Promoting safe prescribing in primary care with a contraceptive vital sign: a cluster-randomized controlled trial

Abstract

Purpose: Routine assessment of women's pregnancy intentions and contraceptive use-a so-called contraceptive vital sign-may help primary care physicians identify patients who need preconception or contraceptive counseling and be of particular benefit when teratogenic medications are prescribed.

Methods: We conducted a cluster-randomized controlled trial to evaluate the effect of a contraceptive vital sign on primary care documentation of contraceptive use and change in primary care physicians' provision of family planning services. Academic internists in the intervention group (n = 26) were provided with information on their female patients' pregnancy intentions and contraceptive use immediately before visits; internists in the control group (n = 27) received only standard intake information. Data were abstracted from the electronic health record for 5,371 visits by 2,304 women aged 18 to 50 years.

Results: Documentation of contraception increased from baseline, from 23% to 57% in the intervention group, but remained 28% in the control group, a change of +77.4 (95% confidence interval [CI], 70.7 to 84.1) adjusted percentage points in the former vs +3.1 (95% CI, 1.2 to 5.0) in the latter (P <.001). For visits involving a teratogenic prescription, documentation increased from 14% to 48% in the intervention group and decreased from 29% to 26% in the control group, a change of +61.5 (95% CI, 35.8 to 87.1) adjusted percentage points in the former vs -0.3 (95% CI, -4.3 to 3.6) in the latter (P <.001). Provision of new family planning services increased only minimally with this intervention, however. When women with documented nonuse of contraception were prescribed potential teratogens, only 7% were provided family planning services.

Conclusions: A contraceptive vital sign improves documentation of contraceptive use; however, ongoing efforts are needed to improve provision of preconception and contraceptive services.

Figure 1

Flow diagram describing physician clusters and patient encounters from the time of recruitment to analysis.

Figure 2

Change in proportion of visits with medical record documentation of contraception before and after introduction of the contraceptive vital sign. Notes: Contraceptive vital sign data and electronic health record data were collected between October 1, 2008, and April 14, 2010. Baseline electronic health record data from the 17 months before introduction of the contraceptive vital sign were used for comparison. In generalized linear mixed-effects models, there was a greater increase in documentation of contraception in the intervention group compared with the control group, both for all visits (P <.001) and visits that involved prescription of potentially teratogenic medications (P <.001). Hormonal or more effective methods = pill, patch, ring, injection, intrauterine devices, subdermal contraceptiveimplants, and vasectomies. Women who had been sterilized were excluded. Not sexually active = women who reported no sex with a man in past 3 months.