Asking for what she needs? Pregnancy testing or EC?

Ulipristal acetate compared to levonorgestrel emergency contraception among current oral contraceptive users: a cost-effectiveness analysis

OBJECTIVE

To estimate the cost-effectiveness of ulipristal acetate (UPA) and levonorgestrel (LNG) emergency contraception (EC) on pregnancy prevention among combined oral contraceptive (COC) pill users with an extended pill-free interval. We accounted for the potential interaction of COCs and obesity on EC efficacy.

METHODS

We built a decision-analytic model using TreeAge software to evaluate the optimal oral EC strategy in a hypothetical cohort of 100,000 twenty-five-year-old women midcycle with a prolonged "missed" pill episode (8-14 days). We used a 5-year time horizon and 3% discount rate. From a healthcare perspective, we obtained probabilities, utilities and costs inflated to 2018 dollars from the literature. We set the threshold for cost-effectiveness at a standard $100,000 per quality-adjusted life-year. We included the following clinical outcomes: number of protected cycles, unintended pregnancies, abortions, deliveries and costs.

RESULTS

We found that UPA was the optimal method of oral EC, as it resulted in 720 fewer unintended pregnancies, 736 fewer abortions and 80 fewer deliveries at a total cost savings of $50,323 and 79 additional adjusted life-years. UPA continued to be the optimal strategy even in the case of obesity or COCs impacting UPA efficacy, in which a COC interaction would have to change efficacy of UPA by 160% before LNG was the dominant strategy.

CONCLUSION

Our models found that UPA was the dominant choice of oral EC among COC users with a prolonged "missed" pill episode, regardless of body mass index or an adverse interaction of COCs on UPA.

IMPLICATIONS

Ulipristal acetate is the dominant choice of oral emergency contraception among combined oral contraceptive users.

A checklist approach to caring for women seeking pregnancy testing: effects on contraceptive knowledge and use

OBJECTIVE

To assess how a checklist reminding clinicians to deliver a bundled intervention affects contraceptive knowledge and use 3 months after women seek walk-in pregnancy testing.

METHODS

Pre-intervention, an inner-city family planning clinic provided unstructured care; during the intervention period, clinic staff used a checklist to ensure women received needed services. Women seeking walk-in pregnancy testing who wished to avoid pregnancy for at least 6 months were asked to complete surveys about their contraceptive knowledge and use immediately after and 3-months after visiting the study clinic. To assess the significance of changes over time, we used logistic regression models.

RESULTS

Between January 2011 and May 2013, over 1500 women sought pregnancy testing from the study clinic; 323 completed surveys (95 pre-intervention and 228 during the intervention period). With this checklist intervention, participants were more likely to receive emergency contraception (EC) (22% vs. 5%, [aOR 4.66 (1.76-12.35)], [corrected] have an intrauterine device or implant placed at the time of their clinic visit (5% vs. 0%, p=0.02), or receive a contraceptive prescription (23% vs. 10%, p<0.001). Three months after visiting the study clinic, participants from the intervention period were more knowledgeable about intrauterine and subdermal contraception and were more likely to report at 3-month follow-up a method of contraception more effective than the method they used prior to seeking pregnancy testing from the study clinic (aOR=2.02, 95% CI=1.03-3.96). The authors would like to apologize for any inconvenience caused. [corrected].

CONCLUSIONS

Women seeking walk-in pregnancy testing appear more likely to receive EC and to have switched to a more effective form of birth control in the 3 months following their visit when clinic staff used a 3-item checklist and provided scripted counseling.

IMPLICATIONS

A checklist reminding clinic staff to assess pregnancy intentions, provide scripted counseling about both emergency and highly-effective reversible contraception, and offer same-day contraceptive initiation to women seeking walk-in pregnancy testing appears to increase use of more effective contraception.