Clinical Audit Team 6 May 2006 1 An Audit of the Cost Effectiveness of Implanon Use Presented by: Dr...

6 May 20066 May 2006 11Clinical Audit TeamClinical Audit Team

An Audit of the Cost EffectivenessAn Audit of the Cost Effectivenessof Implanon Useof Implanon Use

An Audit of the Cost EffectivenessAn Audit of the Cost Effectivenessof Implanon Useof Implanon Use

Presented by: Dr J Seres, Presented by: Dr J Seres, House OfficerHouse Officer

East & North Hertfordshire NHS Trust East & North Hertfordshire NHS Trust United KingdomUnited Kingdom

Presented by: Dr J Seres, Presented by: Dr J Seres, House OfficerHouse Officer

East & North Hertfordshire NHS Trust East & North Hertfordshire NHS Trust United KingdomUnited Kingdom

9th CONGRESS OF THE EUROPEAN SOCIETY OF CONTRACEPTION9th CONGRESS OF THE EUROPEAN SOCIETY OF CONTRACEPTION9th CONGRESS OF THE EUROPEAN SOCIETY OF CONTRACEPTION9th CONGRESS OF THE EUROPEAN SOCIETY OF CONTRACEPTION


IntroductionIntroductionIntroductionIntroduction

Subdermal implant method of contraceptionSubdermal implant method of contraception

In use in UK since October 1999In use in UK since October 1999

Expensive method, Expensive method, (£94 91p per implant),(£94 91p per implant), but long term but long term (up to 3yrs)(up to 3yrs)

‘‘Forgettable’ protectionForgettable’ protection

No oestrogenNo oestrogen

Rapid return to fertility after discontinuationRapid return to fertility after discontinuation

Efficacious method of contraceptionEfficacious method of contraception

Quick and easy insertion and removalQuick and easy insertion and removal

Frequent and/or heavy/irregular bleeding may lead to earlyFrequent and/or heavy/irregular bleeding may lead to early discontinuationdiscontinuation

Subdermal implant method of contraceptionSubdermal implant method of contraception

In use in UK since October 1999In use in UK since October 1999

Expensive method, Expensive method, (£94 91p per implant),(£94 91p per implant), but long term but long term (up to 3yrs)(up to 3yrs)

‘‘Forgettable’ protectionForgettable’ protection

No oestrogenNo oestrogen

Rapid return to fertility after discontinuationRapid return to fertility after discontinuation

Efficacious method of contraceptionEfficacious method of contraception

Quick and easy insertion and removalQuick and easy insertion and removal

Frequent and/or heavy/irregular bleeding may lead to earlyFrequent and/or heavy/irregular bleeding may lead to early discontinuationdiscontinuation

ImplanonImplanonImplanonImplanon


Aims & ObjectivesAims & ObjectivesAims & ObjectivesAims & Objectives

To determine if Implanon is cost effective:To determine if Implanon is cost effective:

By reviewing continuation and discontinuation ratesBy reviewing continuation and discontinuation ratesat 3 yearsat 3 years

Where Implanon discontinued <3 yrs:Where Implanon discontinued <3 yrs:

To determine reasons for removalTo determine reasons for removal

To see if improvements are required in the wayTo see if improvements are required in the way Implanon is prescribed and managed Implanon is prescribed and managed

To determine if Implanon is cost effective:To determine if Implanon is cost effective:

By reviewing continuation and discontinuation ratesBy reviewing continuation and discontinuation ratesat 3 yearsat 3 years

Where Implanon discontinued <3 yrs:Where Implanon discontinued <3 yrs:

To determine reasons for removalTo determine reasons for removal

To see if improvements are required in the wayTo see if improvements are required in the way Implanon is prescribed and managed Implanon is prescribed and managed


BackgroundBackgroundBackgroundBackground

In April 2000, Implanon introduced as an additional In April 2000, Implanon introduced as an additional contraceptive choice in 2 Family Planning Clinics run by the contraceptive choice in 2 Family Planning Clinics run by the then* East & North Hertfordshire NHS Trust:then* East & North Hertfordshire NHS Trust:

Queensway Clinic – HatfieldQueensway Clinic – Hatfield

Danestrete Clinic – StevenageDanestrete Clinic – Stevenage

In April 2000, Implanon introduced as an additional In April 2000, Implanon introduced as an additional contraceptive choice in 2 Family Planning Clinics run by the contraceptive choice in 2 Family Planning Clinics run by the then* East & North Hertfordshire NHS Trust:then* East & North Hertfordshire NHS Trust:

Queensway Clinic – HatfieldQueensway Clinic – Hatfield

Danestrete Clinic – StevenageDanestrete Clinic – Stevenage

* These Family Planning Clinics now within the remit of S E Herts PCT* These Family Planning Clinics now within the remit of S E Herts PCT* These Family Planning Clinics now within the remit of S E Herts PCT* These Family Planning Clinics now within the remit of S E Herts PCT


Standards* Standards* Standards* Standards* Be counselled prior to insertion of Implanon re:Be counselled prior to insertion of Implanon re:

Effectiveness of implantEffectiveness of implant

Duration of useDuration of use

Possible side effectsPossible side effects

Symptoms that require urgent assessmentSymptoms that require urgent assessment

Be given an Implanon information leaflet, and this to be documentedBe given an Implanon information leaflet, and this to be documented

If no problems experienced, to have their Implanon removedIf no problems experienced, to have their Implanon removed3 years after insertion3 years after insertion

Be counselled prior to insertion of Implanon re:Be counselled prior to insertion of Implanon re: Effectiveness of implantEffectiveness of implant

Duration of useDuration of use

Possible side effectsPossible side effects

Symptoms that require urgent assessmentSymptoms that require urgent assessment

Be given an Implanon information leaflet, and this to be documentedBe given an Implanon information leaflet, and this to be documented

If no problems experienced, to have their Implanon removedIf no problems experienced, to have their Implanon removed3 years after insertion3 years after insertion

All clients to:All clients to:All clients to:All clients to:

* Based on Family Planning Association and local guidelines, and * Based on Family Planning Association and local guidelines, and manufacturers’ information manufacturers’ information * Based on Family Planning Association and local guidelines, and * Based on Family Planning Association and local guidelines, and manufacturers’ information manufacturers’ information


Data were collected on all clients fitted with Implanon from its Data were collected on all clients fitted with Implanon from its introduction in April 2000, until Autumn 2002introduction in April 2000, until Autumn 2002

Data collected from the clients’ Family Planning Records by Dr Data collected from the clients’ Family Planning Records by Dr Seres and Dr UthayakumarSeres and Dr Uthayakumar

Data entered on Access database and analysed by Clinical Audit Data entered on Access database and analysed by Clinical Audit Team Team

Data were collected on all clients fitted with Implanon from its Data were collected on all clients fitted with Implanon from its introduction in April 2000, until Autumn 2002introduction in April 2000, until Autumn 2002

Data collected from the clients’ Family Planning Records by Dr Data collected from the clients’ Family Planning Records by Dr Seres and Dr UthayakumarSeres and Dr Uthayakumar

Data entered on Access database and analysed by Clinical Audit Data entered on Access database and analysed by Clinical Audit Team Team

Audit MethodologyAudit MethodologyAudit MethodologyAudit Methodology


Methodology Methodology (cont’d)(cont’d)Methodology Methodology (cont’d)(cont’d)

Data extraction form designed by Clinical Audit Team in conjunction Data extraction form designed by Clinical Audit Team in conjunction with Dr Uthayakumar, Consultant in Sexual Health with Dr Uthayakumar, Consultant in Sexual Health

Data were collected on, inter alia:Data were collected on, inter alia:

Initial fittingInitial fitting

First follow up First follow up

Reasons for removalsReasons for removals

Timing of removalsTiming of removals

Data extraction form designed by Clinical Audit Team in conjunction Data extraction form designed by Clinical Audit Team in conjunction with Dr Uthayakumar, Consultant in Sexual Health with Dr Uthayakumar, Consultant in Sexual Health

Data were collected on, inter alia:Data were collected on, inter alia:

Initial fittingInitial fitting

First follow up First follow up

Reasons for removalsReasons for removals

Timing of removalsTiming of removals


ResultsResultsResultsResults


Sample SizeSample SizeSample SizeSample Size

121 clients had an Implanon device fitted121 clients had an Implanon device fitted

50 @ Queensway Clinic50 @ Queensway Clinic

71 @ Danestrete Clinic71 @ Danestrete Clinic

31 (26%) clients were lost to any follow-up31 (26%) clients were lost to any follow-up

121 clients had an Implanon device fitted121 clients had an Implanon device fitted

50 @ Queensway Clinic50 @ Queensway Clinic

71 @ Danestrete Clinic71 @ Danestrete Clinic

31 (26%) clients were lost to any follow-up31 (26%) clients were lost to any follow-up


Client Information Client Information (n = 121)(n = 121)Client Information Client Information (n = 121)(n = 121)

Clients ranged from 15 – 44 years oldClients ranged from 15 – 44 years old

Mean age 29.5yrsMean age 29.5yrs

43 (36%) were nulliparous43 (36%) were nulliparous

61 (50%) clients had previously attended the FP Clinic61 (50%) clients had previously attended the FP Clinic

The majority, 101 (84%), were self referralsThe majority, 101 (84%), were self referrals

Most common reason for use, 37 (31%), – client wantedMost common reason for use, 37 (31%), – client wanted long term protection long term protection

10 (8%) had used an implant method of contraception10 (8%) had used an implant method of contraception immediately prior to this Implanon insertion immediately prior to this Implanon insertion

Clients ranged from 15 – 44 years oldClients ranged from 15 – 44 years old

Mean age 29.5yrsMean age 29.5yrs

43 (36%) were nulliparous43 (36%) were nulliparous

61 (50%) clients had previously attended the FP Clinic61 (50%) clients had previously attended the FP Clinic

The majority, 101 (84%), were self referralsThe majority, 101 (84%), were self referrals

Most common reason for use, 37 (31%), – client wantedMost common reason for use, 37 (31%), – client wanted long term protection long term protection

10 (8%) had used an implant method of contraception10 (8%) had used an implant method of contraception immediately prior to this Implanon insertion immediately prior to this Implanon insertion


Counselling and InformationCounselling and InformationCounselling and InformationCounselling and Information

110 (91%) 110 (91%) clients recorded as having beenclients recorded as having been counselled prior to insertion counselled prior to insertion

48 (44%) of these clients counselled on day of fitting48 (44%) of these clients counselled on day of fitting

76 (63%) clients were given an information sheet76 (63%) clients were given an information sheet

In 44 (36%) cases, it was not recorded whether orIn 44 (36%) cases, it was not recorded whether or not client had been given information sheet not client had been given information sheet

110 (91%) 110 (91%) clients recorded as having beenclients recorded as having been counselled prior to insertion counselled prior to insertion

48 (44%) of these clients counselled on day of fitting48 (44%) of these clients counselled on day of fitting

76 (63%) clients were given an information sheet76 (63%) clients were given an information sheet

In 44 (36%) cases, it was not recorded whether orIn 44 (36%) cases, it was not recorded whether or not client had been given information sheet not client had been given information sheet

(n = 121)(n = 121)(n = 121)(n = 121)


Continuation RatesContinuation RatesContinuation RatesContinuation Rates

0

20

40

60

80

No

. o

f cl

ien

ts

63 (70%)63 (70%)

44 (49%)44 (49%)

34* (38%)34* (38%)

* includes 7 >3yrs, max 44mthsincludes 7 >3yrs, max 44mths* includes 7 >3yrs, max 44mthsincludes 7 >3yrs, max 44mths

(n = (n = 90)90)(n = (n = 90)90)

At 1 yrAt 1 yr At 2 yrsAt 2 yrs At 3 yrsAt 3 yrs


Reasons for ‘Early’ Implanon Reasons for ‘Early’ Implanon RemovalRemoval

Reasons for ‘Early’ Implanon Reasons for ‘Early’ Implanon RemovalRemoval

Side effects:Side effects:

Irregular/frequent/heavy bleeding - cited in 42 cases (75%)Irregular/frequent/heavy bleeding - cited in 42 cases (75%)

Mood changes/panic attacks - 11 cases (20%)Mood changes/panic attacks - 11 cases (20%)

Weight gain - 5 cases (9%)Weight gain - 5 cases (9%)

Other:Other:

Change of mind re method of contraception - 8 cases (14%)Change of mind re method of contraception - 8 cases (14%)

Contraception no longer needed Contraception no longer needed (inc. no longer sexually active, wishes to get (inc. no longer sexually active, wishes to get

pregnant) - pregnant) - 7 cases (13%)7 cases (13%)

Side effects:Side effects:

Irregular/frequent/heavy bleeding - cited in 42 cases (75%)Irregular/frequent/heavy bleeding - cited in 42 cases (75%)

Mood changes/panic attacks - 11 cases (20%)Mood changes/panic attacks - 11 cases (20%)

Weight gain - 5 cases (9%)Weight gain - 5 cases (9%)

Other:Other:

Change of mind re method of contraception - 8 cases (14%)Change of mind re method of contraception - 8 cases (14%)

Contraception no longer needed Contraception no longer needed (inc. no longer sexually active, wishes to get (inc. no longer sexually active, wishes to get

pregnant) - pregnant) - 7 cases (13%)7 cases (13%)

(Multiple (Multiple response)response)(Multiple (Multiple response)response)

(n = (n = 56)56)(n = (n = 56)56)


3yr Follow Up3yr Follow Up3yr Follow Up3yr Follow Up

7 (11%) 3yr follow up appt letters sent7 (11%) 3yr follow up appt letters sent

Only 1 of these clients attended her 3yr follow up apptOnly 1 of these clients attended her 3yr follow up appt

Blank/NR – 38 (58%)Blank/NR – 38 (58%)

(Not current practice to send these letters)(Not current practice to send these letters)

34 (58%) attended 34 (58%) attended 3yrs post insertion 3yrs post insertion

31 (42%) lost to 3yr follow up31 (42%) lost to 3yr follow up

7 (11%) 3yr follow up appt letters sent7 (11%) 3yr follow up appt letters sent

Only 1 of these clients attended her 3yr follow up apptOnly 1 of these clients attended her 3yr follow up appt

Blank/NR – 38 (58%)Blank/NR – 38 (58%)

(Not current practice to send these letters)(Not current practice to send these letters)

34 (58%) attended 34 (58%) attended 3yrs post insertion 3yrs post insertion

31 (42%) lost to 3yr follow up31 (42%) lost to 3yr follow up

(n = 65*)(n = 65*)(n = 65*)(n = 65*)

* ie those known NOT to have had Implanon removed * ie those known NOT to have had Implanon removed ‘early’‘early’

* ie those known NOT to have had Implanon removed * ie those known NOT to have had Implanon removed ‘early’‘early’


Method of Contraception -Method of Contraception -After Removal of 1After Removal of 1stst Implanon Implanon

Method of Contraception -Method of Contraception -After Removal of 1After Removal of 1stst Implanon Implanon

2828 (31%)(31%) had a second Implanon fitted had a second Implanon fitted

19 (19%) 19 (19%) Barrier methods Barrier methods

15 (17%) 15 (17%) Contraceptive pill Contraceptive pill

9 (10%) 9 (10%) IUD/Mirena IUD/Mirena

8 (9%) 8 (9%) Injectables Injectables

6 (7%) 6 (7%) None None

5 (6%) 5 (6%) Other/NR Other/NR

2828 (31%)(31%) had a second Implanon fitted had a second Implanon fitted

19 (19%) 19 (19%) Barrier methods Barrier methods

15 (17%) 15 (17%) Contraceptive pill Contraceptive pill

9 (10%) 9 (10%) IUD/Mirena IUD/Mirena

8 (9%) 8 (9%) Injectables Injectables

6 (7%) 6 (7%) None None

5 (6%) 5 (6%) Other/NR Other/NR

(n = (n = 90)90)(n = (n = 90)90)


No failures of method were reportedNo failures of method were reportedNo failures of method were reportedNo failures of method were reported

EfficacyEfficacy


ConclusionsConclusionsConclusionsConclusions 31 (26%) clients were lost to any follow-up 31 (26%) clients were lost to any follow-up

Information on these cases would alter discontinuation rate Information on these cases would alter discontinuation rate

Higher discontinuation rate than we would wish,Higher discontinuation rate than we would wish, ie 30% in first year and a further 21% in second year ie 30% in first year and a further 21% in second year

Reasonably cost effective method of contraceptionReasonably cost effective method of contraception – NB no failures! – NB no failures!

Cost effectiveness would be improved by reducingCost effectiveness would be improved by reducing discontinuation rate discontinuation rate

Perhaps discontinuation rate would be reduced if Perhaps discontinuation rate would be reduced if clients were better informed, in advance, re possible clients were better informed, in advance, re possible side effects etc side effects etc

31 (26%) clients were lost to any follow-up 31 (26%) clients were lost to any follow-up

Information on these cases would alter discontinuation rate Information on these cases would alter discontinuation rate

Higher discontinuation rate than we would wish,Higher discontinuation rate than we would wish, ie 30% in first year and a further 21% in second year ie 30% in first year and a further 21% in second year

Reasonably cost effective method of contraceptionReasonably cost effective method of contraception – NB no failures! – NB no failures!

Cost effectiveness would be improved by reducingCost effectiveness would be improved by reducing discontinuation rate discontinuation rate

Perhaps discontinuation rate would be reduced if Perhaps discontinuation rate would be reduced if clients were better informed, in advance, re possible clients were better informed, in advance, re possible side effects etc side effects etc


Conclusions Conclusions (cont’d)(cont’d)Conclusions Conclusions (cont’d)(cont’d)

Implanon is an efficacious method of contraceptionImplanon is an efficacious method of contraception

Where no problems are experienced, Implanon is veryWhere no problems are experienced, Implanon is very acceptable to clients acceptable to clients

24 (71%) of the 34 clients who had their first Implanon24 (71%) of the 34 clients who had their first Implanon removed @ 3 yrs went on to have a new Implanon inserted removed @ 3 yrs went on to have a new Implanon inserted

Most common reason for early removal wasMost common reason for early removal was irregular/frequent/heavy bleeding - 42 (75%) cases irregular/frequent/heavy bleeding - 42 (75%) cases

Recording of information in client records needs improvementRecording of information in client records needs improvement

Implanon is an efficacious method of contraceptionImplanon is an efficacious method of contraception

Where no problems are experienced, Implanon is veryWhere no problems are experienced, Implanon is very acceptable to clients acceptable to clients

24 (71%) of the 34 clients who had their first Implanon24 (71%) of the 34 clients who had their first Implanon removed @ 3 yrs went on to have a new Implanon inserted removed @ 3 yrs went on to have a new Implanon inserted

Most common reason for early removal wasMost common reason for early removal was irregular/frequent/heavy bleeding - 42 (75%) cases irregular/frequent/heavy bleeding - 42 (75%) cases

Recording of information in client records needs improvementRecording of information in client records needs improvement


Points for DiscussionPoints for DiscussionPoints for DiscussionPoints for Discussion

How can we reduce the number of clients lost to follow-up?How can we reduce the number of clients lost to follow-up?

By emphasising at counselling that Implanon should beBy emphasising at counselling that Implanon should beremoved after 3 yrs?removed after 3 yrs?

By stressing at counselling that it is the By stressing at counselling that it is the client’s client’s responsibilityresponsibilityto remember to come back after 3 yrs?to remember to come back after 3 yrs?

By establishing a recall system?By establishing a recall system?

How can we improve our record keeping?How can we improve our record keeping?

By using a customised Implanon proforma that would formBy using a customised Implanon proforma that would formpart of the client’s record?part of the client’s record?

How can we reduce the number of clients lost to follow-up?How can we reduce the number of clients lost to follow-up?

By emphasising at counselling that Implanon should beBy emphasising at counselling that Implanon should beremoved after 3 yrs?removed after 3 yrs?

By stressing at counselling that it is the By stressing at counselling that it is the client’s client’s responsibilityresponsibilityto remember to come back after 3 yrs?to remember to come back after 3 yrs?

By establishing a recall system?By establishing a recall system?

How can we improve our record keeping?How can we improve our record keeping?

By using a customised Implanon proforma that would formBy using a customised Implanon proforma that would formpart of the client’s record?part of the client’s record?


Points for Discussion Points for Discussion (cont’d)(cont’d)

Points for Discussion Points for Discussion (cont’d)(cont’d)

How can we reduce the discontinuation rate?How can we reduce the discontinuation rate?

By counselling clients By counselling clients priorprior to fitting day? to fitting day?

By spending more time counselling clients?By spending more time counselling clients?

By ensuring all clients are given the FPA Implanon leaflet By ensuring all clients are given the FPA Implanon leaflet when counselled?when counselled?

How can we tell if we’ve made any improvements?How can we tell if we’ve made any improvements?

How can we reduce the discontinuation rate?How can we reduce the discontinuation rate?

By counselling clients By counselling clients priorprior to fitting day? to fitting day?

By spending more time counselling clients?By spending more time counselling clients?

By ensuring all clients are given the FPA Implanon leaflet By ensuring all clients are given the FPA Implanon leaflet when counselled?when counselled?

How can we tell if we’ve made any improvements?How can we tell if we’ve made any improvements?

Re-auditRe-audit Re-auditRe-audit


My thanks to everyone My thanks to everyone involved with this study:involved with this study:My thanks to everyone My thanks to everyone

involved with this study:involved with this study: Dr Anjali Agrawal,Dr Anjali Agrawal, Ass. Specialist in Family PlanningAss. Specialist in Family Planning

Ann Ainsworth,Ann Ainsworth, Senior Clinical Audit FacilitatorSenior Clinical Audit Facilitator

Dr Brenda Bean,Dr Brenda Bean, Consultant in Family PlanningConsultant in Family Planning

Heather Davies,Heather Davies, Clinical Audit ManagerClinical Audit Manager

Maureen Jones,Maureen Jones, Clinic SupervisorClinic Supervisor

Juliet Lai,Juliet Lai, Clinical Audit OfficerClinical Audit Officer

Dr H Maiti,Dr H Maiti, Consultant in Sexual HealthConsultant in Sexual Health

Dr Farah Paruk,Dr Farah Paruk, Senior House OfficerSenior House Officer

Dr Uthayakumar,Dr Uthayakumar, Consultant in Sexual HealthConsultant in Sexual Health

Dr Anjali Agrawal,Dr Anjali Agrawal, Ass. Specialist in Family PlanningAss. Specialist in Family Planning

Ann Ainsworth,Ann Ainsworth, Senior Clinical Audit FacilitatorSenior Clinical Audit Facilitator

Dr Brenda Bean,Dr Brenda Bean, Consultant in Family PlanningConsultant in Family Planning

Heather Davies,Heather Davies, Clinical Audit ManagerClinical Audit Manager

Maureen Jones,Maureen Jones, Clinic SupervisorClinic Supervisor

Juliet Lai,Juliet Lai, Clinical Audit OfficerClinical Audit Officer

Dr H Maiti,Dr H Maiti, Consultant in Sexual HealthConsultant in Sexual Health

Dr Farah Paruk,Dr Farah Paruk, Senior House OfficerSenior House Officer

Dr Uthayakumar,Dr Uthayakumar, Consultant in Sexual HealthConsultant in Sexual Health


Thank Thank youyou

Thank Thank youyou

Clinical Audit Team 6 May 2006 1 An Audit of the Cost Effectiveness of Implanon Use Presented by: Dr...

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