Impact of a pay-for-performance scheme for long-acting reversible contraceptive (LARC) advice on contraceptive uptake and abortion in British primary care: An interrupted time series study

Autoři: Richard Ma aff001;  Elizabeth Cecil aff001;  Alex Bottle aff001;  Rebecca French aff002;  Sonia Saxena aff001
Působiště autorů: Department of Primary Care and Public Health, Imperial College London, London, United Kingdom aff001;  Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom aff002
Vyšlo v časopise: Impact of a pay-for-performance scheme for long-acting reversible contraceptive (LARC) advice on contraceptive uptake and abortion in British primary care: An interrupted time series study. PLoS Med 17(9): e32767. doi:10.1371/journal.pmed.1003333
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003333



Long-acting reversible contraception (LARC) is among the most effective contraceptive methods, but uptake remains low even in high-income settings. In 2009/2010, a target-based pay-for-performance (P4P) scheme in Britain was introduced for primary care physicians (PCPs) to offer advice about LARC methods to a specified proportion of women attending for contraceptive care to improve contraceptive choice. We examined the impact and equity of this scheme on LARC uptake and abortions.

Methods and findings

We examined records of 3,281,667 women aged 13 to 54 years registered with a primary care clinic in Britain (England, Wales, and Scotland) using Clinical Practice Research Datalink (CPRD) from 2004/2005 to 2013/2014. We used interrupted time series (ITS) analysis to examine trends in annual LARC and non-LARC hormonal contraception (NLHC) uptake and abortion rates, stratified by age and deprivation groups, before and after the P4P was introduced in 2009/2010. Between 2004/2005 and 2013/2014, crude LARC uptake rates increased by 32.0% from 29.6 per 1,000 women to 39.0 per 1,000 women, compared with 18.0% decrease in NLHC uptake. LARC uptake among women of all ages increased immediately after the P4P with step change of 5.36 per 1,000 women (all values are per 1,000 women unless stated, 95% CI 5.26–5.45, p < 0.001). Women aged 20 to 24 years had the largest step change (8.40, 8.34–8.47, p < 0.001) and sustained trend increase (3.14, 3.08–3.19, p < 0.001) compared with other age groups. NLHC uptake fell in all women with a step change of −22.8 (−24.5 to −21.2, p < 0.001), largely due to fall in combined hormonal contraception (CHC; −15.0, −15.5 to −14.5, p < 0.001). Abortion rates in all women fell immediately after the P4P with a step change of −2.28 (−2.98 to −1.57, p = 0.002) and sustained decrease in trend of −0.88 (−1.12 to −0.63, p < 0.001). The largest falls occurred in women aged 13 to 19 years (step change −5.04, −7.56 to −2.51, p = 0.011), women aged 20 to 24 years (step change −4.52, −7.48 to −1.57, p = 0.030), and women from the most deprived group (step change −4.40, −6.89 to −1.91, p = 0.018). We estimate that by 2013/2014, the P4P scheme resulted in an additional 4.53 LARC prescriptions per 1,000 women (relative increase of 13.4%) more than would have been expected without the scheme. There was a concurrent absolute reduction of −5.31 abortions per 1,000 women, or −38.3% relative reduction. Despite universal coverage of healthcare, some women might have obtained contraception elsewhere or had abortion procedure that was not recorded on CPRD. Other policies aiming to increase LARC use or reduce unplanned pregnancies around the same time could also explain the findings.


In this study, we found that LARC uptake increased and abortions fell in the period after the P4P scheme in British primary care, with additional impact for young women aged 20–24 years and those from deprived backgrounds.

Klíčová slova:

Age groups – England – Female contraception – Finance – Pregnancy – Primary care – Termination of pregnancy – United Kingdom


1. Bearak J, Popinchalk A, Alkema L, Sedgh G. Global, regional, and subregional trends in unintended pregnancy and its outcomes from 1990 to 2014: estimates from a Bayesian hierarchical model. The Lancet Global Health. 2018;6(4):e380–e9. doi: 10.1016/S2214-109X(18)30029-9 29519649

2. Finer LB, Henshaw SK. Disparities in Rates of Unintended Pregnancy In the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health. 2006;38(2):90–6. doi: 10.1363/psrh.38.090.06 16772190

3. Ong J, Temple-Smith M, Wong WCW, McNamee K, Fairley C. Contraception matters: indicators of poor usage of contraception in sexually active women attending family planning clinics in Victoria, Australia. BMC Public Health. 2012;12(1):1108. doi: 10.1186/1471-2458-12-1108 23259407

4. Sedgh G, Bankole A, Singh S, Eilers M. Legal abortion levels and trend by women's age at termination. International Perspectives on Sexual and Reproductive Health. 2012;38(3). doi: 10.1363/3814312 23018136

5. National Statistics. Abortion Statistics England and Wales 2018. Department of Health and Social Care, 2019.

6. Wellings K, Jones KG, Mercer CH, Tanton C, Clifton S, Datta J, et al. The prevalence of unplanned pregnancy and associated factors in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). The Lancet. 2013;382(9907):1807–16. doi: 10.1016/S0140-6736(13)62071-1 24286786

7. Winner B, Peipert JF, Zhao Q, Buckel C, Madden T, Allsworth JE, et al. Effectiveness of Long-Acting Reversible Contraception. New England Journal of Medicine. 2012;366(21):1998–2007. doi: 10.1056/NEJMoa1110855 22621627.

8. National Institute for Health and Care Excellence. Long-acting reversible contraception. Manchester: National Institute for Health and Care Excellence; 2005.

9. Blumenthal PD, Voedisch A, Gemzell-Danielsson K. Strategies to prevent unintended pregnancy: increasing use of long-acting reversible contraception. Human Reproduction Update. 2011;17(1):121–37. Epub 2010/07/17. doi: 10.1093/humupd/dmq026 20634208.

10. Eeckhaut MCW, Sweeney MM, Gipson JD. Who Is Using Long-Acting Reversible Contraceptive Methods? Findings from Nine Low-Fertility Countries. Perspectives on Sexual and Reproductive Health. 2014;46(3):149–55. doi: 10.1363/46e1914 25040454

11. National Statistics. Opinions Survey Report No.41 - Contraception and Sexual Health 2008/09. London: NHS Information Centre for Health and Social Care, 2009.

12. Geary RS, Tomes C, Jones KG, Glasier A, Macdowall W, Datta J, et al. Actual and preferred contraceptive sources among young people: findings from the British National Survey of Sexual Attitudes and Lifestyles. BMJ Open. 2016;6(9). doi: 10.1136/bmjopen-2016-011966 27678537

13. NHS Employers, British Medical Association. Quality and Outcomes Framework guidance for GMS contract 2009/10—delivering investment in general practice. Leeds: NHS Confederation (Employers) Company Ltd.; 2009.

14. Arrowsmith ME, Majeed A, Lee JT, Saxena S. Impact of Pay for Performance on Prescribing of Long-Acting Reversible Contraception in Primary Care: An Interrupted Time Series Study. PLoS ONE. 2014;9(4):e92205. doi: 10.1371/journal.pone.0092205 24694949

15. Herrett E, Gallagher AM, Bhaskaran K, Forbes H, Mathur R, van Staa T, et al. Data Resource Profile: Clinical Practice Research Datalink (CPRD). International Journal of Epidemiology. 2015;44(3):827–36. doi: 10.1093/ije/dyv098 26050254

16. Department for Communities and Local Government. English Index of Multiple Deprivation 2010 [19/12/2018]. Available from:

17. Wagner AK, Soumerai SB, Zhang F, Ross-Degnan D. Segmented regression analysis of interrupted time series studies in medication use research. Journal of Clinical Pharmacy and Therapeutics. 2002;27(4):299–309. doi: 10.1046/j.1365-2710.2002.00430.x 12174032

18. Helfenstein U. The Use of Transfer Function Models, Intervention Analysis and Related Time Series Methods in Epidemiology. International Journal of Epidemiology. 1991;20(3):808–15. doi: 10.1093/ije/20.3.808 1955267

19. Bhaskaran K, Gasparrini A, Hajat S, Smeeth L, Armstrong B. Time series regression studies in environmental epidemiology. International Journal of Epidemiology. 2013;42(4):1187–95. doi: 10.1093/ije/dyt092 23760528

20. Box GEP, Jenkins GM, Reinsel GC, Ljung GM. Time Series Analysis: Forecasting and Control. 5th ed. Hoboken, NJ, USA: John Wiley & Sons, Inc. 2015.

21. Office for National Statistics. Opinions Survey Report No 41 Contraception and Sexual Health 2008/09. The Information Centre for Health and Social Care, 2009.

22. Firman N, Palmer MJ, Timæus IM, Wellings K. Contraceptive method use among women and its association with age, relationship status and duration: findings from the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3). BMJ Sexual & Reproductive Health. 2018;44(3):165–74. doi: 10.1136/bmjsrh-2017-200037 29972356

23. National Statistics. Abortion Statistics, England and Wales: 2013. Department of Health, 2014.

24. Campbell SM, Reeves D, Kontopantelis E, Sibbald B, Roland M. Effects of Pay for Performance on the Quality of Primary Care in England. New England Journal of Medicine. 2009;361(4):368–78. doi: 10.1056/NEJMsa0807651 19625717.

25. Doran T, Kontopantelis E, Valderas JM, Campbell S, Roland M, Salisbury C, et al. Effect of financial incentives on incentivised and non-incentivised clinical activities: longitudinal analysis of data from the UK Quality and Outcomes Framework. BMJ. 2011;342. doi: 10.1136/bmj.d3590 21712336

26. Jandoc R, Burden AM, Mamdani M, Lévesque LE, Cadarette SM. Interrupted time series analysis in drug utilization research is increasing: systematic review and recommendations. Journal of Clinical Epidemiology. 2015;68(8):950–6. doi: 10.1016/j.jclinepi.2014.12.018 25890805

27. Gobin M, Verlander N, Maurici C, Bone A, Nardone A. Do sexual health campaigns work? An outcome evaluation of a media campaign to increase chlamydia testing among young people aged 15–24 in England. BMC Public Health. 2013;13:484. doi: 10.1186/1471-2458-13-484 23683345

28. Wellings K, Palmer MJ, Geary RS, Gibson LJ, Copas A, Datta J, et al. Changes in conceptions in women younger than 18 years and the circumstances of young mothers in England in 2000–12: an observational study. The Lancet. 2016. doi: 10.1016/S0140-6736(16)30449-4 27229190

29. Glasier A, Manners R, Loudon JC, Muir A. Community pharmacists providing emergency contraception give little advice about future contraceptive use: a mystery shopper study. Contraception. 2010;82(6):538–42. doi: 10.1016/j.contraception.2010.05.008 21074017

30. Mantzourani E, Hodson K, Evans A, Alzetani S, Hayward R, Deslandes R, et al. A 5-year evaluation of the emergency contraception enhanced community pharmacy service provided in Wales. BMJ Sexual & Reproductive Health. 2019;45(4):275–82. doi: 10.1136/bmjsrh-2018-200236 31395752

31. NHS England. Report of the Review of the Quality and Outcomes Framework in England. 2018.

32. Roland M, Olesen F. Can pay for performance improve the quality of primary care? BMJ. 2016;354:i4058. doi: 10.1136/bmj.i4058 27492822

33. Roland M, Guthrie B. Quality and Outcomes Framework: what have we learnt? BMJ. 2016;354:i4060. doi: 10.1136/bmj.i4060 27492602

34. Chew-Graham C, Hunter C, Langer S, Stenhoff A, Drinkwater J, Guthrie E, et al. How QOF is shaping primary care review consultations: a longitudinal qualitative study. BMC Family Practice. 2013;14(1):103. doi: 10.1186/1471-2296-14-103 23870537

35. Minchin M, Roland M, Richardson J, Rowark S, Guthrie B. Quality of Care in the United Kingdom after Removal of Financial Incentives. New England Journal of Medicine. 2018;379(10):948–57. doi: 10.1056/NEJMsa1801495 30184445.

36. Thomas A, Karpilow Q. The intensive and extensive margins of contraceptive use: comparing the effects of method choice and method initiation. Contraception. 2016;94(2):160–7. doi: 10.1016/j.contraception.2016.03.014 27036300

37. Moreau C, Bohet A, Trussell J, Bajos N. Estimates of unintended pregnancy rates over the last decade in France as a function of contraceptive behaviors. Contraception. 2014;89(4):314–21. doi: 10.1016/j.contraception.2013.11.004 24560475

38. Rowlands S, Ingham R. Long-acting reversible contraception: conflicting perspectives of advocates and potential users. BJOG: An International Journal of Obstetrics & Gynaecology. 2017;124(10):1474–6. doi: 10.1111/1471-0528.14699 28432718

39. Gomez AM, Fuentes L, Allina A. Women or LARC first? Reproductive autonomy and the promotion of long-acting reversible contraceptive methods. Perspectives on sexual and reproductive health. 2014;46(3):171–5. doi: 10.1363/46e1614 24861029

Článek vyšel v časopise

PLOS Medicine

2020 Číslo 9

Nejčtenější v tomto čísle

Tomuto tématu se dále věnují…

Zapomenuté heslo

Nemáte účet?  Registrujte se

Zapomenuté heslo

Zadejte e-mailovou adresu se kterou jste vytvářel(a) účet, budou Vám na ni zaslány informace k nastavení nového hesla.


Nemáte účet?  Registrujte se