Comparison of Telephone Follow-up With In-person Follow-up After Medical Abortion
Background: Medical abortions in Canada are provided using a standard regimen of methotrexate and misoprostol. After these medications are administered, patients are most commonly checked for termination of the pregnancy with an ultrasound and physical examination at an in-clinic follow-up appointment. These follow-up appointments can be inconvenient, costly, and take away from patient privacy. Furthermore, it has been suggested that these follow-up appointments may not be necessary for patients.
Objective: To determine whether remote follow-up, using telephone and blood testing is a feasible, safe, and effective method of follow‐up after medical abortion, compared to standard care that requires an in-clinic visit and ultrasound.
This study offers women the option of remote follow-up by telephone combined with serum Beta-human chorionic gonadotropin (β-hCG) testing or standard in-clinic follow up. We will determine women's preferences for follow up, and compare adherence to the follow-up schedule, number of clinical contacts, and outcomes of the abortion. This study will be performed at two clinics in Toronto, the Bay Centre for Birth Control (BCBC) and the Choice in Health Clinic (CIHC).
Primary Hypothesis: Follow-up will be more successful with RFU, compared to SFU.
Medical; Abortion, Fetus
Other: Remote Follow-up (RFU)
Other: Standard Follow-up (SFU)
|Study Design:||Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Health Services Research
|Official Title:||A Comparison of Remote Follow-up After Medical Abortion Using Telephone and Serum Pregnancy Testing With Standard In-person Follow-up|
- Rate of successful follow-up in women choosing RFU compared with those choosing SFU after medical abortion with M&M [ Time Frame: Within the designated time of 15 days post methotrexate injection ±3 days ]Successful follow-up will be defined as completion of telephone follow-up contact and serum β-hCG testing (for the RFU cohort) or attendance for the in-clinic follow-up visit within the designated time of 15 days post methotrexate injection ±3 days (for the SFU cohort).
- Percent of women who choose RFU [ Time Frame: 1 day ]
- Percent of women choosing RFU who complete follow-up without a clinic visit [ Time Frame: Within the designated time of 15 days post methotrexate injection ±3 days ]
- Percent of women in RFU and SFU groups who made no unscheduled visits related to medical abortion [ Time Frame: Within 28 days of methotrexate injection ±3 days ]
- Emergency department visit [ Time Frame: Within 28 days of methotrexate injection ±3 days ]Determined through subject history
- Hemorrhage - defined as bleeding resulting in transfusion, intravenous fluids or a drop in hemoglobin of 20 g [ Time Frame: Within 28 days of methotrexate injection ±3 days ]Determined from patient history with retrieval of emergency department/hospital records or documented drop of 20 g.
- D&C with the cause characterized as 1) for bleeding, at clinician's recommendation, 2) for continuing pregnancy, 3) at patient's request (usually because of delayed expulsion of the pregnancy in a medically stable patient) [ Time Frame: Within 35 days of methotrexate injection ]
- Infection requiring antibiotics [ Time Frame: Within 28 days of methotrexate injection ±3 days ]Determined from the clinic record or subject history
- Acceptability of SFU and RFU [ Time Frame: At 28 days after methotrexate injection ±3 days ]Measured using an Acceptability Questionnaire administered at discharge from ongoing care. This questionnaire is adapted from a previous study of acceptability of mifepristone and misoprostol abortions by Winikoff et al. It contains four close-ended and three open-ended questions designed to capture the patient's perspective on their medical abortion experience, whether they would choose the same method of follow-up in future, and their opinions on the best and worst features of their chosen follow-up method.
- Number of subject-initiated telephone contacts during clinic hours [ Time Frame: Within 28 days of methotrexate injection ±3 days ]Abstracted from the medical record
- Number of subject-initiated telephone contacts to on-call physician [ Time Frame: Within 28 days of methotrexate injection ±3 days ]Abstracted from the medical record
- Number of clinic-initiated telephone contacts outside of the scheduled follow-up contact for the RFU group [ Time Frame: Within 28 days of methotrexate injection ±3 days ]Abstracted from the medical record
- Number of letters sent [ Time Frame: Within 28 days of methotrexate injection ±3 days ]Abstracted from the medical record
- Selected method of contraception [ Time Frame: At 28 days after methotrexate injection ±3 days ]
- Reason for choice of follow-up method [ Time Frame: 1 day ]
|Study Start Date:||July 2011|
|Study Completion Date:||December 2014|
|Primary Completion Date:||July 2013 (Final data collection date for primary outcome measure)|
Active Comparator: Standard Follow-up (SFU)
Women selecting SFU at either site (BCBC or CIHC) will schedule their in-person follow-up appointment before leaving the BCBC clinic on Study Day 1, when they receive their medication. In-person follow-up appointment will be scheduled for Study Day 15 (± 3 days)where, as per usual care, includes a history and a Post-abortion Checklist, transvaginal ultrasound, and a bimanual exam to confirm successful pregnancy expulsion.
Other: Standard Follow-up (SFU)
Study Day 15 (± 3 days)requires an in-person post-abortion checkup: transvaginal ultrasound, and a bimanual exam to confirm successful pregnancy expulsion.
Experimental: Remote Follow-up (RFU)
On Study Day 1 in both sites, women selecting RFU will receive 3 laboratory requisition forms for serum β-hCG testing and will be instructed to have testing done at a laboratory site of her choice on Study Day 10-12. The follow-up telephone appointment will be scheduled to take place on Study Day 15 (±3 days). For the follow-up telephone appointment, the research nurse/nurse practitioner will calculate the percentage fall in the β-hCG value. She will contact the subject by phone at the specified time, take a history of the timing of misoprostol use, resulting symptoms and complete the symptom Post-abortion Check-list. The research nurse/nurse practitioner, in consultation with the clinic physician if necessary, will confirm the information, determine whether other follow-up is required.
Other: Remote Follow-up (RFU)
Women in the RFU group will be asked to return to the clinic for assessment if they have any complications.
Please refer to this study by its ClinicalTrials.gov identifier: NCT01943279
|Women's College Hospital-Bay Center for Birth Control|
|Toronto, Ontario, Canada, M5G1N8|
|Choice in Health Clinic|
|Toronto, Ontario, Canada, M6P 1A9|
|Principal Investigator:||Sheila Dunn, MD MSc CCFP||Women's College Hospital, University of Toronto|