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The percentage of patients assigned female at birth ages 15-44 who were asked the Self-Identified Need for Contraception (SINC) question with a recorded response, among patients with a qualifying encounter. (Contraceptive Care Screening eCQM)

CBE ID
4655e
1.5 Project
Endorsement Status
1.0 New or Maintenance
Is Under Review
Yes
Next Maintenance Cycle
Fall 2024
1.6 Measure Description

Percentage of patients assigned female at birth and ages 15-44 who were asked if they wanted to talk about contraception or pregnancy prevention and had their response recorded during the measurement period (which is a calendar year), among patients with a qualifying encounter; to focus on the population of non-postpartum women, the measure excludes those individuals who had a live birth making them eligible for postpartum contraceptive services, and also excludes those who are anatomically infecund or  have had female sterilization from the denominator.

Measure Specs
General Information
1.7 Measure Type
1.7 Composite Measure
No
1.3 Electronic Clinical Quality Measure (eCQM)
1.8 Level of Analysis
1.9b Other Care Setting
Community Health Center
1.10 Measure Rationale

 

Supporting patients to prevent pregnancy when they wish to do so has social and health benefits for individuals and their families (1–3). Contraception is a highly effective clinical preventive service that can assist patients in reaching their reproductive health goals (4,5). In order to support patients to achieve their reproductive goals, facilities at which individuals receive care must ensure that their patients’ contraceptive needs are assessed and met. In the care pathway to meeting patients’ contraceptive service needs, healthcare systems and facilities must first identify that the individual desires contraceptive services (see logic model). Building on previous work to optimize contraceptive care and promote positive reproductive health outcomes through the use of performance measures (6–8), the University of California, San Francisco (UCSF) designed the Contraceptive Care Screening eCQM as a process measure to give health care organizations and facilities the ability to monitor and address the provision of screening as a critical part of the contraceptive care pathway that enables those in need of contraceptive services to receive this care.

 

This measure is aligned with evidence and serves to address a gap in care. Integration of proactive screening for need for pregnancy prevention has been promoted by the Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG) (9,10). However, only 14% of ambulatory visits in the United States include any care related to achieving or preventing pregnancy (11) and only 54% of women report receiving family planning care during the prior 12 months (12). In an analytic sample published this year that included 53,489 patient visits of reproductive age individuals at outpatient care visits, only 8% of visits included family planning services (13). These data indicate that there is a sizeable opportunity to improve integration of contraceptive counseling services into ambulatory care settings. Challenges to providing reproductive health services in primary care have been explored in the research and include uncertainty about patient interest in these conversations and assumptions about patient pregnancy risk and/or desire to discussion pregnancy prevention (14–17). Providers report relying on patients to initiate conversations about contraception (14). This  is particularly salient in primary care settings, where many people of reproductive age receive care but where there are many competing priorities that can result in neglect of reproductive health care (18,19). 

 

Implementation of standardized screening for contraceptive care need can address many of these key challenges by overriding provider assumptions about patient preferences and needs and instead asking them directly about their service needs in the care pathway. One study found that after introducing a standardized reproductive health screening tool and training staff on its use, contraceptive counseling increased 24% (20). Implementation of standardized screening can work with other systems-level efforts, including provider training and use of patient decision support tools, to optimize contraceptive care (21). Together training and screening can center reproductive health integration into routine care and can result in increased provision of contraception to those who want the service. A study in a primary care setting found that patients who received contraceptive counseling were more likely to report use of hormonal contraception seven to thirty days post-visit compared to those who did not (22) Moreover, a study of adolescent care delivery found that it took on average three visits for providers to initiate contraceptive counseling, however, once they did, among patients who were not using contraception, 39% left the visit on a method (23). 

 

The Contraceptive Care Screening eCQM complements existing performance measures related to contraceptive care. Currently endorsed measures evaluate provision of contraceptive methods and whether or not counseling was person-centered. The proposed measure adds an additional dimension in the quality care pathway by identifying whether or not people have their needs for contraceptive care evaluated. In addition, this measure is aligned with the endorsed eCQMs of contraceptive use (CBE #3699e and #3682e). Specified for EHR system data, these measures utilize SINC to exclude those from the denominator not interested in contraceptive care in order to focus the measure on the population of patients interested in contraceptive services. Implementing the Contraceptive Care Screening eCQM alone or in combination with other contraceptive care performance measures will result in quality improvement initiatives that help health care organizations better meet clients’ needs by increasing person-centered access to contraception in a wider range of settings, a step towards the goal of reproductive autonomy and well-being for all. 

 

REFERENCES

1.           Conde-Agudelo A, Rosas-Bermúdez A, Kafury-Goeta AC. Birth Spacing and Risk of Adverse Perinatal Outcomes: A Meta-analysis. JAMA. 2006 Apr 19;295(15):1809. 

2.           Conde-Agudelo A, Rosas-Bermúdez A, Kafury-Goeta AC. Effects of birth spacing on maternal health: a systematic review. American Journal of Obstetrics and Gynecology. 2007 Apr;196(4):297–308. 

3.           Congdon JL, Baer RJ, Arcara J, Feuer SK, Gómez AM, Karasek D, et al. Interpregnancy Interval and Birth Outcomes: A Propensity Matching Study in the California Population. Matern Child Health J. 2022 May;26(5):1115–25. 

4.           Mansour D, Inki P, Gemzell-Danielsson K. Efficacy of contraceptive methods: A review of the literature. The European Journal of Contraception & Reproductive Health Care. 2010 Feb;15(1):4–16. 

5.           Trussell J, Aiken ARA, Micks, E, Guthrie K. Efficacy, safety, and personal considerations. In: Contraceptive Technology. 21st ed. )Ayer Company Publishers, Inc.; 2018. p. 95–128. 

6.           Gavin L, Frederiksen B, Robbins C, Pazol K, Moskosky S. New clinical performance measures for contraceptive care: their importance to healthcare quality. Contraception. 2017 Sep;96(3):149–57. 

7.           Gavin LE, Ahrens KA, Dehlendorf C, Frederiksen BN, Decker E, Moskosky S. Future directions in performance measures for contraceptive care: a proposed framework. Contraception. 2017 Sep;96(3):138–44. 

8.           Moniz MH, Gavin LE, Dalton VK. Performance Measures for Contraceptive Care: A New Tool to Enhance Access to Contraception. Obstetrics & Gynecology. 2017 Nov;130(5):1121–5. 

9.           Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, et al. Recommendations to improve preconception health and health care--United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep. 2006 Apr 21;55(RR-6):1–23. 

10.         ACOG Committee Opinion No. 762: Prepregnancy Counseling. Obstetrics & Gynecology. 2019 Jan;133(1):e78–89. 

11.          Bello JK, Rao G, Stulberg DB. Trends in contraceptive and preconception care in United States ambulatory practices. Fam Med. 2015 Apr;47(4):264–71. 

12.         Borrero S, Schwarz EB, Creinin M, Ibrahim S. The Impact of Race and Ethnicity on Receipt of Family Planning Services in the United States. Journal of Women’s Health. 2009 Jan;18(1):91–6. 

13.         Schulte A, Biggs MA. Association Between Facility and Clinician Characteristics and Family Planning Services Provided During U.S. Outpatient Care Visits. Women’s Health Issues. 2023 Nov;33(6):573–81. 

14.         Akers AY, Gold MA, Borrero S, Santucci A, Schwarz EB. Providers’ Perspectives on Challenges to Contraceptive Counseling in Primary Care Settings. Journal of Women’s Health. 2010 Jun;19(6):1163–70. 

15.         Chuang CH, Hwang SW, McCall‐Hosenfeld JS, Rosenwasser L, Hillemeier MM, Weisman CS. Primary Care Physicians’ Perceptions of Barriers To Preventive Reproductive Health Care In Rural Communities. Perspect Sexual Reproductive. 2012 Jun;44(2):78–83. 

16.         Zephyrin L, Suennen L, Viswanathan P, Augenstein J, Bachrach D. TRansforming Primary Health Care for Women: Part 1: A Framework for Addressing Gaps and Barriers [Internet]. The Commonwealth Fund; 2020 Jul. Available from: https://www.commonwealthfund.org/sites/default/files/2020-07/Zephyrin_primary_care_for_women_part_1_framework.pdf

17.         Dunlop AL, Jack B, Frey K. National Recommendations for Preconception Care: The Essential Role of the Family Physician. The Journal of the American Board of Family Medicine. 2007 Jan 1;20(1):81–4. 

18.         Saloner B, Wilk AS, Levin J. Community Health Centers and Access to Care Among Underserved Populations: A Synthesis Review. Med Care Res Rev. 2020 Feb;77(1):3–18. 

19.         Chen C, Strasser J, Banawa R, Luo Q, Bodas M, Castruccio-Prince C, et al. Who Is Providing Contraception Care in the United States? An Observational Study of the Contraception Workforce. Obstetrical & Gynecological Survey. 2022 Jun;77(6):351–3. 

20.         Stulberg DB, Dahlquist IH, Disterhoft J, Bello JK, Hunter MS. Increase in Contraceptive Counseling by Primary Care Clinicians After Implementation of One Key Question® at an Urban Community Health Center. Matern Child Health J. 2019 Aug;23(8):996–1002. 

21.         Borrero S, Callegari L. Integrating Family Planning into Primary Care—a Call to Action. J GEN INTERN MED. 2020 Mar;35(3):625–7. 

22.         Lee JK, Parisi SM, Akers AY, Borrerro S, Schwarz EB. The Impact of Contraceptive Counseling in Primary Care on Contraceptive Use. J GEN INTERN MED. 2011 Jul;26(7):731–6. 

23.         Woods JL, Sheeder JL. Missed Opportunities for Discussing Contraception in Adolescent Primary Care. Journal of Pediatric and Adolescent Gynecology. 2020 Dec;33(6):667–72. 

 

1.20 Types of Data Sources
1.25 Data Source Details

The Contraceptive Care Screening eCQM uses Electronic Health Record (EHR) data collected from ambulatory, outpatient clinical encounters and entered into the EHR system. The SINC question and its response options are specified in the LOINC code system (see https://loinc.org/98076-3/) and published online as a value set named “Self Identified Need for Contraception (SINC)” (OID: 2.16.840.1.113762.1.4.1166.115) in the National Library of Medicine (NLM) Value Set Authority Center (VSAC, https://vsac.nlm.nih.gov/ - registration required). This element defines the numerator. 

 

We implemented and tested the Contraceptive Care Screening eCQM in primary care settings through a quality improvement learning collaborative among federally qualified health centers (FQHCs). All value sets utilized in our measure rely on standardized coding systems and are published on VSAC. 

 

For more information on the feasibility of the Contraceptive Care Screening eCQM, see Section 3 Feasibility. To review our reliability and validity analyses methods and results, see Section 4, Scientific Acceptability.