Promoting Safe Prescribing in Primary Care With a Contraceptive Vital Sign: A Cluster-Randomized Controlled Trial

With National Health and Nutrition Examination Survey (NHANES) data demonstrating that over 2/3 of the US population is overweight or obese, the provision of contraception to women of reproductive age has become ever more important (1). The obesity epidemic has increased the proportion of adolescents and young women with type II diabetes, hypertension, and hyperlipidemia. Given that these comorbidites often require treatment with teratogenic medications (ACE inhibitors, statins) and markedly increase the risk of adverse obstetric outcomes (cesarean section, preeclampsia, stillbirth among others), adequate contraceptive counseling is critical (2). Additionally, evidence supports the notion that family planning is truly vital to the health of women, exemplified by the fact that increasing use of contraception in developing countries over the past two decades has reduced the number of maternal deaths by 40% (3).

In this issue of the Annals, Schwartz and colleagues report the results of a cluster randomized control trial evaluating the impact of a introducing a "contraceptive vital sign" on provider documentation of contraceptive use and the provision of family planning services. The intervention in this trial is innovative in the use of the electronic medical record (EMR) to embed a quality and safety tool into clinical care. Importantly, this study demonstrated improved documentation of contraceptive use by providers in the intervention group. However, the intervention failed to improve the end goal - increasing the provision of contraception and family planning services, particularly among women receiving prescriptions for teratogenic medications. The authors appropriately acknowledge the shortcomings of the study, particularly the lack of power secondary to the omission of annual exams which, in a population of reproductive age women, often represents one of the most important opportunities for counseling and provision of contraception.

This study clearly identifies an important area for improvement in the provision of primary care services to reproductive age women. Moving forward, how can we impact change? As an Obstetrician Gynecologist by training, I typically evaluate and counsel women of reproductive age through the lens of "pregnant until proven otherwise". In Schwartz's study, over 90% of women in both groups responded "they were not trying to get pregnant", however only 56% (959/1699) of the women in the study were using contraception. Of those using contraception, approximately 1/3 used barrier or behavioral contraception, which has a significantly higher failure rate than hormonal methods of contraception (4). This provision, along with the determination that women not sexually active in the past 3 months were not at risk for pregnancy, significantly underestimates the women truly at risk for being pregnant in the study. Therefore, broadening the considerations of who may be at risk for pregnancy represents an important first step to any intervention.

Another mechanism to improve contraceptive counseling involves utilizing the power of the EMR. Electronic prescribing could integrate warning boxes when potentially teratogenic medications are prescribed to women of reproductive age, which has been demonstrated to decrease medical errors when used with inpatient EMR systems (5). Integrated EMR systems could provide comprehensive problem lists, history, and notes across disciplines. The addition of "contraceptive plan" to the problem list for all women of reproductive age should be considered. Lastly, educational initiatives in medical school and residency must target contraceptive counseling as a vital and necessary component to the annual exam for reproductive age women. Strategies to improve education include multidisciplinary initiatives across primary care specialties (Internal Medicine, Pediatrics, Family Medicine, Obstetrics and Gynecology) or the integration of contraception into primary care board certification.

Schwartz and colleagues hit the proverbial "nail on the head" in identifying that in primary care, contraception is truly "vital". It must be equally vital to the physicians caring for them.

References:
1. Centers for Disease Control and Prevention, Data and Statistics. US Obesity Trends. http://www.cdc.gov/obesity/data/trends.html
2. Catalano PM. Management of obesity in pregnancy. Obstet Gynecol. 2007 Feb;109(2 Pt 1):419-33.
3. Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A. Contraception and health. Lancet 2012;380:149-56.
4. Trussell J. Contraceptive failure in the United States. Contraception 2011; 83:397.
5. Schnipper JL, Hamann C, Ndumele CD, Liang CL, Carty MG, Karson AS, Bhan I, Coley CM, Poon E, Turchin A, Labonville SA, Diedrichsen EK, Lipsitz S, Broverman CA, McCarthy P, Gandhi TK. Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial. Arch Intern Med. 2009 Apr 27;169(8):771-80.

Competing interests:   None declared