Association of Pharmacist Prescription With Dispensed Duration of Hormonal Contraception.
ABSTRACT: Importance:Since 2016, 11 states have expanded the scope of pharmacists to include direct prescription of hormonal contraception. Dispensing greater than 1 month's supply is associated with improved contraceptive continuation rates and fewer breaks in coverage. Scant data exist on the practice of pharmacist prescription of contraception and its outcomes compared with traditional, clinic-based prescriptions. Objective:To compare the amount of hormonal contraceptive supply dispensed between pharmacists and clinic-based prescriptions. Prescribing patterns were assessed by describing prescribing practices for women with contraindications to combined hormonal contraception. Characteristics of women seeking hormonal contraception directly from pharmacists were also described. Design, Setting, and Participants:This cohort study surveyed women aged 18 to 50 years who presented to pharmacies in California, Colorado, Hawaii, and Oregon for hormonal contraception prescribed by a clinician or a pharmacist between January 30 and November 1, 2019. Exposures:Pharmacist or clinic-based prescription of contraception. Main Outcomes and Measures:Months of contraceptive supply dispensed. Results:Four hundred ten women (mean [SD] age, 27.1 [7.7] years) were recruited who obtained contraception directly from a pharmacist (n?=?144) or by traditional clinician prescription (n?=?266). Women obtaining contraception from a pharmacist were significantly younger (82 [56.9%] vs 115 [43.2%] participants aged 18-24 years; P?=?.03), had less education (38 [26.4%] vs 100 [37.6%] with a bachelor degree; P?=?.002), and were more likely to be uninsured (16 [11.1%] vs 8 [3.0%] participants; P?=?.001) compared with women with a prescription from a clinician. Pharmacists were significantly more likely to prescribe a 6-month or greater supply of contraceptives than clinicians (6.9% vs 1.5%, P?
Project description:The role of pharmacy in healthcare continues to evolve as pharmacists gain increased clinical responsibilities in the United States, such as the opportunity to prescribe hormonal contraception. Currently, North Carolina (NC) pharmacists do not have this ability. While previous research focused on the perceptions of community pharmacists surrounding this practice, no previous research surveyed all pharmacists in a state. This cross-sectional, web-based survey was distributed to all actively licensed pharmacists residing in the state of NC in November 2018. The primary objective was to determine the likelihood of NC community pharmacists to prescribe hormonal contraception. Secondary outcomes included: evaluation of all respondent support and perceptions of this practice as advocacy occurs on the state organization level and unified support is critical; opinions regarding over-the-counter (OTC) status of contraception; and potential barriers to prescribing. Overall, 83% of community pharmacists were likely to prescribe hormonal contraception. No differences in likelihood to prescribe were detected between geographic settings. Community pharmacists reported that the most common barriers to impact prescribing were added responsibility and liability (69.8%) and time constraints (67.2%). Fewer than 10% of respondents felt that hormonal contraception should be classified as OTC (7.9%). Noncommunity pharmacists were significantly more likely to agree that prescribing hormonal contraception allows pharmacists to practice at a higher level, that increased access to hormonal contraception is an important public health issue, and that rural areas would benefit from pharmacist-prescribed hormonal contraception. Overall, this study found a willingness to prescribe and support from the majority of both community and noncommunity pharmacists. Limitations of the study included a low response rate and potential nonresponse bias. Future research is needed to address solutions to potential barriers and uptake of this practice, if implemented.
Project description:Background:Hormonal contraceptive pills have evolved as a common form of contraception worldwide. Pharmacists play a vital role in providing safe and effective access to these medicines. In many developing countries such as the United Arab Emirates (UAE), these medicines are available to the general public without the presentation of a prescription which requires the pharmacist to shoulder responsibility by assessing and educating patients to assure their appropriate use. Objectives:To evaluate community pharmacists' current practice of dispensing and counseling on hormonal contraceptives. Methods:Simulated patient methodology was used in this study. A single simulated patient visited community pharmacies requesting an oral contraceptive as per a preplanned scenario. Information from the visits were recorded on a data collection form including: pharmacist assessing patient eligibility to take hormonal contraceptives, selecting the appropriate oral contraceptive, providing complete counseling on how to use the pill, adherence, missed dose handlings and side effects of the medication. The Pharmacist was prompted by the simulated patient to provide the information if they did not provide spontaneous counseling. The quality of pharmacists' counseling was rated and consequently coded as complete, incomplete or poor. Results:A total of 201 community pharmacies were visited. More than 92% of the pharmacists did not ask the simulated patient any question to assess their eligibility to use contraceptives. Twenty three pharmacists (11.4%) selected the proper product. One hundred seventeen (58.2%) of the pharmacists provided spontaneous counseling on how to use the pill, 17 of them had their counsel rated as complete, but none of the pharmacists provided spontaneous counseling regarding adherence or side effects of the medications. On prompting, 10 pharmacists (12%) provided complete counseling regarding how to use oral contraceptives, 14 pharmacists (7.0%) provided complete counseling on adherence and missing dose handling and five pharmacists (2.5%) provided complete counseling about expected side effects. Conclusions:Pharmacists' practice regarding hormonal contraceptive dispensing and counseling was suboptimal in this study. Areas needing intervention were related to pharmacist assessment of eligibility for oral contraceptive use, choice of optimal oral contraceptive for patient-specific co-morbidities and provision of adequate counseling regarding proper use, adherence and missed dose handlings.
Project description:The oral contraceptive pill (OCP) remains the most popular form of prescription contraception in many countries, despite adherence difficulties for many. Uptake of long acting reversible contraceptives (LARCs), which are less reliant on user adherence, remains low. The aim of this study was to explore the experiences of, and attitudes towards, prescription contraception amongst samples of contraception users, general practitioners (GPs) and pharmacists.We conducted a qualitative study using semi-structured interviews with 18 contraception users, 18 GPs and 9 pharmacists. The study took place in Galway, Republic of Ireland between June and September 2014. Thematic analysis was used to analyse the data. Overall, contraception users were more familiar with the OCP, and all the women interviewed began their prescription contraception journey using this method. All participants identified episodes of poor adherence throughout the reproductive life course. The identified barriers for use of LARCs were lack of information, misconceptions, lack of access and high cost. In contrast, GPs believed that adherence to the OCP was good and stated they were more likely to prescribe the OCP than other methods, as they were most familiar with this option. Barriers to prescribing LARCSs were time, cost to practice, training and deskilling. Pharmacists also believed that adherence to the OCP was generally good and that their role was limited to dispensing medication and providing information when asked.There are contrasting perspectives between contraception service providers and contraceptive users. Training for healthcare providers is required to support informed contraceptive choice and adherence. It is necessary to address the practice barriers of cost and lack of time, to promote better communication around adherence issues and prescription contraception options. There is a need for more easily-accessible public health information to promote awareness on all methods of prescription contraception.
Project description:BACKGROUND:Unless women start effective contraception after oral emergency contraception, they remain at risk of unintended pregnancy. Most women in the UK obtain emergency contraception from community pharmacies. We hypothesised that pharmacist provision of the progestogen-only pill as a bridging interim method of contraception with emergency contraception plus an invitation to a sexual and reproductive health clinic, in which all methods of contraception are available, would result in increased subsequent use of effective contraception. METHODS:We did a pragmatic cluster-randomised crossover trial in 29 UK pharmacies among women receiving levonorgestrel emergency contraception. Women aged 16 years or older, not already using hormonal contraception, not on medication that could interfere with the progestogen-only pill, and willing to give contact details for follow-up were invited to participate. In the intervention group, women received a 3-month supply of the progestogen-only pill (75 ?g desogestrel) plus a rapid access card to a participating sexual and reproductive health clinic. In the control group, pharmacists advised women to attend their usual contraceptive provider. The order in which each pharmacy provided the intervention or control was randomly assigned using a computer software algorithm. The primary outcome was the use of effective contraception (hormonal or intrauterine) at 4 months. This study is registered, ISRCTN70616901 (complete). FINDINGS:Between Dec 19, 2017, and June 26, 2019, 636 women were recruited to the intervention group (316 [49·6%], mean age 22·7 years [SD 5·7]) or the control group (320 [50·3%], 22·6 years [5·1]). Three women (one in the intervention group and two in the control group) were excluded after randomisation. 4-month follow-up data were available for 406 (64%) participants, 25 were lost to follow-up, and two participants no longer wanted to participate in the study. The proportion of women using effective contraception was 20·1% greater (95% CI 5·2-35·0) in the intervention group (mean 58·4%, 48·6-68·2), than in the control group (mean 40·5%, 29·7-51·3 [adjusted for recruitment period, treatment group, and centre]; p=0·011).The difference remained significant after adjusting for age, current sexual relationship, and history of effective contraception use, and was robust to the effect of missing data (assuming missingness at random). No serious adverse events occurred. INTERPRETATION:Provision of a supply of the progestogen-only pill with emergency contraception from a community pharmacist, along with an invitation to a sexual and reproductive health clinic, results in a clinically meaningful increase in subsequent use of effective contraception. Widely implemented, this practice could prevent unintended pregnancies after use of emergency contraception. FUNDING:National Institute for Health Research (Health Technology Assessment Programme project 15/113/01).
Project description:INTRODUCTION:Oral emergency contraception (EC) can prevent unintended pregnancy but it is important to start a regular method of contraception. Women in the UK usually access EC from a pharmacy but then need a subsequent appointment with a general practitioner or a sexual and reproductive health (SRH) service to access regular contraception. Unintended pregnancies can occur during this time. METHODS AND ANALYSIS:Bridge-It is a pragmatic cluster randomised cohort cross-over trial designed to determine whether pharmacist provision of a bridging supply of a progestogen-only pill (POP) plus rapid access to a local SRH clinic, results in increased uptake of effective contraception and prevents more unintended pregnancies than provision of EC alone. Bridge-It involves 31 pharmacies in three UK regions (London, Lothian and Tayside) aiming to recruit 626-737 women. Pharmacies will give EC (levonorgestrel) according to normal practice and recruit women to both intervention and the control phases of the study. In the intervention phase, pharmacists will provide the POP (desogestrel) and offer rapid access to an SRH clinic. In the control phase, pharmacists will advise women to attend a contraceptive provider for contraception (standard care).Women will be asked 4?months later about contraceptive use. Data linkage to abortion registries will provide abortion rates over 12 months. The sample size is calculated on the primary outcome of effective contraception use at 4?months (yes/no) with 90% power and a 5% level of significance. Abortion rates will be an exploratory secondary analysis. Process evaluation includes interviews with pharmacists, SRH clinicians and women. Cost-effectiveness analysis will use a healthcare system perspective and be expressed as incremental cost-effectiveness ratio. ETHICS AND DISSEMINATION:Ethical approval was received from South East Scotland REC June 2017. Results will be published in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER:ISRCTN70616901.
Project description:OBJECTIVE:To evaluate the potential for a clinically relevant drug-drug interaction with concomitant use of a dapivirine vaginal ring, a novel antiretroviral-based HIV-1 prevention strategy, and hormonal contraception by examining contraceptive efficacies with and without dapivirine ring use. DESIGN:A secondary analysis of women participating in MTN-020/ASPIRE, a randomized, double-blind, placebo-controlled trial of the dapivirine vaginal ring for HIV-1 prevention. METHODS:Use of a highly effective method of contraception was an eligibility criterion for study participation. Urine pregnancy tests were performed monthly. Pregnancy incidence by arm was calculated separately for each hormonal contraceptive method and compared using an Andersen-Gill proportional hazards model stratified by site and censored at HIV-1 infection. RESULTS:Of 2629 women enrolled, 2310 women returned for follow-up and reported using a hormonal contraceptive method at any point during study participation (1139 in the dapivirine arm and 1171 in the placebo arm). Pregnancy incidence in the dapivirine arm versus placebo among women using injectable depot medroxyprogesterone acetate was 0.43% vs. 0.54%, among women using injectable norethisterone enanthate was 1.15% vs. 0%, among women using hormonal implants was 0.22% vs. 0.69%, and among women using oral contraceptive pills was 32.26% vs. 28.01%. Pregnancy incidence did not differ by study arm for any of the hormonal contraceptive methods. CONCLUSIONS:Use of the dapivirine ring does not reduce the effectiveness of hormonal contraceptives for pregnancy prevention. Oral contraceptive pill use was associated with high pregnancy incidence, potentially because of poor pill adherence. Injectable and implantable methods were highly effective in preventing pregnancy.
Project description:IMPORTANCE:The association between the use of hormonal contraceptive and pancreatic cancer among premenopausal women has until now been unclear. This is the first study to investigate the risk of pancreatic cancer in pre-menopausal women. OBJECTIVE:To determine whether hormonal contraception increases the risk of developing pancreatic cancer in pre-menopausal women. DESIGN:A nationwide prospective cohort study followed all women in Denmark in the age range of 15-49 years without previous cancer or venous thrombosis from 1995 to 2014. The Danish National Prescription Registry provided individually updated exposure information on use of hormonal contraception. The Danish Cancer Registry provided cancer diagnoses, and the Danish National Patient Register containing clinical diagnoses and surgical codes at discharge from public and private hospitals. SETTING:Population-based cohort study. PARTICIPANTS:All women living in Denmark aged 15-49 years at January 1st, 1995, and those subsequently reaching age 15 years up to December 31st, 2014 were eligible for the study. RESULTS:Among 1.9 million women who were followed on average for 11.4 years, 235 pancreatic cancers occurred. Compared to never users, ever users of any type of hormonal contraception had a relative risk (RR) of pancreatic cancer of 0.90 (95% confidence interval (CI) 0.68-1.19). No overall association between duration of hormonal contraceptive use and pancreatic cancer risk was found. Neither was long-term use of hormonal contraception associated with pancreas cancer, RR 0.83 (95% CI 0.47-1.50). The risk did not vary between users of combined and progestogen-only products. All models were adjusted for age, completed or ongoing education, polycystic ovary syndrome, endometriosis and among parous women; parity, age at first birth, smoking and body mass index. CONCLUSIONS AND RELEVANCE:Compared to never users the risk of pancreatic cancer is not significantly higher among current and recent users of contemporary hormonal contraception and does not vary between users of combined and progestogen-only products. In conclusion, our study suggests no risk of pancreatic cancer with use of any type of hormonal contraception.
Project description:OBJECTIVES:In the United States, 45% of pregnancies continue to be unintended. Although many previous studies have focused on external barriers to contraceptive use such as cost or access, fewer studies have evaluated internal barriers such as individual characteristics. We hypothesize that high self-efficacy for contraception will be associated with use of more effective contraceptive methods. STUDY DESIGN:The analytic sample is 861 privately insured Pennsylvania women aged 18 to 40 years not intending pregnancy for 12 months at enrollment. Contraceptive self-efficacy (high vs. low) was measured using an eight-item scale. The association of self-efficacy with prescription contraceptive use was determined using multivariable logistic regression adjusting for future pregnancy intention, history of unintended pregnancy, number of live births, non-White race, frequency of sexual intercourse, marital status, and age group. RESULTS:Prescription contraceptive use was higher among those with high self-efficacy (adjusted odds ratio, 1.75; 95% confidence interval, 1.29-2.37). CONCLUSIONS:Women with high self-efficacy for contraception had an increased use of prescription contraceptive methods compared with nonprescription methods. Strategies for encouraging effective contraceptive choices in women with low contraceptive self-efficacy should be further studied.
Project description:OBJECTIVE:The effects of sex hormones on the immune defenses of the female genital mucosa and its susceptibility to infections are poorly understood. The injectable hormonal contraceptive depot medroxyprogesterone acetate (DMPA) may increase the risk for HIV-1 acquisition. We assessed the local concentration in the female genital mucosa of cationic polypeptides with reported antiviral activity in relation to DMPA use. METHODS:HIV-1-uninfected women were recruited from among couples testing for HIV in Nairobi, Kenya. Cervicovaginal secretion samples were collected, and the concentrations of HNP1-3, LL-37, lactoferrin, HBD-2, and SLPI were measured by enzyme-linked immunosorbent assays. Levels of cationic polypeptides in cervicovaginal secretions were compared between women who were not using hormonal contraception and those using DMPA, oral, or implantable contraception. RESULTS:Among 228 women, 165 (72%) reported not using hormonal contraception at enrollment, 41 (18%) used DMPA, 16 (7%) used an oral contraceptive, and 6 (3%) used a contraceptive implant. Compared with nonusers of hormonal contraception, DMPA users had significantly higher mean levels of HNP1-3 (2.38 vs. 2.04 log?? ng/mL; P = 0.024), LL-37 (0.81 vs. 0.40 log10 ng/mL; P = 0.027), and lactoferrin (3.03 vs. 2.60 log?? ng/mL; P = 0.002), whereas SLPI and HBD-2 were similar. CONCLUSIONS:Although all analyzed cationic polypeptides have intrinsic antiviral capacity, their interaction and cumulative effect on female genital mucosa susceptibility to infections in vivo has yet to be unraveled. This study suggests a potential mechanism underlying the effect of DMPA on the innate immune defenses, providing a rationale to investigate its effect on HIV-1 acquisition risk.
Project description:The majority of women prescribed category D or X medications may not receive adequate contraceptive counseling or a reliable contraceptive method. Physicians who prescribe potentially teratogenic medications have a responsibility to provide women with contraceptive counseling, a method of highly-effective contraception, or both.Investigate the knowledge, beliefs and barriers of primary care physicians toward providing adequate contraception to women taking potential teratogens.Self-administered confidential survey of primary care internal medicine physicians at an urban, academic medical center.Knowledge of potential teratogenic medications and contraceptive failure rates was assessed. Participants' beliefs about adequacy of their medical education, practice limitations and attitudes toward improving provision of contraception to women on potential teratogens were assessed.One hundred and ten physicians responded (57.3%). Nearly two-thirds (62.3%) of participants had cared for reproductive aged women taking category D or X medications in the past year. The mean percent of correctly identified category D or X medications was 58.4% (SD 22.1%). The mean percent correct for knowledge of published contraceptive failure rates was 64.6% (SD 23.1%). Most respondents (87.6%) felt it is the responsibility of primary care physicians to provide contraception. Time constraints were reported to be somewhat or very limiting by 61.3% and over half felt medical school (63.2%) or residency (58.1%) inadequately prepared them to prescribe or counsel about contraceptives.Primary care physicians commonly encounter reproductive age women taking category D or X medications, but may lack sufficient knowledge and time to counsel about potential teratogens and contraception to prevent fetal exposure to these drugs.