9 th CONGRESS OF THE EUROPEAN SOCIETY OF

9 th CONGRESS OF THE EUROPEAN SOCIETY OF CONTRACEPTION An Audit of the Cost Effectiveness of Implanon Use Presented by: Dr J Seres, House Officer East & North Hertfordshire NHS Trust United Kingdom Clinical Audit 6 May 2006 1

Introduction Implanon v Subdermal implant method of contraception v In use in UK since October 1999 v Expensive method, (£ 94 91 p per implant), but long term (up to 3 yrs) v ‘Forgettable’ protection v No oestrogen v Rapid return to fertility after discontinuation v Efficacious method of contraception v Quick and easy insertion and removal v Frequent and/or heavy/irregular bleeding may lead to early discontinuation Clinical Audit 6 May 2006 2

Aims & Objectives v To determine if Implanon is cost effective: Ø By reviewing continuation and discontinuation rates at 3 years v Where Implanon discontinued <3 yrs: Ø To determine reasons for removal v Clinical Audit To see if improvements are required in the way Implanon is prescribed and managed 6 May 2006 3

Background v In April 2000, Implanon introduced as an additional contraceptive choice in 2 Family Planning Clinics run by then* East & North Hertfordshire NHS Trust: Ø Queensway Clinic – Hatfield Ø Danestrete Clinic – Stevenage * These Family Planning Clinics now within the remit of S E Herts PCT Clinical Audit 6 May 2006 4

Standards* All clients to: v Be counselled prior to insertion of Implanon re: Ø Effectiveness of implant Ø Duration of use Ø Possible side effects Ø Symptoms that require urgent assessment v Be given an Implanon information leaflet, and this to be documented v If no problems experienced, to have their Implanon removed 3 years after insertion * Based on Family Planning Association and local guidelines, and manufacturers’ information Clinical Audit 6 May 2006 5

Audit Methodology v Data were collected on all clients fitted with Implanon from its introduction in April 2000, until Autumn 2002 v Data collected from the clients’ Family Planning Records by Dr Seres and Dr Uthayakumar v Data entered on Access database and analysed by Clinical Audit Team Clinical Audit 6 May 2006 6

Methodology (cont’d) v Data extraction form designed by Clinical Audit Team in conjunction with Dr Uthayakumar, Consultant in Sexual Health v Data were collected on, inter alia: Ø Initial fitting Ø First follow up Ø Reasons for removals Ø Timing of removals Clinical Audit 6 May 2006 7

Results Clinical Audit 6 May 2006 8

Sample Size v 121 clients had an Implanon device fitted Ø 50 @ Queensway Clinic Ø 71 @ Danestrete Clinic v Clinical Audit 31 (26%) clients were lost to any follow-up 6 May 2006 9

Client Information (n = 121) v Clients ranged from 15 – 44 years old Ø Mean age 29. 5 yrs v 43 (36%) were nulliparous v 61 (50%) clients had previously attended the FP Clinic v The majority, 101 (84%), were self referrals v Most common reason for use, 37 (31%), – client wanted long term protection v 10 (8%) had used an implant method of contraception immediately prior to this Implanon insertion Clinical Audit 6 May 2006 10

Counselling and Information (n = 121) v 110 (91%) clients recorded as having been counselled prior to insertion Ø 48 (44%) of these clients counselled on day of fitting v 76 (63%) clients were given an information sheet v In 44 (36%) cases, it was not recorded whether or not client had been given information sheet Clinical Audit 6 May 2006 11

Continuation Rates (n = 90) 63 (70%) 44 (49%) 34* (38%) At 1 yr At 2 yrs At 3 yrs * includes 7 >3 yrs, max 44 mths Clinical Audit 6 May 2006 12

Reasons for ‘Early’ Implanon Removal (Multiple response) (n = 56) Side effects: v Irregular/frequent/heavy bleeding - cited in 42 cases (75%) v Mood changes/panic attacks - 11 cases (20%) v Weight gain - 5 cases (9%) Other: v Change of mind re method of contraception - 8 cases (14%) v Contraception no longer needed (inc. no longer sexually active, wishes to get pregnant) - 7 cases (13%) Clinical Audit 6 May 2006 13

3 yr Follow Up (n = 65*) v 7 (11%) 3 yr follow up appt letters sent Ø Only 1 of these clients attended her 3 yr follow up appt Ø Blank/NR – 38 (58%) Ø (Not current practice to send these letters) v 34 (58%) attended 3 yrs post insertion v 31 (42%) lost to 3 yr follow up * ie those known NOT to have had Implanon removed ‘early’ Clinical Audit 6 May 2006 14

Method of Contraception After Removal of 1 st Implanon (n = 90) v 28 (31%) had a second Implanon fitted v 19 (19%) Barrier methods v 15 (17%) Contraceptive pill v v 8 (9%) Injectables v 6 (7%) None v Clinical Audit 9 (10%) IUD/Mirena 5 (6%) Other/NR 6 May 2006 15

Efficacy No failures of method were reported Clinical Audit 6 May 2006 16

Conclusions v 31 (26%) clients were lost to any follow-up Ø Information on these cases would alter discontinuation rate v Higher discontinuation rate than we would wish, ie 30% in first year and a further 21% in second year v Reasonably cost effective method of contraception – NB no failures! v Cost effectiveness would be improved by reducing discontinuation rate v Perhaps discontinuation rate would be reduced if clients were better informed, in advance, re possible side effects etc Clinical Audit 6 May 2006 17

Conclusions (cont’d) v Implanon is an efficacious method of contraception v Where no problems are experienced, Implanon is very acceptable to clients Ø 24 (71%) of the 34 clients who had their first Implanon removed @ 3 yrs went on to have a new Implanon inserted v Most common reason for early removal was irregular/frequent/heavy bleeding - 42 (75%) cases v Recording of information in client records needs improvement Clinical Audit 6 May 2006 18

Points for Discussion v How can we reduce the number of clients lost to follow-up? Ø By emphasising at counselling that Implanon should be removed after 3 yrs? Ø By stressing at counselling that it is the client’s responsibility to remember to come back after 3 yrs? Ø By establishing a recall system? v How can we improve our record keeping? Ø By using a customised Implanon proforma that would form part of the client’s record? Clinical Audit 6 May 2006 19

Points for Discussion v (cont’d) How can we reduce the discontinuation rate? Ø By counselling clients prior to fitting day? Ø By spending more time counselling clients? Ø By ensuring all clients are given the FPA Implanon leaflet when counselled? v How can we tell if we’ve made any improvements? Ø Re-audit Clinical Audit 6 May 2006 20

My thanks to everyone involved with this study: v v Ann Ainsworth, Senior Clinical Audit Facilitator v Dr Brenda Bean, Consultant in Family Planning v Heather Davies, Clinical Audit Manager v Maureen Jones, Clinic Supervisor v Juliet Lai, Clinical Audit Officer v Dr H Maiti, Consultant in Sexual Health v Dr Farah Paruk, Senior House Officer v Clinical Audit Dr Anjali Agrawal, Ass. Specialist in Family Planning Dr Uthayakumar, Consultant in Sexual Health 6 May 2006 21

Thank you Clinical Audit 6 May 2006 22

Clinical Audit 6 May 2006 23