Abstract
Objective:
To evaluate the proportion of 12-month contraceptive pill, patch, and ring prescriptions before and after an institution-wide change of default electronic medical record facility orders to dispensing 12-month supply.
Study Design:
This retrospective pre-post study compares outpatient contraception prescriptions from August 10, 2019 through April 9, 2020 obtained from our institutional electronic medical record prescription database. On December 10, 2019, we facilitated a change in the default orders for dispensing self-administered hormonal contraceptives from one-month to 12-months. We evaluated the primary outcome of 12-month supply prescriptions during the four months before and after the change. We also compared 12-month supply prescriptions for pills, patch, and ring by prescriber specialty and location.
Results:
The dataset included 4897 distinct evaluable prescriptions for the pill, patch, or ring, with an overall increase in 12-month prescriptions from 260/2437 (10.7%) to 669/2460 (27.2%) after the order change (p<0.001). Twelve-month pill prescriptions increased from 238/2250 (10.6%) to 607/2250 (27.0%) (p<0.001), patch prescriptions from 6/40 (15.0%) to 21/44 (47.7%) (p=0.002), and ring prescriptions from 16/147 (10.9%) to 41/165 (24.8%) (p=0.001). Twelve-month prescriptions increased after the order change among all provider types at the medical center campus (194/594 [32.7%] to 329/623 [52.8%], p<0.001). At community clinics, non-obstetrics/gynecology providers increased 12-month prescriptions after the order change (58/1616 [3.6%] to 327/1612 [20.3%], p<0.001), but obstetrics/gynecology providers did not (8/227 [3.5%] to 13/225 [5.8%], p=0.27).
Conclusion:
Providers more frequently prescribed a 12-month supply of contraceptive pills, patches, and rings after a change in the default dispensing quantity in electronic medical record orders.
Keywords: contraception, extended supply, California legislation, birth control, electronic medical record, prescription
1.0. Introduction
The Centers for Disease Control and Prevention (CDC) Selected Practice Recommendations (SPR) for Contraceptive Use advises dispensing a one-year supply of self-administered hormonal contraception and urges reduction in barriers and restrictions limiting the number of pills packs dispensed at one time [1]. Running out of pills is one of the most cited reasons for inconsistent pill use [2,3]. One-year continuation rates are higher with a 12-month contraceptive pill supply and results in a 30% reduction in unintended pregnancy [2–5]. As insurance coverage did not reflect this evidence, policymakers and legislators in many states have acted to improve access. In California, Medicaid enrollees have had coverage of a 12-month supply of contraceptive pills, patches, and rings since May 1, 2016 [6,7]. Effective January 1, 2017, California Senate Bill (SB) 999 required all insurances to cover up to a 12-month supply of these methods at one time [8]. As of June 2020, California is one of 20 jurisdictions (19 states and the District of Columbia) that mandate coverage for extended supply of contraceptive methods [9].
However, California has not widely advertised the law, and prescribers, pharmacists, patients, and insurers may not all be aware of the mandate. Despite the evidence-based benefits, current medical literature lacks description of systems-based attempts and outcomes to encourage such prescribing. We recognized our institutional electronic medical record (EMR) ordering practices as a potential means to facilitate 12-month prescribing of contraceptive pills, patches, and rings. To address this quality improvement initiative, we formed a multi-disciplinary team to change our default orders in the EMR system. This study aims to describe how an EMR default order change impacted the dispensing quantity of each of these methods prescribed across multiple medical specialties at our institution before and after this standardized change.
2.0. Materials and Methods
We performed a retrospective study utilizing University of California (UC) Davis Health’s outpatient prescription data of contraceptive pill, patch, and ring formulations within an 8-month period (August 10, 2019 through April 9, 2020), four months before and after the default order change. The data included outpatient prescriptions from the UC Davis Medical Center in Sacramento, California and 17 UC Davis Health offices in 10 communities across the Sacramento region. Providers prescribe medications through the EMR using default facility orders or their saved favorite orders. The favorite orders include providers’ preferred settings for dispensing, refills, and other instructions. The UC Davis Health Information Technology (IT) Applications EMR Pharmacy team instituted an EMR order change from dispensing one-month with refills to dispensing 12-month quantities for all formulary contraceptive combined and progestin-only pills (n=45), patches (n=1), and rings (n=2) on December 10, 2019. Prior to December 10, 2019, the default facility order for pills, patches, and rings were for one month followed by 11 refills, or 28 pills, 3 patches, or 1 ring, respectively. Starting on December 10, 2019, facility orders defaulted to 360 to 365 pills, 36 patches, or 12 rings. The IT EMR Pharmacy team can only make system-wide changes to default facility orders and not to favorite orders. The UC Davis Institutional Review Board determined this study, which used de-identified outpatient prescription data, to be exempt from human subjects’ review.
The Pharmacy EMR IT team supplied electronic prescription codes corresponding to each pill, patch, and ring formulation. An investigator (EDC) generated a system report based on these codes for the study period which included the following variables: medical record number, drug name and corresponding prescription code, dispensing quantity, number of refills, start date, prescriber name, and department affiliation. Prior to data receipt, medical record numbers (MRNs) were replaced by a corresponding study number; duplicate MRNs received the same study number.
We searched the identified records for duplicate study numbers within each four-month period and included only the last entry in the analysis. We selected the last duplicate entry for analysis to capture finalized prescriptions after potential modifications within days of original entry and to minimize the number of short-term “trial” prescriptions that patients may have opted for prior to deciding on their contraception of choice. We also excluded patient-reported entries (not actual prescriptions) and prescriptions without a dispensing quantity or provider name available from the final analysis dataset.
We analyzed the primary outcome of overall 12-month prescriptions of self-administered hormonal contraception during the four months before and after the EMR change, defining a 12-month supply of each of the contraceptive methods as dispensing ≥360 pills, ≥36 patches, or ≥12 rings. We compared the frequency of 12-month prescriptions for each of these methods at this institution and the proportion of 12-month prescriptions by prescriber department affiliation (obstetrics/gynecology vs. non-obstetrics/gynecology) and by clinic location (UC Davis Medical Center campus or community clinics). We used SPSS 26.0 (IBM Corp., Armonk, NY, USA) to perform descriptive statistics and Fisher’s exact and Chi-square tests for categorical variables.
3.0. Results
The electronic prescription code report generated 7131 outpatient prescription entries with 4897 outpatient prescriptions meeting criteria for analysis; most (98%) excluded entries consisted of duplicates or patient-reported prescriptions (Figure 1). Over the 8-month study period, UC Davis Health providers ordered 4501 (91.9%) pill, 84 (1.7%) patch, and 312 (6.4%) ring prescriptions. We found similar numbers of overall prescriptions of self-administered hormonal contraception before and after the EMR change (p=0.52) (Figure 1). Physicians ordered more prescriptions (n=4828, 98.6%) as compared to nurse practitioners (n=69, 1.4%), and most prescriptions (n=3680, 75.1%) came from providers in the UC Davis Medical Center community clinics. Of non-obstetrics/gynecology providers, internal, family, and pediatric medicine providers prescribed the most prescriptions (n=3454, 90.8%).
Figure 1:
Outpatient contraceptive pill, patch, and ring prescriptions before (August 10, 2019 through December 9, 2019) and after (December 10, 2019 through April 9, 2020) an electronic medical record default order change
UCD: University of California, Davis
Table 1 shows the change in 12-month prescribing before and after the EMR change for each method and overall prescribing stratified by provider specialty and clinic location. Overall, prescribers ordered 260 (10.7%) and 669 (27.2%) 12-month prescriptions before and after the EMR change (p<0.001). Prescribers in obstetrics/gynecology departments more frequently prescribed a 12-month supply compared with other specialties overall (375/1093 [34.3%] vs. 556/3804 [14.6%], respectively, p<0.001), before (163/539 [30.2%] vs. 99/1898 [5.2%], respectively, p<0.001), and after the order change (212/554 [38.3%] vs. 457/1906 [24.0%], respectively, p<0.001). Although 12-month prescribing increased significantly in both locations, prescribers at the medical center campus clinics ordered a 12-month supply more frequently than those at community clinics before (194/594 [32.7%] vs. 66/1843 [3.6%], respectively, p<0.001) and after the order change (329/623) [52.8%] vs. 340/1837 [18.5%], respectively, p<0.001). Notably, obstetrics/gynecology providers provided 641 (52.7%) and 452 (12.3%) of total prescriptions at the medical center campus and community clinics, respectively. The proportion of 12-month prescriptions increased after the EMR change among all providers on the medical center campus and among non-obstetrics/gynecology providers at community clinics, but not among obstetrics/gynecology providers at community clinics.
Table 1:
Proportion of 12-month prescriptions for contraceptive pill, patch, and ring before and after EMR default order change and differentiated by provider type and clinic location
| Contraceptive method | All Providers | Obstetrics/Gynecology | Non-Obstetrics/Gynecology | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 12-month prescription | p-value* | 12-month prescription | p-value* | 12-month prescription | p-value* | |||||
| Before† | After‡ | Before† | After‡ | Before† | After‡ | |||||
| Overall | Total | 260/2437 (10.7%) | 669/2460 (27.2%) | <0.001 | 161/539 (30.2%) | 212/554 (38.3%) | 0.006 | 99/1898 (5.2%) | 457/1906 (24.0%) | <0.001 |
| OCP | 238/2250 (10.6%) | 607/2251 (27.0%) | <0.001 | 147/500 (29.4%) | 192/497 (38.6%) | 0.002 | 91/1750 (5.2%) | 415/1754 (23.7%) | <0.001 | |
| Patch | 6/40 (15.0%) | 21/44 (47.7%) | 0.002 | 4/15 (26.7%) | 9/23 (39.1%) | 0.73 | 2/25 (8.0%) | 12/21 (57.1%) | 0.004 | |
| Ring | 16/147 (10.9%) | 41/165 (24.8%) | 0.002 | 10/24 (41.7%) | 11/34 (32.3%) | 0.58 | 6/123 (4.9%) | 30/131 (22.9%) | <0.001 | |
| Medical Center Campus clinics | Total | 194/594 (32.7%) | 329/623 (52.8%) | <0.001 | 153/312 (49.0%) | 199/329 (60.5%) | 0.004 | 41/282 (14.5%) | 130/294 (44.2%) | <0.001 |
| Community clinics | Total | 66/1843 (3.6%) | 340/1837 (18.5%) | <0.001 | 8/227 (3.5%) | 13/225 (5.8%) | 0.27 | 58/1616 (3.6%) | 327/1612 (20.3%) | <0.001 |
EMR: electronic medical record; OCP: oral contraceptive pill
12-month prescription defined as quantities of oral contraceptives ≥360, patches ≥36, rings ≥12
Fisher’s Exact test
Before: August 10, 2019 through December 9, 2019
After: December 10, 2019 through April 9, 2020
4.0. Discussion
We found a significant increase in 12-month prescriptions of contraceptive pills, patches, and rings at UC Davis Health after changing the default EMR orders from a one-month to 12-month prescriptions. The overall prescribing pattern of our providers, with pills representing 92% of prescription entries, reflects national contraceptive pill use of 91% among pill, patch, and ring users [10]. Obstetrics/gynecology providers increased the number of 12-month prescriptions for pills after the EMR change, but not for patches or rings, whereas providers in other departments increased the proportion of 12-month prescriptions for all three methods. At baseline, obstetrics/gynecology providers prescribed a 12-month supply six times more frequently than those in other departments and demonstrated a 27% increase in 12-month prescriptions after the EMR change. This finding differed based on clinic location as obstetrics/gynecology providers on the medical center campus increased the proportion of 12-month prescriptions after the change (49% to 61%, p<0.001), but those at community clinics did not (3.5% to 5.8%, p=0.27). Although non-obstetrics/gynecology providers prescribed a 12-month supply less frequently, they responded significantly to the EMR change, increasing 12-month prescriptions 360% overall, specifically, by over 200% and 460% at the medical center and community clinics, respectively.
The lower proportions of 12-month prescriptions among non-obstetrics/gynecology and community clinic obstetrics/gynecology prescribers identifies provider groups to target for additional extended supply education. Favorite electronic orders may also play a key part in differences in 12-month prescription orders before and after the EMR change. We anticipate that many providers utilize these saved orders, and the differences we observed may partially reflect who uses these orders more often. As the EMR change only modified the standard facility order settings, favorite orders would not be affected and could be preferentially utilized on a routine basis. We expect that this will become less prevalent over time; as new providers are hired, subsequent favorite orders will be designed using the new default contraception orders. There is no expectation for 100% of pill, patch, and ring prescriptions to be 12-month supplies, even after changing the EMR default facility order. Prescribers can modify the new EMR default facility order settings due to their own or patient preferences, as not all patients will need a full 12-month supply with every prescription.
Our study is limited in that we cannot determine whether the patient ever filled the prescription. Additionally, because the pharmacy database has limited information related to duplicate entries, we cannot discern if these duplicates reflect a refill of a short interval (1- or 3-month) prescription, a new prescription because the patient did not like the first one, or an unfilled initial prescription. Although we cannot differentiate these reasons for the large number of duplicate prescriptions in our system, the goal of this evaluation is to assess for 12-month dispensing quantity. Accordingly, differentiating these points is not relevant for the primary purpose of this evaluation. Lastly, our database is an administrative dataset which lacks patient characteristics so we cannot discern patient level details that can be evaluated with future prospective studies.
Analysis of California claims data predicted that contraception users receiving a 12-month supply of pill, patch, or ring at one time would increase from 0.6% to 38% with enactment of SB 999 [6]. More than three years after passage of SB 999, providers at our institution ordered a 12-month supply for only 11% of prescriptions. The rate increased to 27% in only 3 months with a change in the default orders, and we hope that the rate will continue to increase closer to the predicted 38%. Considering decreased unintended pregnancy rates, reduced office and hospital costs, and increased pill wastage, the California Health Benefits Review Program anticipated a 12-month supply to decrease health care expenditures in California by 0.03%, translating to $42.8 million over the year [6]. A systems-based approach with a relatively simple change to EMR default orders may help achieve these outcomes while promoting greater patient-centered care and self-efficacy. While these data are specific to our institution, the increased proportion of 12-month prescription is promising should other institutions make similar changes. However, a 12-month prescription order is just the first step to eliminating barriers and ensuring access to contraception. Unfortunately, the prescription itself does not necessarily result in a patient receiving a 12-month supply of her preferred contraceptive method at one time as knowledge of the legislation, concerns about reimbursement and/or pharmacy-specific policies, and adequate stock remain obstacles [11]. Further evaluations need to assess patient-level data regarding receipt of a 12-month supply and evaluate implementation strategies to increase overall knowledge of extended contraceptive supply coverage and reduce insurance and pharmacy barriers.
Implications:
Institution-wide changes to the electronic medical record default facility order settings can increase 12-month supply contraceptive prescriptions. As a 12-month prescription order represents only one step of many in obtaining a 12-month contraception supply, additional research is required to elucidate and remove other potential barriers.
Acknowledgements:
We thank Scott MacDonald MD, FACP, Michael Fong, PharmD, BCPS, and David Egi, PharmD for assisting with the EMR order change.
Funding: Dr. Chen’s work was supported by the National Institutes of Health [NICHD K23 HD090323]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
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Disclosures: MDC serves on an Advisory Board for Evofem, Mayne, Merck & Co., and TherapeuticsMD and is a consultant for Estetra, Mayne, Medicines360 and Searchlight. All other authors report no conflicts. The Department of Obstetrics and Gynecology, University of California, Davis, receives research funding for contraceptive research from Daré, HRA Pharma, Medicines360, Merck & Co., and Sebela.
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