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Transcript of Www.sandyford.org Increasing the Proportion of Women using Long Acting Reversible Contraception...
www.sandyford.org
Increasing the Proportion of Women using Long Acting Reversible Contraception (LARC) within a Geographical Area in
Scotland
Dr Audrey Brown
www.sandyford.org
Greater Glasgow and Clyde
www.sandyford.org
Long-acting reversible contraception
• National Institute for Clinical Health and Excellence (NICE) 2005– Women should be offered a choice of all methods
including LARC. – All LARC methods are more cost effective than the
combined oral contraceptive pill even at 1 year of use.– IUDs, IUS and implants are more cost effective than
the injectable contraceptives.– Increasing the use of LARC will reduce unwanted
pregnancies
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Scotland 2004/5 Uptake intra-uterine device, intra-uterine system,
contraceptive implantper 1000 women aged 15-44
Rate per 1000 women
within Scotland
Rate per 1000 women
within GGC
23 17
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vLARC rate per 1000 women 2004/05
0 5 10 15 20 25 30 35 40 45
Greater Glasgow & Clyde
Lanarkshire
Lothian
Fife
Forth Valley
Scotland
Grampian
Tayside
Dumfries and Galloway
Ayrshire & Arran
Borders
Islands
Highland
www.sandyford.org
GGC – time for action• Target set to increase from
17/1000 to 85/1000 in 5 years
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National Drivers
• Key Clinical Indicator (KCI) on LARC – Information and Statistics Division – annual reporting of uptake by board area
• Quality Improvement Scotland (QIS) – standard on intrauterine and implantable methods of contraception
• National LARC awareness campaign
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Key Clinical Indicators for Sexual Health: Population Based Indicator
Termination of Pregnancy Sterilisation Long Acting Reversible Contraception
Chlamydia HIV Therapy
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QIS LARC standardEssential Criteria
• Women requiring contraception are given information about, and offered a choice of, all methods of contraception including intra-uterine and implantable contraceptives
• 60 or more females per 1000 of reproductive age per year are prescribed intrauterine and implantable contraceptives
• Contraceptive providers who do not provide intrauterine and implantable contraceptives have an agreed mechanism in place for referring women
• A consultation appointment with a service providing intrauterine and implantable contraceptives is available within 5 working days
Desirable criterion
• 100 or more females per 1000 of reproductive age per year are prescribed intrauterine and implantable contraceptives by the end of 2011
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• Media launch• Retail outlets• Cinemas• Gym changing rooms• Bar toilets
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Local action:• Raise awareness through distribution of LARC
resource pack• Contraceptive prescribing guidance for primary
care• Improve access to free training, especially for
nursing staff, both primary care and acutes• Reimburse primary care practitioners for
provision of LARC in general practice• Locality mapping to drive local planning• Improve access to LARC at Sandyford
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LARC Resource PackThis resource pack is designed to support both CHPs and specialist sexual health services in planning developments and implementation of local LARC (Long Acting Reversible
Contraception) services.
Section 1 – National LARC Policy & Perspective Major documents supporting the rationale of increasing the use of LARC methods will reduce rates of unintended pregnancy in a cost effective manner
Comparative rates of effectiveness of different contraceptive methods
Section 2 – An Overview of LARC Usage Levels at National, Board & CHP LevelAn overview of LARC usage for the national board-wide and CHP perspective including local mapping reports.
Section 3 – LARC Protocols & Guidance DocumentsProtocols and Clinical Guidance documents supporting provision of LARC
GP Contraceptive Prescribing Guidance Faculty of Sexual & Reproductive Healthcare Guidance on LARC
Section 4 – GP Income & Local PaymentsQOF Agreement for LARC 2009/10
Enhanced Service Agreements
Section 5A – LARC TrainingFaculty of Sexual & Reproductive Healthcare training package CDs for fitting Implants, IUD/IUS and EHC provisionn
Faculty Information re obtainment of Letters of Competence Nurse training documentation – RCN & West MCN Guidance, PGDs
Information on how to access training locally through Sandyford
Section 5B – LARC Education Useful websites & online resources
Available meetings & coursesResources available refer to sections 6 & 7
Section 6 – LARC Patient PerspectivePatient/Client perspective
2 Articles from Peer Review Journals (article D Mansour et all European Journal of Contraception 13.4.2008) RAGS article WISH Report
National Sexual Health Awareness Campaign materials
Section 7 – Patient Resources for LARCPatient/Client Information
Information on how to access written leaflets and posters locallyUseful websites
Examples of patient information leaflets (FPA, Health Scotland )Sandyford materials for signposting/referring patients to local services.
Section 8 – Templates & Tools for Local LARC Planning, Audit & Implementation.This section contains some examples of templates that can be adapted and supported at a local CHP level.
Some examples have been included:Needs Assessment Audits
Implementation/Action Plans
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CONTRACEPTIVE PRESCRIBING IN PRIMARY CARE
Patient requests contraception
Take full medical and sexual history Check BP and smear status Offer STI screening Discuss contraceptive choices taking into account the above and
patient preference
Consider long-acting reversible contraception (LARC) as first line option as this is the most effective way to avoid pregnancy
LONG-ACTING REVERSIBLE CONTRACEPTION (LARC)See Nice CG30 (Long-acting Reversible Contraception – Oct 2005)
Progesterone-only implant (Implanon®) - Lasts 3 years Copper IUD (TT380 Slimline®) - Lasts 10 years Progestogen-only IUS (Mirena®) - Lasts 5 years
•Useful if menorrhagia present Progestogen-only depot (Depo-Provera®)
•Given every 12 weeks NB: The effectiveness of LARC preparations containing hormones, such as
Implanon® may be affected by interacting medicines. Refer to individual SPC or BNF for guidance
Consider appropriateness of COC or POP taking into account patients age, medical history, risk factors and patient
preferences
COC appropriatePOP appropriate
Micronor® or Femulen®
Should be considered 1st line POPs
Cerazette® should only be considered in women who cannot tolerate or have contraindications to oestrogen containing contraceptives
Cerazette® may also have advantages in women with a history of poor compliance
1st line choice should be a standard strength 2nd generation such as Microgynon 30® or Loestrin 30®
If patient suffers from acne, consider Marvelon®
Adverse effects, poor cycle control or poor compliance may dictate
further options
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Local Enhanced ServiceNational Enhanced Service
Contraceptive Implant
• In 2009-10 each practice contracted to provide the contraceptive implant service will receive a £25.81 insertion fee and £51.61 removal fee per patient
IUD/IUS
• In 2009-10 each practice contracted to provide the IUD/IUS service will receive a £79.92 insertion fee per patient.
www.sandyford.org
www.sandyford.org
Capturing termination of pregnancy population
• Over 3000 TOPs annually in GGC• Over 1 in 4 are repeat TOP• Two thirds performed medically• Local training programme for gynaecology
nurses to train in implant insertion
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GGC women undergoing MTOP in 2007 and 2010
Contraceptive method chosen at time of assessment clinic in 2007 and 2010
0
5
10
15
20
25
30
35
COCPPOP
Impla
nt
IUD/IU
S
DMPA
Barrie
r
Nil/und
ecide
d
pe
rce
nta
ge
of
all
wo
me
n
% requesting method in 2007 % requesting method in 2010
www.sandyford.org
GGC women undergoing MTOP in 2007 and 2010
Contraceptive method supplied on day of abortion in 2007 and 2010
0
5
10
15
20
25
30
35
40
45
COCPPOP
Impla
nt
IUD/IU
S
DMPA
Barrie
r
Nil/und
ecide
d
pe
rce
nta
ge
of
all
wo
me
n
% supplied with method in 2007 % supplied with method in 2010
www.sandyford.org
MTOP and STOP women
Method of contraception provided on day of TOPJul-Sept 2010 TOPAR clients
0
5
10
15
20
25
30
coc pop depo impl iud ius nil
Method
% % receiving method on day
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Improving access to LARC at Sandyford
• Redesign of Sandyford Central drop-in services Sept 2009
• Increase drop-in registration hours from 2 hour window to 5 hour window
• Offer LARC fitting at drop-in
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• IUD/IUS insertion or reinsertion
– Jan - Aug 09
• 103
– Sept 09 – Feb10
• 152
0
20
40
60
80
100
120
140
160
Insertion only IUD/IUS check Not Recorded Procedure abandoned Removal only Removal/insertion
2009 32009 42009 52009 62009 72009 82009 92009 102009 112009 122010 12010 22010 3
Cou
nt o
f Pro
cedu
res
IUD/IUS Procedure Type by Month
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• Implant insertion or reinsertion– Jan – Aug 09
• 86
– Sept 09 – Feb 10• 180
0
20
40
60
80
100
120
140
160
180
Implant Insertion Implant Removal Implant Removal and Insertion Not Recorded
2009 32009 42009 52009 62009 72009 82009 92009 102009 112009 122010 12010 22010 3
Cou
nt o
f Pro
cedu
res
Implant Procedure Type by Month
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Activity in 2004/05 vs 2009/10 in GGC
1° Care 2°Care Total
Impl 257 1259 1516
IUD/
IUS
1384 2483 3867
vLARC 1641 3742 5383
1° Care 2°Care Total
Impl 2964 7883 10847
IUD/
IUS
1854 8431 10285
vLARC 4818 16314 21132
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5 years on…..Rate per 1000 women
within Scotland
Rate per 1000 women
within GGC
2004/5 23 17
2005/6 30 31
2006/7 34 37
2007/8 41 46
2008/9 47 53
2009/10 57 69
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vLARC rate per 1000 women 2009/10
0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0
Lanarkshire
Fife
Forth Valley
Lothian
Borders
Grampian
Scotland
Tayside
Ayrshire & Arran
Western Isles
Shetland Islands
Highland
Greater Glasgow & Clyde
Dumfries and Galloway
Orkney Islands
NHS board area
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Abortions performed in Scotland, 1968-2009p
-
2 000
4 000
6 000
8 000
10 000
12 000
14 000
16 000
19
68
19
69
19
70
19
71
19
72
19
73
19
74
19
75
19
76
19
77
19
78
19
79
19
80
19
81
19
82
19
83
19
84
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
Year
Nu
mb
er
1 Refers to therapeutic abortions notified in accordance with the Abortion Act 1967. p Provisional.Source : Notifications (to the Chief Medical Officer for Scotland) of abortions performed under the Abortion Act 1967
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Summary• Uptake of LARC in GGC has increased from
17/1000 women to 69/1000 women over 5 years• Increase in uptake in GGC has outperformed
that in Scotland as a whole• A combination of national and local drivers are
likely to have contributed• We did not meet our own target of a 5 fold
increase in uptake in 5 years• But we did meet the essential QIS target of 60
per 1000 women being prescribed LARC