From the Editor

Permanent contraception provides a lesson in cost-effective medicine

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Moving interval sterilization into the office, using the hysteroscope, appears to benefit patients and society—a good thing in 2010



Better! Cheaper! Faster! Safer! Health care for you!

Lawmakers in Washington have promised that recently enacted national health legislation will increase patients’ access to a range of health services—from prevention to in-hospital care—and, remarkably, reduce the total national cost of care at the same time. This can only mean that, as more patients obtain access to health insurance and, consequently, costs rise, economic and social pressures will build to control expenses by belt-tightening and cost-cutting.

That need to contain costs will challenge you to examine every aspect of your practice—the objective being to identify and adopt, expediently, the most cost-effective approaches to care. At the same time, you’ll need to improve the quality of the care you provide and maximize patients’ freedom to choose the kind of care they receive.

That’s a tall order for all of us—difficult, yes, but important.

A case in point from gyn practice

Contraception offers an excellent example of how our specialty can address the twin central goals of ensuring quality care while practicing cost-effectively. The effort here isn’t novel: Over the past 5 years, many experts have addressed the cost-effectiveness of various contraceptive methods.

Here is a brief look at 1) what has been reported and discussed about cost-conscious provision of efficacious contraception and 2) how you can adopt that information by, in particular, weighing the cost-effectiveness of moving from hospital-based to office-based tubal sterilization.

All contraceptives are cost-effective

In adult populations that are sexually active and trying to avoid conception, all contraceptives are cost-effective when measured against the cost of using no contraceptive. This obvious conclusion is based on the high cost of an unintended pregnancy and birth.

Today, the hospital-related costs alone of a vaginal and a cesarean delivery are in the range of, respectively, $4,000 and $8,000.1 To that, add the costs of a pregnancy that include antepartum visits, ultrasonographic imaging, genetic testing, social services, and other services.

In the British National Health Service, estimates are that public funding of family planning services saves the health system the equivalent of approximately $3.8 billion in direct health costs annually. From a broader perspective, public funding of contraception is estimated to save the British social service system (including child benefits and single-parent allowances) approximately 10 times that amount—$38 billion—annually.2

The conclusion that I reach from observing the British system is that insurers in the United States (including state insurers) would be wise to invest heavily in contraception programs to avoid the costs of unintended pregnancy.

Long-acting contraceptives are the most effective

A more complex matter is raised by the question: What’s the relative cost-effectiveness of the various available contraceptives? From a clinical perspective, any contraceptive that a patient uses faithfully is much more effective than a contraceptive that she, or he, does not use. An important corollary to that statement: Having multiple contraceptive options available to patients increases the likelihood that they will identify one that they are going to use reliably.

Thoughtful assumptions are needed to begin a cost-effectiveness analysis of a contraceptive for any given woman:

  • the time interval of interest (for how long does she need, or intend, to use the method?)
  • the relative effectiveness of each contraceptive at preventing pregnancy
  • the cost of each contraceptive
  • the cost of complications arising from each contraceptive.

If the interval of use will be brief—say, 1 year—then a contraceptive that has low initial cost—an estrogen-progestin contraceptive, for example, is relatively more cost-effective than a method with a high initial cost, such as an intrauterine device (IUD).

As the interval of use extends to 5 years, and then 20 years, however, such options as the (IUD), vasectomy, and tubal sterilization become increasingly cost-effective.

What one study showed. In a recent comprehensive cost-effectiveness analysis, the most effective contraceptives were:

  • vasectomy
  • tubal sterilization
  • the IUD
  • implants.

The least expensive methods over 5 years of use were:

  • the copper IUD
  • vasectomy
  • the levonorgestrel-releasing intrauterine system (Mirena).3

Analyses by other authorities have yielded similar findings.4,5

What we know from practice. Patient preference plays an important role in selecting an optimal intervention. Despite the effectiveness of vasectomy and its low cost over 5 years, it might not be a practical choice for many women because their partner won’t consent to the procedure or they have multiple male partners.

Among contraceptive options under the woman’s control, the IUD, contraceptive implant, and tubal sterilization are most effective. But, as I appealed in a previous Editorial (see “As uses widen for intrauterine contraception, why haven’t ObGyns become advocates?” in the November 2009 issue), clinicians in the United States could work much harder to increase the number of women who use an IUD.


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