摘要：Objectives. We assessed the effect of a telemedicine model providing medical abortion on service delivery in a clinic system in Iowa. Methods. We reviewed Iowa vital statistic data and billing data from the clinic system for all abortion encounters during the 2 years prior to and after the introduction of telemedicine in June 2008 (n = 17 956 encounters). We calculated the distance from the patient’s residential zip code to the clinic and to the closest clinic providing surgical abortion. Results. The abortion rate decreased in Iowa after telemedicine introduction, and the proportion of abortions in the clinics that were medical increased from 46% to 54%. After telemedicine was introduced, and with adjustment for other factors, clinic patients had increased odds of obtaining both medical abortion and abortion before 13 weeks’ gestation. Although distance traveled to the clinic decreased only slightly, women living farther than 50 miles from the nearest clinic offering surgical abortion were more likely to obtain an abortion after telemedicine introduction. Conclusions. Telemedicine could improve access to medical abortion, especially for women living in remote areas, and reduce second-trimester abortion. Medical abortion involves the use of medication to induce an abortion nonsurgically, and the regimen used most commonly in the United States involves oral mifepristone followed by misoprostol administered vaginally, orally, buccally, or sublingually. 1 The mifepristone–misoprostol regimen is highly effective up to 9 weeks’ gestation and has been found to be very safe. 2,3 Studies in the United States and elsewhere have found that women are very satisfied with this abortion method, and some women prefer it to vacuum aspiration. 4,5 Medical abortion is not a surgical procedure and can be offered by nonphysician clinicians or by physicians who do not perform surgical abortion. 6 However, US clinicians outside of abortion clinics do not appear to have adopted the technology in large numbers. An analysis of data from 2007 found that almost all medical abortion–only providers were located within 50 miles of a large-volume surgical abortion provider. 7 One factor limiting the uptake of medical abortion is the restriction that most states impose regarding who can provide the service. As of 2009, only 15 states allowed advanced practice clinicians to provide medical abortion; the remainder required that a physician provide the service. 8 Iowa is one such state where a physician must provide medical abortion. Telemedicine is the delivery of health care services at a distance through information and communication technology. A recent systematic review of economic analyses of telemedicine services found that this care model was cost effective for a range of services. 9 In June 2008, Planned Parenthood of the Heartland in Iowa launched a telemedicine program to allow physicians to provide medical abortion to patients at clinic sites not staffed by a physician to improve access to early abortion and reduce physician travel to outlying clinics. Prior to introducing telemedicine, the network had 17 clinic sites. Two clinics had an on-site physician and offered both medical and surgical abortion, 2 sites offered surgical and medical abortion when a physician traveled there, and 2 additional sites offered only medical abortion when the physician traveled there. The remaining 11 clinics did not provide abortions. A recently published cohort study found that the telemedicine model provided by this clinic system was as effective as a model involving an in-person visit with a physician; telemedicine was also found to be highly acceptable to women, with a low rate of adverse events. 10 We examined how the clinic system’s service delivery patterns changed after the introduction of telemedicine. In particular, we asked whether the proportion of abortions that were medical abortion and second-trimester abortion changed, as well as whether there were changes in the geographical patterns of service delivery.
