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Clinical Audit Team 6 May 2006 1 An Audit of the Cost Effectiveness of Implanon Use Presented by: Dr J Seres, House Officer East & North Hertfordshire.

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Presentation on theme: "Clinical Audit Team 6 May 2006 1 An Audit of the Cost Effectiveness of Implanon Use Presented by: Dr J Seres, House Officer East & North Hertfordshire."— Presentation transcript:

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

2 Clinical Audit Team 6 May IntroductionIntroduction  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 discontinuation  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 discontinuation ImplanonImplanon

3 Clinical Audit Team 6 May 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  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

4 Clinical Audit Team 6 May BackgroundBackground  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  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

5 Clinical Audit Team 6 May Standards*Standards*  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  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 All clients to: * Based on Family Planning Association and local guidelines, and manufacturers’ information

6 Clinical Audit Team 6 May  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  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 Audit Methodology

7 Clinical Audit Team 6 May 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  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

8 Clinical Audit Team 6 May ResultsResults

9 Clinical Audit Team 6 May Sample Size  121 clients had an Implanon device fitted  Queensway Clinic  Danestrete Clinic  31 (26%) clients were lost to any follow-up  121 clients had an Implanon device fitted  Queensway Clinic  Danestrete Clinic  31 (26%) clients were lost to any follow-up

10 Clinical Audit Team 6 May 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  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

11 Clinical Audit Team 6 May 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  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 (n = 121)

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

13 Clinical Audit Team 6 May Reasons for ‘Early’ Implanon Removal 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%) 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%) (Multiple response) (n = 56)

14 Clinical Audit Team 6 May yr Follow Up  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  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 (n = 65*) * ie those known NOT to have had Implanon removed ‘early’

15 Clinical Audit Team 6 May Method of Contraception - After Removal of 1 st 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  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 (n = 90)

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

17 Clinical Audit Team 6 May ConclusionsConclusions  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  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

18 Clinical Audit Team 6 May 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  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

19 Clinical Audit Team 6 May 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?  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?

20 Clinical Audit Team 6 May Points for Discussion (cont’d) 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?  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?  Re-audit

21 Clinical Audit Team 6 May 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  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

22 Clinical Audit Team 6 May Thank you

23 Clinical Audit Team 6 May


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