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Dr Audrey Brown

Increasing the Proportion of Women using Long Acting Reversible Contraception (LARC) within a Geographical Area in Scotland. Dr Audrey Brown. Greater Glasgow and Clyde. Long-acting reversible contraception National Institute for Clinical Health and Excellence (NICE) 2005

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Dr Audrey Brown

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  1. Increasing the Proportion of Women using Long Acting Reversible Contraception (LARC) within a Geographical Area in Scotland Dr Audrey Brown

  2. Greater Glasgow and Clyde

  3. Long-acting reversible contraception National Institute for Clinical Health and Excellence (NICE) 2005 Women should be offered a choice of all methods including LARC. All LARC methods are more cost effective than the combined oral contraceptive pill even at 1 year of use. IUDs, IUS and implants are more cost effective than the injectable contraceptives. Increasing the use of LARC will reduce unwanted pregnancies

  4. Scotland 2004/5Uptake intra-uterine device, intra-uterine system, contraceptive implantper 1000 women aged 15-44

  5. Target set to increase from 17/1000 to 85/1000 in 5 years GGC – time for action

  6. Key Clinical Indicator (KCI) on LARC – Information and Statistics Division – annual reporting of uptake by board area Quality Improvement Scotland (QIS) – standard on intrauterine and implantable methods of contraception National LARC awareness campaign National Drivers

  7. Termination of Pregnancy Sterilisation Long Acting Reversible Contraception Chlamydia HIV Therapy Key Clinical Indicators for Sexual Health: Population Based Indicator

  8. Essential Criteria Women requiring contraception are given information about, and offered a choice of, all methods of contraception including intra-uterine and implantable contraceptives 60 or more females per 1000 of reproductive age per year are prescribed intrauterine and implantable contraceptives Contraceptive providers who do not provide intrauterine and implantable contraceptives have an agreed mechanism in place for referring women A consultation appointment with a service providing intrauterine and implantable contraceptives is available within 5 working days Desirable criterion 100 or more females per 1000 of reproductive age per year are prescribed intrauterine and implantable contraceptives by the end of 2011 QIS LARC standard

  9. Media launch • Retail outlets • Cinemas • Gym changing rooms • Bar toilets

  10. Raise awareness through distribution of LARC resource pack Contraceptive prescribing guidance for primary care Improve access to free training, especially for nursing staff, both primary care and acutes Reimburse primary care practitioners for provision of LARC in general practice Locality mapping to drive local planning Improve access to LARC at Sandyford Local action:

  11. LARC Resource PackThis resource pack is designed to support both CHPs and specialist sexual health services in planning developments and implementation of local LARC (Long Acting Reversible Contraception) services. Section 1 – National LARC Policy & PerspectiveMajor documents supporting the rationale of increasing the use of LARC methods will reduce rates of unintended pregnancy in a cost effective mannerComparative rates of effectiveness of different contraceptive methods Section 2 – An Overview of LARC Usage Levels at National, Board & CHP LevelAn overview of LARC usage for the national board-wide and CHP perspective including local mapping reports.Section 3 – LARC Protocols & Guidance DocumentsProtocols and Clinical Guidance documents supporting provision of LARC GP Contraceptive Prescribing Guidance Faculty of Sexual & Reproductive Healthcare Guidance on LARC Section 4 – GP Income & Local PaymentsQOF Agreement for LARC 2009/10Enhanced Service Agreements Section 5A – LARC TrainingFaculty of Sexual & Reproductive Healthcare training package CDs for fitting Implants, IUD/IUS and EHC provisionn Faculty Information re obtainment of Letters of Competence Nurse training documentation – RCN & West MCN Guidance, PGDsInformation on how to access training locally through Sandyford Section 5B – LARC Education Useful websites & online resourcesAvailable meetings & coursesResources available refer to sections 6 & 7Section 6 – LARC Patient PerspectivePatient/Client perspective 2 Articles from Peer Review Journals (article D Mansour et all European Journal of Contraception 13.4.2008) RAGS article WISH Report National Sexual Health Awareness Campaign materialsSection 7 – Patient Resources for LARCPatient/Client InformationInformation on how to access written leaflets and posters locallyUseful websites Examples of patient information leaflets (FPA, Health Scotland )Sandyford materials for signposting/referring patients to local services.Section 8 – Templates & Tools for Local LARC Planning, Audit & Implementation.This section contains some examples of templates that can be adapted and supported at a local CHP level. Some examples have been included:Needs Assessment AuditsImplementation/Action Plans

  12. CONTRACEPTIVE PRESCRIBING IN PRIMARY CARE • Cerazette®should only be considered in women who cannot tolerate or have contraindications to oestrogen containing contraceptives • Cerazette® may also have advantages in women with a history of poor compliance Consider long-acting reversible contraception (LARC) as first line option as this is the most effective way to avoid pregnancy COC appropriate POP appropriate Micronor®or Femulen® Should be considered 1st line POPs • 1st line choice should be a standard strength 2nd generation such as Microgynon 30®or Loestrin 30® • If patient suffers from acne, consider Marvelon® Adverse effects, poor cycle control or poor compliance may dictate further options Patient requests contraception • Take full medical and sexual history • Check BP and smear status • Offer STI screening • Discuss contraceptive choices taking into account the above and patient preference Consider appropriateness of COC or POP taking into account patients age, medical history, risk factors and patient preferences LONG-ACTING REVERSIBLE CONTRACEPTION (LARC) See Nice CG30 (Long-acting Reversible Contraception – Oct 2005) • Progesterone-only implant (Implanon®) - Lasts 3 years • Copper IUD (TT380 Slimline®) - Lasts 10 years • Progestogen-only IUS (Mirena®) - Lasts 5 years • Useful if menorrhagia present • Progestogen-only depot (Depo-Provera®) • Given every 12 weeks • NB: The effectiveness of LARC preparations containing hormones, such as Implanon® may be affected by interacting medicines. Refer to individual SPC or BNF for guidance

  13. Contraceptive Implant In 2009-10 each practice contracted to provide the contraceptive implant service will receive a £25.81 insertion fee and £51.61 removal fee per patient IUD/IUS In 2009-10 each practice contracted to provide the IUD/IUS service will receive a £79.92 insertion fee per patient. Local Enhanced ServiceNational Enhanced Service

  14. Over 3000 TOPs annually in GGC Over 1 in 4 are repeat TOP Two thirds performed medically Local training programme for gynaecology nurses to train in implant insertion Capturing termination of pregnancy population

  15. GGC women undergoing MTOP in 2007 and 2010

  16. GGC women undergoing MTOP in 2007 and 2010

  17. MTOP and STOP women

  18. Redesign of Sandyford Central drop-in services Sept 2009 Increase drop-in registration hours from 2 hour window to 5 hour window Offer LARC fitting at drop-in Improving access to LARC at Sandyford

  19. IUD/IUS insertion or reinsertion • Jan - Aug 09 • 103 • Sept 09 – Feb10 • 152

  20. Implant insertion or reinsertion • Jan – Aug 09 • 86 • Sept 09 – Feb 10 • 180

  21. Activity in 2004/05 vs 2009/10 in GGC

  22. 5 years on…..

  23. Uptake of LARC in GGC has increased from 17/1000 women to 69/1000 women over 5 years Increase in uptake in GGC has outperformed that in Scotland as a whole A combination of national and local drivers are likely to have contributed We did not meet our own target of a 5 fold increase in uptake in 5 years But we did meet the essential QIS target of 60 per 1000 women being prescribed LARC Summary

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