Get practice up to speed on LARC methods
How can your clinic increase use of long-acting reversible contraceptive (LARC) methods? Take notes from the LARC First web site, www.larcfirst.com. Developed by the St. Louis-based Washington University School of Medicine's Contraceptive CHOICE project, the site offers a compilation of materials that will help your facility become a "LARC First" practice.
Executive Summary
Clinics looking to increase use of long-acting reversible contraceptive (LARC) methods have tools and evidence to support their actions.
- Visit www.larcfirst.com to access a compilation of materials from the Washington University School of Medicine's Contraceptive CHOICE Project. Materials are designed to make your clinic a "LARC First" facility.
- Check that all employees have equal understanding of LARC eligibility. Results of a recent survey indicate differences between health educators' and clinicians' practices. Educators considered a smaller proportion of their clients eligible to use LARC methods than did clinicians.
The online resource center is divided into six modules:
- The opening module provides a starting point for exploring what makes a practice LARC friendly.
- The second module gives information to support organizational adoption of the CHOICE model of contraceptive care.
- The third module provides tools to help clinics successfully put CHOICE contraceptive counseling into practice.
- The fourth module lists evidence-based resources and provision guidelines for advanced practitioners who work in primary care, pediatric, or gynecological practice settings.
- The fifth module provides tips on cross-training, managing patient concerns, and providing reassurance and resources for sexually transmitted infection testing and follow-up.
- The final module details the materials and best practices used by the Contraceptive CHOICE Project to hire staff, set organizational goals, and create a mission-focused environment.
It is essential that all staff members within a LARC First practice, from receptionist to administrator, are on board with the mission to ensure quality patient care and experience, say Contraceptive CHOICE staffers. (See how positive LARC messages can be used by all clinic staff, p. 41.)
Requests are increasing
Respondents to the 2013 Contraceptive Technology Update Contraception Survey say word of mouth from satisfied users is bringing in more women requesting LARC options.
The copper-T 380A intrauterine device (ParaGard IUD, Teva North America, North Wales, PA), the levonorgestrel IUDs (Mirena and Skyla, Bayer HealthCare Pharmaceuticals, Wayne, NJ), and the contraceptive implant (Nexplanon, Merck & Co, Whitehouse Station, NJ) are becoming more popular due to their convenience, say survey respondents. LARC methods require no pharmacy visits and no need to do something about contraception on a daily basis, says Donna Gray, CNM, WHNP, a clinician at the Wyoming County Health Department's Men's and Women's Reproductive Health Services in Silver Springs, NY. Many patients are switching to LARC methods based on their friends' positive experiences with such options, Gray reports.
Use of LARC methods has definitely grown since the 2000 introduction of the Mirena IUD. Just 3% of respondents to the 2001 CTU survey reported 25 or more IUD insertions; in 2013, that number jumped to 32%.
Check clinic LARC IQ
While you might be up to date on the latest evidence-based medicine when it comes to LARC methods, how about the rest of your clinic staff?
Results of a survey conducted at 40 Planned Parenthood clinics in 2011-2012 indicate differences between health educators' and clinicians' practices regarding LARC options. According to survey results, educators considered a smaller proportion of their clients eligible to use LARC methods than did clinicians (57% versus 77%). Educators were less likely to consider offering IUDs to teenagers (79% versus 96%), to women who had never had children (82% versus 98%) and to unmarried women (90% versus 99%).1 (To review research backing safety of IUD use in teens and nulliparous women, see the CTU articles, "Old myth debunked: Data show IUD is safe birth control option for teens," July 2013, p. 73,2 and "LARC methods: 7 things you need to know, January 2014, p. 4.3)
Based on the survey results, 64% of educators and 40% of clinicians desired additional LARC training.1 "Even in clinics that specialize in reproductive health care, health educators are less likely than clinicians to apply current evidence-based criteria in counseling about LARC," the researchers note. "To provide evidence-based contraceptive counseling, health educators need training on LARC eligibility and indications."
Even clinicians might not be clear on potential LARC candidates. To assess such knowledge, researchers conducted a survey regarding LARC beliefs and practices among medical directors from 1,000 sites in the Family Planning Access Care and Treatment program (California's family planning Medicaid program) provider database. Most respondents (448/587) were physicians.4
Respondents were most likely to consider women with a history of pelvic inflammatory disease (PID) unsuitable for hormonal (27%, n=161) and copper (26%, n=154) intrauterine devices. According to the U.S. Medical Eligibility Guidelines for Contraceptive Use, the copper T380A IUD and the levonorgestrel IUD are rated "1" (no restrictions on use) for women with a past history of PID and a subsequent pregnancy, and a "2" (advantages generally outweigh theoretical/proven risks) for women with past PID history and no subsequent pregnancy.3 Nearly three-fourths of respondents routinely discussed IUDs (413/561) and nearly half (271/558) discussed implants with their contraceptive patients.
"Although there has been significant progress in expanding access and understanding about LARC, many clinicians from sites offering family planning services held beliefs limiting the provision of intrauterine devices and were unfamiliar with the implant, suggesting the need for targeted trainings aimed at informing clinicians of recent developments in LARC recommendations," researchers state.
- Thompson KMJ, Stern L, Gelt M, et al. Counseling for IUDs and implants: are health educators and clinicians on the same page? Perspect Sex Reprod Health 2013; 45(4):191-195.
- Centers for Disease Control and Prevention. U.S. Medical Eligibility Criteria for Contraceptive Use. MMWR 2010; 59(RR04):1-6.
- Berenson AB, Tan A, Hirth JM, et al. Complications and continuation of intrauterine device use among commercially insured teenagers. Obstet Gynecol 2013; 121(5):951-958.
- Biggs MA, Harper CC, Malvin J, et al. Factors influencing the provision of long-acting reversible contraception in California. Obstet Gynecol 2014; doi: 10.1097/AOG.0000000000000137.
