Increasing intrauterine contraception use by reducing barriers to post-abortal and interval insertion.

BACKGROUND: We hypothesize that barriers to IUD insertion are central to low utilization in the USA. This study evaluates methods to minimize barriers, including post-abortal insertion, staff training and simplified screening. STUDY DESIGN: We obtained data on IUD utilization during three study periods: a control period (Period 1), a period after initiating post-abortal insertion and staff training (Period 2), and a period with these interventions plus simplified screening for interval insertions (Period 3). We evaluated IUD utilization, associated complications and utilization at a similar local agency in which the interventions were not implemented. RESULTS: We inserted 2172 IUDs during the study, including 1493 interval and 679 post-abortal insertions. In the control period, there were 28 monthly IUD insertions on average, compared to 71 (a 151% increase) and 122 (a 334% increase) in Periods 2 and 3, respectively. IUD utilization at the nearby agency remained relatively constant. Complications remained low. CONCLUSIONS: IUD utilization can be substantially increased through relatively simple, low-cost interventions, with significant potential to reduce unintended pregnancy.

Impact of immediate postabortal insertion of intrauterine contraception on repeat abortion.

BACKGROUND: Of the 1.3 million abortions performed annually in the United States, approximately half are repeat procedures. Immediate postabortal intrauterine device (IUD) insertion is a safe, effective, practical and underutilized intervention that we hypothesize will significantly decrease repeat unintended pregnancy and abortion. STUDY DESIGN: All women receiving immediate postabortal IUD insertion in eight clinics of a Northern California Planned Parenthood agency during a 3-year period comprise the IUD cohort. We selected a cohort of controls receiving abortions but choosing other, non-IUD contraception on the day of the abortion visit in a 2:1 ratio matched by date of abortion. We obtained follow-up data on repeat abortions within the agency for both cohorts through 14 months after the 3-year period. We evaluated differences in repeat abortion between cohorts. All analyses were intent-to-treat. RESULTS: Women who received an immediate postabortal IUD had a lower rate of repeat abortions than controls (p<.001). Women who received a postabortal IUD had 34.6 abortions per 1000 woman-years of follow-up compared to 91.3 for the control group. The hazard ratio for repeat abortion was 0.38 [95% confidence interval (CI), 0.27-0.53] for women receiving a postabortal IUD compared to controls. When adjusted for age, race/ethnicity, marital status, and family size, the hazard ratio was 0.37 (95% CI, 0.26-0.52). CONCLUSION: Immediate postabortal intrauterine contraception has the potential to significantly reduce repeat abortion.

Contraceptive and noncontraceptive benefits of the LNG-IUS in a vertically integrated HMO.

BACKGROUND: The study was conducted to assess outcomes among women using the levonorgestrel-releasing intrauterine system (LNG-IUS). STUDY DESIGN: The data were collected via a retrospective claims database analysis of 152 women. Two nested cohorts were further distinguished based on length of follow-up: two and three continuous years (n=73 and n=29, respectively). RESULTS: Over 90% had a single insertion, and fewer than 4% experienced an LNG-IUS-related complication. Thirteen percent of women experienced menorrhagia in the year preceding insertion; this figure dropped to 12.5%, 1.2% and 0% in the 1, 2 and 3 years postinsertion. Mean number of gynecology-related visits decreased from four to two in the overall cohort, from seven to four in the cohort with 2 years of follow-up and from nine to four in the cohort with 3 years of follow-up. CONCLUSION: LNG-IUS use prevented pregnancy in all patients and was associated with decreased vaginal bleeding starting in the second year postinsertion.

Direct costs of blindness experienced by patients enrolled in managed care.

PURPOSE: To evaluate total and condition-related charges incurred by blind patients in a managed care population in the United States and compare total charges with those of a matched nonblind cohort. DESIGN: Retrospective cohort study. PARTICIPANTS: Patients with blindness (N = 10 796) and a 1:1 matched cohort of nonblind patients were selected from a managed care claims database. All study subjects were required to be > or =18 years old at diagnosis (blind patients) or enrollment (nonblind patients) and to have had > or =1 years of continuous follow-up. METHODS: Total and pharmacy-related direct medical charges in the first year of follow-up were calculated for both blind and nonblind cohorts. Among blind patients, condition-related charges, charge per treated person, and charge breakdown by age group were calculated. For patients with follow-up extending past 1 year, total charges (both cohorts) and condition-related charges (blind cohort only) were assessed and annualized. Mean and median charges were assessed for blind and nonblind patients within each stratum of matched covariates; a multivariate linear regression assessed the statistical significance of the difference in charges between the 2 cohorts. MAIN OUTCOME MEASURES: Total health care charges in the first year of follow-up and condition-related health care charges in the first year of follow-up for blind patients. RESULTS: For the blind population (mean age, 52 years [standard deviation (SD), 17.5]), the total mean and median health care charges per person in the first year were $20,677 (SD, $48,835) and $6854, respectively. Total mean and median health care charges per nonblind patient in the first year were $13,321 (SD, $40,059) and $3778, respectively. Condition-related charges among blind patients were substantially lower than total charges, with mean and median charges per person of $4565 (SD, $17,472) and $371, respectively. After adjusting for covariates, blind patients had significantly higher total health care charges in the first year of follow-up than nonblind patients (P<0.0001). Costs of the blind did not differ substantially from costs of the normally sighted in subsequent years of follow-up. CONCLUSION: This study demonstrates the substantial direct cost burden of blindness during the first year of follow-up in a managed care population.

Bleeding patterns after misoprostol vs surgical treatment of early pregnancy failure: results from a randomized trial.

OBJECTIVE: The purpose of this study was to describe bleeding patterns after misoprostol or curettage for early pregnancy failure (EPF). STUDY DESIGN: This was a randomized trial that included women (n = 652) with EPF. Participants were assigned to vaginal misoprostol (800 microg) or curettage in a 3:1 ratio. Participants completed a bleeding diary. We measured hemoglobin levels at baseline and 2 weeks after the treatment. RESULTS: Decreases in hemoglobin levels were greater after misoprostol (-0.7 g/dL; SD, 1.2) than curettage (-0.2 g/dL; SD, 0.9; P < .001). Large changes in hemoglobin levels (at least 2 g/dL) or low nadir hemoglobin levels (< 10 g/dL) were more frequent after misoprostol (55/428 women; 12.8%) than after curettage (6/135 women; 4.4%; P = .02). More participants in the misoprostol group reported "any bleeding" or "heavy bleeding" every study day. Four women who were treated with misoprostol required blood transfusion. CONCLUSION: Bleeding is heavier and more prolonged after medical treatment with misoprostol than with curettage for EPF; however, bleeding rarely requires intervention.