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Improved Access to Medication Abortion in Oregon Using Improved access to medication OHSUabortion in Oregon using telemedicine DATE: Nov 14, 2019 PRESENTED BY: Maureen Baldwin, MD MPH Pacific NW Update, Portland, OR Objectives • Review the epidemiology of FDA-approved medication abortion in Oregon • Understand barriers to abortion access, particularly in rural Oregon • Compare strategies for medical abortion via telemedicine: The TelAbortion Project OHSU• Review a model for implementation of direct to patient telemedicine medical abortion in Oregon 2 Disclosures • Merck Pharmaceuticals – trainer • Bayer Healthcare – trainer, medical advisory committee • Medicines360 – research site co-investigator OHSU• National Hemophilia Foundation – medical advisory committee 3 16.4 2006 11.1 OHSU2016 Oregon abortion rates 33% decline in a decade 20 15 10 16.4/1000 5 11.1/1000 0 OHSU2006 2016 8,900 abortions per year half at Planned Parenthood clinics 65% use medication abortion 5 Office medication abortion: - medical history - gestational dating - options counseling - informed consent OHSU- medications *screening and prevention 6 Medication abortion <10 weeks • Two medication regimen: – Mifepristone – Misoprostol taken 1-2 days later – Most pass the pregnancy in 4-6 hours • Follow-up to ensure completed abortion OHSU– Self-evaluation + • Repeat ultrasound (1-2 weeks) • Serial blood tests (before and 1-2 weeks) • Negative pregnancy test (3-4 weeks) 7 Best practices – combined regimen OHSU 8 Medication management of EPL - RCT OHSU 9 Schreiber et al. NEJM 2018 Addition of mifepristone improves outcomes Women receiving combined treatment were 63% less likely to need a procedure OHSU(NNT=6) 10 Safe and effective • Review of 2927 medical abortions <7 weeks – Serious adverse outcomes in 0.6% • Infection in 17 • Hemorrhage in 2 – ED visits in 1.3% – Ongoing pregnancy in <1% OHSU– Aspiration procedure in <3% 11 Baldwin MK, Bednarek PH, Russo J. 2017 NAAFP conference poster What am I going to do? • 26 year old with 2 kids under 5 • Lives in Astoria • Just started a new job • 6 weeks pregnant OHSU• Seeking abortion 12 How soon can it happen? • Where can I go that’s safe? • How far away? • How much time does it take? • How long do I need to be off work? • How much childcare will I need? OHSU• How much does it cost? • Will it be private? 13 How much does it cost? • Medicaid: free • Private insurance: variable • Planned Parenthood: $475 • OHSU out of pocket: $514 OHSU In-hospital ~$10,000 14 Where can I go? 97 miles to Portland from Astoria OHSU$ tank of gas $ full day of childcare 30% of Oregon women live in a county without an abortion provider 15 OHSU OHSU Health system barriers • Trained providers • Health system restrictions – Ethical and Religious Directives (ERDS) • FDA restrictions OHSU– Risk Evaluation and Mitigation Strategy (REMS) – mifepristone not in pharmacies 18 Abortion restrictions by state OHSU remappingdebate.org FDA restrictions OHSU 20 FDA restrictions OHSU Mifeprex prescribers: • Review prescribing information • Complete Prescriber Agreement Form – Have the following qualifications: • Ability to assess the duration of pregnancy accurately • Ability to diagnose ectopic pregnancies • Ability to provide surgical intervention in cases of incomplete abortion or severe bleeding, or to have OHSUmade plans to provide such care through others, and ability to assure patient access to medical facilities equipped to provide blood transfusions and resuscitation, if necessary • Will follow the guidelines for use of Mifeprex 22 FDA protocol for medical abortion Prior version 2011-2016 Current since March 2016 • Pregnancy up to 49 days • Pregnancy up to 70 days • Mifepristone 600 mg • Mifepristone 200 mg • Mifepristone administered • Mifepristone dispensed • Misoprostol taken in office • Misoprostol taken at home OHSU• Follow-up in clinic • Follow-up as preferred FDA exemption filed (an IND) to be able to use medication off-label for research Telemedicine in OR/WA • Synchronous two-way interactive video conferencing • Visit occurs/originates where the patient is located – Site to site – Direct to patient OHSU• Insurance coverage = office visits http://cchpca.org 24 OHSU www.telabortion.org OHSU OHSU www.telabortion.org Visit flow Ultrasound Video Screening Package Follow-up OHSULab tests Visit Videoconference medication abortion: - medical history - review of gestational dating - options counseling - informed consent OHSU- medications *screening and prevention States and Partners MT (PPMT) OR & WA MN (PPMNS) (OHSU, PPCW) ME & NY (MFP) CO & NM OHSU(PPRM) GA (carafem) HI (Univ of HI) OHSU Abortions Provided 522 500 Total Oregon 400 300 200 100OHSU88 0 Through October 20 2019 Distance from Home to Site Total excluding Hawaii Oregon residents 30% 20% OHSU10% 0% <10 10-49 50-99 100-149 ≥150 Miles Abortion Outcome 522 packages sent • Lost or still being followed: 22% • Changed mind about abortion: 2% • Completed abortion: 76% OHSUComplete medical abortion: 95% Aspiration: 5% Complications 444 patients with follow-up • No related significant complications • 2 hospitalizations, neither related to telemedicine OHSU• 37 ED visits (8%), mostly for bleeding/cramping ‒ All but 8 lived ≥50 miles from study site Acceptability N=343 Satisfaction Recommend to a friend OHSUVery satisfied: 81% Yes: 96% Unsatisifed: 0.6% Satisfied: 19% No or maybe: 4% Quotes from OR More Face to face I was able to comfortable experience decide when in own was great & how was home best for me We could do it on our Not needing OHSUown time. to drive 60+ miles twice Didn't have to find care Done Confidentiality for children quicker Implementation outcomes ADVANTAGESNOT CHALLENGES CHALLENGES PrivacyCommunication Billing and coding PatientFinding- centeredultrasound sites Multiple components ConvenienceRhogam Multiple communications EfficiencyFollow-up Dis-coordinated medical OHSUEquivalent systems Lost opportunities for screening and prevention 38 www.earlyoptionpill.com OHSU 39 Thank you!!! [email protected] OHSUwww.telabortion.org OHSU Physician Advice & Referral Service • 503-494-4567 • 800-245-6478 (toll-free).
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