PC2003: Addressing Pediatricians’ Unique Needs Allows Pediatric Clinics to Integrate Etonogestrel Implant Procedures and Improve Adolescent Reproductive Healthcare Access

Purpose/Objectives: Access to reproductive healthcare – especially long-acting reversible contraceptives (LARCs) – is limited in pediatric primary care clinics (PPCC). The Ohio Chapter of the American Academy of Pediatrics (OH AAP) developed a quality improvement (QI) pilot program to determine sustainable strategies to reduce this care gap. The goals were to develop a QI program to address the unique challenges faced by pediatricians and provide the scaffolding necessary to integrate reproductive counseling and LARC procedures into PPCCs.

Design/Methods: Twelve pediatric clinics in the Midwestern United States, representing a variety of practice settings and serving >7500 adolescent females, were recruited (Table 1). Clinics focused on four QI goals:
1) Integrate a LARC implant process and clinic education
2) Increase pediatrician self-efficacy and clinic performance in reproductive counseling
3) Increase pediatrician self-efficacy and implant insertions
4) Increase adolescent-friendly services

Rolling admission occurred between August-December 2020, with a minimum 9-month QI phase per site. Clinics then entered a 3-year sustainability phase to be completed by December 2024. Three of the 12 clinics were comparison sites, focusing on reproductive counseling while continuing referrals for LARCs. Practice support included:
1) Pediatrician-tailored reproductive health and clinic-wide adolescent services education
2) Coordination of LARC implant training, procedure mentorship and credentialing
3) EHR documentation, scheduling and coding strategies, procedure bundling options, and staff protocols
4) Procedure “starter kits” plus a stipend to purchase an optional etonogestrel implant for clinic stock, creating a sustainable “medical bundle” billing structure
5) Adolescent-friendly resources
6) Data analysis with real-time logistical and clinical support

Results: As of April 2022, all clinics completed the QI phase and entered the 3-year sustainability phase. All LARC clinics trained at least 1 provider to perform implant procedures (range: 1-4). The cohort nearly met the 90% clinic education goal (average=79.7%; range: 20.6%-100%) and met the 20% adolescent-friendly services improvement goal (average=20.5%; range: -5.2%-72%; P=.08).

All LARC clinics successfully integrated implant procedures with a cohort median of 5.3 insertions/month by month nine (P <.01) (Figure 1). In contrast, the three comparison sites did not increase LARC referrals over that time (P=.43). In order to reduce missed opportunities for care, we monitored reproductive counseling at all adolescent visits, not just well visits. Not all clinics reached their individual 50% reproductive counseling improvement goal, but the aggregate improvement was statistically significant (P <.001). In exit interviews, procedure mentorship, “starter kits”, pediatrician-tailored education and adolescent-friendly resources were consistently noted as the most useful supports by practices.

Conclusion/Discussion: With the right combination of pediatrician-tailored education, procedure mentorship, and logistical support, PPCCs can successfully integrate a LARC implant infrastructure and increase reproductive health counseling. That infrastructure can improve adolescent access to reproductive healthcare and can provide a blueprint for further expansion of LARC access including same-day procedures or IUDs.