Chantel I Washington1, Roxanne Jamshidi2, Stephen F Thung3, Unzila A Nayeri4, Aaron B Caughey5, Erika F Werner6. 1. Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address: cwashi19@jhmi.edu. 2. Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland. 3. Obstetrics and Gynecology, Ohio State University Medical School, Columbus, Ohio. 4. Obstetrics and Gynecology, State Universities of New York Upstate Medical University, Syracuse, New York. 5. Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon. 6. Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; Obstetrics and Gynecology, Alpert Medical School at Brown University, Providence, Rhode Island.
Abstract
OBJECTIVE: To determine if immediate postpartum (PP) intrauterine device (IUD) placement prevents pregnancy and is cost-effective compared with routine placement. DESIGN: We developed a decision-analysis model to determine the number of pregnancies prevented and the cost-effectiveness of immediate PP IUD placement defined as within the first 10 minutes of placental expulsion compared with routine placement at the PP visit. Associated costs and probability estimates for adherence to PP follow-up, IUD placement, expulsion, and pregnancy were determined from the literature. SETTING: Hospital and outpatient facility. PATIENT(S): Women desiring PP IUDs. INTERVENTION(S): IUD placement. MAIN OUTCOME MEASURE(S): The main outcome measure was the number of pregnancies prevented per 1,000 women. The secondary outcome was an incremental cost-effectiveness ratio (ICER) defined as the marginal cost per quality-adjusted life-year (QALY) gained. An ICER of <$50,000/QALY gained was considered to be cost-effective. RESULT(S): Immediate PP IUD placement prevented 88 unintended pregnancies per 1,000 women over a 2-year time horizon. Immediate PP IUD placement was the dominant strategy. For every 1,000 women who desired a PP IUD, attempted immediate PP placement resulted in a cost savings of $282,540 and a gain of 10 QALYs. The model is most sensitive to the cost of an undesired pregnancy. When the cost of a live birth is <$6,000, immediate placement is no longer cost-saving but remains cost-effective. Monte Carlo simulation demonstrates that immediate PP IUD placement is cost-effective in 99% of simulations. CONCLUSION(S): Immediate PP IUD placement is a dominant strategy that prevents unintended pregnancy.
OBJECTIVE: To determine if immediate postpartum (PP) intrauterine device (IUD) placement prevents pregnancy and is cost-effective compared with routine placement. DESIGN: We developed a decision-analysis model to determine the number of pregnancies prevented and the cost-effectiveness of immediate PP IUD placement defined as within the first 10 minutes of placental expulsion compared with routine placement at the PP visit. Associated costs and probability estimates for adherence to PP follow-up, IUD placement, expulsion, and pregnancy were determined from the literature. SETTING: Hospital and outpatient facility. PATIENT(S): Women desiring PP IUDs. INTERVENTION(S): IUD placement. MAIN OUTCOME MEASURE(S): The main outcome measure was the number of pregnancies prevented per 1,000 women. The secondary outcome was an incremental cost-effectiveness ratio (ICER) defined as the marginal cost per quality-adjusted life-year (QALY) gained. An ICER of <$50,000/QALY gained was considered to be cost-effective. RESULT(S): Immediate PP IUD placement prevented 88 unintended pregnancies per 1,000 women over a 2-year time horizon. Immediate PP IUD placement was the dominant strategy. For every 1,000 women who desired a PP IUD, attempted immediate PP placement resulted in a cost savings of $282,540 and a gain of 10 QALYs. The model is most sensitive to the cost of an undesired pregnancy. When the cost of a live birth is <$6,000, immediate placement is no longer cost-saving but remains cost-effective. Monte Carlo simulation demonstrates that immediate PP IUD placement is cost-effective in 99% of simulations. CONCLUSION(S): Immediate PP IUD placement is a dominant strategy that prevents unintended pregnancy.
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