Effectiveness, safety and acceptability of no-test medical abortion provided via telemedicine: a national cohort study

ObjectivesTo compare the effectiveness, safety and acceptability of medical abortion before and after the introduction of no-test telemedicine abortion care.DesignCohort study to assess whether a no-test telemedicine-hybrid care model (telemedicine with in-person provision only when indicated) was non-inferior to the traditional service model (blanket in-person provision including ultrasound scan).SettingThe three main abortion providers in England and Wales.ParticipantsAll patients having an early medical abortion in the two months before and after the service model change. Patient demographic and clinical characteristics were compared between the cohorts to adjust for any systematic differences in the two groups.Main outcome measuresAccesswaiting time, gestation at abortionEffectivenessthe proportion of successful medical abortionsSafetysignificant adverse events defined as: haemorrhage requiring transfusion, significant infection requiring hospital admission, major surgery, death. We also examined the incidence of ectopic pregnancy and late gestation.AcceptabilityPatient-reported outcomes of satisfaction, future preference, and privacy of consultationResultsThe study sample included 52,142 medical abortions; 22,158 in the traditional cohort and 29,984 in the telemedicine-hybrid cohort, of which 61% were provided using no-test telemedicine. The cohorts accounted for 85% of all medical abortions provided in England and Wales during the study period. Mean waiting times were 4.2 days shorter in the telemedicine-hybrid cohort, and 40% were provided at ≤6 weeks’ gestation compared to 25% in the traditional cohort (p<0.001). There was no difference in success rates between the two groups (98.2% vs. 98.8%, p=1.0), nor in the prevalence of serious adverse events (0.04% vs. 0.02%, p=0.557). The incidence of ectopic pregnancy was equivalent in both cohorts (0.2%, p=0.796), with no significant difference in the proportions being treated after abortion (0.01% vs 0.03%, p=0.123). In 0.04% of cases the abortion appeared to have been provided at over 10 weeks’ gestation; these abortions were all completed at home without additional medical complications. In the telemedicine-hybrid group, the effectiveness for abortions conducted using telemedicine (n=18,435) was higher than for those conducted in-person (n=11,549), 99.2% vs. 98.1%, p<0.001. Acceptability was high (96% satisfied), 80% reported a future preference for telemedicine and none reported that they were unable to consult in private using teleconsultation.ConclusionsMedical abortion provided through a hybrid model that includes no-test telemedicine without routine ultrasound is effective, safe, acceptable, and improves access to care.Summary BoxWhat is already known on this topicThe UK’s National Institute for Health and Care Excellence (NICE) conducted a systematic review and recommended using telemedicine to improve access to medical abortion care.Several models for using telemedicine to facilitate medical abortion have been described, but most existing trials are small, and many required attendances to have medicines administered or for an ultrasound scan or blood tests.What this study addsThis study (n=52,142) is the first to assess a real-world no-test telemedicine abortion care pathway in a national population. The new national model demonstrates how a permissive framework for medical abortion can deliver significant quality improvements to those needing to access abortion care. There was no difference in effectiveness (p=1.0) or safety (p=0.6) when compared to a traditional in-person model, but the no-test telemedicine pathway improved access to care, was highly acceptable to patients and is likely to be especially beneficial for vulnerable groups and in resource-poor settings.