jurnal - preventing repeat pregnancy
TRANSCRIPT
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Preventing Repeat Pregnancy In Adolescents:
Is Immediate Postpartum Insertion Of The
Contraceptive Implant Cost-effective?
Leo Han, MD Stephanie B. Teal, MD, MPH Jeanelle Sheeder,MSPH, PhD Kristina Tocce, MD, MPH
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Introduction
Adolescents are at high risk for rapid repeat pregnancy: 12%to 49% of adolescent mothers are pregnant again within oneyear of delivery.
Rapid repeat adolescent pregnancy has significant costs tothe healthcare system. Medical costs of adolescentpregnancy are estimated to be 1.5 billion dollars per year toUS taxpayers.
Adolescents are receptive to initiating LARC immediatelypostpartum, but reimbursement policies limit this practice to
the outpatient setting. A program attempting outpatientimplant insertion within the first two weeks postpartumresulted in fewer adolescent patients receiving implantinsertions than anticipated.
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Objective
The purpose of this study was to determine cost-effectiveness of a hypothetical state-funded programoffering immediate postpartum implant (IPI) insertionfor adolescent mothers.
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Methods
Participants in an adolescent prenatal-postnatal programwere enrolled in a prospective observational study of IPIinsertion (IPI group, n=171) versus standardcontraceptive initiation (comparison group, n=225).
Implant discontinuation, repeat pregnancies andpregnancy outcomes were determined.
We compared the anticipated public expenditures for IPIrecipients and comparisons at 6, 12, 24 and 36 monthspostpartum using the actual outcomes of this cohort and
Colorado Medicaid reimbursement estimates.
Costs were normalized to 1000 adolescents in each armand included one year of well-baby care for deliveredpregnancies
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Result
At 6 months, expenditures of the IPI group exceed thecomparison group by $73,000.
However, at 12, 24 and 36 months, publically funded IPIswould result in a savings of over $550,000, $2.5 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, 36 months.
Expenditures between the IPI and comparison groupswould be equal if the comparison group pregnancy ratewas 13.8%, 18.6% and 30.5% at 12, 24 and 36 months.
Actual rates were 20.1% 46.5% and 83.7%.
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Discussion
Repeat pregnancy rates were significantly lower at eachtime point in the IPI group.
When comparing 1000 women choosing IPI to 1000 womenchoosing an outpatient contraceptive strategy, there is a
small initial loss for the program at 6 months of $73,000. However, evaluation at 12, 24 and 36 months demonstrated
a net savings of $550,000, $2.5 million and $4.5 milliondollars respectively.
It has been estimated that approximately $4.13 is savednationally in pregnancy related and newborn costs for everydollar Medicaid spends on contraceptive services
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Discussion
Strengths of our study include a design that was deliberatelybiased towards a conservative estimate of potential cost savings.
Costs of obstetrical complications such as preterm labormanagement or preeclampsia were not included. Moreover, wedid not include the cost of the contraceptives used by the
comparison group although Colorado Medicaid paid them. Thus,our calculations reflect the additional costs to Medicaid over apresumed baseline cost of contraception when IPI is notavailable.
Although allowing the participants to self select their groups
clearly introduces selection bias, self-selected groups allowaccounting for unmeasured factors that guide patientpreferences. Contraceptive and pregnancy choices were basedon real values of the adolescents
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Discussion
While the analysis is based on actual outcomes, the resultsmay be less generalizable than if we used hypotheticaloutcomes from the literature.
Incident pregnancy data was obtained from both chart reviewand patient report, introducing another potential source of biasas patients may have over or under reported bothspontaneous miscarriages and induced abortions.
Loss to follow-up was lower in the comparison group at threeyears than the implant group and this is a potential source of
bias. Moreover, given that pregnancy outcomes werecumulatively added over time, our data could be biased tolosing women who did not get pregnant, and thus potentiallyinflate overall pregnancy rates.
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Discussion
Last, these results cannot be extrapolated to immediatepostpartum placement of all LARC methods. Immediate post-placental IUDs were not included in this study and previousIUD cost analyses have not focused on the postpartumadolescent population.
IPI cost-effectiveness may differ from immediate postplacental IUDs if method retention and method failure ratesdiffer.
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Conclusion
Offering immediate postpartum implants toadolescent mothers is cost effective.
Payors that do not currently cover IPI should
integrate this data into policy considerations
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Critical Appraisal
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396 patients who attending ColoradoAdolescent Maternity Program (CAMP)and who delivered at the University ofColorado Hospital
POPULATION
Immediate postpartum subdermal implant(IPI)INTERVENTION
Intervention group (IPI) vs comparisongroup (other contraception methodsstarted at any time 4 weeks)
COMPARISON
Cost-effectiveness Implant discontinuation Repeat pregnancies Pregnancy outcomes
OUTCOME
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Are the aims clearly stated? Yes. To determine cost-effectiveness of a hypothetical
state-funded program offering immediate postpartumimplant (IPI) insertion for adolescent mothers.
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Were the basic data adequately described? Data used in this study was all adolescents who were
attending the Colorado Adolescent Maternity Program(CAMP) and who delivered at the University of Colorado
Hospital over the 18-month period of June 1, 2008, toNovember 30, 2009
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Was the sample size justified? Yes. Actually, All of the patients expressed the desire to
prevent pregnancy for at least one year after delivery wereeligible for inclusion in the study cohort. However, it still had
an exclusion criteria, included contraindications toetonogestrel use, relinquishing the child for adoption,stillbirth, being delivered at a different hospital, having nopostpartum visits at the CAMP and women who did not takehome infants.
The number of initial population and excluded samples werenot explained.
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Was the statistical significance assessed? Yes, the value of P < 0,05 was considered to indicate
statistical significance
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Are the statistical methods described? Summary statistics were used to describe the population
as well as the outcomes.
The Students t-tests were used to compare means; the X2
test were used to compare proportions, and the Fishersexact tests were used when cell sizes were
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Where are the biases? Allowing the participants to self select their groups clearly
introduces selection bias. Thus, it made unbalance samplesbetween groups.
Incident pregnancy data was obtained from both chart reviewand patient report, introducing another potential source ofbias as patients may have over or under reported bothspontaneous miscarriages and induced abortions.
Loss to follow-up was lower in the comparison group at three
years than the implant group and this is a potential source ofbias.
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Did untoward events occur during the study? There was no untoward events during the study
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How do the results compare with previousreports?
No comparative reports that held regarding this field. Thiswas the first study to determine the cost-effectiveness of twocontraception approaches.
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What implications does the study have for
your practice?
This study result indicate the cost-effectiveness of IPIprogram, with better outcome of repeat pregnancy andpregnancy outcome.
It is important to counsel our patient to use thisapproaches, primarily the adolescense ones. Becausealthough Indonesians policy have not integrated this
approach yet, it still shows significantly cost-saving and
better outcome to patient itself.
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Thank You