The cost-effectiveness of family planning service provision

Quantifying the economic burden of unintended pregnancies due to drug–drug interactions with hormonal contraceptives from the United States payer perspective

Background: In the United States of America (USA), nearly 10 million women use oral contraceptives (OCs). Concomitant administration of certain medications can result in contraceptive failure, and consequently unintended pregnancies due to drug–drug interactions (DDIs). The objective of this analysis was to estimate the economic impact of unintended pregnancies due to DDIs among women of reproductive age using an OC alone or in combination with an enzyme inducer co-medication in the USA from a payer perspective. Methods: A Markov model using a cohort of 1,000 reproductive-age women was developed to estimate costs due to contraceptive failure for OC alone versus OC with concomitant enzyme inducer drugs. All women were assumed to begin an initial state, continuing until experiencing an unintended pregnancy. Unintended pregnancies could result in birth, induced abortion, spontaneous abortion, or ectopic pregnancy. The cohort was analyzed over a time horizon of 1 year with a cycle length of 1 month. Estimates of costs and probabilities of unintended pregnancy outcomes were obtained from the literature. Probabilities from the Markov cohort trace was used to estimate number of pregnancy outcomes. Results: On average, enzyme inducers resulted in 20 additional unintended pregnancies with additional unadjusted and adjusted costs median (range) of USD136,304 (USD57,436–USD320,093) and USD65,146 (USD28,491–USD162,635), respectively. The major component of the direct cost is attributed to the cost of births. Considering the full range of events, DDIs with enzyme inducers could result in 16–25 additional unintended pregnancies and total unadjusted and adjusted costs ranging between USD46,041 to USD399,121 and USD22,839 to USD202,788 respectively. Conclusion: The direct costs associated with unintended pregnancies due to DDIs may be substantial and are potentially avoidable. Greater awareness of DDI risk with oral contraceptives among payers, physicians, pharmacists and patients may reduce unintended pregnancies in at-risk populations.

Development of a pharmacoeconomic registry: an example using hormonal contraceptives

BACKGROUND

Disease-specific registries, documenting costs and probabilities from pharmacoeconomic studies along with health state utility values from quality-of-life studies could serve as a resource to guide researchers in evaluating the published literature and in the conduct of future economic evaluations for their own research. Registries cataloging economic evaluations currently exist, however they are restricted by the type of economic evaluations they include. There is a need for intervention-specific registries, that document all types of complete and partial economic evaluations and auxiliary information such as quality of life studies. The objective of this study is to describe the development of a pharmacoeconomic registry and provide best practices using an example of hormonal contraceptives.

METHODS

An expert panel consisting of researchers with expertise in pharmacoeconomics and outcomes research was convened and the clinical focus of the registry was finalized after extensive discussion. A list of key continuous, categorical and descriptive variables was developed to capture all relevant data with each variable defined in a data dictionary. A web-based data collection tool was designed to capture and store the resulting metadata. A keyword based search strategy was developed to retrieve the published sources of literature. Finally, articles were screened for relevancy and data was extracted to populate the registry. Expert opinions were taken from the panel at each stage to arrive at consensus and ensure validity of the registry.

RESULTS

The registry focused on economic evaluation literature of hormonal contraceptives used for contraception. The registry consisted of 65 articles comprising of 22 cost-effectiveness analyses, 9 cost-utility analyses, 7 cost-benefit analyses, 1 cost-minimization, 14 cost analyses, 10 cost of illness studies and 2 quality of life studies. The best practices followed in the development of the registry were summarized as recommendations. The completed registry, data dictionary and associated data files can be accessed in the supplementary information files.

CONCLUSION

This registry is a comprehensive database of economic evaluations, including costs, clinical probabilities and health-state utility estimates. The collated data captured from published information in this registry can be used to identify trends in the literature, conduct systematic reviews and meta-analysis and develop novel pharmacoeconomic models.

A demographic dividend of the FP2020 Initiative and the SDG reproductive health target: Case studies of India and Nigeria

Background: The demographic dividend, defined as the economic growth potential resulting from favorable shifts in population age structure following rapid fertility decline, has been widely employed to advocate improving access to family planning. The current framework focuses on the long-term potential, while the short-term benefits may also help persuade policy makers to invest in family planning.

Methods: We estimate the short- and medium-term economic benefits from two major family planning goals: the Family Planning 2020 (FP2020)’s goal of adding 120 million modern contraceptive users by 2020; Sustainable Development Goals (SDG) 3.7 of ensuring universal access to family planning by 2030. We apply the cohort component method to World Population Prospects and National Transfer Accounts data. India and Nigeria, respectively the most populous Asian and African country under the FP2020 initiative, are used as case studies.

Results: Meeting the FP2020 target implies that on average, the number of children that need to be supported by every 100 working-age people would decrease by 8 persons in India and 11 persons in Nigeria in 2020; the associated reduction remains at 8 persons in India, but increases to 14 persons in Nigeria by 2030 under the SDG 3.7. In India meeting the FP2020 target would yield a saving of US$18.2 billion (PPP) in consumption expenditures for children and youth in the year 2020 alone, and that increased to US$89.7 billion by 2030. In Nigeria the consumption saved would be US$2.5 billion in 2020 and $12.9 billion by 2030.

Conclusions: The tremendous economic benefits from meeting the FP2020 and SDG family planning targets demonstrate the cost-effectiveness of investment in promoting access to contraceptive methods. The gap already apparent between the observed and targeted trajectories indicates tremendous missing opportunities. Accelerated progress is needed to achieve the FP2020 and SDG goals and so reap the demographic dividend.

Cost-effectiveness of emergency contraception options over 1 year

BACKGROUND

The copper intrauterine device is the most effective form of emergency contraception and can also provide long-term contraception. The levonorgestrel intrauterine device has also been studied in combination with oral levonorgestrel for women seeking emergency contraception. However, intrauterine devices have higher up-front costs than oral methods, such as ulipristal acetate and levonorgestrel. Health care payers and decision makers (eg, health care insurers, government programs) with financial constraints must determine if the increased effectiveness of intrauterine device emergency contraception methods are worth the additional costs.

OBJECTIVE

We sought to compare the cost-effectiveness of 4 emergency contraception strategies-ulipristal acetate, oral levonorgestrel, copper intrauterine device, and oral levonorgestrel plus same-day levonorgestrel intrauterine device-over 1 year from a US payer perspective.

STUDY DESIGN

Costs (2017 US dollars) and pregnancies were estimated over 1 year using a Markov model of 1000 women seeking emergency contraception. Every 28-day cycle, the model estimated the predicted number of pregnancy outcomes (ie, live birth, ectopic pregnancy, spontaneous abortion, or induced abortion) resulting from emergency contraception failure and subsequent contraception use. Model inputs were derived from published literature and national sources. An emergency contraception strategy was considered cost-effective if the incremental cost-effectiveness ratio (ie, the cost to prevent 1 additional pregnancy) was less than the weighted average cost of pregnancy outcomes in the United States ($5167). The incremental cost-effectiveness ratios and probability of being the most cost-effective emergency contraception strategy were calculated from 1000 probabilistic model iterations. One-way sensitivity analyses were used to examine uncertainty in the cost of emergency contraception, subsequent contraception, and pregnancy outcomes as well as the model probabilities.

RESULTS

In 1000 women seeking emergency contraception, the model estimated direct medical costs of $1,228,000 and 137 unintended pregnancies with ulipristal acetate, compared to $1,279,000 and 150 unintended pregnancies with oral levonorgestrel, $1,376,000 and 61 unintended pregnancies with copper intrauterine devices, and $1,558,000 and 63 unintended pregnancies with oral levonorgestrel plus same-day levonorgestrel intrauterine device. The copper intrauterine device was the most cost-effective emergency contraception strategy in the majority (63.9%) of model iterations and, compared to ulipristal acetate, cost $1957 per additional pregnancy prevented. Model estimates were most sensitive to changes in the cost of the copper intrauterine device (with higher copper intrauterine device costs, oral levonorgestrel plus same-day levonorgestrel intrauterine device became the most cost-effective option) and the cost of a live birth (with lower-cost births, ulipristal acetate became the most cost-effective option). When the proportion of obese women in the population increased, the copper intrauterine device became even more most cost-effective.

CONCLUSION

Over 1 year, the copper intrauterine device is currently the most cost-effective emergency contraception option. Policy makers and health care insurance companies should consider the potential for long-term savings when women seeking emergency contraception can promptly obtain whatever contraceptive best meets their personal preferences and needs; this will require removing barriers and promoting access to intrauterine devices at emergency contraception visits.

A demographic dividend of the FP2020 Initiative and the SDG reproductive health target: Case studies of India and Nigeria

Background: The demographic dividend, defined as the economic growth potential resulting from favorable shifts in population age structure following rapid fertility decline, has been widely employed to advocate improving access to family planning. The current framework focuses on the long-term potential, while the short-term benefits may also help persuade policy makers to invest in family planning. Methods: We estimate the short- and medium-term economic benefits from two major family planning goals: the Family Planning 2020 (FP2020)’s goal of adding 120 million modern contraceptive users by 2020; Sustainable Development Goals (SDG) 3.7 of ensuring universal access to family planning by 2030. We apply the cohort component method to World Population Prospects and National Transfer Accounts data. India and Nigeria, respectively the most populous Asian and African country under the FP2020 initiative, are used as case studies. Results: Meeting the FP2020 target implies that on average, the number of children that need to be supported by every 100 working-age people would decrease by 8 persons in India and 11 persons in Nigeria in 2020; the associated reduction remains at 8 persons in India, but increases to 14 persons in Nigeria by 2030 under the SDG 3.7. In India meeting the FP2020 target would yield a saving of US$18.2 billion (PPP) in consumption expenditures for children and youth in the year 2020 alone, and that increased to US$89.7 billion by 2030. In Nigeria the consumption saved would be US$2.5 billion in 2020 and $12.9 billion by 2030. Conclusions: The tremendous economic benefits from meeting the FP2020 and SDG family planning targets demonstrate the cost-effectiveness of investment in promoting access to contraceptive methods. The gap already apparent between the observed and targeted trajectories indicates tremendous missing opportunities. Accelerated progress is needed to achieve the FP2020 and SDG goals and so reap the demographic dividend.

Is it worth paying more for emergency hormonal contraception? The cost-effectiveness of ulipristal acetate versus levonorgestrel 1.5 mg

BACKGROUND AND METHODOLOGY

Emergency hormonal contraception (EHC) can reduce unintended pregnancy and the associated costs and consequences for the individual and National Health Service (NHS). Levonorgestrel (LNG 1.5 mg) is currently the standard of care in the UK; however, it is not licensed for use >72 hours after unprotected sexual intercourse (UPSI). This cost-effectiveness analysis compares LNG 1.5 mg with ulipristal acetate (UPA) (ellaOne(®)), a new emergency hormonal contraceptive that is licensed for use up to 120 hours post-UPSI. The costs of both drugs and the costs of the consequences of unintended pregnancy - namely miscarriage, induced abortion and birth - are compared in a decision model from the perspective of the UK NHS.

RESULTS

The incremental cost-effectiveness ratio (ICER) is the cost of preventing one additional unintended pregnancy with UPA and is calculated to be £311 compared to LNG 1.5 mg when taken up to 120 hours post-UPSI. In sensitivity analysis, looking at different time frames and costs, the ICER ranges from £183 to £500. All these costs are less than the estimated cost of an unintended pregnancy (£948) regardless of the outcome or the cost of an induced abortion (£672).

DISCUSSION AND CONCLUSIONS

Even when considering only the direct costs of an unintended pregnancy, UPA represents value for money as a method of EHC when taken up to 120 hours post-UPSI. UPA is a cost-effective alternative to LNG 1.5 mg for all women presenting for EHC.

Designing sexual health services for young people: a methodology for capturing the user voice

The aim of the study was to assess the suitability of the Thurstone paired comparison method for capturing the user voice, through a survey of young people's views on the most salient priorities for a sexual health service. A convenience sample of 161 12-24 year olds was used. A psychometrically robust questionnaire was developed from a review of the relevant literature and from the information provided by three focus groups. The data derived from both stages were distilled into seven themes, and adapted to a Thurstone paired comparison format, in which each theme was paired with every other theme, with an 8-point scale between each pairing (21 pairings in total). Respondents were required to indicate their preference for one theme over the other in each pairing. The questionnaire was completed by 161 young people between April and July 2007, and the results were analysed using the Kendall coefficient of concordance to establish the degree of within-group agreement. The results suggested that there was significant agreement as to the essential desirable features of a sexual health service, both within the whole sample as well as within sub-samples (i.e. gender, age group and previous sexual health service use). The priorities were privacy, and a dedicated service close to home, with a drop-in facility and male and female staff being next most important, and an informal service and young staff being lowest priorities. The feedback from the pilot study, the 40% return and absence of spoiled questionnaires together indicated that the respondents found the method acceptable, while the actual findings corroborated those from other studies. Taken together, these results suggest that the Thurstone method offers a quick and simple method of capturing the user voice, with the results having sufficient validity to inform the planning of a local sexual health service.

Health economics of contraception

Unintended pregnancies constitute a global problem associated with substantial costs to health and social services, and emotional distress to women, their families and society as a whole. Provision of contraception has been demonstrated to be a particularly cost-effective healthcare intervention as, besides preventing a significant number of unintended pregnancies, it also results in great cost-savings to society. Male and female sterilization and long-acting reversible methods (such as the copper-T intra-uterine device and the subdermal implant) constitute the most cost-effective contraceptive options, followed by other hormonal methods (such as oral contraceptives); barrier and behavioural methods (such as the male condom and withdrawal, respectively) are least cost-effective compared with other contraceptive options. Nevertheless, when compared with no method, they still prevent a large number of unintended pregnancies, thus leading to important cost-savings. Improvements in compliance and continuation rates are expected to further enhance the contraceptive benefits and cost-savings associated with contraceptive use.

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.

Health authority commissioning for quality in contraception services

OBJECTIVE

To compare the commissioning of contraception services by London health authorities with accepted models of good practice.

DESIGN

Combined interview and postal surveys of all health authorities and National Health Service (NHS) trusts responsible for running family planning clinics in the Greater London area.

MAIN OUTCOME MEASURES

Health authority commissioning was assessed on the presence of four key elements of good practice--strategies, coordination, service specifications, and quality standards in contracts--by monitoring activity and quality.

RESULTS

Less than half the health authorities surveyed had written strategies or service specifications for contraception services. Arrangements for coordination of services were limited and monitoring was underdeveloped.

CONCLUSION

The process of commissioning services for contraception seems to be relatively underdeveloped despite the importance of health problems associated with unplanned pregnancy in London. These findings raise questions about the capacity of health authorities to improve the quality of these services through the commissioning process.