first trimester medical abortion: adherence and staff effort Email follow-up after first trimester medical abortion: adherence and staff effort Tika Okuda1 & Kirsten Duckitt2 September 15, 2017 1University of British Columbia, Island Medical Program, BC 2 Department of Obstetrics and Gynecology, Clinical Associate Professor UBC, Campbell River, BC

Affiliations University of British Columbia Faculty of Medicine University of Victoria, Island Medical Program Island Health Authority

Disclosure I have no disclosures

Understanding the Problem Map notes locations of medical first trimester abortion providers Vancouver Island is 31,285km2 and 460km long South Isl1: (61-64) Pop: 383,360 Central Isl1: (65-70) Pop: 270,418 North Isl1: (71,72,84,85) Pop: 122,233 Distance to providers can be great due to the large geographical area and limited motorways. Eg. driving time from Port Hardy (northern end) to Campbell River is 2.5 hours. In addition multiple small Island communities are served with infrequent sailings. This study is based in Campbell River 2:http://www.viha.ca/about_viha 1; Statistics Canada. 2017. Campbell River [Population centre], British Columbia and British Columbia [Province] (table). Census Profile. 2016 Census. Statistics Canada Catalogue no. 98-316-X2016001. Ottawa. Released August 2, 2017. http://www12.statcan.gc.ca/census-recensement/2016/dp-pd/prof/index.cfm?Lang=E (accessed August 23, 2017). 1) Statistics Canada 2016 Census Population 2) Image: http://www.viha.ca/about_viha

Methods Retrospective chart review of medical abortions following SOGC 2006 guidelines1 January 2012- December 2016 Protocol used Methotrexate and Misoprostol and successful treatment was noted by a serial drop in quantitative B-hCG of > 80% Every patient was considered to require one email from the medical provider Lost to follow-up: inconclusive B-hCG and no response to email or telephone communication Extra email correspondence: any patient requiring more than one email Completely lost to follow-up: unknown status post chart review (May 2017) Serial labs= 1 pre treatment B-hCG and 2 subsequent tests 7 days after each other. 1)http://old.sogc.org/wp-content/uploads/2013/01/gui184E0611.pdf

Results 469 requested medical abortion services 462 prescriptions given 7 declined prescriptions 278 B-hCG drop in initial set of 2 labs 179- more than one email 5 presented to ER for RPOC 5 D&C 116 < 80% B-hCG drop or less than 2 serum levels 16 no bleeding, no labs drawn 47 required extra prescriptions 15 emailed in with signs & symptoms of success 57 lost to follow up 44 D&C 16 D&C 47 Successful medical abortion 33 completely lost to follow up 24 found through chart review RPOC= retained products of conception D&C= dilatation and curettage Yellow= required extra email communication Red= lost to follow up 462 people requested and received counselling for the procedure. 18 successful medical abortion 6 D&C

Results Adherence rates 12.3% (57/462) lost to f/u Staff effort 38.7% (179/462) required extra communication

Results Staff effort 8.9% (16/179) emailed-in no bleeding → D&C 26.3% (47/179) required an extra prescription 24.6% (44/179) needed to return for a D&C Compliance with serial B-hCG levels 16.3% 72/(462-5-16) had less than 2 lab tests 3.4% 15/(462-5-16) emailed in signs of success See the breakdown of emails sent by the medical provider.

This is a retrospective chart review, which is limited to a patient population on Vancouver Island. The noted trends could be biased due to location or patient population of the provider. Extra email correspondence was set based on each patient requiring one email from the care provider. However, this does not reflect the number of extra emails or time required for each response. Limitations

Discussion: Adherence to Follow-up and B-hCG Patient compliance Only 16.3% completed less than 2 B- hCG values. Considering limited laboratory locations, barriers to travel like distance, and poor public transportation this is a small number of non compliant patients Email adherence rates are acceptable A Canadian Study from 2015 notes complete lost to f/u rates for telephone and office visits at 4.8% and 5.6% respectively1 This email f/u study had a complete lost to f/u rate of 7.1%. Of note 3.4% of the 16.3% of laboratory non-adherence emailed in with perceived signs of successful medical abortion; including, return of menstruation. Emailing the care provider presumed signs and symptoms of a successful medical abortion is not an encouraged form of follow-up but allowed the patient to communicate with their medical provider and overcome some of the noted barriers to this patient population. Comparing office and telephone follow-up after medical abortion. Chen MJ, et al. Contraception. 2016.Authors Chen MJ1, Rounds KM2, Creinin MD2, Cansino C2, Hou MY2. https://www.ncbi.nlm.nih.gov/m/pubmed/27101901/?i=22&from=follow%20up%20rates%20after%20abortion# 1)Chen MJ. et al., 2015. Comparing office and telephone follow-up after medical abortion: https://www.ncbi.nlm.nih.gov/m/pubmed/27101901/?i=22&from=follow%20up%20rates%20after%20abortion

Discussion: Staff Effort Email is a viable tool A Canadian Study on medical abortion f/u from 2015 notes 43.9% required more than one telephone call1. The noted 38.7% of patients who required extra communication is expected. Templates can streamline f/u MIFEGYMISO might decrease % requiring extra communication Clinical Pearl The legal risks of email communications are clearly outlined by the Canadian Medical Protective Association and a consent form is available2. Each physician should look at the email communication statement from their governing College of Physicians and Surgeons Comparing office and telephone follow-up after medical abortion. Chen MJ, et al. Contraception. 2016.Authors Chen MJ1, Rounds KM2, Creinin MD2, Cansino C2, Hou MY2. https://www.ncbi.nlm.nih.gov/m/pubmed/27101901/?i=22&from=follow%20up%20rates%20after%20abortion# 1)Chen MJ, 2015. Comparing office and telephone follow-up after medical abortion: https://www.ncbi.nlm.nih.gov/m/pubmed/27101901/?i=22&from=follow%20up%20rates%20after%20abortion 2)https://www.cmpa-acpm.ca/static-assets/pdf/advice-and-publications/risk-management-toolbox/com_16_consent_to_use_electronic_communication_form-e.pdf

In 2016 medical abortions made up 3 In 2016 medical abortions made up 3.8% of Canadian first trimester abortions1. With the recent approval of MIFEGYMISO in Canada this number will hopeful increase.. Future studies should include and compare rural and urban populations Pragmatic, preference trial to compare lost to f/u rates and staff effort with; office, telephone, telemedicine and email follow-up Qualitative study on patients’ perceptions of email communication and privacy Investigate barriers to physician uptake of emaeil correspondnce Future Directions Our site about 40% are medidal of campbell river has MIFEGYMISO (mifepristone and misoprostol tablets) which has less teratogenic effects 1) Guilbert, E., etc., 2016. First-trimester medical abortion practices in Canada https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4830676/