AT THE PAS ANNUAL MEETING
BALTIMORE (FRONTLINE MEDICAL NEWS) – A pilot program that trained pediatric primary care providers to insert long-acting reversible contraceptives (LARCs) delivered etonogestrel contraceptive implants to 135 adolescent and young women, with insertions provided by 16 providers within the first 16 months of the project.
“Pediatric offices offer a unique opportunity to provide contraceptive education and offer LARCs, reducing the need for referrals and potential delay in LARC provision that could lead to an unintended pregnancy,” wrote Dr. Kristine Schmitz , director of medical services for the Healthy Generations Program at Children’s National Health System, and her collaborators.
In a poster session of the annual meeting of the Pediatric Academic Societies, Dr. Schmitz reported that 20 general pediatricians and 2 pediatric nurse practitioners participated in LARC insertion training, and 16 providers, some of whom had previously received training, went on to begin LARC education and insertion as part of their primary care practice. Merck, the company that manufactures the etonogestrel implant marketed as Nexplanon, requires training and a certification for providers who implant the devices, which provide contraception for 3 years but can be removed at any time.
Intrauterine devices constitute the other form of LARC; taken together, they are the most effective form of contraception, but have historically been underutilized in the teen population.
In structuring the pilot program, Dr. Schmitz and her coinvestigators sought to assess not just the willingness of pediatricians to insert LARCs, but also to see how willing teenage girls were to receive the implants in their pediatricians’ offices; those data were not analyzed for this poster presentation. The study also polled clinicians to see what barriers existed to providing LARCs in a primary care setting.
In the pilot program, pediatricians at six general pediatric offices received etonogestrel implant insertion certification. Over the 16 months of the pilot study, a total of 135 teenage girls received implants. The number of insertions performed per provider during the study period ranged from 1 to 31.
Patient age for those receiving implants ranged from 12 to 22 years, with a median age of 18.
An electronic survey tracking clinician attitudes about LARC counseling and implantation was conducted 10 months into the study. The voluntary, non-anonymous survey was given to all providers at the pilot clinics, whether or not they were trained to insert LARCs. When providers were questioned about barriers to offering LARCs in the pediatric medical home, the primary barrier was simply the lack of availability of insertion trainings, cited by 48% of respondents as a “moderate” or “significant” barrier. Patient no-show rate was the second most common barrier, falling into the “moderate” or “significant” category for 29% of providers.
When surveyed, most pediatric primary care providers in the participating practices felt “comfortable” or “very comfortable” counseling teens on all birth control options (24/30 providers). Most (20/30) also felt “comfortable” or “very comfortable” providing anticipatory guidance about side effects of etonogestrel implants. Fewer clinicians (14/30) had the same degree of assurance that they could provide follow-up care for patients who experienced negative side effects from the implants, prompting Dr. Schmitz and her colleagues to comment that “Clinicians need additional training on side effect management.”
In an interview, Dr. Schmitz commented that pediatric primary care providers have relationships with patients and their family members, and can build on that trust to provide optimal contraceptive counseling.
Still, Dr. Schmitz and her colleagues quoted a survey response that observed, “The biggest difficulty in inserting and removing Nexplanon is time constraints – fitting patients into the schedule… and patients not showing up for scheduled procedures.”
Some providers also called for more case management support, she said.
Overall, she thinks the project shows great promise, saying, “It’s exciting to see how passionate our pediatric providers are about preventing unintended teen pregnancies, and how receptive our teen patients have been to receiving their chosen birth control method from their pediatrician.”
The study was funded by the Naomi and Nehemiah Cohen Foundation and the Children’s Health Board. Dr. Schmitz had no relevant financial disclosures.
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