MyPath: A Patient-Centered Web-Based Intervention to Improve Reproductive Planning for Women Veterans

背景：高比例的医疗和精神健康共病导致贫困孕产妇的风险增加 和新生儿的结果在女性退伍军人相比，他们的平民同行。积极规划 在怀孕前优化身心健康可以减轻这些风险;然而， 40%的退伍军人怀孕是意外的。国家指导方针建议定期提供 初级保健中以病人为中心的生殖计划服务，包括生殖目标评估 其次是量身定制的避孕和/或孕前咨询，以减少意外怀孕， 改善妊娠结局。然而，只有38%的有怀孕风险的退伍军人报告说， 避孕或孕前健康讨论与他们的初级保健提供者在过去的一年。我们 开发了“MyPath”，这是一种面向患者的新型基于网络的决策支持工具， 在VA初级保健规划服务。MyPath的目标是帮助女性退伍军人考虑他们的 生殖目标，增加他们的知识，调整避孕和怀孕时间的决定， 目标和健康需求，并与提供者共同决策。在58个试点测试中， 退伍军人，在诊所就诊前使用MyPath对退伍军人来说是高度可接受的， 与常规护理相比，计划讨论不会增加提供者的感知工作量。MyPath使用 也与提高决策质量和有效避孕有关。额外评价 MyPath需要在一个实用的随机试验中评估有效性并收集实施数据。 意义/影响：以患者为中心的可扩展干预措施可增强VA生殖 迫切需要在不给初级保健提供者造成负担的情况下规划服务。MyPath 干预利用面向患者的交互式技术，使妇女能够提供高质量的信息 决定，并与提供者就其生殖健康需求进行接触。如果发现成功，MyPath 将导致在VA初级保健中增加以患者为中心的生殖计划服务， 关键的HSR&D优先事项，包括获取，初级保健实践，妇女健康和整体健康。 创新：MyPath是第一个在线决策支持工具，旨在促进以患者为中心的生殖健康。 规划初级保健环境中的服务，并促进符合生殖健康的高质量决定， 目标.我们将使用与国家VEText计划合作的创新战略提供工具， 在预约之前，在自动短信预约提醒中向退伍军人发送MyPath链接。 具体目标：1）目标1将测试初级保健就诊前使用的MyPath工具对发生以下情况的影响 生殖计划讨论与共同决策（主要结局），患者-提供者 沟通自我效能和避孕决策质量，与常规护理相比; 2）目标2将测试 MyPath对避孕药使用、意外怀孕和孕前健康的长期影响 行为，与常规护理相比; 3）目标3是实施过程评估，包括定量 定性数据收集，以确定执行障碍和促进因素以及干预成本。 方法：本研究是一项3中心混合1型实用随机对照试验，集中在 24名妇女健康初级保健提供者及其育龄退伍军人患者的提供者水平。 我们将通过电话调查评估至少342名女性退伍军人的结果。 并进行6个月随访。我们将收集有关实施障碍和促进因素的信息， 定量和定性方法，包括与退伍军人，供应商和诊所领导人的访谈。 后续步骤/实施：务实的设计与强大的业务伙伴关系相结合，将 如果发现MyPath有效，则能够将研究结果快速转化为实践，最终 改善全国退伍军人妇女生殖健康成果和福祉的目标。

Background: High rates of medical and mental health comorbidities result in elevated risks of poor maternal and neonatal outcomes among women Veterans compared to their civilian counterparts. Proactive planning and optimization of physical and mental health prior to pregnancy can mitigate these risks; however, nearly 40% of pregnancies among Veterans are unintended. National guidelines recommend routine delivery of patient-centered reproductive planning services in primary care, including assessment of reproductive goals followed by tailored contraceptive and/or preconception counseling, to reduce unintended pregnancy and improve pregnancy outcomes. Only 38% of women Veterans at risk of pregnancy, however, report having contraceptive or preconception health discussions with their primary care provider in the past year. We developed “MyPath,” a novel patient-facing web-based decision support tool, to address gaps in reproductive planning services in VA primary care. MyPath’s objectives are to help women Veterans consider their reproductive goals, increase their knowledge, align contraceptive and pregnancy timing decisions with their goals and health needs, and engage in shared decision making with providers. In pilot testing among 58 Veterans, use of MyPath prior to clinic visits was highly acceptable to Veterans and increased reproductive planning discussions compared to usual care without increasing providers’ perceived workload. MyPath use was also associated with increased decision quality and effective contraceptive use. Additional evaluation of MyPath in a pragmatic randomized trial is needed to assess effectiveness and collect implementation data. Significance/Impact: Patient-centered, scalable interventions that can enhance delivery of VA reproductive planning services without creating burden on primary care providers are urgently needed. The MyPath intervention leverages interactive patient-facing technology to empower women to make high-quality informed decisions and engage with providers about their reproductive health needs. If found to be successful, MyPath will lead to increased access to patient-centered reproductive planning services in VA primary care, addressing key HSR&D priorities, including access, primary care practice, women’s health, and whole health. Innovation: MyPath is the first online decision support tool designed to promote patient-centered reproductive planning services in primary care settings and to facilitate high-quality decisions aligned with reproductive goals. We will deliver the tool using the innovative strategy of partnering with the national VEText program to send the MyPath link to Veterans before appointments in an automated text message appointment reminder. Specific Aims: 1) Aim 1 will test the effect of the MyPath tool used before primary care visits on occurrence of reproductive planning discussions with shared decision making (primary outcome), patient-provider communication self-efficacy, and contraceptive decision quality, compared to usual care; 2) Aim 2 will test the longer-term effect of MyPath on contraceptive utilization, unintended pregnancy, and preconception health behaviors, compared to usual care; 3) Aim 3 is an implementation process evaluation, including quantitative and qualitative data collection to identify implementation barriers and facilitators and intervention costs. Methodology: This study is a 3-site hybrid type 1 pragmatic randomized controlled trial clustered at the provider level among 24 women’s health primary care providers and their reproductive-aged Veteran patients. We will assess outcomes among a minimum of 342 women Veterans by telephone surveys post-visit and at 3- and 6-month follow up. We will collect information on barriers and facilitators to implementation using quantitative and qualitative methods, including interviews with Veterans, providers, and clinic leaders. Next Steps/Implementation: The pragmatic design, in combination with strong operational partnerships, will enable rapid translation of research findings into practice if MyPath is found to be effective, with the ultimate objective of improving reproductive health outcomes and well-being among women Veterans nationally.