Tips to increase LARC provision among family physicians

Christine Greves

Though the number of family physicians providing long-acting reversible contraceptive services has increased from 11.4% to 21.5% during the past few years, researchers say this rate remains low.

“As demand for [long-acting reversible contraceptives] increases, it is important to ensure that an appropriate primary care workforce is available to provide these services, allowing all patients to have access to these valuable contraceptive methods,” Meenadchi Chelvakumar, MD, a health services research and development fellow within the Veterans Affairs Medical Center in Palo Alto, California, and colleagues recently wrote in a policy brief published in the Journal of the American Board of Family Medicine.

Doctors who discussed the survey with Healio Primary Care Today said Chelvakumar et al’s comment came as little surprise.

“Future physicians ultimately have to decide what they are going to specialize in,” Christine Greves, MD, an OB/GYN at Orlando Health, said in an interview. “Those who go the family medicine route have so much they need to learn about, so to hear that less than 25% of family medicine doctors offer to insert long-acting reversible contraceptive provision is not particularly surprising,” she added.

Sabrina Fernandez, MD, a primary care pediatrician at the University of California, San Francisco, offered other possible reasons for the low uptake.

“The demand for long-acting reversible contraceptive services has increased faster than the workforce has adapted. Recent graduates may feel ill-equipped to deal with the red-tape and billing aspects of the procedure,” she said in the interview.

Education, communication with patients, and/or collaboration are viewed as critical steps to improve awareness and increase utilization among family physicians.

Though the number of family physicians providing long-acting reversible contraceptive services has increased from 11.4% to 21.5% during the past few years, researchers say this rate remains low.

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“Training ... should include enhanced patient-centered, non-judgmental counseling, procedural skills for insertion and removal, and knowledge of system-based practice so trained family practitioners can overcome barriers to implementing long-acting reversible contraceptive services in their practice,” Marji Gold, MD, of the department of family and social medicine at Montefiore Medical Center/Albert Einstein School of Medicine in Bronx, New York, wrote in a commentary accompanying Chelvakumar and colleagues’ paper.

Greves acknowledged even family physicians with such training, or their patients, may find long-acting reversible contraceptives difficult to discuss. She, Fernandez and Chelvakumar provided recommendations for family physicians to start conversations with their patients.

They should be discussed at a woman’s annual physical if she is of reproductive age.
They should be the first method of contraception discussed when patients ask or when the family practitioner opens a conversation about contraception.
They should be touted as eliminating the failure that can inadvertently occur with other forms of birth control (eg, forgetting to take a pill or having a condom break).
They cannot be removed by anyone or anything but a physician, and this removal can occur at any time.
They currently are used by approximately 14% of U.S. women.

Greves said family practitioners who are still uncomfortable discussing long-acting reversible contraceptive services with their patients should be willing to look to their peers, or collaborate with them, for guidance.

“Many family practitioners are on a team, connected with other physicians, but only some may ask for help, even within their own network. But it’s likely that a family practice has an OB/GYN on staff that the family practitioner can ask, or perhaps even briefly shadow to get the answers to their questions or even refer the patient to for a discussion on long-acting reversible contraceptives,” she told Healio Primary Care Today.

Sabrina Fernandez

“There should be a readily available referral to a different provider that can provide long-acting reversible contraceptive services if the family practitioner is unwilling to do so,” Fernandez added.

A biennial survey from The Physicians Foundation indicates the average physician age is 52.04 years. Greves admitted that a slew of changes have occurred in women’s health since physicians currently in their 50s entered the workforce. However, she said physicians should not use their age and/or unfamiliarity with subject as reasons for not discussing this type of birth control with their patients.

“Long-acting reversible contraception existed when clinicians who were 52 were in medical school. The form the device took may have been different in the past, but the whole principle of insertion is the same,” she said. – by Janel Miller

References:

Chelvakumar M, et al. J Am Board Fam Med. 2019;32:10-12.

Gold M. J Am Board Fam Med. 2019;32:4-5.

The Physicians Foundation. “2018 Survey of America’s Physicians.” https://physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf. Accessed Feb. 6, 2019.

Disclosures: Chelvakumar, Fernandez, Gold and Greves report no relevant financial disclosures.