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Am Fam Physician. 2023;107(5):535-538

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Key Clinical Issue

Does telehealth allow for the effective delivery of preventive services for women, and how can it best be used to address these needs?

Evidence-Based Answer

Telehealth interventions alone had similar outcomes compared with in-person visits for women presenting for care related to contraception and interpersonal violence (IPV). (Strength of recommendation [SOR]: B, inconsistent or limited-quality patient-oriented evidence.) Telehealth interventions used to supplement usual care resulted in similar outcomes for contraceptive use at six months and had similar rates of sexually transmitted infections (STIs) and pregnancy. (SOR: B, inconsistent or limited-quality patient-oriented outcomes.) Outcomes related to abortion rates were unclear. There were no studies addressing telehealth services for family planning or STI counseling. There is insufficient evidence for factors related to health equity and health care access or potential harms.1,2

Preventive serviceOutcomeInterventionComparisonNumber of studies (participants)Overall effectStrength of evidence
Family planningNo studies
ContraceptionContraceptive useSupplemental telephone counseling; structured telephone supportFour-month supply of OCs and condoms and in-person counseling; general advice for follow-up as needed2 RCTs (n = 1,724)Similar rates of OC continuation and condom use at three, six, and 12 months; similar rates of long-acting reversible contraception use at six months●○○
Sexually transmitted infection ratesSupplemental telephone counselingFour-month supply of OCs and condoms and in-person counseling1 RCT (n = 1,155)Similar rates of sexually transmitted infections●○○
Pregnancy ratesSupplemental telephone counselingFour-month supply of OCs and condoms and in-person counseling1 RCT (n = 1,155)Similar pregnancy rates●○○
Abortion ratesStructured telephone supportGeneral advice for follow-up as needed1 RCT (n = 569)Similar rates of abortion in both groups of post abortion patients at one year; reduction of subsequent abortion in both groups within two years○○○
Sexually transmitted infection counselingNo studies
Interpersonal violenceInterpersonal violence ratesInteractive online toolsNoninteractive online tools2 RCTs (n = 1,132)No difference in repeat interpersonal violence between interactive vs. noninteractive online tools in two RCTs●○○
Depression scoresIn-person interviews, followed by phone calls; interactive online toolsReferral; noninteractive online tools5 RCTs (n = 2,322)Telehealth is at least as effective as usual care alternatives for improving measures of depression●○○
Posttraumatic stress disorder scoresInteractive online toolsNoninteractive online tools2 RCTs (n = 1,182)No difference in posttraumatic stress disorder symptoms between interactive vs. noninteractive online tools●○○
Fear, coercive controlInteractive online toolsNoninteractive online tools2 RCTs (n = 884)No difference between interactive vs. noninteractive online tools●○○
Self-efficacyInteractive online tools; computerized encounters; in-person interviews followed by telephone callsNoninteractive online tools; in-person encounters; referral3 RCTs (n = 919)Telehealth is at least as effective as usual care alternatives for improving self-efficacy scores●○○
Safety behaviorsTelephone calls; computerized encounters; in-person interviews followed by telephone callsUsual care; in-person encounters; referral4 RCTs (n = 1,175)Telehealth is at least as effective as usual care for increasing safety behaviors●○○
HarmsInteractive online toolNoninteractive online tool1 RCT (n = 231)No difference in patient-reported anxiety using a tailored, online safety tool vs. a static version○○○

Practice Pointers

Research conducted before the COVID-19 pandemic suggests women are more likely than men to choose telehealth, even when the overall uptake of telemedicine is low.3 This may be because the time savings and virtual convenience are particularly attractive to caregivers, a role traditionally filled by women.3 The number of clinics reporting telehealth capabilities increased with the start of the COVID-19 pandemic, thereby presenting new opportunities for health care delivery, including preventive services.4

Research on telehealth effectiveness and acceptability has been proliferating. An Agency for Healthcare Research and Quality (AHRQ) review published before the COVID-19 pandemic found that telehealth visits improved clinical outcomes for wound care, psychiatry, and some chronic conditions. They may increase patient satisfaction, reduce costs, and decrease health care use.5

The most recent AHRQ review included 16 studies evaluating the effectiveness of telehealth for women's preventive services, specifically contraceptive care and IPV. Two studies assessed telehealth as a supplement to in-person visits, and 14 studies compared in-person consultations with telehealth alone.

There was enough evidence to assess the effectiveness of telehealth on clinical outcomes for some women's health preventive services. In assessing telehealth interventions for contraceptive care, two studies concluded that the rates of STIs were similar between the in-person consultation group and the group that received care supplemented with telephone counseling, although the strength of evidence is low. Based on one study, continuation of oral contraceptives and long-acting reversible contraception was similar among these two groups with low strength of evidence. Pregnancy rates were similar between the two groups with low strength of evidence. There was insufficient evidence to support conclusions about abortion rates in the groups. No studies compared the effectiveness of telehealth alone with in-person consultations alone.

In assessing telehealth interventions related to IPV, six studies found no differences between women randomized to telehealth compared with usual care in relation to the clinical outcomes of repeat episodes of IPV, depressive symptoms, posttraumatic stress disorder, fear of partner, coercive control, self-efficacy, and safety behaviors. The strength of evidence for these outcomes is rated as low because of a lack of consistency in the nature and type of telehealth intervention across studies.

There were no studies evaluating the effectiveness of telehealth in the delivery of STI counseling or family planning, defined as preconception counseling or birth spacing. An American Academy of Family Physicians position paper on preconception care does not offer recommendations about telemedicine care.6 Effectiveness of tele-health for medical abortion consultation was not included in the AHRQ review, although abortion rates were a patient-centered outcome of some of the included studies. No studies addressed tele-health outcomes related to health care access, health equity, or health disparities. There were insufficient data for harms related to IPV care via telehealth, and harms were not addressed in any studies of contraceptive care.

Based on limited evidence, telehealth interventions for contraceptive care and IPV have similar clinical outcomes as in-person care. The most effective approaches for delivering these telehealth services remain unclear, as does the impact of telehealth on women in marginalized and underserved communities.

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The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to produce evidence to improve health care and to make sure the evidence is understood and used. A key clinical question based on the AHRQ Effective Health Care Program systematic review of the literature is presented, followed by an evidence-based answer based on the review. AHRQ’s summary is accompanied by an interpretation by an AFP author that will help guide clinicians in making treatment decisions.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor. A collection of Implementing AHRQ Effective Health Care Reviews published in AFP is available at https://www.aafp.org/afp/ahrq.

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