Jain T, Schwarz EB, Mehrotra A. A Study of Telecontraception. N Engl J Med. 2019;381(13):1287-1288.

I had late last year made a deep dive into the realm of direct-to-consumer (DTC) prescription services available in the US with some surprising results. Overwhelmingly, companies are getting into some really interesting areas beyond traditional low-stake conditions, and we are seeing massive expansions take place. However, one area that got the most attention was birth control and sexual health.

Now, one thing that has been on my mind is with the large rise of these companies gaining a presence, and some criticism in the medical community, how soon till someone evaluated them? I had actually expected someone to look into using some mock male patients to get ED medications. But while doing a literature search on digital health came across an article (well, a short correspondence) published in the NEJM by Jain and colleagues titled "A study of telecontraception" back in September 2019. Now, I have not seen this small article get much attention, so I am going with it probably got sidelined since it was a correspondence article (basically <1000 words) and not racked up like a traditional RCT press.

Nonetheless, it is one of the first studies I've seen investigating the DTC space with a set methodology, so I think it worth a breakdown assessment. The article in the NEJM had a supplementary file that is much more in-depth and where I am pulling much of this information from for this summary. Their goal, using a 'secret shopper' approach was to determine the experience of patients looking for contraception and if they were screened appropriately.

Methodology:

• Created seven standardized patients

  • Several had relative and absolute contraindications to OCs based on the CDC MEC categorization. This included some patients with a history of DVTs, and hepatocellular adenoma, or postpartum.

  • Each standardized patient was designated as uninsured and to request the company choose a brand with a low cost.

• Nine telecontraception companies were utilized

  • Planned Parenthood

  • Nurx

  • Prjkt Ruby

  • Vituwell

  • Lemonaid

  • The Pill Club

  • Pandia Health

  • HeyDoctor

  • MAVEN

Results

I will not go into all the results but highlight some interesting items that stood out to me:

• 7/9 companies required the use of a website as their process

• 3/9 companies did not require a patient-provider interaction after doing the online questionnaire

• Interactions varied across all patients - with the average duration being 7.5 minutes

• Six vendors had the option to maile the prescriptions directly to a patient home

• The average cost for a visit ranged from $0-$49. The average price for a 12-month supply was $313 (range $67-$519)

• None of the companies asked patients about adhering to oral medications, and 7/9 did not discuss other options (e.g., intrauterine or subdermal) that a patient could potentially take.

• They found 93% adherence to the CDC MEC guidelines, and interestingly several of the standardized patients with relative or absolute contradictions to OCs were still prescribed a contraindicated product.

One thing not in the supplementary file was how each company performed. Interestingly, the file discusses that the standardized patients did end up (though it is a small sample) preferring some companies over others and that they disliked one in particular. Overall, the authors thought that telecontraception could be better than currently understood in evaluating patients, though I would say a larger sample is always warranted.

Nonetheless, I think this was a good methodological approach and would love to see this repeated with an ED focused company, and some other conditions. In the pharmacy space, we are not foreign to the approach of secret shoppers, with the Chicago Tribune has done these multiple times over the past decade on drug interactions, for instance. Mental health and migraine conditions, as they move beyond such low stake areas, would also be worth more scrutiny as well, as I see them gaining more attention in the future.

The results of this small study, I think, are very promising and demonstrate several items. One, they work. Two, with an average time of performing these interactions <7.5 mins and convenience of mailing a medication, they are definitely going to be attractive to a changing society that wants retail health services. Three, I feel that the reason that there wasn't a higher rate of prescribed contraindications is that these companies are leverage a lot of data to get the evaluation down. This is a focal point for me with low-stakes conditions, as it could very much follow a flow-chart of care. As a condition gets more complicated with required data points from a patient, I would expect more issues, and I think that warrants further analysis. Lastly, the costs look reasonable for certain patients, and the fact that several companies did not require any ID will probably lead to many women using them to avoid oversight by others, and I could see being grassroots growth amongst certain crowds.

Well, I welcome your thoughts and feel free to comment!