March 26, 2015 —Summary of "Performance Measures for Contraceptive Care: What are We Actually Trying To Measure?" Dehlendorf et al., Contraception, Feb. 9, 2015.
While there has been an increasing push to measure "quality in specific areas of health care," which "can drive quality improvement and influence the degree to which these areas are prioritized" by stakeholders, no such performance measures have been developed for family planning, write Christine Dehlendorf of the University of California-San Francisco and colleagues.
Meanwhile, "the reproductive health community is increasingly directing research and interventions towards the perceived underuse of highly effective" contraceptive methods, particularly long-acting reversible contraception (LARC), such as intrauterine devices and implants, they write.
As a result, some stakeholders have urged using measures to help encourage LARC use. The authors write that one option would be "to simply measure the percentage of women receiving family planning care who decide to use a highly effective method, with higher uptake being equated with higher quality of care," or to use an approach weighting methods by their effectiveness and taking into account their level of use in the population.
'Cause for Concern'
At first glance, using measures that prioritize "the uptake of higher efficacy methods" appears logical when considering the desire to reduce unintended pregnancies and combat provider misconceptions about LARCs, the researchers write.
However, Dehlendorf and colleagues add that "there is cause for concern that this focused, outcome-based measure may not be appropriate in the setting of a decision as complex and contextualized as the choice of a contraceptive method."
They explain that the selection of a birth control method "is highly preference-sensitive due to the large number of available options and women's varied preferences for method characteristics," such as efficacy, bleeding patterns and whether methods contain hormones.
In addition, they note that method selection is connected "to intimate issues related to fertility, relationships and sexuality," including whether women want to get pregnant and their comfort level with a device inside their body, among other considerations. They add, "Protecting women's reproductive autonomy therefore requires the recognition that women's preferences need to be paramount in the choice of a contraceptive method even if they are not consistent with the public health goal of decreasing unintended pregnancies."
Further, the researchers argue that "quality measures that focus only on the short-term outcome of choice of a [LARC] method are problematic" because they encourage providers to promote or emphasize certain "methods at the expense of attention to patient preferences." There are also potentially negative effects on "long-term outcomes, such as patient satisfaction and method continuation," which have been shown to be linked to each other.
Consideration of Vulnerable Populations
Dehlendorf and colleagues add that "[i]ncentivizing counseling ... focused on LARC methods could be particularly problematic among" groups of women who have historically experienced "reproductive coercion," such as low-income women, "women of color, women with disabilities, young women and those in the correctional system."
Thus, "counseling that is biased towards [LARCs], rather than focused on women's needs and preferences, has the potential to amplify existing biases and disparities within the US health care system and worsen preexisting distrust among communities of color and other vulnerable populations," the authors explain.
They add that such a quality measure "may be problematic even if it did not influence counseling, as its mere existence could be perceived negatively by communities sensitized to these issues as evidence of a focus on controlling women's reproduction, rather than on empowering women."
Dehlendorf and colleagues suggest that a "combination of measures" likely will be needed to capture "the multidimensional nature of quality, including interpersonal quality, availability of information and access to services," as well as "the importance of both the patient experience of counseling and whether each woman is able to choose the appropriate contraceptive method for her."
Specifically, patient experience measures are "of particular value in the assessment of contraceptive care" because of "the personal nature and complex context of contraceptive decision making," they argue.
Meanwhile, the authors state that process metrics based on the availability of contraceptive choice could help combat "provider resistance to provision of [LARC] methods and the resulting limitation on women's ability to choose these methods -- while avoiding [the] pitfalls" of uptake-based measures. They write that such measures could include "a measure that incentivizes the provision of information about LARC methods," as implemented by the United Kingdom's National Health Services. Another option, they write, could be "a performance measure based on whether ... women are offered LARC methods," as recommended by the American College of Obstetricians and Gynecologists.
In addition, another approach could be to use claims data on LARC uptake to "identify practices that are well below the mean" of LARC use "in order to provide the opportunity to address" related barriers, without setting an explicit benchmark for providers to reach. A similar option could be to establish "a minimum 'floor' standard ... in order to differentiate providers who offer these methods at all from those who do not." The researchers caution that "care would need to be taken" with such an approach "to ensure that [the] intent [of the measure] was clear in order to avoid the interpretation that promotion of LARC methods was being incentivized."
Further, the researchers also raise the possibility of having "an intermediate-outcome measure" that "focuses on use of any" contraceptive method "considered to be either moderately or highly effective." They add that while such an approach "allows for greater consideration of patient preferences," it could also "incentivize providers to deemphasize counseling about condoms," resulting in negative effects for patient preferences and sexually transmitted infection risk.
Dehlendorf and colleagues continue, "Measurement of quality in contraceptive care may ensure that family planning services are prioritized in our evolving health care system and that attention is paid to continuous quality improvement in order to ensure that women receive the best possible care."
They add that "[m]easures that, either individually or in combination, reward the quality of contraceptive care from both a patient and systems perspective, while protecting women's autonomy, should be prioritized by those developing performance measures."
The researchers also stress that organizations that formally endorse quality measures, including the National Quality Forum, "can help to ensure that the preference-sensitive nature of contraceptive decision making is reflected in measures designed to incentivize quality family planning care."