In total, 2040 out of 3591 contacted participants responded to our mailings for an overall response rate of 56.8%. Within each specialty, responses rates were 51.1, 70.9, and 53.5% for obstetrician/gynecologists (Ob/Gyns), certified nurse midwives/certified midwives (CNMs/CMs) and family physicians (FPs). Of these, 1040 were excluded because they had not evaluated or treated a patient for early pregnancy failure in the past 6 months. An additional 24 respondents were excluded because they were not employed as one of our targeted practitioner groups. This process left 976 respondents eligible for further analysis.
presents the demographic and practice characteristics of our study population. Participants were predominately white, between 14 and 18 years since completing training, and currently practicing in a single specialty practice setting. Almost all Ob/Gyns identified at least one office procedure performed in their practice but only 21.7% reported offering office uterine evacuations. FPs were least likely to offer any of the listed office procedures.
presents the reported treatment patterns among the three specialties. These patterns reflect how patients were ultimately managed and does not necessarily indicate that the respondent themselves provided the service. As expected, practices differed significantly between provider specialties. For instance, Ob/Gyns were much less likely than other providers to report that their patients were managed expectantly (12.3 vs. 36.3% respectively, p<0.001). Misoprostol use was most commonly reported among Ob/Gyns (p<0.001) but only 19.3% of Ob/Gyns reported that more than 25% of their patients were treated with misoprostol. In fact, most providers had not used misoprostol at all in the past 6 months for EPF treatment. Similarly, office uterine evacuations were uncommon among all groups, even Ob/Gyns. Only 16.2% reported ever using office evacuations to treat EPF in the past 6 months. Finally, referrals were also an important feature of services: 32.7% of CNMs/CMs and 37.4% of FPs reported referring over 25% of patients to specialists for EPF treatment.
EPF treatment patterns by provider type in the last 6 months*
Personal rank of the four treatment options differed by provider specialty. Expectant management was the most commonly reported “most preferred” treatment by both CNMs/CMs (55.2%) and FPs (64.5%). Only 24.4% of Ob/Gyns reported expectant management as “most preferred”. A uterine evacuation in the operating room was reported to be the “most preferred” option by 137 (45.7%) of Ob/Gyns. Treatment with misoprostol was frequently ranked second best treatment: 33.2%, 61.8% and 60.7% of Ob/Gyns, CNMs/CMs and FPs respectively. Office uterine evacuations were most frequently cited as “least preferred” among Ob/Gyns (37.2%) and CNMs/CMs (43.9%), while operating room uterine evacuations were most commonly the “least preferred” option among FPs (41.8%). As provider ranking of misoprostol and office uterine evacuation increased, the likelihood of misoprostol and office uterine evacuation use in the last 6 months increased, respectively. (p<0.001)
In addition to their own preferences, participants also reported how they believed patients rank the four treatment options. Perceived patient preferences followed the same overall pattern as provider personal preference: expectant management was most commonly believed to be “most preferred” treatment by both CNMs/CMs and FPs and uterine evacuation in the operating room was most frequently believed to be the “most preferred” option by Ob/Gyns. However, there was some evidence that providers believe their patients' treatment preferences differ from their own. For example, fewer health care providers believed that their patients would consider uterine evacuation as the “most preferred” treatment than they would personally (15.6% vs. 28.4%, p<0.001, perceived patient and provider rank respectively). Further, more providers believed that their patients consider expectant management as “most preferred” than they would personally. (62.3% vs. 48.1%, p<0.001 patient and provider rank respectively).
Views toward misoprostol and office uterine evacuation use in EPF treatment were similar among the 3 groups of providers with a few exceptions. () FPs were most likely to identify barriers to implementing misoprostol use in their practice. (p<0.01) Although Ob/Gyns reported the most favorable views towards office uterine evacuations, 65.7% agreed that most women preferred general anesthesia and 46.4% agreed that the best treatment for EPF is an operating room uterine evacuation. Office space limitations was the most frequently identified barrier to offering office uterine evacuations identified.
Provider Attitudes and Beliefs towards EPF treatment
Bivariate tests concluded that provider specialty, practice setting, years in practice, and prior training in induced abortion were significantly associated with ever using misoprostol and with performing office uterine evacuations, while provider sex and race were not. When we examined misoprostol use, our multivariate analysis concluded that a health care provider's belief that misoprostol is safe was associated with misoprostol use (OR=2.68, p<0.001), while a belief that patients would not accept treatment with misoprostol is negatively associated with its use. (OR=0.16, p<0.001) after controlling for provider sex, specialty, years in practice, practice type and prior induced abortion training. Prior induced abortion training was not significantly associated with misoprostol use in the multivariate model. ()
Predictors of misoprostol and office uterine evacuations for EPF In the past 6 months
During our examination of office uterine evacuation use, we limited our analysis to Ob/Gyns with dilation and curettage privileges. () In this model, prior induced abortion training (OR=5.12, p<0.05) was associated with office uterine evacuation use after controlling for provider sex, specialty, years in practice, practice type and provider attitudes. A belief that operating room procedures are safer (OR=0.20, p<0.01), or that women prefer to be under general anesthesia was inversely associated with use. (OR=0.16, p<0.01)