Variation In Provision Research Articles

Trends in survival of colorectal cancer in Malta for patients diagnosed from 1995 to 2009 followed up to 2010

Background In Europe it is estimated that 446,800 cases of colorectal cancer are diagnosed yearly with an estimated 214,000 deaths annually. It is one of the most common cancers among the elderly and will remain a major public health concern as the population ages. Despite this, there are wide variations in provision, coverage and uptake of colorectal cancer screening programs and survival varies across countries. More needs to be done to understand these variations. The aim of this analysis is to assess trends …

Walking the talk. Implementation of transitional care guidance in a UK paediatric and a neighbouring adult facility

To examine the quality of transitional care in a paediatric and adult hospital by investigating (i) adherence to national transition guidance and (ii) whether implementation is associated with better patient/carer experiences. A cross-sectional study was conducted in a UK paediatric hospital (PH) and neighbouring adult hospital. Clinics completed a questionnaire to determine characteristics of their transitional care provision and invited patients aged 11-21 years and parents/carers to complete a questionnaire ('Mind the Gap') to assess their satisfaction. Twenty-three clinics participated. Fourteen (70%) reported delivering a transition programme, but only 5 (25%) indicated this was holistic (addressing medical, psychosocial and vocational issues). Participants included 457 young people and 330 parents, 71% and 88% respectively attending the PH. Ratings of current care were significantly lower than ratings of best care. These 'gap' scores were not excessive, although some participants were very dissatisfied. Better satisfaction was associated with attending clinics that provided transitional care, especially when defined as 'holistic' and youth-friendly. Transition programmes that adhere to current guidance are associated with better satisfaction, but variations in provision suggest barriers to implementation. Attention is required to how youth-friendly transitional care is defined with particular reference to the specific clinic model.

The delivery of renal replacement therapy in Scotland--why the geographic variation?

The incidence of patients starting renal replacement therapy (RRT) for established renal failure (ERF) in Scotland has fallen from 2005 to 2011 due to a reduction in older patients starting RRT; there are significant differences between NHS Health board areas. To understand the apparent inequality in provision of RRT between NHS board areas in Scotland. Retrospective population analysis of Scottish renal registry (SRR) data, population statistics and quality outcomes framework summary statistics. The incidence of patients starting RRT for ERF in Scotland fell from 123 per million population (pmp) in 2005 to 96 pmp in 2011. The incidence of ≥75 year olds fell from 406 to 274 pmp. There are significant differences between NHS board areas when standardized for age and social deprivation. There is no relationship between the population prevalence of CKD as reported by QOF and the incidence of RRT for ERF. Those areas with high incidence rates of ≥75 year olds have higher 90-day [Spearman's rank correlation: coefficient = 0.662; P = 0.03] and 1-year [Spearman's rank correlation: coefficient = 0.776; P = 0.003] mortality rates. The significant variation in provision of RRT for ERF between Scottish NHS Board areas is not explained by age or social deprivation. There is evidence of change in practice towards RRT for patients aged ≥75 years but variation between NHS Board areas. This disparity must be further investigated to ensure equity of access to RRT for those who will benefit from it, and to non-dialytic care for those who would not.

Multicentre observational study of performance variation in provision and outcome of emergency appendicectomy

Identification of variation in practice is a key step towards standardization of service and determination of reliable quality markers. This study aimed to investigate variation in provision and outcome of emergency appendicectomy. A multicentre, trainee-led, protocol-driven, prospective observational cohort study was performed during May and June 2012. The main outcome of interest was the normal histopathology rate; secondary outcomes were laparoscopy and 30-day adverse event rates. Analysis included funnel plots and binary logistic regression models to identify patient- and hospital-related predictors of outcome. A total of 3326 patients from 95 centres were included. An initial laparoscopic approach was performed in 66.3 per cent of patients (range in centres performing more than 25 appendicectomies over the study period: 8.7-100 per cent). A histologically normal appendix was removed in 20.6 per cent of patients (range in centres performing more than 25 procedures: 3.3-36.8 per cent). Funnel plot analysis revealed that 22 centres fell below three standard deviations of the mean for laparoscopy rates. Higher centre volume, consultant presence in theatre and daytime surgery were independently associated with an increased use of laparoscopy, which in turn was associated with a reduction in 30-day morbidity (adjusted for disease severity). Daytime surgery further reduced normal appendicectomy rates. Increasing volume came at the cost of higher negative rates, and low negative rates came at the cost of higher perforation rates. This study reveals the extremely wide variation in practice patterns and outcomes among hospitals. Organizational factors leading to this variation have been identified and should be addressed to improve performance.

Initiation of Physical, Occupational, and Speech Therapy in Children With Traumatic Brain Injury

Objectives(1) To determine factors associated with physical therapy (PT) or occupational therapy (OT) evaluation and speech or swallow therapy evaluation in hospitalized children with traumatic brain injury (TBI); (2) to describe when during the hospital stay the initial therapy evaluations typically occur; and (3) to quantify any between-hospital variation in therapy evaluation. DesignRetrospective cohort study. SettingChildren's hospitals participating in the Pediatric Health Information System database (January 2001–June 2011). ParticipantsChildren (age <18y) with TBI (N=21,399) who were admitted to the intensive care unit and survived to hospital discharge. InterventionsNot applicable. Main Outcome MeasuresPT or OT evaluation and speech or swallow therapy evaluation. A propensity score was calculated to allow comparison of expected with observed rates of therapy evaluations by the hospital. ResultsThe median hospital length of stay was 5 days (interquartile range, 3–10d). Overall, 8748 (41%) of 21,399 children received either a PT or OT evaluation, and 5490 (26%) out of 21,399 children received either a speech or swallow evaluation. Older children and those with higher energy injury mechanisms, more severe injuries, extremity fractures, more treatment with neuromuscular blocking agents or pentobarbital, and admission to a hospital with an American College of Surgeons Level I pediatric trauma designation were more likely to receive therapy evaluations. The median time until the first therapy evaluation was 5 (PT or OT) and 7 days (speech or swallow). Expected hospital evaluation rates were 25% to 54% (PT or OT) and 16% to 35% (speech or swallow), while observed hospital evaluation rates were 11% to 74% (PT or OT) and 4% to 55% (speech or swallow). ConclusionsThere is wide between-hospital variation in provision of rehabilitation therapies for children with TBI. Evidence-based criteria for initiation of routine therapy evaluations after TBI are needed.

GPs returning to practice are being asked to work for free, reports BMA

Some GPs who return to practice after a career break are not being paid a salary, whereas others receive pay as low as £50 a session, research by the BMA has found. The union’s unpublished survey of deaneries and health boards in the United Kingdom highlights the wide variation in provision and payment for GPs who want to return to work through the GP induction and refresher (I+R) scheme. The I+R scheme allows GPs who have been away from UK practice for two years or more to return safely and confidently to general practice. GPs on the scheme—most of whom have taken time out to work abroad or start a family—spend between three and six months working supervised in a training practice. Up until 2006, the I+R scheme in England was funded by the Department …

Impact of Cardiac Care Variation on ST-Elevation Myocardial Infarction Outcomes in Malaysia

Developing countries face challenges in providing the best reperfusion strategy for patients with ST-segment elevation myocardial infarction because of limited resources. This causes wide variation in the provision of cardiac care. The aim of this study was to assess the impact of variation in cardiac care provision and reperfusion strategies on patient outcomes in Malaysia. Data from a prospective national registry of acute coronary syndromes were used. Thirty-day all-cause mortality in 4,562 patients with ST-segment elevation myocardial infarctions was assessed by (1) cardiac care provision (specialist vs nonspecialist centers), and (2) primary reperfusion therapy (thrombolysis or primary percutaneous coronary intervention [P-PCI]). All patients were risk adjusted by Thrombolysis In Myocardial Infarction (TIMI) risk score. Thrombolytic therapy was administered to 75% of patients with ST-segment elevation myocardial infarctions (12% prehospital and 63% in-hospital fibrinolytics), 7.6% underwent P-PCI, and the remainder received conservative management. In-hospital acute reperfusion therapy was administered to 68% and 73% of patients at specialist and nonspecialist cardiac care facilities, respectively. Timely reperfusion was low, at 24% versus 31%, respectively, for in-hospital fibrinolysis and 28% for P-PCI. Specialist centers had statistically significantly higher use of evidence-based treatments. The adjusted 30-day mortality rates for in-hospital fibrinolytics and P-PCI were 7% (95% confidence interval 5% to 9%) and 7% (95% confidence interval 3% to 11%), respectively (p = 0.75). In conclusion, variation in cardiac care provision and reperfusion strategy did not adversely affect patient outcomes. However, to further improve cardiac care, increased use of evidence-based resources, improvement in the quality of P-PCI care, and reduction in door-to-reperfusion times should be achieved.

Investigating variations in the provision of digital services in public libraries using network-based GIS models

Public libraries have been seen to have an important role in providing digital services to potentially excluded groups in order to help meet government targets regarding the delivery of digital services. Geographical information systems (GIS) have been used to investigate library service areas, to aid initial location decisions, and to model the implications of the opening and closure of library services. Recent studies have promoted the use of GIS-based techniques to investigate spatial variations in accessibility to public and private services in relation to socio-economic characteristics of population groups. One such technique, based on floating catchment area (FCA) approaches, has been primarily used to investigate potential inequalities in health services, access to employment and leisure opportunities, as well as planning public transport. In this study, FCA techniques are used to research variations in accessibility to public library facilities using bespoke application tools developed within a commercial GIS package. Drawing on a preliminary analysis of variations in accessibility to library services in a local authority area in south Wales, UK, a case study is presented whereby GIS-based models can be used to investigate spatial variations in digital services provision. As a result, provision gaps of such services can be identified. This study's findings help guide national government delivery programs to promote digital inclusion.

History education in comprehensive schools: using school-level data to interpret national patterns

This paper reports the findings from two large-scale national online surveys carried out in 2009 and 2010, which explored the state of history teaching in English secondary schools. Large variation in provision was identified within comprehensive schools in response to national policy decisions and initiatives. Using the data from the surveys and school-level data that are publicly available, this study examines situated factors, particularly the nature of the school intake, the numbers of pupils with special educational needs and the socio-economic status of the area surrounding the school, and the impact these have on the provision of history education. The findings show that there is a growing divide between those students that have access to the ‘powerful knowledge' provided by subjects like history, and those that do not.

Abstract 2477: Moving Toward 100% Stroke Patient Education Compliance

Background: Evidence has shown that if patients are provided with basic stroke education (i.e. stroke risk factors, warning signs, emergency actions, follow-up considerations, general medication information), they have improved self-care. Provision of stroke education is a performance measure for Joint Commission Certified-Primary Stroke Centers (JC-PSC). In our 2 hospital system, variation in provision of education, effectiveness of materials provided, and documentation of teaching was found. Purpose: The purpose of this initiative was to identify barriers to providing optimal stroke education and implement strategies for improvement. Method: Current educational delivery methods/materials were clarified with input from multi-disciplinary team members and past/current patients and families. Compliance with provision of this patient education measure was tracked. Barriers to optimal compliance and educational delivery identified included inconsistent patient education provision and documentation methods, handouts of poor visual quality that weren’t helpful for people with visual problems, varying content for discharge instructions, and lack of real time assessment of measure compliance. Improvement strategies implemented included stroke program CNS or RN seeing all known stroke/TIA inpatients, creation of a spiral bound stroke educational booklet and an audio CD version, development of a stroke education teaching screen in the electronic health record, and revision of an individualizable Stoke/TIA Patient Discharge Instruction template that included required content. Results: Strategies for improvement took time and involved significant staff education; however improvement in stroke education measure compliance was noted at both of our hospitals during the first year. In the second year of this initiative, continued efforts resulted in 100% compliance with the measure for most months. Conclusions: Having the stroke program CNS or RN see the stroke/TIA inpatients improved not only consistency of care delivery but also afforded the opportunity to do ongoing education for staff. Creation of consistent educational materials that could meet individual patient/family needs along with creation of user-friendly documentation methods increased our ability to successfully meet the needs of our patients and show we had excellent stroke education delivery outcomes.

An initial analysis on the variation in health service provision for older people in Wales

To consider the provision of services to older people in Wales and to undertake an initial analysis, without judgement, of the variation that might exist. Wales has a National Service Framework for Older People which presents evidence-based standards for service provision. Analysis of one of these standards has suggested that there is variation in practice within Wales. A ‘realist review’ was undertaken using the search engine ‘Pubmed’. The method has been used in other situations and the ‘realist reviewer’ makes annotated comments on documents and extracts a summary of messages. Certain broad themes emerge from the studies included. Primarily, there is an observed variation in the provision of a number of services in Wales. Variations appear in the provision of health services to older people in Wales. Establishing a research, policy and practice interface arrangement which includes researchers, providers and policy makers may be helpful.

Equity of access to specialist chronic fatigue syndrome (CFS/ME) services in England (2008–2010): a national survey and cross-sectional study

ObjectivesProvision of National Health Service (NHS) specialist chronic fatigue syndrome or myalgic encephalomyelitis (CFS/ME) services in England has been deemed patchy and inconsistent. Our objective was to explore variation in...

Compliance with focused antenatal care services: do health workers in rural Burkina Faso, Uganda and Tanzania perform all ANC procedures?

To assess health workers' compliance with the procedures set in the focused antenatal care (ANC) guidelines in rural Uganda, Tanzania and Burkina Faso; to compare the compliance within and among the three study sites; and to appraise the logistic and supply of the respective health facilities (HF). The cross-sectional study was conducted in the rural HF in three African countries. This descriptive observational study took place in HF in Nouna, Burkina Faso (5), Iganga, Uganda (6) and Rufiji, Tanzania (7). In total, 788 ANC sessions and service provisions were observed, the duration of each ANC service provision was calculated, and the infrastructures of the respective HF were assessed. Health workers in all HF performed most of the procedures but also omitted certain practices stipulated in the focused ANC guidelines. There was a substantial variation in provision of ANC services among HF within and among the country sites. The findings also revealed that the duration of first visits was <15 min and health workers spent even less time in subsequent visits in all three sites. Reagents for laboratory tests and drugs as outlined in the focus ANC guidelines were often out of stock in most facilities. Health workers in all three country sites failed to perform all procedures stipulated in the focused ANC guideline; this could not be always explained by the lack of supplies. It is crucial to point out the necessity of the core procedures of ANC repeatedly.

Abstract P301: Are Variations in Delivery of Guideline Recommended Therapies by Cardiology Practices Reduced After Implementation of a Performance Improvement Initiative? Findings From IMPROVE HF

Background: Variations between outpatient cardiology practices in adherence to guideline-recommended therapies for heart failure (HF) have previously been described. The effect of performance improvement initiatives on reducing these variations has not been evaluated. Methods: IMPROVE HF is a prospective evaluation of a practice-based, performance improvement intervention implemented at cardiology practices to increase use of evidence-based, guideline-recommended care for eligible outpatients with systolic HF or post-myocardial infarction LVSD. Variations in use of 7 individual and 2 summary care measures were assessed by comparing the 10 th and 90 th percentiles, the inter-decile differences, and variance for each measure at baseline (pre-intervention) and 24 months post-intervention. Results: A total of 15,177 patients followed in 155 of 167 practices were available for analysis. Substantial variations for all care measures were evident at baseline with inter-decile differences ranging from 23.6% for β-blockers to 81.3% for CRT-P/CRT-D. The 24-month evaluation revealed significant improvements in adherence to 6 of 7 specific measures, the composite, and all-or-none care measures. However, large care variations persisted among practices with interdecile differences at 24 months ranging from 16.2% to 75.0%. No measure demonstrated significantly reduced variation at 24 months compared to baseline. Conclusions: Implementation of a practice-based performance improvement initiative resulted in substantial improvement in adherence to guideline-recommended therapies for HF. However, wide variations in provision of evidence-based care persisted among cardiology practices. Additional targeted interventions may be necessary to reduce variations in use of guideline-recommended HF therapies in outpatient cardiology practices.

Ring-fencing a budget for cancer drugs: is it fair?

Ring-fencing is defined as protecting funds for use in a specific area. In the National Health Service in the UK, various methods to ring-fence cancer have been employed over the years; more recently the Cancer Drugs Fund in England has enabled cancer drugs that would not normally be considered cost-effective to be provided to patients. This has created variation in provision between England and the devolved countries. While some would argue that ring-fencing allows major advances to be made in the treatment of a particular condition, others would argue that it is intrinsically unfair. In this debate, Graham and Cassidy have written an article arguing the affirmative position and Hughes and Duerden were invited to respond directly to their arguments. As with all the RCPE's 'Current controversies', the authors have been asked to take a deliberately polarised position and so the views they express may be somewhat overstated.

The variance in distribution of cancer nurse specialists in England

Background The role of the specialist nurse in the UK evolved in the 1970s. In cancer care, policy drivers have seen an increase in the number of, and an increase in the role of, the pathology‐based, or ‘site‐specific’, cancer clinical nurse specialists, and also an increase in the variety specialist cancer nursing roles; the recommendation being that every cancer patient has access to a specialist cancer nurse. Methods A census of the specialist cancer nursing workforce was undertaken in 2008. These data were then compared with cancer registry data (incidence) to give an indication of caseload and access to a clinical nurse specialist by patients. Results There is a wide variation in provision of clinical nurse specialists both geographically and by pathology across England. Conclusions Cancer specialist nursing is a pivotal part of cancer care. Given the uneven distribution of cancer clinical nurse specialists, it is unlikely that patients and families have equitable access across pathology or geography. In terms of a realistic workload, more research is needed into optimum caseload guidance.

Epilepsy in the WHO European region: Fostering epilepsy care in Europe

On 26th August 2010 at the European International Bureau for Epilepsy (IBE) congress in Oporto, Portugal, the report “Epilepsy in the WHO European Region” was launched, a joint publication produced by SEIN (WHO Collaborating Centre for Research, Training and Treatment in Epilepsy), WHO Headquarters, and the ILAE/IBE/WHO Global Campaign Against Epilepsy. The European Region of the World Health Organisation comprises 53 countries. It has a population of 850 million people, who speak approximately 45 official languages. Striking is the diversity in economy and culture seen across the region, with 11 countries designated as low or low middle income by World Bank categories. This report examines the prevalence of epilepsy and its management across the region, highlighting some key areas that require action. Within Europe there is a relatively large number of individuals with epilepsy. With a prevalence of 8.2 per 1,000, around 6 million individuals have epilepsy, and 15 million people will have had epilepsy at some time in their lives. Despite the fact that up to 70% of individuals can be treated effectively, the treatment gap between those requiring treatment and those receiving it is large. This may not be surprising in the low income countries, not helped by cultural perceptions of the condition, as well as the high cost of and availability of antiepileptic drugs (AEDs) and services, but it has been demonstrated that even the more “developed” countries are “developing” where epilepsy management is considered. The provision of epilepsy treatment and care across Europe was investigated in a survey of the European International League Against Epilepsy (ILAE) chapters by the Commission for European Affairs. A questionnaire, the European Epilepsy Services Inventory, was sent to all 36 European chapters of the ILAE, with responses from 32. In addition to showing the regional variations in provision of epilepsy care, the results also demonstrated a wide range in the numbers of physicians and specialists involved in epilepsy care. Furthermore, although there was a high number of epilepsy specialists listed in many countries, the highest of all the World Health Organization (WHO) regions, access to comprehensive epilepsy care in many countries was limited, with a high rate of misdiagnosis, over investigation, as well as over treatment and under treatment. In addition, although epilepsy surgery is recognized as curative for selected individuals, the survey demonstrated such management to be underutilized in many countries in Europe. Although there were large regional and national variations in the provision of epilepsy care, similar problems were reported. The most common problems were lack or underuse of epilepsy surgery; lack of comprehensive care; stigma and social problems; the high cost of AEDs (especially the newer drugs); lack of specialists and of specialized epilepsy care; lack of financing, equipment, and resource allocation; insufficient professional education and knowledge about epilepsy; and lack of epidemiologic data, violation of patients rights, and employment problems. Furthermore, the mortality rate among people with epilepsy is higher than that among the general population; it is estimated that there are 33,000 epilepsy deaths in Europe each year, 13,000 of which are preventable. In response, several initiatives are already in process in an attempt to address the situation. These include communication with the European Medicines Agency (EMEA) to contribute to the process of and guidelines for the approval of new AEDs, the development of European guidelines for the treatment of status epilepticus, and harmonizing the availability of and indications for AEDs across Europe. However, there is a need for further action to raise the profile of epilepsy within the European community, to reduce the stigma, enhance policy making and services for individuals with epilepsy, and improve access to care. This includes access to appropriate specialist care, medication, and surgery. The need for the promotion of existing and collaborative research across the region is also emphasized. The ILAE Commission for European Affairs has prepared a position paper on research priorities for use as a tool for communication with regard to further European support. I confirm that I have read the Journal’s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. I am currently Co-Chair Global Outreach Task Force ILAE and IBE. I have no conflicts of interest to disclose.

Health equity in the New Zealand health care system: a national survey

IntroductionIn all countries people experience different social circumstances that result in avoidable differences in health. In New Zealand, Māori, Pacific peoples, and those with lower socioeconomic status experience higher levels of chronic illness, which is the leading cause of mortality, morbidity and inequitable health outcomes. Whilst the health system can enable a fairer distribution of good health, limited national data is available to measure health equity. Therefore, we sought to find out whether health services in New Zealand were equitable by measuring the level of development of components of chronic care management systems across district health boards. Variation in provision by geography, condition or ethnicity can be interpreted as inequitable.MethodsA national survey of district health boards (DHBs) was undertaken on macro approaches to chronic condition management with detail on cardiovascular disease, chronic obstructive pulmonary disease, congestive heart failure, stroke and diabetes. Additional data from expert informant interviews on program reach and the cultural needs of Māori and Pacific peoples was sought. Survey data were analyzed on dimensions of health equity relevant to strategic planning and program delivery. Results are presented as descriptive statistics and free text. Interviews were transcribed and NVivo 8 software supported a general inductive approach to identify common themes.ResultsSurvey responses were received from the majority of DHBs (15/21), some PHOs (21/84) and 31 expert informants. Measuring, monitoring and targeting equity is not systematically undertaken. The Health Equity Assessment Tool is used in strategic planning but not in decisions about implementing or monitoring disease programs. Variable implementation of evidence-based practices in disease management and multiple funding streams made program implementation difficult. Equity for Māori is embedded in policy, this is not so for other ethnic groups or by geography. Populations that conventional practitioners find hard to reach, despite recognized needs, are often underserved. Nurses and community health workers carried a disproportionate burden of care. Cultural and diversity training is not a condition of employment.ConclusionsThere is a struggle to put equity principles into practice, indicating will without enactment. Equity is not addressed systematically below strategic levels and equity does not shape funding decisions, program development, implementation and monitoring. Equity is not incentivized although examples of exceptional practice, driven by individuals, are evident across New Zealand.

Out‐of‐school learning: The uneven distribution of school provision and local authority support

A significant volume of research demonstrates that out‐of‐school learning activities enhance student development in terms of cognitive, affective and social outcomes. However, there is also evidence that the opportunity to engage in these activities has been severely reduced in recent years. This paper explores the extent to which the provision of such opportunities is unevenly distributed—spatially and institutionally. The paper draws on research from two recently completed projects: one charting the distribution, attributes and vulnerability of local authority outdoor education centres across England and the other exploring variations in provision and participation in out‐of‐school learning within secondary schools throughout the UK. The paper highlights the uneven, precarious and uncertain nature of such activities and demonstrates that important regional and structural variations in the support and provision of opportunities for such activities by local authorities appear to have an important role in determining the provision of activities at the level of the schools.

Contraceptive policies affect post-abortion provision of long-acting reversible contraception

Background Placement of long-acting reversible contraceptives (LARC) — intrauterine devices (IUDs) and the implant — directly after an abortion provides immediate contraceptive protection and has been proven safe. Study Design We conducted a survey of National Abortion Federation member facilities ( n=326; response rate 75%) to assess post-abortion contraceptive practices. Using multivariable logistic regression, we measured variations in provision of long-acting contraception by clinic factors and state contraceptive laws and policies. Results The majority (69%) of providers surveyed offered long-acting methods, but fewer offered immediate post-abortion placement of intrauterine devices (36%) or implants (17%). Most patients were provided with contraception; 6.6% chose LARC methods offering the highest level of protection. Post-abortion provision of these methods was lower in stand-alone abortion clinics (p≤.001), but higher with recent clinician training (p≤.001) and in the absence of clinic flow barriers (p≤.001). State policies had a significant impact on how women paid for contraception and the likelihood of LARC use. Patient use was higher in states with contraceptive coverage mandates (p≤.01) or Medicaid family planning expansion programs (p≤.05). Conclusions Use of the most effective contraceptives immediately post-abortion is rare in the United States. State policies, high cost to patients, and the ongoing need for clinician training in the methods hinder provision and patient uptake. Contraceptive policies are an important component of abortion patient access to the most effective methods.