvement in their WWI scores.

Impact of UK Medical Eligibility Criteria implementation on prescribing of combined hormonal contraceptives

ObjectivesCombined hormonal contraceptives (CHCs) are the most widely prescribed contraceptive methods in the UK; however, their use is associated with significant cardiovascular risk for women with some medical conditions and...

A select issue in the postpartum period: contraception

A select issue in the postpartum period: contraception

Committee Opinion No. 540

Although the risk of venous thromboembolism is increased among oral contraceptive users compared with nonusers who are not pregnant and not taking hormones, and some data have suggested that use of drospirenone-containing pills has a higher risk of venous thromboembolism, this risk is still very low and is much lower than the risk of venous thromboembolism during pregnancy and the immediate postpartum period. When prescribing any oral contraceptive, clinicians should consider a woman's risk factors for venous thromboembolism and refer to the U.S. Medical Eligibility Criteria for Contraceptive Use issued by the Centers for Disease Control and Prevention. Patient education materials, including product labeling, should place information regarding oral contraceptive use and venous thromboembolism risks in context by also providing information about overall venous thromboembolism risks and venous thromboembolism risks during pregnancy and the postpartum period. Decisions regarding choice of oral contraceptive should be left to clinicians and their patients, taking into account the possible minimally increased risk of venous thromboembolism, patient preference, and available alternatives.

First-trimester abortion in women with medical conditions

Most women undergoing first-trimester abortion are healthy. However, abortion providers also encounter women with a wide variety of medical conditions, some of which are serious and complex. When such a condition exists, consultation with the woman's physician or a specialist can facilitate decision making regarding hospital referral and additional preparations that may be required. Medical conditions may determine the approach to abortion. Surgical abortion is preferred when mifepristone or methotrexate is contraindicated. Medication abortion may be preferred when lithotomy position is not possible or in patients with extreme obesity. Limited data suggest that women treated with anticoagulation therapy bleed more than other women during surgical abortion, although this additional bleeding may be clinically unimportant. The decision to temporarily discontinue anticoagulation therapy will depend on the agent used and the underlying risk of thrombosis. According to the American Heart Association, additional antibiotics are not recommended to prevent endocarditis in women with cardiac lesions during surgical abortion. We review specific recommendations for women with common medical conditions. In some women, highly effective postabortion contraception is essential to prevent pregnancy-related morbidity. The U.S. Medical Eligibility Criteria for Contraceptive Use, 2010, provides guidance for method selection for women with medical problems.

Long-acting Reversible Contraceptive Methods for Adolescents with Chronic Medical Problems

Adolescents with chronic medical problems are just as at-risk for unintended pregnancy as their healthy counterparts, but pregnancy in these adolescents can carry greater health risks.The objective of this article is to provide an overview of the United States Medical Eligibility Criteria for Contraceptive Use, the concept of contraceptive effectiveness, and a risk-benefit algorithm. Together these tools provide an evidence-based and clinically sound method of providing contraception to adolescents with chronic medical problems. Three cases of adolescents with chronic medical problems are used to illustrate this approach.To best avoid the complicated problem of a teenager with a chronic medical problem becoming pregnant, LARC should be considered as first-line contraception. In most cases, LARC methods are safe to prescribe, and preferable to less effective methods.

Inappropriate use of combined hormonal contraceptives among adult reproductive-age women in the United States

Inappropriate use of combined hormonal contraceptives among adult reproductive-age women in the United States

Use of the CDC US medical eligibility criteria for contraceptive use among primary care physicians

In May 2010, the Centers for Disease Control and Prevention (CDC) released the US Medical Eligibility Criteria for Contraceptive Use (CDC MEC) to provide evidence-based guidance on contraceptive safety in US women with medical conditions. This study evaluates use of the CDC MEC by physicians who have completed residency training and prescribe contraception.

Federal Report Probes Increased Demand for Services

Federal Report Probes Increased Demand for Services

A Study on the Improvement of the Medical Education System in Korea Since 1999

The main purpose of this study is to examine the improvement and discourse of the medical education system in Korea since 1990. In particular, this study, focusing on the graduate medical education system initiated in 2002, has explored the discussions that led to the system’s establishment and what the context of those discussions. To meet this objective, this study analyzed research report related to the medical education system authored by members of the government and medical community, suggestions to the government, discussion materials, and data with regard to the Medical (Dental) Education Eligibility Test. The improvement of the medical education system in Korea has been an important issue in education reform by the expansion of the number of years of higher education, the requirements for increased levels of professional knowledge by improving public educational standards, and the basic formation policy of higher education consisting of graduate school, special graduate school, and professional graduate school. Nevertheless, the views of the government and the medical community on improving medical education system have made an obvious difference. This was due to different aims about how to improve the medical education system and different perception of the degree and medical education system. The medical community at least tended to prefer the status of academic positions over professional positions. The policy of medical education for people with a bachelor’s degree which was introduced in 2002 spread to many colleges of medicine based on the government’s administrative and financial support policy. Even so, the absence of accompanying policy by the relevant government agencies and department of education, which could have ensured the success of the system, has led to continued debate. In conclusion, without a consistent and persistent government policy, the graduate medical education system has led to confusion in many medical institutions. Above all, an evidence-based policy decision and policy approach based on a long-term perspective are necessary in order to improve the medical education system.

CANNABIS AND PSYCHOSIS – THE STATE OF THE ART

Combined hormonal contraceptives (CHC), containing estrogen, remain the most popular choice of contraceptive among women. While the method offers many benefits, the use of CHC involves potential health risks. The aim of this study was to analyze the available evidence on the prevalence of CHC use among women with contraindications to their use according to the WHO recommendations (2015).Pubmed, Lilacs, and Web of Sciences databases were searched. Selection was based on articles that described the use of combined hormonal contraceptives according to the characteristics that are listed as contraindications in WHO medical eligibility criteria for contraceptive use.A total of 4363 articles were identified and 18 articles were selected for the review. The most prevalent contraindications against use of CHC were systemic arterial hypertension, migraine, and smoking (in women aged 35 years or older). Prevalence rates of contraindications against use of CHC ranged from 5.9% to 41.9%.A high proportion of women still use CHC when contraindicated to do so according to the WHO criteria. Health policies should focus on highlighting the importance of a detailed health evaluation on CHC candidates, to reduce the proportion of inappropriate prescriptions.