Background

National guidelines recommend that maternity systems provide patient-centered access to immediate postpartum long-acting reversible contraception (ie, insertion of an intrauterine device or implant during the delivery hospitalization). Hospitals face significant barriers to offering these services, and efforts to improve peripartum contraception care quality have met with mixed success. Implementation toolkits—packages of resources and strategies to facilitate the implementation of new services—are a promising approach for guiding clinical practice change.

Objective

This study aimed to develop a theory-informed toolkit, evaluate the feasibility of toolkit-based implementation of immediate postpartum long-acting reversible contraception care in a single site, and refine the toolkit and implementation process for future effectiveness testing.

Study Design

We conducted a single-site feasibility study of the toolkit-based implementation of immediate postpartum contraception services at a large academic medical center in 2017 to 2020. Based on previous qualitative work, we developed a theory-informed implementation toolkit. A stakeholder panel selected toolkit resources to use in a multicomponent implementation intervention at the study site. These resources included tools and strategies designed to optimize implementation conditions (ie, implementation leadership, planning, and evaluation; the financial environment; engagement of key stakeholders; patient needs; compatibility with workflow; and clinician and staff knowledge, skills, and attitudes). The implementation intervention was executed from January 2018 to April 2019. Study outcomes included implementation outcomes (ie, provider perceptions of the implementation process and implementation tools [assessed via online provider survey]) and healthcare quality outcomes (ie, trends in prenatal contraceptive counseling, trends in immediate postpartum long-acting reversible contraceptive utilization [both ascertained by institutional administrative data], and the patient experience of contraceptive care [assessed via serial, cross-sectional, online patient survey items adapted from the National Quality Forum-endorsed, validated Person-Centered Contraceptive Counseling measure]).

Results

In the implementation process, among 172 of 401 eligible clinicians (43%) participating in surveys, 70% were “extremely” or “somewhat” satisfied with the implementation process overall. In the prenatal contraceptive counseling, among 4960 individuals undergoing childbirth at the study site in 2019, 1789 (36.1%) had documented prenatal counseling about postpartum contraception. Documented counseling rates increased overall throughout 2019 (Q1, 12.5%; Q4, 51.0%) but varied significantly by clinic site (Q4, range 30%–79%). Immediate postpartum long-acting reversible contraception utilization increased throughout the study period (before implementation, 5.46% of deliveries; during implementation, 8.95%; after implementation, 8.58%). In the patient experience of contraceptive care, patient survey respondents (response rate, 15%–29%) were largely White (344/425 [81%]) and highly educated (309/425 [73%] with at least a 4-year college degree), reflecting the study site population. Scores were poor across settings, with modest improvements in the hospital setting from 2018 to 2020 (prenatal visits, 67%–63%; hospitalization, 45%–58%; outpatient after delivery, 69%–65%). Based on these findings, toolkit refinements included additional resources designed to routinize prenatal contraceptive counseling and support a more patient-centered experience of contraceptive care.

Conclusion

A toolkit-based process to implement immediate postpartum long-acting reversible contraceptive services at a single academic center was associated with high acceptability but mixed healthcare quality outcomes. Toolkit resources were added to optimize counseling rates and the patient experience of contraceptive care. Future research should formally test the effectiveness of the refined toolkit in a multisite, prospective trial.

中文翻译：

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基于工具包的流程实施以患者为中心的产后即刻长效可逆避孕服务的可行性和可接受性

背景

国家指南建议生育系统提供以患者为中心的产后即时长效可逆避孕措施（即在分娩住院期间插入宫内节育器或植入物）。医院在提供这些服务方面面临着重大障碍，提高围产期避孕护理质量的努力也取得了不同程度的成功。实施工具包——促进新服务实施的资源和策略包——是一种很有前途的指导临床实践变革的方法。

客观的

本研究旨在开发一个基于理论的工具包，评估基于工具包在单一地点实施产后即刻长效可逆避孕护理的可行性，并完善工具包和实施过程以供未来有效性测试。

学习规划

2017 年至 2020 年，我们在一家大型学术医疗中心对基于工具包的即时产后避孕服务的实施进行了单点可行性研究。基于之前的定性工作，我们开发了一个基于理论的实施工具包。利益相关者小组选择了工具包资源以用于研究地点的多组件实施干预。这些资源包括旨在优化实施条件的工具和策略（即，实施领导、规划和评估；财务环境；关键利益相关者的参与；患者需求；与工作流程的兼容性；以及临床医生和员工的知识、技能和态度）。实施干预于 2018 年 1 月至 2019 年 4 月执行。研究结果包括实施结果（即，

结果

在实施过程中，在参与调查的 401 名符合条件的临床医生中，有 172 名 (43%) 对实施过程整体表示“非常”或“有些”满意，其中 70% 表示满意。在产前避孕咨询方面，2019年在研究点分娩的4960人中，1789人（36.1%）记录了有关产后避孕的产前咨询。记录的咨询率在整个 2019 年总体上有所增加（第一季度，12.5%；第四季度，51.0%），但因诊所地点而异（第四季度，范围 30%–79%）。在整个研究期间，产后即刻长效可逆避孕药的使用率有所增加（实施前，分娩的 5.46%；实施期间，8.95%；实施后，8.58%）。在避孕护理的患者体验中，患者调查受访者（回复率，15%–29% 主要是白人 (344/425 [81%]) 和受过高等教育（309/425 [73%] 至少拥有 4 年大学学位），反映了研究地点的人口。各个环境的得分都很低，从 2018 年到 2020 年，医院环境略有改善（产前检查，67%–63%；住院，45%–58%；分娩后门诊，69%–65%）。基于这些发现，工具包改进包括额外的资源，旨在使产前避孕咨询常规化，并支持更以患者为中心的避孕护理体验。69%–65%）。基于这些发现，工具包改进包括额外的资源，旨在使产前避孕咨询常规化，并支持更以患者为中心的避孕护理体验。69%–65%）。基于这些发现，工具包改进包括额外的资源，旨在使产前避孕咨询常规化，并支持更以患者为中心的避孕护理体验。

结论

在单个学术中心实施产后立即长效可逆避孕服务的基于工具包的过程与高可接受性但混合的医疗质量结果相关。添加了工具包资源以优化咨询率和避孕护理的患者体验。未来的研究应该在多站点、前瞻性试验中正式测试改进工具包的有效性。