Estimated economic impact of the levonorgestrel intrauterine system on unintended pregnancy in active duty women

Assuring TRICARE Coverage of Preventive Health Services for Women Beneficiaries of the Military Health System

WHY DEFENSE HEALTH HORIZONS PERFORMED THIS STUDY

The primary role of the Military Health System is to assure readiness by protecting the health of the force by providing expert care to wounded, ill, and injured service members. In addition to this mission, the Military Health System (both directly through its own personnel and indirectly, through TRICARE) provides health services to millions of military family members, retirees, and their dependents. Women's preventive health services are an important part of comprehensive health care to reduce rates of disease and premature death and were included in the 2010 Patient Protection and Affordable Care Act's (ACA) expanded coverage of women's preventive health services, based on the best available evidence and guidelines. These guidelines were updated by the Health Resources and Services Administrations and the American College of Obstetrics and Gynecology in 2016. However, TRICARE is not subject to the ACA, and therefore, TRICARE's provisions or the access of TRICARE's female beneficiaries to women's preventive health services was not directly changed by the ACA. This report compares women's reproductive health care coverage under TRICARE with coverage available to women enrolled in civilian health insurance plans subject to the 2010 ACA.

WHAT DEFENSE HEALTH HORIZONS RECOMMENDS

Three recommendations are proposed to ensure that women who are TRICARE beneficiaries have access to and receive preventive reproductive health services that are consistent with Health Resources and Services Administration recommendations as implemented in the ACA. Each recommendation has strengths and weaknesses that are described in detail in the body of this paper.

WHAT DEFENSE HEALTH HORIZONS FOUND

In covering contraceptive drugs and devices, TRICARE appears to reflect the scope of coverage found in ACA-compliant plans but, by not incorporating the term "all FDA-approved methods" of contraception, TRICARE leaves open the possibility that a narrower definition could be adopted at a future date. There are important differences in how TRICARE and ACA-compliant plans address reproductive counseling and health screening, including TRICARE's more restrictive counseling benefit and some limits to preventive screening. By not aligning with policies related to the provision of clinical preventive services established under the ACA, TRICARE allows health care providers in purchased care to diverge from evidence-based guidelines. Although the ACA respects medical judgment when providing women's preventive services, standards restrict the extent to which health care systems and providers can depart from evidence-based screening and prevention guidelines essential to optimizing quality, cost, and patient outcomes.

A Scoping Review of Unintended Pregnancy in Active Duty United States Military Women

INTRODUCTION

The purpose of this scoping review was to apply the Social Ecological Model for Military Women's Health to literature on unintended pregnancy (UIP) to answer the question: In United States active duty military women (population) with the potential for UIP (context), what is known about risk factors, prevention, and pregnancy outcomes (concepts)?

METHODS

We conducted this review based on a PRISMA-ScR protocol registered a priori in Open Science Framework. Following a literature search of six databases and the grey literature, we used DistillerSR to manage data screening and data charting. The Social Ecological Model for Military Women's Health served as the theoretical framework to chart findings regarding UIP at the individual, microsystem, mesosystem, exosystem, and macrosystem levels.

RESULTS

A total of 74 research, review, and grey literature articles met the inclusion criteria. Risk factors included specific demographics, military service, and recent deployment. Prevention included contraceptive practices, access, and education that should take place early in servicewomen's careers and before deployment. Outcomes included early return from deployment, personal career challenges, and seeking alternative health services outside the military health system.

CONCLUSIONS

Research and policy initiatives should focus on decreasing risk factors in the military working environment, with particular attention to the deployed environment. These initiatives should include input from military leaders, health care providers, servicewomen, and servicemen with the goal of decreasing the incidence of unintended pregnancies. Pregnancy intentionality among military women should be considered as a concept to shape intervention research to reduce unintended pregnancies.

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.

Contraception and Unintended Pregnancy in the Military Healthcare System

The number of women serving in the Armed Forces is growing and readiness has been decreed as the number 1 priority for the total Army. Provision of contraception and unintended pregnancy rates higher than the general population are two key factors in readiness of female soldiers. An in-depth review of women's healthcare in the military identified these two areas of women's health as greatly understudied. Long-acting reversible contraception provides effective and cost-efficient method for contraception and a proven way to decrease unintended pregnancy. Increased research and focus into these two areas of women's health is crucial to providing the best care for our female service members.

Reviewing the cost-effectiveness of long-acting reversible contraceptive methods in an Australian context

BACKGROUND

Relative to the oral contraceptive pill, uptake of long-acting reversible contraceptive methods (LARCs) in Australia continues to be lower than might be suggested by the evidence on their clinical and economic benefits.

AIM

To undertake a critical appraisal of published economic evaluations of LARCs to assess the generalisability of their results to the Australian healthcare context.

MATERIALS AND METHODS

A search of the literature was conducted to identify studies of economic evaluations of LARCs using the Medline, Embase and PubMed databases. The quality of the studies was evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

A total of 1009 citations were screened, from which 20 papers, typically reporting the cost per pregnancy avoided, were reviewed. The overall quality of the studies varied but was generally poor (average score of 62/100). To aid comparisons, results have been grouped under the headings IUS (all hormonal intrauterine systems), IUDs (all non-hormonal intrauterine devices), injectables (all contraceptive injections) and implants (all subdermal contraceptive implants). Overall, the results indicated that LARCs were more effective and less costly than oral contraceptives.

CONCLUSIONS

Despite evidence that LARCs represent value for money, limitations in study quality and approaches must be taken into account when applying these results to Australia. Differences in healthcare settings aside, LARCs may also have benefits beyond their effect on pregnancy that might be captured in broader analyses, such as cost-benefit analyses using willingness to pay methods. These would capture benefits beyond health, which seem to be particularly relevant to contraception.