Telemedicine early medical abortion at home: evaluation

Discussion

The evaluation set out to determine whether the new models of telemedicine delivery of EMAH in Scotland, which were introduced in response to COVID-19, are safe and effective. It also aimed to address: patient experiences; the advantages and disadvantages of the different models of care, how they impact on different groups; and wider aspects of care such as wider sexual health care provision. The findings as they relate to the specific research questions are examined below.

1. What are the clinical benefits and risks of delivery of early medical abortion at home in Scotland without an in-person appointment?

WP1 was designed to consider the question of risks and benefits of EMAH with or without an in-person appointment. The findings from analysis of the national data on outcomes and complications (WP1) showed continuing effectiveness after the changes introduced in March 2020 that included the switch from in-person consultations before EMAH to increased use of telephone consultations, with a subsequent in-person visit only if required. Indeed, no statistical difference was seen in the high success rate. Although it is acknowleged that the numbers of rare complications were too low to test robustly, serious complications were observed to be low over both time periods examined with no cause for concern and consistent with existing published literature^[18].

Another risk previously identified is that the shift to a telephone consultation may mean that staff may miss visual cues that would alert them to safeguarding issues. Staff interviewed in WP4 also reported that with the shift to telephone consultations, they had initially been concerned that they may be less able to detect safeguarding matters by phone. However, they reported that their confidence with conducting safeguarding by phone grew over time and they felt confident with telephone questioning to determine who may have safeguarding issues and so subsequently needed to make an in-person visit. The patient pathways from the Health Boards (WP2) showed that questioning on safeguarding was indeed a routine part of the telemedicine pre-abortion consultation and that assessment tools for identifying safeguarding issues were in use by some.

The patient survey (WP3) showed that 7 out of 10 respondents could recall being asked about domestic violence or a partner being abusive to them. Staff (WP4) also noted that services had considered safeguarding issues, including being alert (during a telephone consultation) to safety issues without patients having to directly voice their concerns. For example, staff described how any concerns, voiced by the patient or picked up through other cues, triggered staff to arrange an in-person visit for them to be seen and assessed further. The findings from staff interviews echoed those from earlier qualitative research of abortion staff working in the NHS Lothian region, which outlined the use of ‘safe words’ that when used during a telephone consultation would trigger alternative arrangements and an in-person appointment. In addition, consultations can also be conducted by video call to gain more visual cues. Abortion service leads (WP2) reported that although video calls were an option available to them, they seldom used it.

In the patient survey (WP3), most respondents had a telephone consultation, either exclusively or before an in-person visit, and most reported they were able to speak privately. Furthermore, when asked which form of consultation they would choose in the future, the most common response was telephone consultation. An earlier qualitative study in Lothian, reported that woman valued the privacy, convenience and comfort afforded by a telephone consultation, and some felt better able to ask questions of the provider about abortion by telephone^[19]. The same factors: privacy, convenience, comfort and flexibility were also cited in positive free text comments made by patients in this national survey (WP3). However, it is also notable that a sizeable minority (33%) would have preferred to have a consultation in the clinic in future, therefore reiterating that patients value being given a choice.

Findings from staff interviews (WP4) were consistent with the patient survey in identifying the benefits for patients. A further benefit of the shift to consultations by telemedicine noted in staff interviews was around its use in rural and remote areas because it enabled them to provide high-quality care via phone, even when in a different geographic location. Staff also noted that the current approach helped reduce waiting times for treatment for patients compared to what they would otherwise have been and allowed staff to work more flexibly. Staff reported that telemedicine provision of abortion care also offered benefits for the wider NHS in the context of ongoing workforce pressures across NHS Health Boards. From a practical perspective, staff felt that it offered increased flexibility in managing staffing within services. There may also be cost benefits for the NHS with a telemedicine EMAH model. Although this evaluation did not include a cost effectiveness analysis, findings from England and Wales provide evidence of modest cost savings with new models of telemedicine EMAH care^[20].

2. What are the advantages and disadvantages for patients of the current approach to early medical abortion at home versus the pre-March 2020 approach?

There are advantages for patients with the new approach to EMAH care, notably improved access to abortion as identified by staff in WP4. Data for 2021 on termination of pregnancy statistics from PHS also provides indirect evidence for improved access to abortion with this model of care as they show a decrease in average stage of pregnancy of patients having abortions of around one week following the introduction of changes. National evidence-based guidelines on abortion care advise that abortion is safer at earlier stages of pregnancy and that there is less pain and bleeding with earlier compared to later medical abortion procedures.

The findings from the patient survey (WP3) contribute understanding of patient experiences of the new model(s) of care and provide evidence of strong support from patients for keeping the current approach to EMAH. Indeed, most survey respondents (92%) were either very satisfied or slightly satisfied with the overall EMAH care they had received. They expressed support for retaining the options of: a telemedicine consultation; administering both abortion medications at home; and having medications delivered to their home or collected from clinics or a community pharmacy. Findings from the staff interviews (WP4) also provided support for keeping the new models of EMAH care. Staff considered that the changes had been positive, resulting in improved access and patient-centred care, and giving patients more autonomy over the process. They noted that the new model resulted in less clinic appointments for patients, and so less time off work and less need to arrange childcare or carer duties. They also noted that the telemedicine appointment may offer less ‘visibility’ for those patients who may be concerned about maintaining privacy and confidentiality of their care. Staff noted that this might be particularly relevant for abortion services in small or remote and rural communities.

Furthermore, avoiding an in-person visit would avoid feeling intimidated or harassed by anti-abortion protests or vigils outside clinics, as raised in some of the negative feedback in free text comments in the patient survey (WP3). However, it should be noted that it was clear from the Health Board pathways and the patient survey that the great majority of patients still visited a clinic to collect their medication, even if they did not have an in-person appointment.

Staff interviews also pointed out that the new models of care had provided greater choice and flexibility around the various elements of EMAH care. There was widespread agreement that reverting to former models of care with in-person visits and routine ultrasound for all would reduce flexibility in service delivery, and increase waiting times and delays to treatment and care. This in turn would be likely to lead to more abortions at later gestations and increased need for procedures in hospital settings.

However, the staff interviews also noted the importance of building in more choice, as whilst some elements of the new model of EMAH care might be desired by most patients, they may not be the preference for others. An example of this is the pre-abortion ultrasound, which was routine before March 2020, but subsequently was conducted upon clinical need. In the patient survey WP3, responses from those who did not have an ultrasound showed that, whilst most did not want an ultrasound, around one in five might, choose to have one if given the opportunity.

In terms of disadvantages for patients, the shift to telephone or video call consultation from an in-person visit removes the opportunity to provide certain methods of contraception to patients at that time. Methods such as contraceptive pills, condoms or even supplies of the contraceptive injection for self-administration can be provided in the medication packs for patients to start after EMAH. However, methods such as the contraceptive implant require to be fitted by a healthcare provider and so this means that patients wishing to use such methods after EMAH need to make a subsequent clinic visit. Review of the patient pathways (WP2) did show variation in the methods of contraception that abortion services across Scotland were providing after EMAH. It will therefore be important moving forward for services to review how they can ensure patients can access a comprehensive range of contraceptive methods in a timely fashion after EMAH.

The loss of an in-person visit also removes the opportunity to undertake testing for sexually transmitted infections (STIs) at the clinical appointment. This does not prevent a discussion about STIs and the offer to arrange testing either by arranging for them to be sent a self-sampling kit to return by post, or to arrange a subsequent clinic visit for this for patients who want this or are at high risk of having a STI. The review of patient pathways (WP2) showed that Health Boards did have pathways in place for STI testing with the new models of care and the patient survey (WP3) showed that seven out of 10 respondents could recall having been offered STI testing. This suggests that the new models of care are largely managing to mitigate these potential disadvantages.

3. To what extent have different groups of patients been impacted in different ways by the delivery of early medical abortion at home in Scotland without an in-person appointment, how and why?

In staff interviews (WP4), staff reported that the new model of care offered advantages that may particularly benefit certain groups, such as those facing geographic barriers to care as it was associated with fewer visits, less travel and time off work or reduced need to make arrangements for those who were carers for others. Staff noted that this way of delivering care was especially important in rural and remote areas because it enabled them to provide high-quality care via phone/video, even when in a different geographic location.

The patient survey (WP3) showed high support for continuing the current models of care. Whilst most respondents were from the two largest Health Boards, it did have respondents across Scotland. In addition, just under one half of all respondents were from the most deprived postcode areas, showing that the new ways of delivering EMAH care are supported by patients from both deprived and affluent backgrounds. Unfortunately though there were not sufficient numbers of responses from either patients from minority ethnic groups or from patients reporting having a disability to allow for any comment about how the approach to EMAH affected them.

Analysis of the EMAH pathways across Scotland (WP2) revealed some variations in EMAH service delivery, most notably in what proportion of patients had ultrasound, whether patients were given options in how they could access their abortion medications and access to a comprehensive range of ongoing contraception. In addition, not all Health Boards provided EMAH up to 12 weeks of pregnancy as per WHO recommendations^[21] and in line with what is permitted in Scotland^[22]. This means that in some Health Boards patients may have more or less choice of elements of care than in others.

4. In comparison with the pre-March 2020 approach, how effective are the different approaches adopted to delivery of early medical abortion at home in different NHS Health Boards in terms of:

Patient safety

Given the high rates of safety and effectiveness in both time periods, and extremely small numbers of any adverse outcomes, any meaningful comparison of the relative safety of the approaches between different Health Boards was not possible.

Patient experience

The overall responses to the patient survey suggested that the great majority of patients were keen to be offered choice in how they accessed the service, which suggests those Health Boards offering greater flexibility were more likely to be welcomed by patients. Findings from the staff interviews recognised that some Health Boards, particularly smaller services, faced greater challenges than others in ensuring flexibility for patients or adapting to changes in Ministerial approvals.

However, similarly to patient safety, unfortunately whilst there were responses from patients in all except two of Scotland’s Health Board areas, many of the Board areas had too few responses to allow for any real comparison of how responses between patients in different Health Board areas varied.

Access to and uptake of wider sexual health service provision

The patient pathways (WP2) showed that some Health Boards were providing a wide range of contraceptive methods along with abortion medication. For those patients that wanted to use a method such as the contraceptive implant or intrauterine device that require to be fitted by a health care professional, Health Boards had pathways in place to help the patients access this and at the same time provided them with a short term supply of temporary contraception. The pathways did however show that some Boards were less proactive in offering contraception for patients. It will therefore be important for other abortion services that are not currently doing this to review how they can ensure patients can access a comprehensive range of contraceptive methods in a timely fashion after EMAH.

The review of patient pathways (WP2) showed that all Health Boards did have pathways in place for STI testing with the new models of care and these included sending self-sampling kits to patients, providing antibiotic prophylaxis to those at highest risk of STI or offering for the patient to reattend for testing or signposting them to local sexual health clinics.

Strengths and limitations

The strengths of this evaluation are that it is a Scotland-wide evaluation that examines the effectiveness of the new model of EMAH care and considers views of patients and staff across the country. The study design permitted comparison of outcomes of EMAH and complications in a six month period immediately before and 12 month period immediately after introduction of changes to EMAH and review of cases of complications and adverse outcomes for validation.

The evaluation has some notable limitations. In particular, the rarity of serious complications with EMAH means that the sample size is too small to detect differences in rates of rare events. In addition, not all NHS Health Boards contributed data on outcomes and complications; those not providing full data tended to be smaller Health Boards with limited staff resources. However, data from PHS on numbers of hospital readmissions (for validation purposes) suggested that numbers of complications related to abortion in small Health Boards were likely to be few in number.

Another limitation was that due to the protracted approvals process and the requirement for individual Quality Improvement Team (QIT) approval for the patient survey by each Health Board, the survey had a delayed and staggered start and most respondents came from the two largest boards of NHS Greater Glasgow and Clyde and NHS Lothian. However, these large boards were also early adopters of telemedicine EMAH and so were those mainly using this model of care. In addition, although the survey was national, patients had to actively choose to participate in the survey and so it is possible that patients who chose to participate may differ from those who chose not to.