Accuracy of survey-based assessment of eligibility for medication abortion compared with clinician assessment

Abstract

Background

With increasingly restricted access to facility-based abortion in the United States, pregnant people are increasingly relying on models of care that use history-based or no-test approaches for eligibility assessment. Minimal research has examined the accuracy of abortion patients’ self-assessment of eligibility for medication abortion using their health history. This step is necessary for ensuring optimal access to history-based or no-test models, as well as potential over-the-counter access.

Objective

This study aimed to examine the accuracy of pregnant people’s eligibility for medication abortion as determined using their self-reported health history, compared with clinician assessments using ultrasound and other tests.

Study design

In this diagnostic accuracy study, we recruited people seeking medication or procedural abortion from 9 abortion facilities, aged ≥15 years, English- or Spanish-speaking, and with no prior ultrasound conducted at the recruitment facility. Before ultrasound, we surveyed participants on medication abortion eligibility, including estimated gestational duration, medical history, contraindications, and ectopic pregnancy risk factors such as pain and bleeding symptoms. We compared patients’ eligibility based on self-reported history with subsequent clinician assessment, focusing on overall diagnostic accuracy, or area under the receiver operating characteristic curve, sensitivity, specificity, and proportion with discordant patient and clinician eligibility assessment, using 77 days as the upper gestational duration limit.

Results

Overall, 22.1% of 1386 participants were ineligible for medication abortion according to clinician assessment. Overall diagnostic accuracy of self-assessment was acceptable (area under the receiver operating characteristic curve=0.65; 95% confidence interval, 0.63–0.67), with sensitivity of 92.2% (88.6–94.9) and specificity of 37.8% (34.9–40.7). Very few participants (n=24; 1.7%) self-assessed as eligible when the clinician deemed them ineligible; many more (n=672; 48.5%) self-assessed as ineligible when the clinician deemed them eligible. The most common patient-reported contraindications included unexplained pain (55.5%), gestational duration >77 days (36.5%), and anemia (29.0%). On its own, unexplained pain had poor sensitivity in identifying those with clinician concern for ectopic pregnancy (41.7%; 95% confidence interval, 15.2–72.3). Removing unexplained pain as a screening criterion resulted in higher accuracy (0.71; 95% confidence interval, 0.69–0.74) (P<.001).

Conclusion

History-based screening protocols are highly effective at ensuring that few people receive medication abortion when ineligible. However, a sizable group screens as ineligible when they are in fact eligible, suggesting a need for more specific screening questions.