Onsite provision of specialized contraceptive services: does Title X funding enhance access?

BACKGROUND: This article presents the extent to which providers enrolled in Californias Family Planning, Access, Care, and Treatment (Family PACT) program offer contraceptive methods onsite, thus eliminating one important access barrier. Family PACT has a diverse provider network, including public-sector providers receiving Title X funding, public-sector providers not receiving Title X funding, and private-sector providers. We explored whether Title X funding enhances providers ability to offer contraceptive methods that require specialized skills onsite. METHODS: Data were derived from 1,072 survey responses to a 2010 provider-capacity survey matched by unique identifier to administrative claims data. RESULTS: A significantly greater proportion of Title X-funded providers compared to non-Title X public and private providers offered onsite services for the following studied methods: intrauterine contraceptives (90% Title X, 51% public non-Title X, 38% private); contraceptive implants (58% Title X, 19% public non-Title X, 7% private); vasectomy (8% Title X, 4% public non-Title X, 1% private); and fertility-awareness methods (69% Title X, 55% public non-Title X, 49% private) (all p<0.0001). The association between onsite provision and Title X funding remained after stratifying individually by clinic specialty, facility capacity to provide reproductive health services (based on staffing), and rural/urban location. CONCLUSIONS: Extra funding for publicly funded family-planning programs, through mechanisms such as Title X, appears to be associated with increased onsite access to a wide range of contraceptive services, including those that require special skills and training

Onsite provision of specialized contraceptive services: does Title X funding enhance access?

BACKGROUND: This article presents the extent to which providers enrolled in California's Family Planning, Access, Care, and Treatment (Family PACT) program offer contraceptive methods onsite, thus eliminating one important access barrier. Family PACT has a diverse provider network, including public-sector providers receiving Title X funding, public-sector providers not receiving Title X funding, and private-sector providers. We explored whether Title X funding enhances providers' ability to offer contraceptive methods that require specialized skills onsite. METHODS: Data were derived from 1,072 survey responses to a 2010 provider-capacity survey matched by unique identifier to administrative claims data. RESULTS: A significantly greater proportion of Title X-funded providers compared to non-Title X public and private providers offered onsite services for the following studied methods: intrauterine contraceptives (90% Title X, 51% public non-Title X, 38% private); contraceptive implants (58% Title X, 19% public non-Title X, 7% private); vasectomy (8% Title X, 4% public non-Title X, 1% private); and fertility-awareness methods (69% Title X, 55% public non-Title X, 49% private) (all p<0.0001). The association between onsite provision and Title X funding remained after stratifying individually by clinic specialty, facility capacity to provide reproductive health services (based on staffing), and rural/urban location. CONCLUSIONS: Extra funding for publicly funded family-planning programs, through mechanisms such as Title X, appears to be associated with increased onsite access to a wide range of contraceptive services, including those that require special skills and training

Postpartum care and contraception provided to women with gestational and preconception diabetes in California's Medicaid program.

ObjectivesTo compare rates of postpartum care and contraception provided to women with gestational or preconception diabetes mellitus to women with no known diabetes mellitus.MethodsA retrospective cohort study of 199,860 women aged 15-44 years who were continuously enrolled in California's Medicaid program, Medi-Cal, from 43 days prior to 99 days after delivering in 2012. Claims for postpartum clinic visits and contraceptive supplies were compared for 11,494 mothers with preconception diabetes, 17,970 mothers with gestational diabetes, and 170,396 mothers without diabetes. Multivariable logistic regression was used to control for maternal age, race/ethnicity, primary language, residence in a primary care shortage area, state-funded healthcare program and Cesarean delivery, when examining the effects of diabetes on postpartum care and contraception.ResultsAlthough postpartum clinic visits were more common with diabetes (55% preconception, 55% gestational, 48% no diabetes, p=<.0001), almost half did not receive any postpartum care within 99 days of delivery. Women with pregnancies complicated by diabetes were more likely to receive permanent contraception than women without diabetes (preconception diabetes, aOR: 1.39, 95% CI: 1.31-1.47; gestational diabetes, aOR: 1.20, 95% CI: 1.14-1.27). However, among women without permanent contraception, less than half received any reversible contraception within 99 days of delivery (44% preconception, 43% gestational, 43% no diabetes) and less effective, barrier contraceptives were more commonly provided to women with preconception diabetes than women without diabetes (aOR: 1.24, 95% CI:1.16-1.33).ConclusionsLow-income Californian women with pregnancies complicated by diabetes do not consistently receive postpartum care or contraception that may prevent complication of future pregnancies.ImplicationsEfforts are needed to improve rates of provision of postpartum care and high quality contraceptive services to low income women in California, particularly following pregnancies complicated by diabetes

Postpartum care and contraception provided to women with gestational and preconception diabetes in California's Medicaid program.

ObjectivesTo compare rates of postpartum care and contraception provided to women with gestational or preconception diabetes mellitus to women with no known diabetes mellitus.MethodsA retrospective cohort study of 199,860 women aged 15-44 years who were continuously enrolled in California's Medicaid program, Medi-Cal, from 43 days prior to 99 days after delivering in 2012. Claims for postpartum clinic visits and contraceptive supplies were compared for 11,494 mothers with preconception diabetes, 17,970 mothers with gestational diabetes, and 170,396 mothers without diabetes. Multivariable logistic regression was used to control for maternal age, race/ethnicity, primary language, residence in a primary care shortage area, state-funded healthcare program and Cesarean delivery, when examining the effects of diabetes on postpartum care and contraception.ResultsAlthough postpartum clinic visits were more common with diabetes (55% preconception, 55% gestational, 48% no diabetes, p=<.0001), almost half did not receive any postpartum care within 99 days of delivery. Women with pregnancies complicated by diabetes were more likely to receive permanent contraception than women without diabetes (preconception diabetes, aOR: 1.39, 95% CI: 1.31-1.47; gestational diabetes, aOR: 1.20, 95% CI: 1.14-1.27). However, among women without permanent contraception, less than half received any reversible contraception within 99 days of delivery (44% preconception, 43% gestational, 43% no diabetes) and less effective, barrier contraceptives were more commonly provided to women with preconception diabetes than women without diabetes (aOR: 1.24, 95% CI:1.16-1.33).ConclusionsLow-income Californian women with pregnancies complicated by diabetes do not consistently receive postpartum care or contraception that may prevent complication of future pregnancies.ImplicationsEfforts are needed to improve rates of provision of postpartum care and high quality contraceptive services to low income women in California, particularly following pregnancies complicated by diabetes

Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data

Background: General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. Methods: For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. Findings: Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09–2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75–3·10, p<0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95% CI 1·14–2·04, p=0·0044). The risk of bias and variability between studies was assessed to be low. Interpretation: Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons