1. Debbie Postlethwaite RNP, MPH Adekemi Ogultala, MD Maqdooda Merchant MSc, MA

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 1995 1  Healthy People 2020 goal: 56% planned pregnancies 1  IUC: most cost-effective LARC within 12 months of use 2  SCI: lowest failure rate (0.05%) within 12 months 2,3  ACOG supports the use of LARC in adolescent and young women 4 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)http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=13 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 * Other: Islander, Native American, Multi-racial Characteristics Percent (N) Total N = 303 Age 15-2435.6% (108) 25-3464.4% (195) Race Asian13.5% (41) Black7.3% (22) Hispanic 33.0% (100) Other* 4.0% (12) White33.3% (101) Missing8.9% (27) Living Situation/Marital Status Single/Separated/Divorced37.3% (113) Married/Living with Partner45.2% (137) Other/Unknown17.5% (53) Gravidity 023.0% (70) 1-240.0% (121) 319.5% (59) > 417.5% (53) Table 1: Demographic and Clinical Characteristics of LARC Users

7. Table 1: Demographic and Clinical Characteristics of LARC Users (continued) CharacteristicsPercent (N) Total N = 303 Parity 0 28.7% (87) 1-2 53.8% (163) ≥3 17.5% (53) BMI (Mean) [Median] (27.3) [26.2] <2541.9% (127) 25-29.930.4% (92) >3027.7% (84) LARC Type by Age Group Cu-T IUC, Age 15-246.9% (21) Cu-T IUC, Age 25-3426.4% (80) LNG-IUC, Age 15-24 8.6% (26) LNG-IUC Age 25-3424.8% (75) SCI, Age 15-2520.1% (61) SCI, Age 25-3413.2% (40)

8. Table 2: Early LARC Removal by Demographic and Clinical Characteristics CharacteristicsOutcomes Early LARC Removal Within 12 Months No Early LARC Removal P Value † Age % (Total N=303) 15-2423.1% (25)76.9% (83) 0.52 25-3420.0% (39)80.0% (156) Race % (Total N=303) Asian 17.1% (7)82.9% (34) 0.82 Black (non-Hispanic) 27.3% (6) 72.7% (16) Hispanic 23.0% (23)77.0% (77) White (non-Hispanic) 18.8% (19)81.2% (82) Other* 23.1% (9)76.9% (30) Living Situation/Marital Status Single/Separated/Divorced17.7% (20)82.3% (93) 0.42 Married/Living with Partner21.9% (30)78.1% (107) Other/Unknown26.4% (14)73.6% (39) Gravidity % (Total N=303) 017.4% (12)82.6% (57) 0.42 1-224.8% (30)75.2% (91) > 319.5% (22)80.5% (91) Parity % (Total N=303) 022.1% (19)77.9% (67) 0.67 1-222.1% (36)77.9% (127) > 316.7% (9)83.3% (45) BMI % (Total N=303) < 2518.9% (24)81.1% 103) 0.72 25-29.922.8% (21)77.1% (71) > 3022.6% (19)77.4% (65) * Other race: Islander, Native American, Multi-racial, missing † P values calculated using Chi-Square tests

9. Early Removal by LARC Type and Age CharacteristicsOutcomes Early Removal No Early Removal P value* LARC Type by Age Category SCI, Age 15-2427.9% (17)72.1% (44)0.45 SCI, Age 25-3435.0% (14)65.0% (26) Cu-T IUC, Age 15-2419.0% (4)81.0% (17)0.75 Cu-T IUC, Age 25-3416.2% (13)83.8% (67) LNG IUC, Age 15-24 15.4% (4)84.6% (22)1.00 LNG IUC, Age 25-3416.0% (12)84.0% (63) IUC: Cu-T vs. LNC Cu-T16.8% (17)83.2% (84) 0.85 LNG15.8% (16)84.2% (85) LARC: IUC vs. LARC Any IUC16.3% (33) 83.7% (169)0.004 SCI30.7% (31)69.3% (70) * P values calculated using Chi-Square tests

10. Early LARC Removal by Reported Complaints CharacteristicOutcome Early Removal No Early Removal P value* Reported Complaints Bleeding/Any Time Period35.5% (33)64.5% (60)<0.0001 Pain/ Any Time Period34.0% (16)66.0% (31) 0.02 Amenorrhea/Any Time Period26.7% (8)73.3% (22) 0.43 Other † /Any Time period33.3% (30)66.7% (60) 0.0007 Reported Bleeding Complaints by Time Period < 3 months33.3% (21)66.7% (42)0.008 4 - 6 months33.3% (5)66.7% (10) 0.32 ‡ 7-12 months48.4% (15)51.6% (16) <0.001 * 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 * Complaints included: 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 Complaints and CounselingAge CategoryP value* Age: 15-24Age: 25-34 Any Complaint †, Any Timeframe ‡ ; % (N) 57.4% (62)58.5% (114)0.86 Retention Counseling, Any Timeframe ‡ % (N) 40.7% (44)43.1% (84)0.69 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 ( 30: 24.1%; p=0.19)

12. Predictors of Early SCI Removal Predictive CharacteristicsOdds* Ratio Confidence Interval P value* Age (categorical) 15-24 vs. 25-34 1.010.51 – 1.990.99 Cu-T IUC vs. SCI0.380.17 – 0.84< 0.02 LNG IUC vs. SCI0.280.12 – 0.63< 0.002 BMI 250.580.31 – 1.0980.10 Any Reported Bleeding2.951.62 – 5.370.004 Any Reported Pain3.091.41 – 6.760.005 * 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