1. An Audit of the Cost Effectiveness of Implanon Use
9th 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
6 May 2006

2. Introduction Implanon Subdermal implant method of contraception
In use in UK since October 1999
Expensive method, (£94 91p per implant), but long term (up to 3yrs)
‘Forgettable’ protection
No oestrogen
Rapid return to fertility after discontinuation
Efficacious method of contraception
Quick and easy insertion and removal
Frequent and/or heavy/irregular bleeding may lead to early
discontinuation
Cost given by Pharmacy E&NH
Absolute contra-indication:
Unexplained vaginal bleeding; active thromboembolic disease, thrombosis in any vein; active – or previous – liver disease; progesterone dependant cancer, breast cancer, hypersensitivity to any component; suspected pregnancy
Use with caution:
Serous arterial disease, heart attack or stroke, diabetes, high BP, chloasma
The following medicines make Implanon less effective and necessitate the use of additional contraception:
Enzyme inducers eg used for HIV, TB, epilepsy
St John's Wort
Also, is less effective in women >100Kg
6 May 2006

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

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

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

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

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

8. Results
6 May 2006

9. Sample Size 121 clients had an Implanon device fitted
Queensway Clinic
Danestrete Clinic
31 (26%) clients were lost to any follow-up
6 May 2006

10. Client Information (n = 121)
Clients ranged from 15 – 44 years old
Mean age 29.5yrs
43 (36%) were nulliparous
61 (50%) clients had previously attended the FP Clinic
The majority, 101 (84%), were self referrals
Most common reason for use, 37 (31%), – client wanted long term protection
10 (8%) had used an implant method of contraception immediately prior to this Implanon insertion
6 May 2006

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

12. Continuation Rates * includes 7 >3yrs, max 44mths 63 (70%) 44 (49%)
34* (38%)
Discontinuation rates:
In 1st year – 27 (30%)
In 2nd year – a further 19 (21%)
ie total discontinuation after 2 yrs of 46 (51%)
In 3rd year – another 10 (11%)
ie total discontinuation after 3 yrs of 56 (62%)
At 1 yr
At 2 yrs
At 3 yrs
* includes 7 >3yrs, max 44mths
6 May 2006

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

14. * ie those known NOT to have had Implanon removed ‘early’
3yr Follow Up
(n = 65*)
7 (11%) 3yr follow up appt letters sent
Only 1 of these clients attended her 3yr follow up appt
Blank/NR – 38 (58%)
(Not current practice to send these letters)
34 (58%) attended  3yrs post insertion
31 (42%) lost to 3yr follow up
As spelled out with the *, this n = the number of people whom we know HAD NOT had their Implanon removed, and so should have been called in for FU. This figure comprises the 34 we know still had it 3 yrs, (as shown on graph) + the 31 we knew nothing about (ie the original the 90.)
34 refers to ALL ie includes the 1 client who had been sent a letter and attended
* ie those known NOT to have had Implanon removed ‘early’
6 May 2006

15. Method of Contraception - After Removal of 1st Implanon
28 (31%) had a second Implanon fitted
19 (19%)  Barrier methods
15 (17%)  Contraceptive pill
9 (10%)  IUD/Mirena
8 (9%)  Injectables
6 (7%)  None
5 (6%)  Other/NR
Of the 34 women who had their Implanon in place for 3 yrs, 24 (71%) had it re-inserted. The other 4 re-insertions were for clients who had had an 'early' removal.
6 May 2006

16. No failures of method were reported
Efficacy
No failures of method were reported
6 May 2006

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

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

19. Points for Discussion
How can we reduce the number of clients lost to follow-up?
By emphasising at counselling that Implanon should be removed after 3 yrs?
By stressing at counselling that it is the client’s responsibility to remember to come back after 3 yrs?
By establishing a recall system?
How can we improve our record keeping?
By using a customised Implanon proforma that would form part of the client’s record?
Pts to leave clinic after insertion with appt made for 3 mth FU
Flag up on a system to recall clients after 3 yrs. Send ltrs and chase up DNAs.
?? Chase GPs for DNAs.
Potential discontinuation rate if added in lost to FU
6 May 2006

20. Points for Discussion (cont’d)
How can we reduce the discontinuation rate?
By counselling clients prior to fitting day?
By spending more time counselling clients?
By ensuring all clients are given the FPA Implanon leaflet when counselled?
How can we tell if we’ve made any improvements?
Pts to leave clinic after insertion with appt made for 3 mth FU
Flag up on a system to recall clients after 3 yrs. Send ltrs and chase up DNAs.
?? Chase GPs for DNAs.
Potential discontinuation rate if added in lost to FU
Re-audit
6 May 2006

21. My thanks to everyone involved with this study:
Dr Anjali Agrawal, Ass. Specialist in Family Planning
Ann Ainsworth, Senior Clinical Audit Facilitator
Dr Brenda Bean, Consultant in Family Planning
Heather Davies, Clinical Audit Manager
Maureen Jones, Clinic Supervisor
Juliet Lai, Clinical Audit Officer
Dr H Maiti, Consultant in Sexual Health
Dr Farah Paruk, Senior House Officer
Dr Uthayakumar, Consultant in Sexual Health
Pts to leave clinic after insertion with appt made for 3 mth FU
Flag up on a system to recall clients after 3 yrs. Send ltrs and chase up DNAs.
?? Chase GPs for DNAs.
Potential discontinuation rate if added in lost to FU
6 May 2006

22. Thank you
6 May 2006

23. 6 May 2006