Factors Predicting LARC Continuation in Adolescent/Young Adults vs. Adult Women

1. Debbie Postlethwaite RNP, MPH Adekemi Ogultala, MD Maqdooda Merchant MSc, MA Factors Predicting LARC Continuation in Adolescent/Young Adults vs. Adult Women

2. Presenter Disclosure • Presenter: Debbie Postlethwaite RNP, MPH No Relationships to Disclose This study was funded by: Kaiser Permanente Community Benefits Program

3. Background • Long Acting Reversible Contraception (LARC) • IUC: Levonorgestrel 20 and Copper-T 380 A • SCI: Etonogestrel Subdermal Contraceptive Implant • 49% of US pregnancies have remained unintended since 19951 • Healthy People 2020 goal: 56% planned pregnancies1 • IUC: most cost-effective LARC within 12 months of use2 • SCI: lowest failure rate (0.05%) within 12 months2,3 • ACOG supports the use of LARC in adolescent and young women4 1. U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC. Available at http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=13 (accessed 9/30/2011) 2. Trussell J, Lalla AM, DoanQV, et al. Cost effectiveness of contraceptives in the United States. Contraception, 2009, 79: 5-14. 3. Trussell J. Contraceptive Failures in the United States. Contraception, 2011; 83: 397-404. 4. Long-Acting Reversible Contraception: Implants and Intrauterine Devices . ACOG Practice Bulletin, Clinical Management Guidelines for Obstetricians-Gynecologists, 121; Obstetrics and Gynecology 2011 (118), 1: 184-196.

4. Research Question • What factors contribute to the 12 month continuation rate of LARC use in adolescents & young adults compared to adult women? Goal: To gain knowledge about the role that post-insertion counseling plays, demographic and clinical variables in predicting higher retention/continuation of LARC use in adolescent & young compared to adult women at KPNC.

5. Methods • Study design: Retrospective Cohort study of LARC users between 1/1/2007 to 12/31/2008 with minimum of 12 months membership following LARC insertion • Study subjects: Random proportional stratified sampling of 303 KPNC women with an SCI or IUC insertion; stratified by age: 15-24 vs. 25-34 and by method • Data Collection: Electronic database extraction and detailed medical record review • Variables of interest: • Demographic and Clinical: age, race, living situation, and marital status, Gravidity, Parity, BMI • Reported side effects and complications (< 3, 4-6, 7-12 mo.) • Post-insertion counseling (< 3, 4-6, 7-12 mo.) • Early LARC removal by time period and reason for removal • Analysis Plan: Descriptive, Chi-square and Fisher Exact tests, Wilcoxon Rank Test, Multtest, and Multivariable logistic regression

6. Results Table 1: Demographic and Clinical Characteristics of LARC Users * Other: Islander, Native American, Multi-racial

7. Table 1:Demographic and Clinical Characteristics of LARC Users (continued)

8. Table 2: Early LARC Removal by Demographic and Clinical Characteristics * Other race:Islander, Native American, Multi-racial, missing † P values calculated using Chi-Square tests

9. Early Removal by LARC Type and Age * P values calculated using Chi-Square tests

10. Early LARC Removal by Reported Complaints * P values calculated using Chi-Square tests † Other complaints included: headaches, weight gain, mood changes or depression ‡ P value calculated using Fisher Exact test

11. Reported Complaints, Retention Counseling and Early LARC Removal * Complaintsincluded: unscheduled bleeding, amenorrhea, pelvic or LARC insertion site pain, headaches, weight gain, depression or mood changes † Outcome timeframes: < 3 months, 4-6 months, 7-12 months after LARC insertion • There were no statistical differences in early LARC removal among women with complaints + retention counseling • (N=114) by: • Age (15-24: 28.9% vs. 25-34: 22.4%; p=0.44) • LARC type (Cu-T IUC: 20.7%, LNG-IUC: 22.0%, SCI: 31.4%; p=0.52) • BMI(<25: 17.0% , 25-29: 34.2%, > 30: 24.1%; p=0.19)

12. Predictors of Early SCI Removal * ORs, Confidence Intervals and P-values calculated with logistic regression

13. Strengths and Limitations • Strengths: • Large cohort of adolescent, young adult and adult LARC users with diverse demographic and clinical characteristics • KPNC Integrated electronic medical records and databases • Documentation of clinical visits, phone visits and secure e-mail exchanges between patient and healthcare provider • Limitations • Integrated Health Care System (public or privately insured)population limiting generalizability • Retrospective study design • Limited documentation of LARC retention counseling encounters

14. Conclusion • Reported side effects (bleeding, pain) were strong predictors of early LARC removal, regardless of method type or age group of user • Post-insertion counseling did not significantly affect LARC continuation regardless of age group or method type • IUC use, compared to SCI use, had higher continuation rates in both adolescent/young and adult women • LARC methods appeared to be as acceptable to adolescent/young women as they were to adult women • LARC methods have potential to reduce unintended US pregnancies