Abstract
Quality measurement often focuses solely on clinical processes and outcomes, with relative neglect of patient experience. The use of novel measurement approaches, including patient-reported outcome performance measures and electronic clinical quality measures, provide the opportunity for more nuanced and patient-centered measurement in primary care settings. In this commentary, we described the development of such measures to evaluate contraceptive care quality. Primary care is a crucial setting for delivery of contraceptive care, facilitating access in the context of longitudinal care relationships. When providing this care, it is especially critical to have attention to quality grounded in principles of person-centeredness and equity given the personal nature of reproductive health care alongside the history of reproductive oppression. The described measures provide actionable tools that can be leveraged by family medicine leaders and health systems to support quality, person-centered, and equitable contraceptive care.
- Contraceptives
- Health Equity
- Patient-Reported Outcome Measures
- Primary Health Care
- Quality Improvement
- Quality of Health Care
- Reproductive Health
High-quality primary care is fundamental to a functional health care system. The National Academies of Science, Engineering, and Medicine define 6 key quality dimensions: safe, effective, timely, efficient, equitable and patient-centered.1 Despite this scope, the current ecosystem of quality measures heavily favors clinical processes and outcomes that, while relatively easily assessed, fail to capture patient experience and, as a result, often fails to encapsulate the complexities necessary to fully assess—and address—quality.2
Measurement innovations can help fill this gap and offer opportunity to better center person-centeredness and equity. First, patient-reported outcome performance measures (PRO-PMs) are increasingly utilized as a means to directly assess patient experience. In addition, electronic clinical quality measures (eCQMs), emergent measures which use data extracted from electronic health records (EHRs), use a greater degree of patient information than is available through claims data—the typical data source for clinical quality measures—allowing for more nuanced measurement.3
Contraceptive Care Quality
Given the sensitive and personal nature of reproductive decision making, alongside the legacy of reproductive oppression in health care settings,4,5 scrutiny of how we define quality in contraceptive care is crucial and needs to center patient preferences, needs, and values. Moreover, while gaps in contraceptive counseling quality are longstanding, the recent push to promote long-acting reversible contraceptive (LARC) methods, which is both not patient-centered and infringes on reproductive autonomy, has heightened the attention to contraceptive care quality.6–8
Primary care is an important source of access to reproductive health care and is a setting from which many patients want to receive their contraceptive care.9–11 Primary care’s delivery of contraception and other reproductive health services may also become increasingly necessary as other clinical sources of reproductive health care are impacted by changing policy contexts.12 Here, we provide actionable tools for quality measurement grounded in equity and person-centeredness that family medicine clinicians and administrators can leverage to improve contraceptive care quality. This effort also serves as a case study of how to define and measure clinical quality in a way that foregrounds patient-centeredness and equity.
The first measures of contraceptive care quality, endorsed by the National Quality Forum in 2016, used claims data to identify provision of most or moderately effective methods and LARC methods specifically. While an important step toward ensuring that contraceptive care was prioritized in the health care ecosystem, there were notable concerns with these measures. Specifically, as these measures cannot exclude people from the denominator who are not interested in pregnancy prevention or contraceptive use, since this data are not available in the EHR, there is the potential to incentivize counseling about and provision of methods that does not prioritize patients’ own needs.13 Moreover, there were concerns that these measures would exacerbate existing disparities in the delivery of care to communities whose reproduction is devalued.6
To improve on these measures and capture additional aspects of quality, the Person-Centered Reproductive Health Program designed a suite of measures to evaluate quality across the contraceptive care pathway that center patient voices, align with reproductive justice and equity imperatives, and are responsive to known gaps in care quality. These measures were developed with patient and health care expert input, have gone through rigorous scientific testing, and have been endorsed by the Centers for Medicare and Medicaid Services (CMS)’s Consensus-Based Entity.14–17
Novel Contraceptive Care Performance Measures
When approaching contraceptive care quality measurement, we can map appropriate measures to each step in the contraceptive care pathway (see Figure 1).
Are patients being asked about their contraceptive service needs? In a primary care context where healthcare team members navigate competing priorities, it is important to first assess whether patients are being screened for their contraceptive service needs. Screening tools commonly used rely on a concept of pregnancy intention, such as One Key Question®,18 create unnecessary complexity, lack resonance with some patients, and may miss some who are interested in contraception.19 We developed the Self-Identified Need for Contraception (SINC) (Figure 2),20 with Reproductive Justice experts and patient input, as a person-centered alternative, service-bound screening question. It asks whether the patient wants to discuss contraception or pregnancy prevention and is designed to be integrated into standard clinic intake procedures. The Contraceptive Care Screening eCQM measures the percent of patients with female-recorded gender in the EHR ages 15-44 years who were asked SINC in the calendar year.17,20
Is contraceptive counseling being provided in a respectful, person-centered manner? Given the record of suboptimal contraceptive counseling that does not meet patient needs—including directive counseling towards LARC methods—patient experience must be centered in evaluating quality in contraceptive quality. The Person-Centered Contraceptive Counseling measure (PCCC) (Figure 3) is a PRO-PM developed to capture 3 patient-defined domains of quality: interpersonal connection, adequate information, and decision support.21 It is comprised of 4 items completed by patients who received contraceptive counseling and is scored as a percent of surveys with the highest rating out of all competed surveys. It can be used to evaluate quality at the clinician or facility level.22
Are those patients who want contraception accessing prescription methods? Last in the pathway, we look at whether patients who want contraception are able to get their needs met using Contraceptive Use eCQMs: a set of measures capturing the percent of patients with female-recorded gender ages 15-44 years using a most or moderately effective contraceptive method.14,15 Those with a recorded “No” response to SINC from the calendar year are excluded to hone the measure to whether those interested in contraceptive services receive that care. This measure includes both provision of contraception and ongoing use of existing methods (as recorded in the EHR) to allow for contraceptive needs met in previous years or via another site. In order to capture whether a site is providing LARC services, as a proxy to measure access to that specific subset of methods, a submeasure reports the percentage of patients who are provided with a LARC method at that site.
Quality measurement across the contraceptive care pathway.
The Self-Identified Need for Contraception (SINC) screening question.* Notes: *SINC implementation guidance available at: https://pcrhp.ucsf.edu/sinc.
The Person-Centered Contraceptive Counseling (PCCC) measure.* Notes: *Implementation guidance available at: https://pcccmeasure.ucsf.edu/.
In concert, these measures capture a full picture of quality, inclusive of access to contraceptive care/methods and patient experience of care and can be analyzed together for monitoring and quality improvement. For example, if a clinic has a high PCCC score but only a small percentage of patients are screened for contraceptive need, then quality improvement initiatives should primarily focus on ensuring patients are asked about their contraceptive care needs and evaluating intake procedures. Alternatively, if a clinic sees a high percentage of patients provided with a LARC method in the LARC provision eCQM while finding PCCC scores are low, this may indicate that suboptimal, directive counseling practices are being used, and quality improvement interventions should focus on understanding patient experience and expanding person-centered contraceptive counseling practices. Stratification can further identify disparities in care experiences by race/ethnicity and sexual orientation, as was recently documented in nationally representative data using the PCCC.23
Uptake of Measures to Date and Next Steps
As documented in this issue, these measures have been used together for clinical quality improvement by Federally Qualified Health Centers (FQHCs) in a structured learning collaborative to improve care quality. Clinical systems and federal agencies also have shown increasing interest and utilization of these tools and measures. For example, the Health Resources and Services Administration implemented a requirement for FQHCs to report on the percentage of patients screened for contraceptive need in a calendar year in the Uniform Data System, with SINC listed as a preferred tool.24 Concurrently, the Office of Population Affairs recently released an update to the Quality Family Planning guidelines that includes a chapter on performance measurement centering these measures,25 and CMS uplifted the PCCC and SINC as “promising practices” that agencies may consider for quality improvement.26 Moreover, SINC is included in the Family Planning Annual Report 2.0, the reporting system for Title X recipients,27 and the PCCC is also utilized by Planned Parenthood Federation of America affiliates across the country.28 Information about these measures, including implementation resources, can be found at https://pcrhp.ucsf.edu/performance-measures.
We note that there is ongoing opportunity for improvement of these measures, such as through consistent EHR documentation of nonprescription methods, allowing for measurement of the full range of pregnancy prevention choices, as well as optimized use of sexual orientation and gender identity data to ensure that all people with pregnancy potential are included in the measures. To further enhance the suite of available measures, we also are developing a version of the PCCC that queries experience with care over the past 6 months, suitable for population-level sampling (as opposed to data collection on the day of the visit) for use at the state or health plan level. Lastly, we have designed these measures to be relatively low-burden for clinical implementation in primary care, introducing standardized patient-centered workflows and including a brief patient survey. However, we recognize that implementing new procedures and prospective data collection always includes some administrative and operational burden, and that this can be challenging in the context of competing demands in primary care. Implementation plans will need to customized to individual health care contexts to minimize burden.
Ensuring Quality Reproductive Health Services in Family Medicine
In this moment of increasing pressure to constrain and restrict access to reproductive health care, family medicine leaders play a key role in ensuring access to necessary health care services that enable patients to live full, self-determined lives. Expansion of contraceptive services in primary care has the potential to meet patient needs in the care context they prefer, while simultaneously recognizing reproductive health as an integral part of care across the life course. However, the care must be delivered in a manner aligned with equity and justice to meet patient need while preventing harm from perceived or real pressure to use contraception. Leveraging actionable tools grounded in person-centeredness and health equity, such as this suite of contraceptive care performance measures, is a practical approach to meet these ethical and practical imperatives. We encourage family medicine leaders and health systems to take up the call to provide high-quality, person-centered contraceptive care. We also encourage ongoing work across a range of clinical contexts and areas to develop and implement multi-dimensional measures that can facilitate quality improvement focused on patient-centeredness and equity. For example, diabetes quality monitoring could be expanded past A1c-exclusive measures29 to approaches that are inclusive of patient experience, such as diabetes distress, or diabetes-specific quality of life measures.30,31 Continuing to innovate quality measures in this way can support ongoing efforts to ensure that primary care services prioritize patient needs and quality of life across the life course.
Notes
See Related Article on Page 791.
This article was externally peer reviewed.
Funding: This project was supported through a grant from an anonymous private donor.
Conflict of interest: The authors have no conflicts to report.
- Received for publication March 14, 2025.
- Revision received May 27, 2025.
- Accepted for publication June 9, 2025.
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