Telehealth Medication Abortion in Primary Care: A Comparison to Usual in-Clinic Care.

INTRODUCTION: Providing abortion in primary care expands access and alleviates delays. The 2020 COVID-19 public health emergency (PHE) led to the expansion of telehealth, including medication abortion (MAB). This study evaluates the accessibility of novel telehealth MAB (teleMAB) initiated during the PHE, with the lifting of mifepristone restrictions, compared with traditional in-clinic MAB offered before the PHE at a Massachusetts safety-net primary care organization. METHODS: We conducted a retrospective electronic medical record review of 267 MABs. We describe sociodemographic, care access, and complete abortion characteristics and compare differences between teleMAB and in-clinic MABs using Chi-squared test, fisher's exact test, independent t test, and Wilcoxon rank sum. We conducted logistic regression to examine differences in time to care (6 days or less vs 7 days or more). RESULTS: 184 MABs were eligible for analysis (137 in-clinic, 47 teleMAB). Patients were not significantly more likely to receive teleMAB versus in-clinic MAB based on race, ethnicity, language, or payment. Completed abortion did not significantly differ between groups (P = .187). Patients received care more quickly when accessing teleMAB compared with usual in-clinic MAB (median 3 days, range 0 to 20 vs median 6 days, range 0 to 32; P < . 001). TeleMAB patients had 2.29 times the odds of having their abortion appointment within 6 days compared with in-clinic (95% CI: 1.13, 4.86). CONCLUSION: TeleMAB in primary care is as effective, timelier, and potentially more accessible than in-clinic MAB when in-person mifepristone regulations were enforced. TeleMAB is feasible and can promote patient-centered and timely access to abortion care.

Abortion Provision and Delays to Care in a Clinic Network in Washington State After Dobbs.

Importance: The Supreme Court decision Dobbs v Jackson Women's Health Organization (Dobbs) overturned federal protections to abortion care and altered the reproductive health care landscape. Thus far, aggregated state-level data reveal increases in the number of abortions in states where abortion is still legal, but there is limited information on delays to care and changes in the characteristics of people accessing abortion in these states after Dobbs. Objective: To examine changes in abortion provision and delays to care after Dobbs. Design, Setting, and Participants: Retrospective cohort study of all abortions performed at an independent, high-volume reproductive health care clinic network in Washington state from January 1, 2017, to July 31, 2023. Using an interrupted time series, the study assessed changes in abortion care after Dobbs. Exposure: Abortion care obtained after (June 24, 2022, to July 31, 2023) vs before (January 1, 2017, to June 23, 2022) Dobbs. Main Outcome and Measure: Primary outcomes included weekly number of abortions and out-of-state patients and weekly average of gestational duration (days) and time to appointment (days). Results: Among the 18 379 abortions during the study period, most were procedural (13 192 abortions [72%]) and funded by public insurance (11 412 abortions [62%]). The mean (SD) age of individuals receiving abortion care was 28.5 (6.44) years. Following Dobbs, the number of procedural abortions per week increased by 6.35 (95% CI, 2.83-9.86), but then trended back toward pre-Dobbs levels. The number of out-of-state patients per week increased by 2 (95% CI, 1.1-3.6) and trends remained stable. The average gestational duration per week increased by 6.9 (95% CI, 3.6-10.2) days following Dobbs, primarily due to increased gestations of procedural abortions. The average gestational duration among out-of-state patients did not change following Dobbs, but it did increase by 6 days for in-state patients (5.9; 95% CI, 3.2-8.6 days). There were no significant changes in time to appointment. Conclusions and Relevance: These findings provide a detailed picture of changes in abortion provision and delays to care after Dobbs in a state bordering a total ban state. In this study, more people traveled from out of state to receive care and in-state patients sought care a week later in gestation. These findings can inform interventions and policies to improve access for all seeking abortion care.

Telemedicine Abortion in Primary Care: An Exploration of Patient Experiences.

PURPOSE: The purpose of the study was to explore patients' experiences and perspectives obtaining telemedicine medication abortion (TeleMAB) through their primary care health system. METHODS: We conducted in-depth telephone interviews with 14 English-, Spanish-, and/or Portuguese-speaking patients who received a TeleMAB between July 2020 and December 2021, within a large primary care safety-net community health system in Massachusetts. We created and piloted a semistructured interview guide informed by patient-clinician communication frameworks and prior studies on patient experiences with TeleMAB. We analyzed data using reflexive thematic analysis and summarized main themes. RESULTS: Overall, participants found TeleMAB services in their primary care health system acceptable, positive, and easy. Participants discussed how TeleMAB supported their ability to exercise control, autonomy, and flexibility, and decreased barriers experienced with in-clinic care. Many participants perceived their primary care health system as the place to go for any pregnancy-related health care need, including abortion. They valued receiving abortion care from their established health care team within the context of ongoing social and medical concerns. CONCLUSIONS: Patients find TeleMAB from their primary care health system acceptable and beneficial. Primary care settings can integrate TeleMAB services to decrease care silos, normalize abortion as a part of comprehensive primary care, and improve access through remote care offerings. TeleMAB supports patients' access and autonomy, with the potential to benefit many people of reproductive age.

Telehealth vs In-Clinic Medication Abortion Services.

This cross-sectional study compares differences in patient characteristics between those using telehealth vs in-clinic services for medication abortion care.

Patient Perspectives Regarding Clinician Communication During Telemedicine Compared With In-Clinic Abortion.

OBJECTIVE: To explore patient perspectives regarding patient-clinician communication during telemedicine medication abortion compared with traditional, facility based, in-clinic visits. METHODS: We conducted semi-structured interviews with participants who received either live, face-to-face telemedicine or in-clinic medication abortion from a large, reproductive health care facility in Washington State. Using Miller's conceptual framework for patient-doctor communication in telemedicine settings, we developed questions exploring participants' experiences of the medication abortion consultation, including the clinician's verbal and nonverbal interpersonal approach and communication of relevant medical information, and the setting where care was received. We used inductive-deductive constant comparative analysis to identify major themes. We summarize patient perspectives using patient-clinician communication terms outlined in Dennis' quality abortion care indicator list. RESULTS: Thirty participants completed interviews (aged 20-38 years), 20 of whom had medication abortion by telemedicine and 10 who received in-clinic services. Participants who received telemedicine abortion services reported high-quality patient-clinician communication, which came from their freedom to choose their consultation location, and reported feeling more relaxed during clinical encounters. In contrast, most in-clinic participants portrayed their consultations as lengthy, chaotic, and lacking comfort. In all other domains, both telemedicine and in-clinic participants reported similar levels of interpersonal connection to their clinicians. Both groups appreciated medical information about how to take the abortion pills and relied heavily on clinic-based printed materials and independent online resources to answer questions during the at-home termination process. Both telemedicine and in-clinic participant groups were highly satisfied with their care. CONCLUSION: Patient-centered communication skills used by clinicians during facility based, in-clinic care translated well to the telemedicine setting. However, we found that patients who received medication abortion through telemedicine favorably ranked their patient-clinician communication overall as compared with those in traditional, in-clinic settings. In this way, telemedicine abortion appears to be a beneficial patient-centered approach to this critical reproductive health service.

Advance provision of medication for induced abortion: A qualitative study of patient perspectives.

OBJECTIVES: To examine potential users' perspectives regarding the provision of abortion medications for future use or "advance provision." STUDY DESIGN: In this qualitative study, we partnered with an independent reproductive health care clinic in Washington State to conduct semistructured, in-depth interviews with 22 individuals who obtained a medication abortion between August 2021 and January 2022. We asked participants their views on advance provision of abortion medications. Interviews were transcribed and deidentified. Inductive content analysis was used to identify major themes. RESULTS: Participants in our sample generally reacted positively to the idea of abortion medications for future use. Having pills in advance could improve timeliness and convenience of care and decrease the stigma associated with their use. Participants stressed the importance of adequate information regarding medication use, what to expect, and potential side effects. Most concerns about advance provision related to the safety and efficacy of medication abortion. CONCLUSIONS: This study found that individuals who recently obtained a medication abortion supported the provision of abortion medications for future use. IMPLICATIONS: Patient-centered educational materials, with adequate information for self-managing pregnancy termination, can be shared at time of prescription. Clinicians have an opportunity to offer these safe and effective medications in advance of need and increase timely access to this essential health care service. User concerns regarding abortion medications for future use should inform clinical innovation and evaluative research of service options.

Remote Delivery in Reproductive Health Care: Operation of Direct-to-Patient Telehealth Medication Abortion Services in Diverse Settings.

PURPOSE: Established models of reproductive health service delivery were disrupted by the coronavirus disease 2019 (COVID-19) pandemic. This study examines rapid innovation of remote abortion service operations across health care settings and describes the use of telehealth consultations with medications delivered directly to patients. METHODS: We conducted semi-structured interviews with 21 clinical staff from 4 practice settings: family planning clinics, online medical services, and primary care practices-independent or within multispecialty health systems. Clinicians and administrators described their telehealth abortion services. Interviews were recorded, transcribed, and analyzed. Staff roles, policies, and procedures were compared across practice settings. RESULTS: Across all practice settings, telehealth abortion services consisted of 5 operational steps: patient engagement, care consultations, payment, medication dispensing, and follow-up communication. Online services and independent primary care practices used asynchronous methods to determine eligibility and complete consultations, resulting in more efficient services (2-5 minutes), while family planning and health system clinics used synchronous video encounters requiring 10-30 minutes of clinician time. Family planning and health system primary care clinics mailed medications from clinic stock or internal pharmacies, while independent primary care practices and online services often used mail-order pharmacies. Online services offered patients asynchronous follow-up; other practice settings scheduled synchronous appointments. CONCLUSIONS: Rapid innovations implemented in response to disrupted in-person reproductive health care included remote medication abortion services with telehealth assessment/follow-up and mailed medications. Though consistent operational steps were identified across health care settings, variation allowed for adaptation of services to individual sites. Understanding remote abortion service operations may facilitate dissemination of a range of patient-centered reproductive health services.Annals "Online First" article.

Family medicine provision of online medication abortion in three US states during COVID-19.

OBJECTIVE: To examine provision of direct-to-patient medication abortion during COVID-19 by United States family physicians through a clinician-supported, asynchronous online service, Aid Access. STUDY DESIGN: We analyzed data from United States residents in New Jersey, New York, and Washington who requested medication abortion from 3 family physicians using the online service from Aid Access between April and November 2020. This study seeks to examine individual characteristics, motivations, and geographic locations of patients receiving abortion care through the Aid Access platform. RESULTS: Over 7 months, three family physicians using the Aid Access platform provided medication abortion care to 534 residents of New Jersey, New York, and Washington. There were no demographic differences between patients seeking care in these states. A high percentage (85%) were less than 7 weeks gestation at the time of their request for care. The reasons patients chose Aid Access for abortion services were similar regardless of state residence. The majority (71%) of Aid Access users lived in urban areas. Each family physician provided care to most counties in their respective states. Among those who received services in the three states, almost one-quarter (24%) lived in high Social Vulnerability Index (SVI) counties, with roughly one-third living in medium-high SVI counties (33%), followed by another quarter (26%) living in medium-low SVI counties. CONCLUSIONS: Family physicians successfully provided medication abortion in three states using asynchronous online consultations and medications mailed directly to patients. IMPLICATIONS: Primary care patients are requesting direct-to-patient first trimester abortion services online. By providing abortion care online, a single provider can serve the entire state, thus greatly increasing geographic access to medication abortion.

Factors associated with successful implementation of telehealth abortion in 4 United States clinical practice settings.

OBJECTIVE: To overcome obstacles to delivering medication abortion services during the COVID-19 pandemic, clinics and providers implemented new medication abortion service models not requiring in-person care. This study identifies organizational factors that promoted successful implementation of telehealth and adoption of "no test" medication abortion protocols. STUDY DESIGN: We conducted 21 semi-structured, in-depth interviews with health care providers and clinic administrators implementing clinician-supported telehealth abortion during the COVID pandemic. We selected 15 clinical sites to represent 4 different practice settings: independent primary care practices, online medical services, specialty family planning clinics, and primary care clinics within multispecialty health systems. The Consolidated Framework for Implementation Research guided our thematic analysis. RESULTS: Successful implementation of telehealth abortion included access to formal and informal inter-organizational networks, including professional organizations and informal mentorship relationships with innovators in the field; organizational readiness for implementation, such as having clinic resources available for telehealth services like functional electronic health records and options for easy-to-use virtual patient-provider interactions; and motivated and effective clinic champions. CONCLUSIONS: In response to the need to offer remote clinical services, 4 different practice settings types leveraged key operational factors to facilitate successful implementation of telehealth abortion. Information from this study can inform implementation strategies to support the dissemination and adoption of this model. IMPLICATIONS: Examples of successfully implemented telehealth medication abortion services provide a framework that can be used to inform and implement similar patient-centered telehealth models in diverse practice settings.