A Successful Multimodal Initiative to Increase Access to Long-Acting Reversible Contraception Among Adolescents

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https://doi.org/10.7812/TPP/18-071-26

From Colorado

Background: The US has the highest teen pregnancy rate of developed nations. These primarily unintended births suffer high rates of poor maternal and infant health outcomes. When financial, educational, and access barriers to contraception are removed, adolescents overwhelmingly choose long-acting reversible contraception (LARC), the most effective, safest, and most cost-efficient option. The Kaiser Permanente (KP) Colorado (KPCO) initiative was uniquely designed to address educational and logistical barriers within the KP integrated health system, using existing infrastructure and focusing on training frontline pediatric providers, resulting in wider use of LARC among adolescents.
Methods: The cohort included all female adolescents age 13-18 years cared for by KPCO pediatric, primary care, and women’s health clinicians between January 2013 and December 2016. The educational intervention included journal clubs, live interactive educational sessions, and in-service training of clinical staff. Primary care clinicians who received training on LARC were linked with a mentor gynecologist to provide further support. The process improvement intervention included development of a LARC implementation toolkit in the electronic health record to assist with prescribing, documentation, consent, and procedural set up, as well as clinical library guidelines and patient education materials on contraceptive choice.
Results: The proportion of LARC placed by primary care clinicians increased from 5.8% in 2013 to 32.5% in 2016 (p < 0.001), with the overall rate of LARC placement increasing from 1.5/1000 members/quarter to 4.8/1000 members/quarter. By the end of the intervention, 61 primary care clinicians had LARC training (vs 8 at baseline) and they practiced in 22 of the 27 primary care clinics (vs 10 at baseline.) Pregnancy rates declined from 1.6/1000 women aged 13-18/quarter to 0.2/1000 women in the same time period. The rate of decline accelerated after the beginning of the intervention (p < 0.0001). LARC educational materials and toolkits have been disseminated to the KP interregional obstetrics/gynecology Chiefs and family planning groups, and thus the socialization and spread of this initiative is already underway.
Discussion: A multimodal initiative that combined principles of adult learning, effective education, behavior change, and system-based process improvement successfully transformed clinician behavior, resulting in increased uptake of LARC by adolescents at KPCO. Although this LARC intervention should be adopted as a KP best practice, the true promise of this work is to apply this comprehensive approach for promoting clinician behavior change to other important quality issues within KP.