Jacqueline Ellison1, Megan B Cole2, Amresh D Hanchate3, Lewis Kazis2, Sarah Lindsay4. 1. Brown University School of Public Health, Providence, RI, USA. Electronic address: jacqueline_ellison@brown.edu. 2. Boston University School of Public Health, Boston, MA, USA. 3. Wake Forest School of Medicine, Winston-Salem, NC, USA. 4. Hartford HealthCare, Hartford, CT, USA.
Abstract
OBJECTIVE: Despite evidence that mandatory pelvic examinations deter contraceptive use and are not clinically necessary, survey research suggests that clinicians regularly perform pelvic examinations prior to prescribing contraceptives. This study estimates prevalence of non-indicated pelvic exams during contraceptive encounters, and variation in prevalence by provider specialty. STUDY DESIGN: Using a national sample of commercial claims data, we identified contraceptive encounters without concurrent indication for pelvic examination among females aged 15-49 from 2007 to 2017. We first calculated the non-indicated exam rate by provider specialty and patient age. Using data from 2017 and linear probability models with metropolitan statistical area fixed effects, we estimated the differences in adjusted rates of non-indicated pelvic examination by provider specialty. To assess trends by provider specialty, we used all years of data and interacted specialty with year. RESULTS: Of 7.9 million identified contraceptive encounters, 81.8% had no identified indications for pelvic exam. Exams were billed at 17.7% of these visits (2007-2017), and this rate increased from 13.4% in 2007 to 20.7% in 2017. The largest increase occurred among encounters with an obstetrician-gynecologist. In 2017, obstetrician-gynecologists were 20.3 percentage points (95% CI: 19% to 21%) more likely to perform a concurrent pelvic exam compared to family physicians. CONCLUSIONS: Pelvic examinations during contraceptive visits increased from 2007 to 2017. Increases occurred across all provider specialties, but were largely driven by obstetrician-gynecologists, who oversaw over half of all contraceptive encounters and performed non-indicated pelvic exams at the highest rate. IMPLICATIONS: This research provides real-world evidence that suggests pelvic exams are increasingly performed during contraceptive encounters and that patients regularly undergo a low-value, invasive examination while obtaining contraceptive care. Continuing education, reimbursement reform, and more evidence on the harms of non-indicated pelvic exams will be necessary to change clinical practice.
OBJECTIVE: Despite evidence that mandatory pelvic examinations deter contraceptive use and are not clinically necessary, survey research suggests that clinicians regularly perform pelvic examinations prior to prescribing contraceptives. This study estimates prevalence of non-indicated pelvic exams during contraceptive encounters, and variation in prevalence by provider specialty. STUDY DESIGN: Using a national sample of commercial claims data, we identified contraceptive encounters without concurrent indication for pelvic examination among females aged 15-49 from 2007 to 2017. We first calculated the non-indicated exam rate by provider specialty and patient age. Using data from 2017 and linear probability models with metropolitan statistical area fixed effects, we estimated the differences in adjusted rates of non-indicated pelvic examination by provider specialty. To assess trends by provider specialty, we used all years of data and interacted specialty with year. RESULTS: Of 7.9 million identified contraceptive encounters, 81.8% had no identified indications for pelvic exam. Exams were billed at 17.7% of these visits (2007-2017), and this rate increased from 13.4% in 2007 to 20.7% in 2017. The largest increase occurred among encounters with an obstetrician-gynecologist. In 2017, obstetrician-gynecologists were 20.3 percentage points (95% CI: 19% to 21%) more likely to perform a concurrent pelvic exam compared to family physicians. CONCLUSIONS: Pelvic examinations during contraceptive visits increased from 2007 to 2017. Increases occurred across all provider specialties, but were largely driven by obstetrician-gynecologists, who oversaw over half of all contraceptive encounters and performed non-indicated pelvic exams at the highest rate. IMPLICATIONS: This research provides real-world evidence that suggests pelvic exams are increasingly performed during contraceptive encounters and that patients regularly undergo a low-value, invasive examination while obtaining contraceptive care. Continuing education, reimbursement reform, and more evidence on the harms of non-indicated pelvic exams will be necessary to change clinical practice.