Original Research ajog.

org

GYNECOLOGY
Initiation and continuation of long-acting reversible
contraception in the United States military healthcare
system
Daniel P. Chiles, DO, MPH; Timothy A. Roberts, MD, MPH; David A. Klein, MD, MPH

BACKGROUND: Long-acting reversible contraception is more effec-
tive for pregnancy prevention than shorter-acting contraceptive methods
and has the potential to reduce healthcare disparities and costs. However,
long-acting reversible contraception is underused in the United States.
One population of interest is beneficiaries of the United States military
healthcare system who have access to universal healthcare, including
no-cost, no-copay contraception with unlimited method switching, and
comprise a large, actual use cohort. Efforts to increase long-acting
reversible contraception initiation and continuation in this population
may improve health outcomes and mitigate the profound consequences of
unintended or mistimed pregnancy on readiness and cost to the military.
OBJECTIVE: We aimed to determine long-acting reversible contra-
ception initiation and continuation rates among the diverse population with
universal healthcare who are enrolled in the US military healthcare system.
STUDY DESIGN: This study is a retrospective cohort of >1.7 million
women, aged 14e40 years, who were enrolled in the US military
healthcare system, TRICARE Prime, between October 2009 and
September 2014. Individuals were assessed for long-acting reversible
contraception initiation and continuation with the use of medical billing
records. Method continuation and factors that were associated with early
method discontinuation were evaluated with the Kaplan-Meier estimator
and Cox proportional hazard models.
RESULTS: During the study dates, 188,533 women initiated
long-acting reversible contraception. Of these, 74.6% women selected
intrauterine contraceptives. Method initiation rates remained relatively
stable (41.7e50.1/1000 women/year) for intrauterine methods, although
the rate for subdermal implants increased from 6.1e23.0/1000 women/
year. In analysis of women who selected intrauterine contraceptives,
61.2% continued their method at 36 months, and 48.8% continued at
60 months. Among women who selected the implant, 32.0% continued
their method at 36 months; however, 45.8% continued until 33 months
(ie, 3 months before the currently recommended expiration date).
Compared with intrauterine contraceptive users, implant users were more
likely to discontinue their method during the 36 months after insertion
(hazard ratio, 1.59; 95% confidence interval, 1.56e1.62; P < .001).
Adolescents aged 14-19 years were the least likely age group to
discontinue the implant before 36 months; women aged 35-40 years were
the least likely to discontinue an intrauterine contraceptive before 60
months. In multivariable analysis that controlled for demographic factors
and contraceptive type, early contraceptive method discontinuation was
most likely among women aged 20-24 years, implant users, and women
with method initiation in military clinics.
CONCLUSION: In the US military healthcare system, TRICARE Prime,
the initiation of long-acting reversible contraception is low but increasing,
and continuation rates are high. This evidence supports long-acting
reversible contraception as first-line recommendations for women of all
ages who seek contraception.
Key words: continuation, contraception, intrauterine device, LARC,
long-acting reversible contraception, subdermal implant

F orty-ve percent of pregnancies

in the United States are unintended;
of these, 42% will result in elective
termination.1,2 Unintended pregnancy is
associated with adverse health outcomes
for mother and child and lower socio-
economic and educational achieve-
ment.1,3 In recent years, major medical
societies and the Centers for Disease
Control and Prevention have endorsed
the provision of long-acting reversible
contraception (LARC) as potential
Cite this article as: Chiles DP, Roberts TA, Klein DA.
Initiation and continuation of long-acting reversible
contraception in the United States Military Healthcare
System. Am J Obstet Gynecol 2016;


:



.
0002-9378/$36.00
Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.ajog.2016.03.027
means to safely and effectively prevent
unplanned pregnancies, reduce health-
care disparities, and control costs for
women of reproductive age.4-9
LARC methods, which include
the levonorgestrel-releasing intrauterine
system (LNG-IUS), the copper-
containing intrauterine device (Cu-
IUD), and the etonogestrel-releasing
implant (implant), offer advantages
over other reversible contraceptive
methods because of their superior ef-
cacy. Moreover, in a recent analysis of
4708 participants in the prospective
cohort study The Contraceptive
CHOICE Project (CHOICE), the
36-month continuation rate of LARC
was 67% compared with 31% using
noneLARC hormonal methods.10
Despite the high efcacy and reliability
of these methods, LARC options account
for approximately 12% of the contra-
ceptives used by women aged 15e44
years in the United States.11 Recent
prospective data suggest that easily
accessible and affordable LARC can
reduce rates of abortion, unintended
pregnancy (including teenage preg-
nancy), and healthcare-associated
costs.8,9,12,13
LARC generally is continued by at
least 80% of users by 12 months; how-
ever, data in the United States regarding
current LARC methods are limited
beyond this duration.14-16 By 3 years, in
combination with international data,
intrauterine contraceptives appear to be
continued by 49e80% of users10,16-22
and the implant by 30e56% of
users.10,17,20,23-25 At 5 years, intrauterine

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Original Research GYNECOLOGY
contraceptives appear to be continued
by 33e55% of users.14,22 The wide
ranges may be due to signicant differ-
ences in study methods and sample
populations.14,17,22
The extent to which members of the
US military, military retirees, and their
family members initiate and continue
LARC is largely unknown. Approxi-
mately 350,000 women of reproductive
age currently serve in the US militarys
active duty or selected reserve force, and
1 million others have a parent or spouse
currently serving in one of these capac-
ities.26 These women have access to
universal healthcare, including no-cost
contraception with unlimited method
switching. Despite these advantages, >7
unintended pregnancies a year occur for
every 100 active-duty service women,
and more than one-half of all pregnan-
cies among active-duty service women
are unintended.27,28 These unintended
pregnancies have a physical and
emotional impact on both the mother
and infant and degrade military readi-
ness. Efforts to increase LARC initiation
may improve health outcomes for this
population and mitigate the profound
consequences on readiness and cost to
the military.29
Previous studies on long-term
continuation of LARC are limited in
that they entailed regional sampling,
random assignment of participants into
contraceptive method types, or contin-
uation rates of 1 year.10,14-16,22 This
study was designed to avoid these limi-
tations and provide additional evidence
on long-term continuation of LARC.
The primary objectives of this study were
to (1) determine initiation and long-
term continuation rates of LARC in a
large, diverse population with universal
healthcare and (2) understand LARC
usage patterns in the US military
healthcare system.
Materials and Methods
This study is a retrospective cohort of
>1.7 million women, ages 14e40 years,
who were enrolled in the military
healthcare insurance program, TRI-
CARE Prime, between October 1, 2009
and September 30, 2014. TRICARE
Prime covers medical care that is
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provided at military treatment facilities
or contracted through civilian providers
for all active-duty service members,
military retirees under the age of 65
years, and members of the national
guard and reserve who have been called
up to active duty. Family members of
these individuals, which include spouses
and dependent children under the age of
26 years, are also eligible for care in this
healthcare plan. We used the Military
Health System Management Analysis
and Reporting Tool (M2) to review
medical and pharmacy billing records of
enrolled women during the study time
period. Records were entered into this
data repository monthly and reect
enrollment status and healthcare use
during the previous month. Billing
records from military clinics were drawn
directly from the militarys electronic
medical record; information from
civilian network clinics and pharmacies
was collected from billing statements.
The institutional review board of Brooke
Army Medical Center, Fort Sam Hous-
ton, Texas, approved this study.
The primary outcome of interest was
time from insertion to discontinuation
of individual LARC methods, which
included the Cu-IUD, the 52-mg LNG-
IUS, and the implant. Of note, the
13.5-mg, 3-year LNG-IUS was approved
for use in 2013 and was used infre-
quently in military treatment facilities in
2014; therefore, cases were not distin-
guished from the 52 mg model and were
excluded from analysis of continuation
beyond 36 months.
Records were assessed for initiation
and discontinuation of LARC methods
using Current Procedural Terminology
(CPT) codes. We identied episodes of
LARC insertion using the following CPT
codes: 11981, 11983, 11975, and 11977
for the implant, and 58300 insertion of
an intrauterine contraceptive. Episodes
of LARC discontinuation were identied
by the use of CPT codes 11976, 11982, or
58301. We attempted to identify the
specic type of intrauterine contracep-
tive inserted using pharmacy records and
associated Healthcare Common Proce-
dure Codes (J7300, J7302, and S4981). If
we were unable to determine the specic
intrauterine method used (LNG-IUS
ajog.org
or Cu-IUD), the type was noted as
unknown.
Only the rst instance of a CPT
insertion code was captured per partici-
pant. Women who had subsequent CPT
codes that documented a removal and
insertion of the same LARC method
during that month were counted as a
method continuation. Women who had
CPT code 11983, which documented
implant removal and replacement and
appeared as the rst episode of LARC
insertion during the study period, were
counted as a rst insertion. Subsequent
occurrences of this or another implant
insertion code after an initial episode
of implant insertion were counted as a
method continuation.
LARC continuation rates were
assessed by Kaplan-Meier analysis,
which measured the time in months
between initiation and discontinuation.
Participants were followed until they
reached 1 of 3 endpoints: method
discontinuation, disenrollment from
TRICARE Prime, or the end of the study
period. Continuation rates were calcu-
lated over the rst 36 months for all
methods and over the rst 60 months
for intrauterine contraceptives, and were
further characterized by examination of
demographic characteristics at the time
of insertion, which included age, mili-
tary duty status, type of clinic where the
method was inserted, and method type.
The 36- and 60-month analyses repre-
sents the Federal Drug Administrations
approved duration of use for the implant
and the 52-mg LNG-IUS, respectively. In
addition, both study durations allow for
comparisons with previously established
benchmarks for method continuation.
Statistical analyses were conducted
with SPSS software (version 22; IBM
Corporation, Armonk, NY). Descriptive
statistics were used for demographic
characteristics at the time of LARC
initiation: age (14e19, 20e24, 25e29,
30e34, and 35e40 years), eligibility
status (service members vs family
members and retirees), and clinic type
used. The chi-square test and indepen-
dent samples t-tests were used to assess
the relationship between the subject
demographics and LARC type selected.
The Kaplan-Meier estimator was used to
ajog.org GYNECOLOGY Original Research

TABLE 1
Baseline characteristics of women initiating long-acting reversible contraception, stratified by age, military duty
status, clinic type, and contraceptive type
Intrauterine contraceptive Etonogestrel implant
Demographic group Total (n 188,533), n (%) (n 140,553), n (%) (n 47,980), n (%) P value
Age group, y <.001
14e19 18,371 (9.7%) 7,690 (5.5%) 10,681 (22.3%)
20e24 69,007 (36.6%) 46,418 (33.0%) 22,589 (47.1%)
25e29 54,337 (28.8%) 44,346 (31.6%) 9,991 (20.8%)
30e34 30,042 (15.9%) 26,635 (19.0%) 3,407 (7.1%)
35e40 16,776 (8.9%) 15,464 (11.0%) 1,312 (2.7%)
Military duty status <.001
Servicewomen on active duty 45,695 (24.2%) 30,334 (21.6%) 15,361 (32.0%)
Family members and retirees 142,774 (75.8%) 11,0157 (78.4%) 32,617 (68.0%)
Clinic type <.001
Military clinic 128,522 (68.2%) 90,342 (64.3%) 38,180 (79.6%)
Civilian Network clinic 59,999 (31.8%) 50,199 (35.7%) 9,800 (20.4%)
Contraceptive type
Levonorgestrel intrauterine system 51,470 (36.6%)
Copper intrauterine device 5,983 (4.3%)
Unknown 83,100 (59.1%)
Chiles et al. Long-term continuation of LARC. Am J Obstet Gynecol 2016.

estimate survival duration (ie, continu-

ation duration) of each LARC type over
the study timeframe and for the different FIGURE 1
demographic groups. The generalized Long-acting reversible contraception initiation among 14- to 40-year-old
Wilcoxon test was used to compare the women in the military healthcare system
survival distributions of the different
groups, including censored observa-
tions. Cox proportional hazard models
were used to assess the independent
association of the demographic charac-
teristics and LARC type with early
discontinuation. An alpha level of .05
was set for all comparisons.

Results
On average, there were 887,646 (stan-
dard deviation [SD]23,006) enrolled
women in our inclusive age range per
month; the average length of TRICARE
enrollment was 36.1 months. Our
analytic sample consisted of 188,533
initiators of LARC, which included
140,553 women who initiated intra-
Inclusive dates: October 2009 to September 2014; each year includes fiscal year data (for example,
uterine contraceptives and 47,980 year 2010 data includes insertions from 2009e2010).
women who initiated a subdermal Chiles et al. Long-term continuation of LARC. Am J Obstet Gynecol 2016.
implant. Women were followed for an

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Original Research GYNECOLOGY ajog.org

IUS, and 6.5% initiated the Cu-IUD.

FIGURE 2
Continuation of long-acting reversible contraception at 36-months
by method type
Blue indicates intrauterine contraception; green indicates etonogestrel implant. Hazard ratio, 1.59;
95% confidence interval, 1.56e1.62; P < .001.
Chiles et al. Long-term continuation of LARC. Am J Obstet Gynecol 2016.
average of 14.7 (SD 13.8) months after
LARC insertion before achieving one
of the study endpoints (range, 1e60
months). At the time of LARC initiation,
the average age of the women in our
sample was 25.9 (SD 5.5) years; 75.8%
were family members, and 31.8% had
the insertion at a civilian network clinics
(Table 1).
Of all women who initiated LARC,
74.6% selected intrauterine contracep-
tives. Among women seen in military
clinics for intrauterine contraception,
56.1% denitively initiated the LNG-
We generally were unable to categorize
the intrauterine contraceptive type
among individuals who received in-
sertions in network clinics. The implant
was initiated in 25.4% of women.
Intrauterine contraceptive users were
signicantly older than implant users
(26.9 years old [SD 5.4] vs 23.0 [SD
4.7]; P < .001). Family members of
military service members were more
likely than servicewomen on active duty
to select intrauterine contraceptives.
Furthermore, women who were seen
for LARC placement in civilian network
clinics were more likely than those
who were seen in military clinics
to select intrauterine contraceptives
(Table 1).
The intrauterine contraception inser-
tion rate remained relatively stable dur-
ing the study interval, with a range of
41.7e50.1 insertions per 1000 enrolled
women per year; the implant insertion
rate increased from 6.1 insertions per
1000 women per year in 2010 to 23.0
insertions per 1000 women per year in
2014 (Figure 1).
Implant continuation rates were
76.8% at 12 months, 58.6% at 24
months, 45.8% at 33 months, and 32.0%
at 36 months (Figure 2; Table 2). Intra-
uterine contraceptive continuation rates
were 83.5% at 12 months, 70.6% at 24
months, 61.2% at 36 months, 54.1% at
48 months, and 48.8% at 60 months
(Figure 2; Table 2). Continuation rates of
intrauterine contraception did not differ
by device type (excluding unknown
types [P .461]; including unknown
types, [P .644]; Figure 3). Overall, the
implant was more likely than intrauter-
ine contraceptives to be discontinued at
<36 months (hazard ratio, 1.59; 95%

TABLE 2
Kaplan-Meier estimates of long-acting reversible contraception method continuation over 60 months
Monthsa
Method 12 24 33 36 48 60
Intrauterine contraceptive 83.5 (83.3e83.7) 70.6 (70.2e71.0) 63.4 (63.0e63.8) 61.2 (60.8e61.6) 54.1 (53.5e54.6) 48.8 (48.0e49.6)
Etonogestrel implant 76.8 (76.4e77.2) 58.6 (57.8e59.4) 45.8 (44.8e46.8) 32.0 (31.0e33.0)
a
Data are continuation rates with 95% confidence interval.
Chiles et al. Long-term continuation of LARC. Am J Obstet Gynecol 2016.

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ajog.org GYNECOLOGY Original Research

condence interval, 1.56e1.62; P <.001;

FIGURE 3
Figure 2).
Continuation of intrauterine contraception over the first
In a univariable analysis that was
60 months of method use by device type
stratied by contraceptive type, adoles-
cents had the highest implant conti-
nuation rates over the rst 36 months
(P < .001), whereas 35- to 40-year-old
women had the highest intrauterine
contraceptive continuation rates of any
age group (Figures 4 and 5; Table 3). In
multivariable analyses that controlled for
demographic factors and contraceptive
type, the likelihood of early LARC
discontinuation was highest among
women who were 20e24 years old at
the time of insertion, who were seen in
a military clinic rather than a network
clinic for method insertion, and who
selected an implant for contraception
rather than an intrauterine contraceptive
(Table 4).

Comment
In the US military healthcare system
that was studied, LARC initiation was
low but increasing, and continuation
rates are similar to those found in
previous studies. Individuals with TRI-
CARE Prime have access to contracep-
tion at no personal nancial cost, with
free and unlimited method switching
and a comprehensive healthcare records
system. Therefore, this is an ideal pop-
ulation to evaluate LARC initiation and
continuation. Approximately one-half
of women who selected the implant
continued their method at least until
3 months before the recommended
expiration date; almost one-half of
all women who selected intrauterine
contraception continued their method
until 60 months.
Our data, which show an overall
increased rate of LARC initiation over
the past several years, were consistent
with national trends.15,30,31 Military
healthcare enrollees appear to have
higher initiation of LARC than do
enrollees of another large US healthcare
plan.30 The extent to which this has to do
with universal healthcare without copay
is unknown.
Our study data are consistent with
recent data that demonstrate that LARC
typically is continued by >80% of
users at 12 months.10,15,16 Continuation
Blue indicates levonorgestrel intrauterine system; green indicates copper intrauterine device; brown
indicates unknown. P .644.
Chiles et al. Long-term continuation of LARC. Am J Obstet Gynecol 2016.
rates of intrauterine contraceptives
approached the middle of the afore-
mentioned ranges, and implant rates
were at the lower end of the known
ranges. However, from 33e36 months
(3 months before the Food and Drug
Administrations approved expiration
date for the implant), 13.8% of users,
including 16.9% of adolescent users,
discontinued the implant. At 33 months,
approximately one-half of implant users
continued the method. Perhaps the
33-month continuation rate of the
implant is a better criterion for judging
method continuation, because removals
after 33 months likely indicate receipt of
recommended care before method
expiration. Notably, more recent data
suggest that the implant and LNG-IUS
may be effective for 1 year after the rec-
ommended removal date.32
Previous studies that have examined
the association between LARC continu-
ation and age found lower continuation
among adolescents than among adults
as a group.10,16 We subdivided older
LARC users by age and discovered a
more nuanced relationship. Adolescents
had lower continuation rates than
women in their late thirties, but higher
continuation rates than women in
their twenties at 36 months and women
in their early twenties at 60 months.
Moreover, the data from this study sug-
gest that adolescents have the highest
implant continuation rates of any age
group, approaching those of intrauterine
contraceptives. These higher continua-
tion rates, compared with women in
their twenties who represent the major-
ity of LARC users, suggest that concerns
about method continuation among

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Original Research
FIGURE 4
Continuation of the etonogesterel implant over the first
36-months of use by age
Blue indicates 14-19 years old; green indicates 20-24 years old; brown indicates 25-29 years old;
purple indicates 30-34 years old; yellow indicates 35-40 years old. P < .001.
Chiles et al. Long-term continuation of LARC. Am J Obstet Gynecol 2016.
adolescents should not be a barrier
to LARC use in this age group. The
high LARC continuation rates that were
found in our study support national
recommendations for clinicians to
recommend the most effective methods
(ie, LARC) before they recommend
less effective methods during contra-
ceptive counseling to women of all
ages.4
The results of this study that show
both an increase in initiation and high
continuation of LARC have military
implications. First, in the military
healthcare system, LARC may have the
same potential to reduce rates of unin-
tended or mistimed pregnancies and to
increase cost-savings, as it has in the
general US population.8,9,12,13 This is
important for the military population,
which tends to be young and at risk for
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GYNECOLOGY
pregnancy.27-29 Approximately one-half
of active-duty enlisted personnel and
20% of all active-duty spouses are 25
years old. Thirty percent of military
children are between ages 12e22 years.26
Rates of unintended pregnancy in the
military healthcare system are thought to
be higher, albeit decreasing over time,
than in the general US population
(perhaps because of LARC initiation
patterns).27,28 Furthermore, LARC may
reduce healthcare disparities, because
rates of unintended pregnancy are
higher among young women, minor-
ities, and those with lower income (eg,
enlisted ranks), even in this universal
healthcare system.27-29 This is especially
relevant, because approximately one-
third of active-duty service members
self-identify as members of minority
groups.26
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ajog.org
Second, downstream effects of LARC
could include an improvement in
military readiness, because pregnancies
among active-duty service members and
their family members directly affect
operational readiness. According to
1 study, among women surveyed
approximately 1 year into deployment,
10% reported having been unintention-
ally pregnant during that year, which
indicates that the pregnancy occurred
during deployment.27 In another study,
11% of servicewomen were unable to
complete a 15-month combat deploy-
ment because of a pregnancy.33 Service-
women report less frequent use of
contraception during deployment than
at home, despite benets on contracep-
tion and menstrual regulation (eg,
menstrual suppression with the LNG-
IUS).29 Those deployed also report
difculty with initiating and continuing
contraception because of logistical
and institutional barriers to obtaining
reproductive health services in a
deployed environment.29 Use of highly
effective, long-term contraceptive op-
tions that can be started before deploy-
ment and continued without need for
medical support during deployment
could make a valuable contribution to
the health and welfare of these women.
Strengths of this study include the
large number of contraception initia-
tions that were identied and the follow-
up duration of up to 5 years, which
allowed for analysis of continuation rates
throughout the Food and Drug Admin-
istrations approved duration of use for
the LNG-IUS and the implant. Enrollees
have access to no-cost contraception
including no copays and unlimited
method switching. The database also
likely identied that the vast majority
of services were sought by enrollees,
because it captures both military and
civilian care billed through TRICARE
Prime.
Limitations of this study include its
retrospective design and dependence on
coding accuracy.34 We were unable to
evaluate for the indication for LARC
initiation. Continuation rates of the
LNG-IUS, for example, which were
inserted exclusively for heavy menstrual
bleeding, are not known. Similar to
ajog.org GYNECOLOGY Original Research

another large retrospective analysis,

FIGURE 5
reasons for early discontinuation were
Continuation of intrauterine contraception over the first
not evaluated.15 This may have led to a
60 months of method use by age
lower estimation of method continua-
tion compared with previous studies,
because we had to count contraceptive
removals for desired return of fertility as
a method failure rather than censoring
them from further analysis. In the
CHOICE project, desired return of
fertility accounted for up to 6e26% of
early removals, depending on duration
of use and method type; the vast ma-
jority requested removal for bleeding,
pain, or other side-effects.10,14 Expul-
sions of intrauterine contraceptives were
not specically identied. Race and
ethnicity were not evaluated indepen-
dently in our analysis because of poor
reporting of such information in the
database. Regarding study endpoints,
perhaps analysis of LARC method
continuation 3 months before the Federal
Drug Administrations recommended
device expiration would represent a more
practical depiction of continuation.
Furthermore, data from the military
clinics and pharmacies were obtained
from the militarys electronic medical
record; data from civilian network
clinics were dependent on submitted
billing statements. This was evident in
Blue indicates 14-19 years old; green indicates 20-24 years old; brown indicates 25-29 years old;
the higher likelihood of missing intra-
purple indicates 30-34 years old; yellow indicates 35-40 years old, P < .001.
uterine contraceptive type among
Chiles et al. Long-term continuation of LARC. Am J Obstet Gynecol 2016.
women who received insertions in
civilian network clinics. Of all women
with a known intrauterine contraceptive Overall, the high rate of LARC recommendations for women of all
type selected in our study, 89.6% continuation that was found in this ages who seek contraception, including
selected the LNG-IUS, and 10.4% analysis supports LARC as rst-line service members and their families,
selected the Cu-IUD. Based on this
and national data, it is reasonable to
suspect that at least 80% of intrauterine TABLE 3
contraceptive users selected the LNG- Univariable analysis of early contraceptive method discontinuation by age
IUS.12,16,30 In any case, analyses that
Intrauterine
included the unknown types showed the Implant 95% contraception 95%
same continuation rates as those that Age discontinuation Confidence discontinuation Confidence
excluded them. Many women enrolled in group, y at <36 moa Interval at <60 moa Interval
the TRICARE Prime insurance program 14-19 Reference 1.72 1.61e1.83
use military and civilian network clinics
20-24 1.56 1.48e1.64 1.96 1.87e2.05
over time; accordingly, we included data
from both sources to obtain a more 25-29 1.52 1.44e1.61 1.72 1.64e1.80
complete understanding of LARC use 30-34 1.35 1.25e1.45 1.33 1.27e1.40
among women who were enrolled in the 35-40 1.15 1.02e1.29 Reference
military healthcare system. This strategy a
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Author and article information
From the Department of Pediatrics (Drs Chiles and Rob-
erts), San Antonio Military Medical Center, San Antonio,
TX; and the Department of Pediatrics (Drs Chiles, Roberts,
and Klein) and Family Medicine (Dr Klein), Uniformed
Services University of the Health Sciences, Bethesda, MD.
Received Jan. 3, 2016; revised March 9, 2016;
accepted March 14, 2016.
The views expressed herein are those of the authors
and do not reflect the official policy or position of Brooke
Army Medical Center, the Departments of the Army, Air
Force, or Navy or their respective Medical Departments,
the Department of Defense, or the U.S. Government.
The authors report no conflict of interest.
Presented at the annual meeting of the Society for
Adolescent Health and Medicine, Washington, DC, Mar.
9-12, 2016.
Corresponding author: David A. Klein, MD, MPH.
david.a.klein26.mil@mail.mil
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