Real-world cost-effectiveness of etonogestrel implants compared to long-term and short term reversible contraceptive methods in France.

BACKGROUND: To estimate the cost-effectiveness (CE) of etonogestrel implants compared to other long-term and short-term reversible contraceptive methods available in France. RESEARCH DESIGN AND METHODS: A 6-year Markov model compared effectiveness between the implant and six other contraceptive methods in sexually active, not-pregnancy-seeking French females of reproductive age. Contraception efficacy, switch rates and outcomes were based on French current medical practice. Incremental CE ratios (ICERs) were calculated as incremental cost per unintended pregnancy (UP) avoided. Efficiency frontier was plotted to identify cost-effective methods. Uncertainty was explored through sensitivity analyses. RESULTS: The implant was on the efficiency frontier along with combined oral contraceptive pill (COC) and copper IUD. Implant avoids between 0.75% and 3.53% additional UP per person-year compared to copper IUD and second generation COC, respectively, with an ICER of €2,221 per UP avoided compared to copper IUD. For the 240,000 French women currently using the implant, up to 8,475 UPs and up to 1,992 abortions may be prevented annually. CONCLUSION: With more unintended pregnancies avoided and comparable costs to copper IUD, the implant is a cost-effective option among long-term and short-term reversible contraceptive methods.

The relationship between long-acting reversible contraception and insurance coverage: a retrospective analysis.

OBJECTIVE: The objective was to determine if there is a relationship between patients' financial responsibility (out-of-pocket expenses) and placement of long-acting, reversible contraceptive (LARC) methods among girls and women living in Appalachia who expressed interest in LARC device placement. STUDY DESIGN: A retrospective chart analysis of patients prescribed an intrauterine device (IUD) or an etonogestrel implant between December 2011 and July 2013 in an Appalachian private practice was performed. Of the 571 identified patients aged 13 to 50, the majority were Caucasian (98.7%) and using Medicaid (53.2%). Outcomes measured the patients' decision regarding whether to use LARC after being informed of out-of-pocket expenses. RESULTS: There was a dramatic increase in the proportion of patients who had LARC methods placed if expense was under $200 (p<.001). Placement rate for privately insured patients was 86.6% for those who paid less than $200 compared to 27.8% for those who paid $200 or more. Medicaid patients, for whom the device was free, had a 78.0% placement rate. For every additional $100 patients had to pay out of pocket, the odds of deciding to use the prescribed LARC method decreased. CONCLUSIONS: LARC methods are utilized significantly more often when out-of-pocket cost is low. Cost appears to be a significant barrier to device placement for the group of privately insured Appalachian patients with out-of-pocket expenses over $200. Despite the improvements in coverage for many women provided under the Affordable Care Act, cost may remain a barrier for privately insured women who are required to pay some or all of the cost of LARC methods. IMPLICATIONS: Unintended pregnancy rates in the United States remain high, especially in Appalachia. One contributing factor is reliance on user-dependent methods which have significantly high typical use failure rates. Placement of LARC methods for more patients could decrease unintended pregnancy, but device costs may be one barrier to utilization, even for those with private insurance.

Cost-Effectiveness of Immediate Compared With Delayed Postpartum Etonogestrel Implant Insertion.

OBJECTIVE: To evaluate the cost-effectiveness of immediate compared with delayed (6 weeks) postpartum etonogestrel implant insertion in preventing future unintended pregnancy. METHODS: We constructed a decision-analytic model to examine a hypothetical population of women who request a contraceptive implant after giving birth. The timeframe for analysis was from the time of childbirth to 1 year postpartum. Model inputs were derived from a comprehensive literature review. We compared immediate (before discharge from the childbirth hospital stay) compared with delayed (at first postpartum office visit) postpartum placement of the contraceptive implant from a health care system's perspective. Implant insertion and removal, loss to follow-up at the postpartum visit, use of alternative contraceptive methods, and contraceptive failure were incorporated into the model. We calculated the incremental cost of immediate insertion for each pregnancy prevented during the first postpartum year and cost savings associated with pregnancies prevented. One-way sensitivity analyses were also performed. Cost estimates are reported in 2014 U.S. dollars. RESULTS: Immediate postpartum implant insertion is associated with higher expected cost than delayed insertion ($1,091/patient compared with $650/patient) but is more effective in preventing pregnancies (expected pregnancy rate: 2.4% and 21.6%, respectively). This results in an incremental cost-effectiveness ratio of $2,304 per pregnancy prevented. When taking into consideration medical costs of the resulting unintended pregnancies that could be avoided, immediate implant insertion is expected to save $1,263 per patient. CONCLUSION: Immediate postpartum provision of the contraceptive implant is cost-effective in preventing unintended pregnancies and should be provided to women requesting this form of contraception.

Increasing LARC utilization: any woman, any place, any time.

Intrauterine contraceptive devices and the progestin implant are the most effective long-acting reversible contraception (LARC) methods available for preventing unintended pregnancy. LARC devices are safe, non-user-dependent methods that have the highest rates of continuation and satisfaction of all reversible contraceptives. Use of these contraceptives remains low in the United States due to several barriers including: misperceptions among both providers and patients; cost barriers; and patient access to the devices. Increasing the opportunities for women to access LARC methods in the primary care, postabortion, and postpartum setting can be achieved by addressing the system, provider, and patient barriers that exist.

Preventing repeat pregnancy in adolescents: is immediate postpartum insertion of the contraceptive implant cost effective?

OBJECTIVE: The objective of the study was to determine the cost-effectiveness of a hypothetical state-funded program offering immediate postpartum implant (IPI) insertion for adolescent mothers. STUDY DESIGN: Participants in an adolescent prenatal-postnatal program were enrolled in a prospective observational study of IPI insertion (IPI group, n = 171) vs standard contraceptive initiation (comparison group, n = 225). Implant discontinuation, repeat pregnancies and pregnancy outcomes were determined. We compared the anticipated public expenditures for IPI recipients and comparisons at 6, 12, 24, and 36 months postpartum using the actual outcomes of this cohort and Colorado Medicaid reimbursement estimates. Costs were normalized to 1000 adolescents in each arm and included 1 year of well-baby care for delivered pregnancies. RESULTS: At 6 months, the expenditures of the IPI group exceed the comparison group by $73,000. However, at 12, 24, and 36 months, publicly funded IPIs would result in a savings of more than $550,000, $2.5 million, and $4.5 million, respectively. For every dollar spent on the IPI program, $0.79, $3.54, and $6.50 would be saved at 12, 24, and 36 months. Expenditures between the IPI and comparison groups would be equal if the comparison group pregnancy rate was 13.8%, 18.6%, and 30.5% at 12, 24, and 36 months. Actual rates were 20.1%, 46.5%, and 83.7%. CONCLUSION: Offering IPIs to adolescent mothers is cost effective. Payors that do not currently cover IPI should integrate these data into policy considerations.

Committee opinion no. 539: adolescents and long-acting reversible contraception: implants and intrauterine devices.

Long-acting reversible contraception (LARC)­intrauterine devices and the contraceptive implant­are safe and appropriate contraceptive methods for most women and adolescents. The LARC methods are top-tier contraceptives based on effectiveness, with pregnancy rates of less than 1% per year for perfect use and typical use. These contraceptives have the highest rates of satisfaction and continuation of all reversible contraceptives. Adolescents are at high risk of unintended pregnancy and may benefit from increased access to LARC methods.

Actual cost of providing long-acting reversible contraception: a study of Implanon cost.

BACKGROUND: The National Institute for Health and Clinical Excellence (NICE) has judged Implanon to be the most cost effective of the long-acting reversible contraception (LARC) methods, and its cost effectiveness is enhanced with increased duration of use. Gwent Sexual and Reproductive Health service provides unrestricted use of Implanon, and with the number of implants fitted increasing annually the service wanted to know how long clients were keeping their contraceptive implants in and the cost of implant provision. METHODS: The actual cost of providing Implanon was calculated in a cohort of 493 patients within a community-based sexual and reproductive health service, and compared to that predicted in the NICE Clinical Guideline 30 on LARC. RESULTS: The annual cost for the method (using Implanon) was pound77.49, 25% lower than the estimate made by NICE, despite a shorter duration of use of the method. CONCLUSION: The actual cost in this community-based sexual and reproductive health service may not be transferable to other settings such as general practice.

The cost-effectiveness of a long-acting reversible contraceptive (Implanon) relative to oral contraception in a community setting.

BACKGROUND: Within the setting of a UK community sexual health service, the cost-effectiveness of Implanon and oral contraception provision over a 36-month period was compared. STUDY DESIGN: A case-controlled retrospective cost-effectiveness study was done on a cohort of 493 Implanon users and 493 oral contraceptive users. The actual cost of provision of both methods was calculated. Cost-effectiveness was calculated based on provision of method and pregnancy costs of each cohort. RESULTS: Implanon provision is more cost-effective than oral contraception at all time points. After 12 months of use, Implanon is half the cost of oral contraception. Oral contraception reached similar annual cost to Implanon at 36 months of use. CONCLUSIONS: Long-acting reversible contraception is perceived to be expensive. It is reassuring to contraception providers that Implanon is, in fact, highly cost-effective when compared to oral contraception with typical use.

The cost-effectiveness of long-acting reversible contraceptive methods in the UK: analysis based on a decision-analytic model developed for a National Institute for Health and Clinical Excellence (NICE) clinical practice guideline.

BACKGROUND: Long-acting reversible contraceptive (LARC) methods are highly effective in preventing unintended pregnancies. However, their uptake is low in much of the developed world. This study aimed at assessing the cost-effectiveness of LARC methods from the British National Health Service (NHS) perspective. METHODS: A decision-analytic model was constructed to estimate the relative cost-effectiveness of the copper intrauterine device (IUD), the levonorgestrel intrauterine system (LNG-IUS), the etonogestrel subdermal implant and the depot medroxyprogesterone acetate injection (DMPA). Comparisons with the combined oral contraceptive pill (COC) and female sterilization were also performed. Effectiveness data were derived from a systematic literature review. Costs were based on UK national sources and expert opinion. RESULTS: LARC methods dominated COC (i.e. they were more effective and less costly). Female sterilization dominated LARC methods beyond 5 years of contraceptive protection. DMPA and LNG-IUS were the least cost-effective LARC methods. The incremental cost-effectiveness ratio of implant (most effective LARC method) versus IUD (cheapest LARC method) was pound13 206 per unintended pregnancy averted for 1 year of use and decreased until implant dominated IUD in 15 years. Discontinuation was a key determinant of the cost-effectiveness of LARC methods. CONCLUSIONS: LARC methods are cost-effective from the British NHS perspective. Practices improving user satisfaction and continuation of LARC method use should be identified and promoted.

Relative cost effectiveness of Depo-Provera, Implanon, and Mirena in reversible long-term hormonal contraception in the UK.

OBJECTIVE: To estimate the relative cost effectiveness for women aged > or =30 years, starting long-term hormonal contraception with either levonorgestrel intrauterine system (Mirena), etonogestrel subdermal implant (Implanon) or medroxyprogesterone acetate injection (Depo-Provera). DESIGN AND SETTING: This was a modelling study, performed from the perspective of the UK NHS, of contraceptive services supplied by a general practitioner. STUDY PARTICIPANTS AND INTERVENTIONS: A dataset was created from the General Practice Research database (GPRD) comprising 16 835 women aged > or =30 years who received levonorgestrel intrauterine system (n = 6080), etonogestrel subdermal implant (n = 277) or medroxyprogesterone acetate injection (n = 10 478) for their long-term contraception between 1997 and 2002. METHODS: Contraception-related healthcare resource utilisation values and contraception continuation rates were obtained from the GPRD. The incidence of pregnancy associated with each contraceptive was obtained from the published literature. By combining the GPRD dataset with published clinical outcomes, a decision model was constructed. This was used to estimate the expected annualised direct healthcare costs and consequences of the provision of each type of contraception per woman-year in pounds sterling (pound) at 2002/03 prices. RESULTS: Our model suggests that starting long-term contraception with levonorgestrel intrauterine system or etonogestrel subdermal implant instead of medroxyprogesterone acetate injection is a dominant strategy from the UK NHS perspective. In contrast, starting long-term contraception with etonogestrel subdermal implant instead of levonorgestrel intrauterine system is likely to be the least cost-effective option, since it would lead to an additional cost for each additional avoided pregnancy (pound 21,000). CONCLUSION: Long-acting reversible hormonal contraception has the benefit of being extremely effective (>99%), and not reliant on patient compliance nor dependent on correct usage. The relative cost effectiveness of using any one contraceptive should be considered in the light of the additional clinical benefits it may confer, user acceptability, QOL, past medical history and the estimated cost of an unintended pregnancy. Choice of contraception is essential to meet diverse user needs and preferences that may change with the user's stage of life. Only by offering choice will the maximum number of women be protected and therefore the greatest savings to the health service be gained.

Is Cerazette the minipill of choice?

Around 5% of women aged 16-49 years in Great Britain use a progestogen-only pill (POP; 'minipill') as contraception. These pills are used as alternatives to combined oral contraceptives (COCs), compared to which they are less reliable at preventing pregnancy: the estimated contraceptive failure rate of POPs is 0.5 pregnancies per 100 woman-years when used consistently and correctly, compared with 0.1 per 100 woman-years for COCs. Cerazette (Organon), a new POP, is being promoted by the company as "the first oestrogen free pill to consistently inhibit ovulation", as having "the efficacy of a combined pill, with the reassurance of an oestrogen free pill" and offering "reliable contraception for women of any reproductive age". Here, we consider whether Cerazette offers advantages over established POPs.

Increased number of induced abortions in Norway after media coverage of adverse vascular events from the use of third-generation oral contraceptives.

After the press release in Lancet (October 18, 1995) of increased risks for adverse vascular events in users of pills containing desogestrel and gestodene the total sales of oral contraceptives dropped over a two-month period by 17%, while sales of the only desogestrel brand available (Marvelon) dropped by over 70% in Norway. From sales, we can estimate that more than 45,000 women either changed from Marvelon to a second or first-generation brand or stopped using OCs. In total, more than 25,000 women discontinued OC use in Norway during November and December of 1995. Abortion data from one Norwegian county, representing 6-7% of the Norwegian population, show no statistically significant changes in the total number of induced abortions from the first quarter of 1996 as compared with that of the first quarter in preceding years. However, abortion rates that had been steadily decreasing from 1992 through 1995 in women 24 years old or younger, were promptly interrupted by a significant 36% increase during the first quarter of 1996. Most of the additional cases were found among single, childless students. The observed increased abortion rate among younger women is most probably linked to changes in contraceptive use during the pill scare of the late October through December of 1995, during which time these women conceived.

PIP: Reports appearing in the mass media in October 1995 citing a two-fold increase in the risk of venous thromboembolism in users of third-generation compared to second-generation oral contraceptives (OCs) were followed, in Norway, by a 17% drop in total OC sales and a 70% drop in sales of the only third-generation OC (Marvelon) on the market. More than 25,000 Norwegian women discontinued OC use in November-December 1995. Abortion data from one Norwegian county, representing 6-7% of the country's population, showed no significant changes in the total number of induced abortions in the first quarter of 1996 compared to the first quarter of preceding years. However, the steady decrease in the abortion rate for women 24 years of age or younger recorded in 1992-95 was interrupted by a 36% increase during the first quarter of 1996 (5.7/1000, compared with 4.2/1000 in the first quarter of 1995). Most of the growth in abortion cases occurred among single, childless students--a subgroup in which OC use tends to be high. Although this finding suggests that the mass media's "pill scare" may have led many young women to discontinue OC use or switch to less effective formulations, evaluation of the full effect of this event cannot be completed without national data on induced abortion and the completion of birth registration.