Promoting Safe Prescribing in Primary Care With a Contraceptive Vital Sign: A Cluster-Randomized Controlled Trial

Article (PDF Available)inThe Annals of Family Medicine 10(6):516-522 · November 2012with16 Reads
DOI: 10.1370/afm.1404 · Source: PubMed
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.
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VOL. 10, NO. 6
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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 contracep-
tive use—a so-called contraceptive vital sign—may help primary care physicians
identify patients who need preconception or contraceptive counseling and be of
particular bene t 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 contracep-
tive use and change in primary care physicians’ provision of family planning ser-
vices. 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% con dence interval [CI], 70.7 to 84.1) adjusted percent-
age 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 poten-
tial teratogens, only 7% were provided family planning services.
CONCLUSIONS A contraceptive vital sign improves documentation of contracep-
tive use; however, ongoing efforts are needed to improve provision of precon-
ception and contraceptive services.
Ann Fam Med 2012;10:516-522. doi:10.1370/afm.1404.
INTRODUCTION
W
omen whose medical condition or medication use may increase
the risk of adverse pregnancy outcomes need preconception
guidance and contraceptive counseling to reduce the risk of unin-
tended pregnancy and optimize pregnancy timing. One-half of US pregnan-
cies remain unintended,
1
however, and family planning services are provided
during only 5% to 20% of visits made by women prescribed potentially tera-
togenic medications.
2
As a result, approximately 6% of US pregnancies are
exposed to potentially teratogenic class D or X medications.
3
As the majority of potentially teratogenic medications are prescribed
by primary care physicians,
2,4
there is a particular need for these physi-
cians to provide preconception and contraceptive counseling. Primary care
physicians have reported that one barrier to safe prescribing to women of
Eleanor Bimla Schwarz, MD, MS
Sara M. Parisi, MS, MPH
Sanithia L. Williams, BS
Grant J. Shevchik, MD
Rachel Hess, MD, MS
University of Pittsburgh, Pittsburgh,
Pennsylvania
Confl icts of interest: authors report none.
CORRESPONDING AUTHOR
Eleanor Bimla Schwarz, MD, MS
Department of Medicine
University of Pittsburgh
230 McKee Pl, Ste 600
Pittsburgh, PA 15213
schwarzeb@upmc.edu
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reproductive age is dif culty ascertaining their preg-
nancy intentions, and they have expressed interest
in strategies for routinely assessing chance of preg-
nancy.
5,6
Obtaining a so-called contraceptive vital sign,
similar to efforts to assess pain as a vital sign,
7, 8
could
help prompt preconception counseling.
In this study, we evaluated the feasibility and
ef cacy of this type of routine intake assessment of
women’s pregnancy intentions and contraceptive use
on the documentation of contraception and primary
care physicians’ provision of family planning services.
We hypothesized that a contraceptive vital sign would
increase documentation of contraception and increase
provision of family planning services, especially for
women prescribed potentially teratogenic medications.
METHODS
Setting and Participants
We conducted a cluster-randomized trial between Octo-
ber 2008 and April 2010 to evaluate the introduction of
a contraceptive vital sign in a large, academic general
internal medicine practice that has collected patient-
entered intake information (eg, alcohol use, physical
activity, last menstrual period) using wirelessly net-
worked tablet computers since 2004. These computers
use branched logic to select appropriate intake questions
for each patient. The computer synthesizes and formats
the information into a paper report for physicians.
9,10
All
primary care physicians at this practice were invited to
participate. As this practice is a residency training site,
participating physicians were both residents and super-
vising physicians. This study was approved by the Uni-
versity of Pittsburgh Institutional Review Board.
Intervention Design
Physicians were randomized to an intervention group
or control group. When female patients aged 18 to 50
years were scheduled to see intervention physicians,
a pair of questions asking about pregnancy intentions
and recent contraceptive usethe contraceptive vital
sign—were added to their intake questionnaire. Spe-
cifi cally, they were asked “Are you currently pregnant
or trying to become pregnant?” and provided with 6
response options: “no,”not trying to get pregnant but
wouldn’t mind being pregnant,” “trying to get preg-
nant,” “currently pregnant,” “been through menopause,”
and “prefer not to answer.” Women who responded
either “no” or “not trying to get pregnant” were then
asked: “There are many ways that people try to avoid
becoming pregnant. Which are you using?” and were
provided with a list of contraceptive methods. Response
options included “no method of birth control,” “not
sexually active with men in the past 3 months,” and
“prefer not to answer.” If a patient reported that she was
pregnant, trying to become pregnant, wouldn’t mind
becoming pregnant, or trying to avoid pregnancy but
not using any contraception, the intake report provided
to physicians included the warning statement “Consider
chance of pregnancy when prescribing” in bold text,
unless the woman responded that she had not had sex
within the past 3 months. The decision to consider
women abstinent for 3 months as at low risk of preg-
nancy refl ected the majority opinion of this practice’s
clinicians. Patients previously indicating that they were
menopausal or had undergone hysterectomy or tubal
ligation were not asked the questions. Also, because of
a programming error, women making annual preventive
visits were not asked the questions.
Patients seeing control physicians were asked only
the standard intake questions. This study was con-
ducted in conjunction with the introduction of clinical
decision support integrated into the clinic’s electronic
health record (EHR), which alerted physicians when
they initiated a prescription for a potentially terato-
genic medication.
Data Collection
We reviewed deidenti ed EHR data from all visits by
women aged 18 to 50 years who started to complete
a computerized intake questionnaire during a baseline
period (May 2007-September 2008) and the interven-
tion period (October 2008-April 2010). Abstracted data
included evidence of new contraceptive prescriptions;
referrals for placement of an intrauterine contraceptive,
contraceptive implant, or diaphragm; contraceptive
counseling received within the past 3 months; prior
contraceptive prescriptions or devices that were still
active; pregnancy tests; potentially teratogenic medica-
tions prescribed at the visit; type of clinical encounter
(new vs return, usual physician vs other); and patients’
age, race, and marital status. Responses to the contra-
ceptive vital sign questions were extracted from the
tablet computers and linked to EHR data by an honest
broker. We eliminated all visits with evidence of steril-
ization, menopause, or infertility, as well as all annual
preventive visits, which did not receive the intervention
as planned. Additionally, because the intake system pro-
vides physicians with information patients have given
at previous visits, in a small number of cases, control
physicians inadvertently received contraceptive vital
sign information from previous visits with intervention
physicians; we also eliminated these “crossover” visits.
Statistical Analysis
Intervention and control physicians were compared
using χ
2
tests and Wilcoxon rank sum tests, and the
characteristics of visits made to the 2 groups during
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the baseline period were compared using mixed-effects
models with random effects to address clustering by
physician and patient. We calculated the response rate
and range of responses to each of the contraceptive
vital sign questions. We calculated the proportion
of visits in each study group with documentation of
contraception, overall and for the subgroup of visits
involving the prescription of a potential teratogen, at
baseline and during the intervention.
To test whether there was signifi cantly different
change in documentation in the intervention group, we
constructed visit-level generalized linear mixed-effects
models with a repeated time measure adjusting for visit
characteristics including patient characteristics (aged
≥30 years, married, white), and physician characteris-
tics (sex, resident, receipt of clinical decision support
when prescribing a potential teratogen). The models
contained an interaction term to test whether changes
over time differed signi cantly between groups.
11
Using
nearly identical models, we also investigated whether
the contraceptive vital sign affected the rate of pre-
scription of potentially teratogenic
medications and provision of new
family planning services (ie, new
contraception prescriptions, contra-
ceptive counseling, pregnancy test-
ing, or referral to a family planning
specialist). Models predicting docu-
mentation of contraception included
a random effect for patients only, as
this information was collected before
seeing the physician. Models predict-
ing physician prescribing and coun-
seling behavior included a random
effect for physician only, as models
containing crossed random effects
for physicians and patients would
not converge. We also tested models
adjusting only for patient clustering,
but the difference between the mod-
els was not appreciable.
From each model, we estimated
the adjusted absolute change in the
outcome over time and the 95% con-
dence interval (CI) (holding covari-
ates at their grand means). Finally, we
calculated the residual intraclass cor-
relation coef cient (ICC) for provi-
sion of teratogenic prescriptions and
family planning services.
12
Community-Based Extension
As an extension of this trial, we pilot
tested the use of a similar intake
system in a community-based family practice. Given
the smaller number of primary care physicians in this
practice (N = 13), implementation was not randomized
by physician; rather, the front desk staff randomly
requested that 10% of women use the new intake sys-
tem. We therefore compared rates of potentially terato-
genic prescriptions among women who were and were
not asked to provide the contraceptive vital sign and
investigated whether provision of new family planning
services when potential teratogens were prescribed was
higher among visits involving the contraceptive vital
sign.
All analyses were conducted using Stata version 11
IC (StataCorp LP); P values less than .05 were consid-
ered signifi cant.
RESULTS
Figure 1 shows the fl ow of participating primary care
physicians and visits. We abstracted data from 11,621
visits. We eliminated 1,834 visits with women who
Figure 1. Flow diagram describing physician clusters and patient
encounters from the time of recruitment to analysis.
69 Physicians in 1 primary care
practice invited to participate
58 Physicians agreed to par-
ticipate and were randomized
29 Physicians in control
group (standard intake only)
29 Physicians in intervention
group (standard intake +
contraceptive vital sign)
2 Excluded from analysis:
2 Contributed no visits
during baseline period
3 Excluded from analysis:
1 Left practice before inter-
vention period
1 Contributed no visits dur-
ing baseline period
1 Contributed no visits dur-
ing intervention period
27 Physician clusters analyzed
(median number of encounters per
physician, 65; range: 1-697)
3,782 Visits by fertile female patients
aged 18-50 years who initiated intake
questionnaire (1,705 during baseline
period, 2,077 during study period)
26 Physician clusters analyzed
(median number of encounters per
physician, 22; range: 1-241)
1,589 Visits by fertile female patients
aged 18-50 years who initiated intake
questionnaire (773 during baseline
period, 816 during study period)
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had evidence of sterilization, menopause, or infertility
(16% of all visits; 22% of visits with a potentially tera-
togenic prescription). We also eliminated 158 visits in
which a control physician inad-
vertently received contraceptive
vital sign information entered on
a previous visit and 4,258 annual
preventive visits, leaving 5,371
visits made by 2,304 unique
women. There were no sig-
nifi cant differences in physician
characteristics between groups
(Table 1).
Feasibility and Acceptability
of the Intervention
During the 816 visits in which
women were asked the contra-
ceptive vital sign questions, 93%
provided answers. The remaining
7% either skipped the question or
did not fi nish the questionnaire.
In total, intervention physicians
were notifi ed to “consider chance
of pregnancy when prescribing”
in 13.5% of visits (110 of 816) in
which contraceptive vital sign
data were collected. Responses to
the contraceptive vital sign ques-
tions are given in Table 2.
Ef cacy of the Intervention
Figure 2 displays the proportion
of visits with documented use of
contraception before and dur-
ing the intervention period, for
all visits as well as the subgroup
of visits with a potentially tera-
togenic prescription. There was
signifi cantly greater improvement
in documentation in the interven-
tion group compared with the
control group: +77.4 (95% CI,
70.7 to 84.1) adjusted percent-
age points in the former vs +3.1
(95% CI, 1.2 to 5.0) in the lat-
ter (P <.001). A similar increase
was seen among visits with a
teratogenic prescription: +61.5
(95% CI, 35.8 to 87.1) adjusted
percentage points vs –0.3 (95%
CI, –4.3 to 3.6; P <.001). The
contraceptive vital sign increased
documentation of use of hor-
monal or more effective methods (ie, intrauterine
devices, implants, and vasectomies), as well as barrier
methods. It also provided additional information about
Table 1. Baseline Characteristics of Participating General Internal
Medicine Physicians and Visits
Characteristic Control Intervention P Value
a
Physicians n = 27 n = 26
Female, No. (%) 17 (63) 14 (54) .50
Resident, No. (%) 11 (41) 13 (50) .50
Study visits
b
per physician, median (IQR), No. 65 (126) 22 (68) .13
Study patients
b
per physician, median (IQR)
No.
52 (88) 14.5 (38) .10
Visits with study physicians n = 1,705 n = 773
Patient age, mean (SD), y 32.6 (8.2) 34.7 (8.4) .82
≥30 years of age, No. (%) 999 (58.6) 545 (70.5) .74
Married,No. (%)
c
546 (33.2) 261 (34.1) .83
White, No. (%) 1,300 (76.2) 555 (71.8) .86
Visit with patient’s usual physician, No. (%) 1,284 (75.3) 571 (73.9) .90
New patient visit, No. (%) 35 (2.1) 22 (2.8) .81
Visit with a female doctor, No. (%) 1,389 (81.5) 404 (52.3) .67
Visit with a resident, No. (%) 65 (3.8) 51 (6.6) .79
Involved prescription of a potential teratogen,
No. (%)
313 (18.4) 104 (13.5) .08
IQR = interquartile range.
a
P values for comparison of physician characteristics are from χ
2
and Wilcoxon rank sum tests. P values for
comparison of visit characteristics are from unadjusted logistic models including physician and patient as
crossed random effects.
b
Fertile women aged 18 to 50 years who initiated the computerized intake questionnaire.
c
For this characteristic, Control n = 1,644 and Intervention n = 765 because of missing data.
Table 2. Responses to the Contraceptive Vital Sign Questions
Question and Responses
General Internal
Medicine Practice,
No. (%)
Family Medicine
Practice,
No. (%)
Are you currently pregnant or trying
to become pregnant?
n = 758 n = 941
No, and not trying to get pregnant 699 (92.2) 849 (90.2)
Not trying, but wouldn’t mind being pregnant 47 (6.2) 34 (3.6)
Trying to get pregnant 2 (0.3) 28 (3.0)
Currently pregnant 3 (0.4) 20 (2.1)
Prefer not to answer 5 (0.7) 10 (1.1)
There are many ways that people try
to avoid becoming pregnant. Which
are you using?
n = 746
a
n = 849
b
Using contraception 392 (52.5) 567 (66.8)
Barrier or behavioral contraception 139 (18.6) 171 (20.1)
Pill, patch, or ring 169 (22.7) 296 (34.9)
Intrauterine or subdermal contraception 52 (7.0) 21 (2.5)
Partner’s vasectomy 32 (4.3) 79 (9.3)
Sexually active without contraception 87 (11.7) 119 (14.0)
Not sexually active with man in the last
3 months
220 (29.5) 84 (9.9)
Prefer not to answer 47 (6.3) 79 (9.3)
a
Asked only of women who responded to the  rst question with “not trying to get pregnant” or “not trying,
but wouldn’t mind being pregnant.”
b
Asked only of women who responded to the  rst question with “not trying to get pregnant.
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which women had not been sexually active in the past
3 months.
At baseline, 14% of intervention visits and 18% of
control visits included prescriptions for potentially
teratogenic medications (P <.01). After introduction of
the contraceptive vital sign, there was little change in
the rate of teratogenic prescriptions for either group:
+2.6 (95% CI, –0.8 to +6.0) adjusted percentage points
in the intervention group vs –0.4 (95% CI, –3.0 to
+2.0) in the control group (P = .1). At baseline, family
planning services were provided at 9% of intervention
visits and 11% of control visits (P = 1.0). After introduc-
tion of the contraceptive vital sign, intervention physi-
cians were not signifi cantly more likely to provide new
family planning services than control physicians: +0.3
(95% CI, –2.8 to 3.3) vs1.4 (95% CI, –3.3 to 0.4)
adjusted percentage points (P = .3). The ICC was 0.01
(95% CI, –0.01 to 0.03) for potentially teratogenic pre-
scriptions and 0.03 (95% CI, 0.002 to 0.048) for family
planning services.
Among the visits with potentially teratogenic
prescriptions, at baseline, family planning services
were provided at 7% of intervention visits and 12% of
control visits (P = .7). Again, however, there was only
minimal increase in provision of new family planning
services by intervention physicians: +3.3 (95% CI, –5.4
to 12.0) adjusted percentage points in the interven-
tion group vs –1.7 (95% CI, –6.6 to 3.3) in the control
group (P = .3). The ICC for family planning services
was less than 0.001 (95% CI, –0.02 to 0.02) in this sub-
group of visits with prescription of potential teratogens.
Of the 133 visits to intervention physicians dur-
ing the study period that involved prescription of a
potential teratogen, 17% still had no documentation of
the patient’s contraceptive status (either because they
did not complete the contraceptive vital sign questions
[9%] or responded “prefer not to answer” [8%]), and
11% had documentation of nonuse of contraception.
Of the 14 visits with documentation of contraceptive
nonuse, only 1 (7%) received a referral for family plan-
ning services; none received pregnancy testing or a
new contraceptive prescription.
At the community-based family practice, new fam-
ily planning services were provided during 9% of visits,
whether or not contraceptive vital sign data were col-
lected. Visits with contraceptive vital sign data were
signifi cantly less likely to include prescriptions for
teratogenic medications: –3.8 (95% CI, –7.1 to –0.3)
adjusted percentage points (P = .03). But visits with
potential teratogens were not more likely to include
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 prescrip-
tion of potentially teratogenic medications (P <.001). Hormonal or more effective methods = pill, patch, ring, injection, intrauterine devices, subdermal contraceptive
implants, and vasectomies. Women who had been sterilized were excluded. Not sexually active = women who reported no sex with a man in past 3 months.
Visits With Prescription
of Potential Teratogen
% of Visits
0
20
40
60
80
0
20
40
60
80
Baseline Study Period Baseline Study Period Baseline Study Period Baseline Study Period
All Visits Visits With Prescription
of Potential Teratogen
All Visits
Control Intervention
28.3
27.8
28.8
25.5
23.4
78.4
56.5
14.1
48.1
72.9
Hormonal or more effective methods Barrier methods Not sexually active
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provision of new family planning services when con-
traceptive vital sign data were collected: –3.2 (95% CI,
6.3 to –0.1) adjusted percentage points (P = .04).
DISCUSSION
This study found that routine collection of contracep-
tive vital sign data was acceptable to the large majority
of women served by 2 primary care practices and sig-
nifi cantly improved documentation of contraception.
The intervention had minimal impact on documented
provision of family planning services, however, and a
substantial number of patients prescribed potentially
teratogenic medications were found to remain at risk
for unintended pregnancy. Although the intervention
was designed to limit primary care physicians’ liability
when a potential teratogen was prescribed, it may have
inadvertently increased liability when contraceptive
nonuse was explicitly documented alongside a poten-
tially teratogenic prescription.
This randomized intervention took place in an aca-
demic general internal medicine practice that trains res-
idents and has established an effi cient electronic intake
system. These fi ndings thus may not be generalizable to
all primary care settings; however, results from our pilot
study in a community-based family practice were simi-
lar. Compared with general internists, family physicians
see a larger proportion of female patients of repro-
ductive age,
2,13
receive more training in reproductive
health, and report being more comfortable providing
routine gynecologic care and initiating contracep-
tion.
14
Nationally, family physicians tend to provide
contraceptive counseling more frequently than general
internists (10.2% of visits to former vs 6.4% of visits to
latter).
2
Family physicians are somewhat less likely to
prescribe potentially teratogenic medications (6.4% vs
8.0% of visits).
2
Nonetheless, provision of appropriate
counseling when teratogenic medications are prescribed
remains a considerable challenge for both family physi-
cians and general internists, as primary care physicians
generally have lower levels of contraceptive knowledge
than gynecologists.
15-17
Recently an extensive educational intervention was
shown to increase family practice residents’ documen-
tation of contraceptive counseling when prescribing
teratogenic medications from 20% to 37%.
18
In a similar
study, documentation of contraceptive counseling rose
from 46% to 80% of family practice visits involving a
teratogenic medication,
19
although the authors were
unable to be certain that this was the result of their
intervention as documentation of contraception had
been rising before the intervention and there was no
control group. A major strength of our study is its
randomized controlled design. Also, although it took
place in a practice that uses an electronic intake system,
contraceptive vital sign data could easily be assessed by
nursing staff or using a paper intake system.
As primary care physicians frequently discuss con-
traception during annual preventive visits, it is unfor-
tunate that a programming error excluded these visits
from our study, and the fi nal sample size was smaller
than intended. With only 110 visits that included a
warning message, we had limited power to detect sig-
nifi cant improvement in physician behaviors. Although
the majority of clinicians in the study clinic felt that
women who had not been sexually active in the last 3
months were at low risk for pregnancy, some of these
women may have resumed sexual activity after fi lling a
teratogenic prescription and might have benefi ted from
contraceptive counseling. As more than one-third of
women see both a primary care physician and gyne-
cologist,
20
we would have liked to ask women if they
wanted to discuss birth control with their primary care
physician; however, concerns about the length of the
intake questionnaire precluded the addition of more
than the 2 questions we studied at this time. Addition-
ally, as primary care physicians have little incentive to
code for provision of counseling services and we did
not review physician notes from these visits, physicians
likely provided preconception and contraceptive coun-
seling more often than is refl ected in the EHR data.
A study by Gilchrist et al
21
suggests that 71% of visits
wherein contraceptive counseling occurs lack docu-
mentation of this counseling. As some physicians who
felt pressured for time may have planned to provide
such counseling at a follow-up visit, the fact that we
examined data from only 1 visit may underestimate the
interventions true effect. Additionally, we have no way
of verifying that physicians in either the general medi-
cine or family practice reviewed the contraceptive vital
sign data that was provided, as they were not instructed
to look for it or to document counseling in the EHR.
In conclusion, a contraceptive vital sign improves
primary care documentation of pregnancy intentions
and contraception in a manner that is acceptable to
patients. Prior research indicates that women prescribed
teratogenic medications prefer to hear about the risks of
these medications directly from their prescribing physi-
cian,
22
and provision of contraceptive counseling in pri-
mary care has been associated with increased likelihood
of contraceptive use.
23
Ongoing efforts are needed,
however, to ensure that primary care patients receive
preconception counseling and family planning services,
and that the provision of these services is documented
in the EHR, particularly when potentially teratogenic
medications are prescribed.
To read or post commentaries in response to this article, see it
online at http://www.annfammed.org/content/10/6/516.
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CONTRACEPTIVE VITAL SIGN FOR SAFE PRESCRIBING
Key words: preconception care; contraception; primary healthcare;
teratogens; health services research
Submitted August 24, 2011; submitted, revised, December 21, 2011;
accepted February 22, 2012.
Funding support: This study was funded by AHRQ R18HS017093 and
NICHD K23HD051585. Ms Williams was supported by a grant from the
Doris Duke Charitable Foundation to the University of Pittsburgh.
Previous presentation: A poster describing a preliminary analysis
of this data was presented at the Reproductive Health Conference in
Atlanta, GA, on September 22-25, 2010.
Trial Registration: ClinicalTrials.gov Identi er: NCT00766207
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  • Article · Nov 2012
  • Article · Nov 2012
  • [Show abstract] [Hide abstract] ABSTRACT: Contraceptive use among women Veterans may not be adequately captured using administrative and pharmacy codes. Clinical progress notes may provide a useful alternative. The objectives of this study were to validate the use of administrative and pharmacy codes to identify contraceptive use in Veterans Health Administration data, and to determine the feasibility and validity of identifying contraceptive use in clinical progress notes. The study included women Veterans who participated in the Women Veterans Cohort Study, enrolled in the Veterans Affairs Connecticut Health Care System, completed a baseline survey, and had clinical progress notes from one year prior to survey completion. Contraceptive ICD-9-CM codes, V-codes, CPT codes, and pharmacy codes were identified. Progress notes were annotated to identify contraceptive use. Self-reported contraceptive use was identified from a baseline survey of health habits and healthcare practices and utilization. Sensitivity, specificity, and positive predictive value were calculated comparing administrative and pharmacy contraceptive codes and progress note-based contraceptive information to self-report survey data. Results showed that administrative and pharmacy codes were specific but not sensitive for identifying contraceptive use. For example, oral contraceptive pill codes were highly specific (1.00) but not sensitive (0.41). Data from clinical progress notes demonstrated greater sensitivity and comparable specificity. For example, for oral contraceptive pills, progress notes were both specific (0.85) and sensitive (0.73). Results suggest that the best approach for identifying contraceptive use, through either administrative codes or progress notes, depends on the research question.
    Article · Jul 2013
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