Explaining Contraceptive Risk to Patients

1. Explaining Contraceptive Risk to Patients Association of Reproductive Health Professionals www.arhp.org Planned Parenthood Federation of America www.plannedparenthood.org Wendy Grube, PhD, CRNP University of Pennsylvania Women’s Healthcare Studies

2. Learning Objectives • Identify at least one factor that influences patients’ perceptions of risk. • List three different means of presenting risk; describe the advantages of each. more…

3. Learning Objectives (continued) • Identify at least three patient characteristics to consider when counseling about risks and benefits. • Describe at least one patient education tool that can be used to effectively communicate the risks and benefits of hormonal contraceptives.

4. Communicating the Risks of Hormonal Contraception Perceptions of Risk Expressing Risk Communicating About Risk

5. TypicalUse Rate PerfectUse Rate Understanding Risk: Relative Effectiveness of Contraceptives Steiner MJ. Obstet Gynecol. 2003.

6. Failure Rates of Contraceptive Methods Trussell J. Ardent Media, 2007.

7. Failure Rates of Hormonal Contraception Trussell J. Ardent Media, 2007.

8. Comparative Risks Trussell J. Ardent Media, 2004.

9. Section 1 Perceptions of Risk

10. Definition of Risk “…The possibility of suffering harm or loss.” ‘ ‘ The American Heritage Dictionary of the English Language

11. Risk & Health Decisions “…Decisions about risk are not technical, but value decisions.” ‘ ‘ Baker B. In: Risk Communication and Public Health. 1999.

12. Risk Misperception & Patients “…incorrect perceptions of excess risk of contraceptive products may lead women to use them less than effectively or not at all.” ‘ ‘ Gardner J, Miller L.J Womens Health 2005 Gardner J, Miller L. J Womens Health. 2005

13. Case Study: Alyssa Smith • 25-year-old nonsmoker, 3 children • Satisfied user of DMPA for 3 years • She decided to resume DMPA more…

14. Case Study: Alyssa Smith (continued) Past contraceptive history • Patch caused nausea • Difficulty remembering OCs • Not interested in IUD or vaginal insertion methods more…

15. Case Study: Alyssa Smith (continued) Ms. Smith left without a plan for an effective contraceptive method Primary care clinic stopped prescribing DMPA Early medication abortion Physician said, “It’s bad for bones” but provided no specifics Pregnant within 3 months more…

16. Case Study: Alyssa Smith (continued) • Specific risks of DMPA were explained and placed in context by another provider • Ms. Smith was comfortable with risks and benefits of DMPA

17. Risk Misperception & Providers Chaker AM. Wall Street Journal. November 22, 2005.

18. Misperceptions Affect Health Decisions • 1995—Warning: possible increased risk of VTE among users of third-generation OCs • Many women discontinued OC use • Prescribing patterns changed • Pregnancy and abortion numbers increased • Deemed a “non-epidemic” of VTE Chasen-Taber L. N Engl J Med. 2001; Drife L. Drug Saf. 2002. Furedi A. Lancet. 1998; Spitzer WO. Hum Reprod. 1997.

19. Unintended Pregnancies (2001) Finer LB. Perspect Sexual Reprod Health. 2006.

20. Case Study: Katherine Wallace Stopped using OCs at age 40 because of perceived risk in older women: “I was afraid of having a stroke” Became pregnant at age 42 while using diaphragm Acknowledges “I didn’t use it every time” but thought it would be less risky than OCs Began having perimenopausal symptoms at age 45 Provider explained that new low-dose OCs can be used with lower risk in older women, and can continue during perimenopause to alleviate symptoms

21. Risk Misperception andHormonal Contraceptives

22. Media Influence – + Widespread dispersion of reproductive health information Misperception of contraceptive risks Grimes DA. In: Oral Contraceptives and Breast Cancer. 1989.

23. Percentage Months after event Media Effect on OC Discontinuation Grimes DA. In: Oral Contraceptives and Breast Cancer. 1989.Jones EF. Fam Plann Perspect. 1980.

24. 400 1982–83 2 3 4 5 6 7 8 9 1991–92 11 12 13 14 15 16 17 1999–00 200 Number of Reports 0 Year/Month Product Launch & Reported Adverse Events Hartnell NR. Pharmacotherapy. 2004. Weber JCP. In: Iatrogenic Diseases. 1986.

25. Perception & Interpretation of Risk Individual Risk Presentation Characteristics of the Risk

26. Individual Factors • Culture • Literacy level and education • Developmental stage • Human tendencies • Underestimate effectiveness and overestimate risk of hormonal contraception • Optimism-pessimism bias more… Noone J, Clin Excell Nurse Pract. 2000; Hubertus AAMV et al., Br J Obstet Gynecol. 2001; Grimes DA, Snively GR, Obstet Gynecol. 1999; Steinberg L, Ann N Y Acad Sci. 2004; Mann L et al., J Adolesc. 1989; Steinberg L, Trends Cogn Sci. 2005; Edwards JE et al., Br J Fam Plann. 2000; Bowling A, Ephraim S, Qual Health Care. 2001.

27. Developmental Stage Reasoning is fully developed in hypothetical situations By Age 15 Early Adolescence Puberty causes increase in reward sensitivity Later Adolescence Self-regulation systems develop Steinberg L. Ann NY Acad Sci. 2004. Luna B. Ann NY Acad Sci. 2004.

28. Risk Presentation • Framing effects • Positive or negative • Uncertainty • Trust Edwards A. BMJ. 2002. Bennett P. Dept Health UK. 1997.

29. Characteristics of the Risk People worry more about risks that: • The individual cannot control • Are involuntary • Are associated with particular dread • Are novel or unfamiliar • Result from man-made sources • Are more easily recalled Harvard Center for Risk Statistics. 2003. Bennett P. In: Risk Communication and Public Health. 1999.

30. Estimated & Actual Mortality Rates 106 All accidents Motor vehicleaccidents 105 All disease All cancer Heart disease 104 Homicide Stroke Estimated number of deaths per year Stomach cancer Pregnancy Diabetes Flood 103 TB Tornado Asthma Botulism Electrocution 102 Smallpox vaccination 10 1 1 102 103 104 105 106 10 Actual number of deaths per year Bennett P. In: Risk Communication and Public Health. 1999.

31. RISKS BENEFITS Weighing the Risks & Benefits Burkman R. Am J Obstet Gynecol. 2004.

32. Section II Expressing Risk

33. Risk Calculations Degree towhich attributable Weigh pros and cons Causality Hennekens CH. Epidemiology in Medicine. 1987.

34. Associations vs. Causality • An association does not always mean exposure caused outcome • It could be due to random chance or bias Grimes DA. Lancet. 2002.

35. Commonly Used Risk Calculations Absolute Risk Attributable Risk Relative Risk

36. Absolute Risk The percentage of people in a group who experience a discrete event Number of events experienced Total exposure time of people at risk New York Academy of Medicine. 2005. Misselbrook D. Fam Practice. 2002.

37. Example of Absolute Risk Of 100,000 women on third-generation OCs, 30 will develop venous thromboembolism (VTE) per year. Absolute risk 30 per 100,000 woman-years Mills A. Hum Reprod. 1997. Bromham D, O’Brien T. 1995.

38. Attributable Risk • The difference in risk between those exposed and those not exposed • Reflects extra risk associated with exposure Risk in unexposed Risk in exposed BMJ Collections. 2007.

39. Risk of cancer in smokers: – Risk of cancer in nonsmokers: 100 per 100,000 10 per 100,000 Attributable risk: = 90 more cancers per 100,000 Attributable Risk: Example 1

40. Attributable Risk: 15 more VTE per 100,000 woman-years Attributable Risk: Example 2 Risk from 2nd-generation OCs Risk from 3rd-generation OCs – 30 VTE per 100,000 woman-years 15 VTE per 100,000 woman-years =

41.  Frequency Exposed Frequency Unexposed Relative Risk Frequency of the outcome in the exposed group divided by the frequency of the outcome in the unexposed group Grimes DA. Lancet. 2002. Hennekens CH. Epidemiology in Medicine. 1987.

42. Relative Risk < 1 Relative Risk > 1 Relative Risk = 1 Increased risk in exposed group No increased risk in exposed group Decreased risk in exposed group Interpreting Relative Risk Compared with unexposed group: Hennekens CH. Epidemiology in Medicine. 1987.

43. Absolute Risk: 3rd-Generation OCs Absolute Risk: 2nd-Generation OCs 15 per 100,000 woman-years 30 per 100,000 woman-years Relative Risk: 2 Relative Risk: Example 1  = Mills A. Hum Reprod. 1997.

44. Relative Risk: Example 2 Relative risk = 20  10 = 2 more… Grimes DA. Lancet. 2002.

45. Relative Risk: Example 2 (continued) Interpretation: “The risk of cesarean delivery with elective induction of labor is 2 times that associated with spontaneous labor.” 2X Or, alternatively stated: “The risk is twice as high.” Grimes DA. Lancet. 2002.

46. Relative Risk: Example 3 = 0.5 Relative risk = 6  12 = 0.5 more… Grimes DA. Lancet. 2002.

47. Relative Risk: Example 3 (continued) Interpretation: “The risk of infection after cesarean delivery with prophylactic antibiotics is 0.5 times that without antibiotics.” Or, alternatively stated: “The risk is half as high.” Grimes DA. Lancet. 2002.

48. Odds Ratio • Similar to relative risk • Used in case-control studies to identify an association between exposure and outcome  X Odds in cases Odds in controls Hennekens CH. Epidemiology in Medicine. 1987.

49. Comparative Risks of VTE 60 40 Incidence of VTE per 100,000 woman-years 20 0 Pregnancy High-dose OC Low-dose OC General Population Shulman LP. J Reprod Med. 2003. Chang J. In: Surveillance Summaries. 2003.

50. Section III Communicating About Risk