Original research articleThe cost-effectiveness of a long-acting reversible contraceptive (Implanon®) relative to oral contraception in a community setting
Introduction
Contraceptive services have been shown to be highly cost-effective and relatively inexpensive compared with the consequences of unintended pregnancies [1]. Each year, around 4 million people use contraceptive services in the UK at a cost benefit of around £11 per £1 spent [2]. This expenditure produces cost savings for the National Health Service (NHS) as a result of the reduction in the number of unintended pregnancies and the accompanying outcomes [3]. However, while the introduction of contraceptive methods has been described as a medical success story, there remain a substantial number of unintended pregnancies. Approximately one third of all pregnancies are unplanned [3]. More than 190,000 terminations are performed in the UK each year [4]. For women under 20, 42% of conceptions result in termination, and for women under 16, the proportion is 60% [5]. The economic, personal and social impact surrounding the continuing large numbers of unwanted pregnancies and resulting abortions clearly demonstrates that policymakers, purchasers and providers cannot afford to be complacent.
The effectiveness (and therefore cost-effectiveness) of contraception is highly dependent on correct and consistent use. However, long-acting methods that do not depend on daily adherence have had a relatively poor uptake partly due to their relatively high initial cost. Expert clinical opinion that long-acting reversible contraception (LARC) methods should have a wider role and an increase in their use could help to reduce unintended pregnancy was the precursor to the development of the Clinical Guideline 30 on long-acting reversible contraceptives [6] produced by the National Institute for Health and Clinical Excellence (NICE) in 2005.
NICE ranked four LARC methods according to cost-effectiveness (Depo Provera® injectable, copper intrauterine device, intrauterine system and implant). The 3-year subdermal etonogestrel implant, Implanon®, was ranked as the most cost-effective method, with maximum cost-effectiveness achieved with increased use. It was calculated to be more cost-effective than oral contraception at 12 months of use.
The economic model developed on behalf of NICE [7] was intended to overcome some of the limitations identified in the previously published studies but relied on effectiveness data sourced from systematic reviews of the literature [8] and used in the clinical section of the guideline. The extent to which research investigations are representative of everyday clinical practice is, at best, dubious, and therefore, this study was constructed to compare the relative cost-effectiveness of Implanon® compared to oral contraception within an actual sexual and reproductive health (SRH) service.
Section snippets
Study setting
Gwent SRH service provides unrestricted use of Implanon® and numbers fitted have increased from 461 in 2002–2003 to around 1400 in 2007–2008. It was important to the service to know how long clients were keeping their contraceptive implants in and the cost of implant provision. A comparison with oral contraceptive (OC) users allowed costs of both methods to be considered.
The service, in southeast Wales, UK, serves a population of 580,000 (109,000 of whom are females who are 15–44 years old). It
Results
Four hundred ninety-three Implanon® users and 493 OC controls were identified. Duration-of-use data were complete for 81% (n=400) of Implanon® users and 90.5% (n=486) of OC users. The lost-to-follow-up group included 2% of Implanon® users and 4% of OC users who requested no contact with them or their GP. Patients who were still minors at the time of data collection or who were known to be illiterate were not contacted (n=9). Within the Implanon® group, 1.4% (n=7) moved out of area and had their
Sensitivity analyses
A probabilistic sensitivity analysis was used to assess the extent to which Implanon® can be regarded as being cost-effective — the extent to which the cost-effectiveness ratio is less than threshold values. The results can be seen in Fig. 5, Fig. 6.
It can be seen that it is highly probable that the cost of Implanon® per pregnancy avoided is extremely small, and therefore, Implanon® can be viewed as being highly cost-effective.
Discussion
It is well established that contraception is cost-effective [1]. LARC methods were thought to be more expensive than daily oral methods because they are often provided by doctors rather than nurses, may take longer to provide if a procedure needs to be done and have a high unit cost compared to oral methods. However, as LARC methods have higher efficacy than OCs, cost benefit for these agents is achievable in terms of pregnancies avoided [7].
Direct method comparison is difficult as there are
Acknowledgments
We thank Hayley Jones for data identification and collection. There was no external funding for this study.
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Cited by (29)
Effectiveness and cost of contraception in France (FACET study): a cohort study from the French National Healthcare Insurance Database
2018, European Journal of Obstetrics and Gynecology and Reproductive BiologyCitation Excerpt :On the economic side, to the best of our knowledge, no cost estimates are available in the French context for contraception and unplanned pregnancy. In several economic studies conducted in the US or the UK, with different healthcare organizations and costs, LARCs methods including etonogestrel implant, were found to be less costly than other contraceptive methods over a pre-defined time horizon [18–23]. The present analysis has some limitations inherent to the use of this medico-administrative cohort.
Preventing unintended pregnancy among young women in Kenya: Prospective cohort study to offer contraceptive implants
2012, ContraceptionCitation Excerpt :Perhaps, we can only say that voluntary continued use appeared to be more desirable than the alternatives; this may reflect conscious decisions to remain protected from pregnancy or simply inertia (easier to keep using the product). In other countries, high continuation rates of long-acting reversible contraception make these methods more cost-effective than the alternatives [23–25]. The primary limitation of our study traces back to design; we did not conduct a randomized trial on this topic because of programmatic concerns.
Bleeding related to etonogestrel subdermal implant in a US population
2011, ContraceptionCitation Excerpt :The etonogestrel subdermal implant has been available worldwide since 1998 and received United States Food and Drug Administration approval in 2006. Although several broadly cited studies have confirmed its high efficacy, convenience and cost-effectiveness, restricted availability to trained providers, limited marketing and initial cost contribute to its limited use in the US [1–3]. A considerable number of patients request early removal due to bleeding changes.
Clinician satisfaction and insertion characteristics of a new applicator to insert radiopaque Implanon: An open-label, noncontrolled, multicenter trial
2010, ContraceptionCitation Excerpt :This implant has been used safely and effectively since 1998 and is currently marketed in over 45 countries, including the United States [1,2]. Several economic analyses have found Implanon to be more cost-effective than other contraceptive methods [3,4]. The single implant contains 68 mg ENG, the active metabolite of desogestrel, a progestin widely used in hormonal contraceptives [1].