Increasing long acting reversible contraceptives: The Australian Contraceptive ChOice pRoject (ACCORd) cluster randomized trial.

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Journal Article
American Journal of Obstetrics and Gynecology, 2020, 222, (4), pp. 1-13
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BACKGROUND:Long-active reversible contraceptives (LARCs) reduce unintended pregnancy and abortions but uptake is low. Interventions to increase uptake in family medicine settings are untested. OBJECTIVE:The Australian Contraceptive ChOice pRoject (ACCORd), adapted from the successful US Contraceptive CHOICE study, aimed to evaluate whether a complex intervention in family medicine practices resulted in increased LARC uptake by women. STUDY DESIGN:This cluster randomized controlled trial was set in family practices in metropolitan Melbourne, Australia. From April 2016 to January 2017 we recruited 57 family physicians by mail invitation. Each family physician aimed to recruit at least 14 women patients. Eligible family physician worked three or more sessions per week in computerized practices. Eligible women were English speaking, sexually active, not pregnant, not planning a pregnancy in the following year, aged 16-45 years and interested in discussing contraception or in starting a new, reversible method. Using a randomization sequence with permuted bocks stratified by whether the family physician performed LARC insertion or not, family physicians were randomly assigned to a complex intervention involving training to provide structured effectiveness-based contraceptive counselling, and access to rapid referral to LARC insertion clinics. The six-hour, online educational intervention was based on the US Contraceptive CHOICE Project and adapted for the Australian context. The control family physicians received neither the educational intervention nor access to the LARC rapid referral clinics and conducted their usual contraception counselling. We used the χ2 test, adjusted for clustering and stratification by whether the family physician inserted LARCs, and binary regression models with generalized estimating equations and robust standard errors, to compare the proportions of women who had a LARC inserted between the intervention and control groups. The primary outcome was the proportion of women with LARCs inserted at 4 weeks. Secondary outcomes included women's choice of contraceptive method, quality of life (QOL) and LARC use at 6 and 12 months. Analyses were performed according to intention-to-treat. RESULTS:A total of 25 intervention and 32 control family physicians recruited 307 and 433 women respectively (N=740). Within 4 weeks 19.3% of women in the intervention group and 12.9% of women in the control group had LARC inserted (RR 2.0, 95% CI 1.1 to 3.9; P=0.033). By 6 months this had risen to 44.4% and 29.3% respectively (RR 1.6, 95% CI 1.2 to 2.17; P<0.001) and by 12 months to 46.6% and 32.8% respectively (RR 1.5, 95% CI 1.2 to 2.0; P=0.0015). The levonorgestrel intra-uterine system was the most commonly chosen LARC by women in the intervention group at all time points. Differences between intervention and control groups in mean QOL scores across all domains at 6 and 12 months were small. CONCLUSIONS:A complex intervention combining family physician training on contraceptive effectiveness counselling and rapid access to LARC insertion clinics resulted in greater LARC uptake and has the potential to reduce unintended pregnancies.
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