FACTORS PREDICTING LARC CONTINUATION IN ADOLESCENT/YOUNG ADULTS VS. ADULT WOMEN

Debbie Postlethwaite RNP, MPHAdekemi Ogultala, MD

Maqdooda Merchant MSc, MA

Presenter Disclosure

Presenter: Debbie Postlethwaite RNP, MPH

No Relationships to Disclose

This study was funded by:

Kaiser Permanente Community Benefits Program

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 19951

Healthy People 2020 goal: 56% planned pregnancies1

IUC: most cost-effective LARC within 12 months of use2

SCI: lowest failure rate (0.05%) within 12 months2,3

ACOG supports the use of LARC in adolescent and young women4

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)

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.

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.

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

Results

* Other: Islander, Native American, Multi-racial

Characteristics Percent (N) Total N = 303

Age 15-24 35.6% (108) 25-34 64.4% (195)

Race Asian 13.5% (41) Black 7.3% (22) Hispanic 33.0% (100)

Other* 4.0% (12)

White 33.3% (101) Missing 8.9% (27)Living Situation/Marital Status Single/Separated/Divorced 37.3% (113) Married/Living with Partner 45.2% (137) Other/Unknown 17.5% (53)Gravidity 0 23.0% (70) 1-2 40.0% (121) 3 19.5% (59) > 4 17.5% (53)

Table 1: Demographic and Clinical Characteristics of LARC Users

Table 1: Demographic and Clinical Characteristics of LARC Users (continued)

Characteristics Percent (N) Total N = 303

Parity 0 28.7% (87)

1-2 53.8% (163)

≥3 17.5% (53)

BMI (Mean) [Median] <Range> (27.3) [26.2] <16.4-56.2> <25 41.9% (127) 25-29.9 30.4% (92) >30 27.7% (84)

LARC Type by Age Group

Cu-T IUC, Age 15-24 6.9% (21)

Cu-T IUC, Age 25-34 26.4% (80)

LNG-IUC, Age 15-24 8.6% (26)

LNG-IUC Age 25-34 24.8% (75)

SCI, Age 15-25 20.1% (61)

SCI, Age 25-34 13.2% (40)

Table 2: Early LARC Removal by Demographic and Clinical CharacteristicsCharacteristics Outcomes

Early LARC Removal

Within 12 Months

No Early LARC Removal

P Value†

Age % (Total N=303) 15-24 23.1% (25) 76.9% (83) 0.52 25-34 20.0% (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/Divorced 17.7% (20) 82.3% (93)  

0.42Married/Living with Partner 21.9% (30) 78.1% (107)

Other/Unknown 26.4% (14) 73.6% (39)Gravidity % (Total N=303) 0 17.4% (12) 82.6% (57)  

0.42 1-2 24.8% (30) 75.2% (91) > 3 19.5% (22) 80.5% (91)Parity % (Total N=303) 0 22.1% (19) 77.9% (67)  

0.67 1-2 22.1% (36) 77.9% (127) > 3 16.7% (9) 83.3% (45)BMI % (Total N=303) < 25 18.9% (24) 81.1% 103)  

0.72 25-29.9 22.8% (21) 77.1% (71) > 30 22.6% (19) 77.4% (65)

* Other race: Islander, Native American, Multi-racial, missing† P values calculated using Chi-Square tests

Early Removal by LARC Type and Age

Characteristics Outcomes  

  Early Removal

No Early Removal

P value*

LARC Type by Age CategorySCI, Age 15-24 27.9% (17) 72.1% (44) 0.45SCI, Age 25-34 35.0% (14) 65.0% (26)Cu-T IUC, Age 15-24 19.0% (4) 81.0% (17) 0.75Cu-T IUC, Age 25-34 16.2% (13) 83.8% (67)LNG IUC, Age 15-24 15.4% (4) 84.6% (22) 1.00LNG IUC, Age 25-34 16.0% (12) 84.0% (63)IUC: Cu-T vs. LNCCu-T 16.8% (17) 83.2% (84) 0.85LNG 15.8% (16) 84.2% (85)LARC: IUC vs. LARCAny IUC 16.3% (33) 83.7% (169) 0.004

 SCI 30.7% (31) 69.3% (70)

* P values calculated using Chi-Square tests 

Early LARC Removal by Reported Complaints

Characteristic Outcome  

  Early Removal

No Early Removal

P value*

Reported Complaints

Bleeding/Any Time Period 35.5% (33) 64.5% (60) <0.0001

Pain/ Any Time Period 34.0% (16) 66.0% (31) 0.02

Amenorrhea/Any Time Period 26.7% (8) 73.3% (22) 0.43

Other†/Any Time period 33.3% (30) 66.7% (60) 0.0007

Reported Bleeding Complaints by Time Period

< 3 months 33.3% (21) 66.7% (42) 0.008

4 - 6 months 33.3% (5) 66.7% (10) 0.32‡

7-12 months 48.4% (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

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 Counseling Age Category P value*

  Age: 15-24 Age: 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 (<25: 17.0% , 25-29: 34.2%, > 30: 24.1%; p=0.19)

Predictors of Early SCI Removal

Predictive Characteristics Odds* Ratio

Confidence Interval

P value*

Age (categorical) 15-24 vs. 25-34

1.01 0.51 – 1.99 0.99

Cu-T IUC vs. SCI 0.38 0.17 – 0.84 < 0.02

LNG IUC vs. SCI 0.28 0.12 – 0.63 < 0.002

BMI < 25 vs. > 25 0.58 0.31 – 1.098 0.10

Any Reported Bleeding 2.95 1.62 – 5.37 0.004

Any Reported Pain 3.09 1.41 – 6.76 0.005

* ORs, Confidence Intervals and P-values calculated with logistic regression

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

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