Patients Receiving Emergency Contraception at Sexually Transmitted Disease Clinics New York City, 2006 – 2009

State: NY Type: Model Practice Year: 2010

:

There are about three million unintended pregnancies in the United States annually. Unintended pregnancies carry unwarranted health and economic burdens for mothers and their newborn infants. Women seeking care for sexually transmitted diseases (STDs) are also at risk for unintended pregnancies therefore, STD clinics can play an important role for these women by providing emergency contraception. Emergency contraception (EC) is a postcoital preventive method of birth control. Plan B, emergency contraception tablets, was FDA approved in 1999; however patient awareness of the product and physician’s active assessment of female patient’s eligibility remains low or unknown (The Guttmacher Report on Public Policy, June 2001). A woman’s risk of pregnancy can be reduced by 89 percent if EC is used within 72 hours of an inadequately protected sexual event. The provision of EC may be able to prevent over 1.5 million unintended pregnancies and up to 7000,000 abortions nationally per year. The goal of the NYC DOHMH STD clinics has been to increase patient awareness of EC as well as provision of EC to every eligible patient requesting this service. We added EC as a reason for visit to our triage intake form in order to let our patients know that we provided this service. Additionally, we’ve added a physician decision support tool to our medical record – this tool prompts our physicians to assess all female patients for their EC eligibility.

The purpose of our evaluation was to describe the proportion of clinic patients who received EC and quantify the proportion of those patients who received EC as a result of eligibility ascertained during physician visits. We were able to describe the proportion of our clinic patients who received EC as well as determine the proportion of patients who actively seeked EC versus those who were made aware of their eligibility through a physician’s assessment. By adding EC to our reason for visit/triage card we were able to notify our patients of its availability at our clinics. The implementation our EC eligibility tool into our medical record enabled us to reach another fifteen percent of eligible female patients who didn’t specifically request it on their reason for visit or as their chief complaint. These patient’s needs may have otherwise gone unmet or unnoticed.

:
New York City Department of Health and Mental Hygiene
:
Patients Receiving Emergency Contraception at Sexually Transmitted Disease Clinics New York City, 2006 – 2009
There are about three million unintended pregnancies in the United States annually. Unintended pregnancies carry unwarranted health and economic burdens for mothers and their newborn infants. Women seeking care for sexually transmitted diseases (STDs) are also at risk for unintended pregnancies therefore, STD clinics can play an important role for these women by providing emergency contraception. Emergency contraception (EC) is a postcoital preventive method of birth control. Plan B, emergency contraception tablets, was FDA approved in 1999; however patient awareness of the product and physician’s active assessment of female patient’s eligibility remains low or unknown (The Guttmacher Report on Public Policy, June 2001). A woman’s risk of pregnancy can be reduced by 89 percent if EC is used within 72 hours of an inadequately protected sexual event. The provision of EC may be able to prevent over 1.5 million unintended pregnancies and up to 7000,000 abortions nationally per year. The goal of the NYC DOHMH STD clinics has been to increase patient awareness of EC as well as provision of EC to every eligible patient requesting this service. We added EC as a reason for visit to our triage intake form in order to let our patients know that we provided this service. Additionally, we’ve added a physician decision support tool to our medical record – this tool prompts our physicians to assess all female patients for their EC eligibility. The purpose of our evaluation was to describe the proportion of clinic patients who received EC and quantify the proportion of those patients who received EC as a result of eligibility ascertained during physician visits. We were able to describe the proportion of our clinic patients who received EC as well as determine the proportion of patients who actively seeked EC versus those who were made aware of their eligibility through a physician’s assessment. By adding EC to our reason for visit/triage card we were able to notify our patients of its availability at our clinics. The implementation our EC eligibility tool into our medical record enabled us to reach another fifteen percent of eligible female patients who didn’t specifically request it on their reason for visit or as their chief complaint. These patient’s needs may have otherwise gone unmet or unnoticed.
There are about three million unintended pregnancies each year in the United States. Unintended pregnancies carry unwarranted health and economic burdens for the mothers and their newborn infants. Delayed prenatal care and lack of smoking cessation during the pregnancy are examples that can lead to low birth weight babies and other adverse birth outcomes. Women seeking care for sexually transmitted diseases (STDs) are also at risk for unintended pregnancies. Therefore, STD clinics can play an important role for women at risk for unintended pregnancies by providing emergency contraception. Emergency contraception (EC) is a postcoital preventative method of birth control. Plan B, emergency contraception tablets, was FDA approved in 1999 however patient awareness of the product and physician’s active assessment of female patient’s eligibility remain low or unknown. (The Guttmacher Report on Public Policy, June 2001). When EC is used within 72 hours of an inadequately protected sexual event it can reduce a woman’s risk of pregnancy by 89 percent. The provision of EC may be able to prevent over 1.5 million unintended pregnancies and up to 7000,000 abortions nationally per year. The New York City Council has recognized the potential impact and the important role that EC could play for women experiencing unplanned pregnancies. In 2002 they conducted an investigation into the availability of EC in New York City pharmacies. Their findings were published in a report called, “Emergency Contraception: Available at a Pharmacy Near You?” which elucidated the low and uneven rates of EC availability and distribution at local pharmacies. In the same report the City Council also proposed recommendations for improving the public’s access to the provision of EC. Included in their proposal was for the New York City Department of Health and Mental Hygiene (DOHMH) to provide EC at their STD clinics; this recommendation became law in March 2003. NYC STD clinics provide EC, as we do all of our services for free and to patients younger than 18. Since adding EC to our publicly provided services we have been able to reach over 13,000 females who were at risk for unintended pregnancies. We have also been able to reach patients who are demographically representative of the communities that we serve and specifically to patients who might not have been able to easily obtain EC for either age related or economic reasons. Although the Centers for Disease Control and Prevention recommends annual chlamydia screening for sexually active women younger than 26 years of age and the American Medical Association, American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics recommend comprehensive reproductive healthcare for sexually active adolescents and young women there remains to be a disconnect between the provision of these services. Contraceptive services have traditionally been a part of family planning clinics and private obstetric and gynecologic practices. The majority of women in the United States receive their contraceptive and family planning services from private medical offices. According to women, ages 15–44 years old who participated in the National Survey of Family Growth, more than 34 million said that they had gone to a private physician in the last 12 months for these or related services while 13.5 million said that they attended publicly funded clinics while the Department of Health and Human Services Title X family planning program served an estimate of 5.4 million women. In addition to EC the NYC STD clinics do offer our patients referrals to family planning services however; we’ve experienced similar results in patient acceptability of EC and family planning referrals as Golden et al (Contraception, 2004). In their study of women with gonorrhea or chlamydial infection they found that there was a high interest in an advanced provision of emergency contraception and a low interest in a referral.
Agency Community RolesThe Bureau of STD Control is part of the NYC Department of Health and Mental Hygiene (DOHMH) all of our clinics are health department clinics. We provide EC on site and for free for all of our eligible female clinic patients who are interested in receiving this service. Our efforts on this project were collaborative with other bureaus within the health department. The NYC DOHMH funded an outreach campaign to increase the public’s awareness of emergency contraception as well as to educate pharmacies. Costs and ExpendituresThe NYC DOHMH Bureau of STD Control (BSTDC) has 9 clinics providing free and confidential STD services to the public (ages 12 and older). We had about 123,000 visits in 2009; 52% of those visits involved a physician. The BSTDC began providing EC for our eligible female patients in March 2003. We added EC to our triage card which is filled out by patients upon arrival to our clinics and used to determine a patient’s reason for visit as well as how we route their visit (to see a clinician or for a testing only visit). Amongst patients waiting for services those requesting EC are given priority to be seen and always see a physician. Medical doctors are the only clinical providers who can assess and distribute EC at our clinics. We also integrated an EC related physician decision support tool into our medical record. This was originally included on our paper medical record and has since been carried over into our electronic medical record (EMR). The EC eligibility assessment is included in the OB/GYN history and builds on information already being asked such as their current method of contraception and if they currently desire to be pregnant. The EC assessment reminds the providing physician to ask the following questions: • Did you have Vaginal—Penile Intercourse in Past 72 Hours? • Was Contraception Used Every Time in Past 72 Hours? • Did Contraception Fail Any Time in Past 72 Hours? This EC assessment tool is meant to remind the providing physician to assess every female patient’s eligibility for EC (whether EC was the patient’s reason for visit or not). The patient’s EC eligibility is automatically determined in our electronic version based on the answers provided. This information as well as documentation of EC being offered to those eligible and if the patient declined or accepted is retained in the medical record. Plan B is the EC regimen that we provide to our patients and all EC tablets are administered at the time of visit. The first tablet of Plan B (0.75mg regimen) is consumed in the presence of the physician and the second tablet is given to the patient to take 12 hours later. The costs associated with EC are covered by New York City tax levy. ImplementationIn order to provide EC services at our STD clinics we needed to think about the following pieces: • Survey our patients for their knowledge and interest in EC • Identify funding • Procure a supply of emergency contraception tablets (Plan B) • Educate staff: physicians, counselors and clerical staff • Have family planning clinic contact information in order to make patient referrals • Have educational information for patients on EC in the waiting room • Update our triage/intake form to include EC as a reason for visit • Update our medical record to include the EC eligibility assessment tool • Add Plan B to our medical record list of diagnoses and treatments • Identify goals and measures for evaluation and marks of success We were able to implement our EC program in a couple of months.
Our practice goal has been to identify and provide EC to eligible female patients who want EC. Our most recent evaluation goal was to describe patients who have received EC and quantify the proportion of those patients who received EC as a result of eligibility ascertained during physician visits.We wanted to quantify the number of patients receiving EC at our clinics. Female patients who received EC, aged 15–44 years old who had a visit with us, on or between Jan. 1, 2006 and Dec. 31, 2009. Our clinics use a Web-based electronic medical record that is built on a Microsoft SQL database. All patient information is entered by clinic staff: registration clerks, physicians, counselors, laboratory micros, clinic managers, phlebotomists, and public health advisors.The patient’s information is entered into the database in real time and is therefore available to analyze immediately. The data that we analyzed was from Jan. 1, 2006 to Dec. 31, 2009.Program administrators request and review data analyses on a regular basis. 1) From 2006 to 2009 there were a total of 13,354 female patients who received EC at one of our NYC DOHMH STD clinics: in 2006: 3,086 patients received EC; 2007: 3,038 patients received EC; 2008: 3,597; 2009: 3,633. Over time the percentage of all female patient visits where EC was received increased from 9.8% in 2006 to 12.2% in 2009. We wanted to describe our patients who received EC at our clinics and compare them to our overall clinic populationFemale patients, aged 15- 44 years old who had a visit with us, on or between January 1, 2006 and December 31, 2009We analyzed our medical record data for females aged 15–44 years old who had a visit with us on or between Jan. 1, 2006 and Dec. 31, 2009 and received EC at our clinic. Our clinics use a Web-based electronic medical record that is built on a Microsoft SQL database. All patient information is entered by clinic staff: registration clerks, physicians, counselors, laboratory micros, clinic managers, phlebotomists, and public health advisors.The patient’s information is entered into the database in real time and is therefore available to analyze immediately. The data that we analyzed was from January 1, 2006 to December 31, 2009. Program administrators request and review data analyses on a regular basis. 2) Among patients who received EC the distribution of race and ethnicity (54% of patients were black, 30% Hispanic, 8% white, 3% Asian, less than 3% were either American Indian, Native Hawaiian/Pacific Islander, other or multi-racial) was comparable to the distribution of race and ethnicity amongst all of our clinic patients (57% black, 28% Hispanic, 8% white, 3% Asian, less than 3% were either American Indian, Native Hawaiian/Pacific Islander, other or multi-racial). Overall, 91% (12,101) of patients were younger than 30 years old while 70% of our female clinic patients were younger than 30. Of EC recipients: 36% were 18 years old or younger, 38% were 19-24, 16% were 25-29, 6% were 30-34, 3% 35-39 and 1% 40-44 years old. Fourteen percent of our clinic population is younger than 18 years of age, 37% 19-24, 19% 25-29, 10% 30-34, 7% 35-39, and 13% older than 40 years old. We wanted to identify the proportion of patients who received EC by actively requesting it (in either their reason for visit or chief complaint) compared to those patients identified as eligible through a physician’s assessment.Female patients who received EC, aged 15–44 years old who had a visit with us, on or between Jan. 1, 2006 and Dec. 31, 2009. EC seekers specifically requested EC in their reason for visit or chief complaint while "opportunistic receivers" received EC as a result of a physician's assessment of their eligibility.We analyzed our medical record data for females aged 15–44 years old who had a visit with us on or between Jan. 1, 2006 and Dec. 31, 2009 and received EC at our clinic. Our clinics use a web based electronic medical record that is built on a Microsoft SQL datab
The New York City Council mandate does not have an expiration date and so the BSTDC does not see where we would discontinue the provision of EC for our eligible female clinic patients. However, the unpredictability of our funding bottom line may lead us to make modifications to the way that we provide our services in the future. Currently physicians are the only clinicians who can assess and provide patients with EC; in the future we my want to see if this can be modified to include other types of clinicians such as nurse practitioners and/or physician assistants. If our funding increased we would like to be able to provide female patients with advanced provisions of EC. If our guidelines change or if other jurisdictions are interested in modifying what we did it may be possible to make a similar impact by including EC on the intake form and continue to evaluate patients for their EC eligibility without providing the EC tablets. This would still prompt conversation on the subject as well as continue to identify EC eligible patients without having to pay for the expense of the pills. Alternatively, you could target the provision by continuing to identify patients yet only provide patients younger than 17 with the needed medication.
 
Processing...


Driving Walking/Biking Public Transit  Get Directions