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September 2001, Vol 91, No. 9 | American Journal of Public Health 1443-1445
© 2001 American Public Health Association

RESEARCH

Modeling the Cost and Outcomes of Pharmacist-Prescribed Emergency Contraception

Kristin D. Marciante, MPH, Jacqueline S. Gardner, PhD, David L. Veenstra, PharmD, PhD and Sean D. Sullivan, PhD

The authors are with the Department of Pharmacy, University of Washington, Seattle. Sean D. Sullivan is also with the Department of Health Services, University of Washington.

Correspondence: Requests for reprints should be sent to Kristin D. Marciante, MPH, Department of Pharmacy, University of Washington, Box 357630, Seattle, WA 98195 (e-mail: marciant{at}u.washington.edu).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 References
 

Objectives. This study investigated the effect on the risk and cost of unintended pregnancies of emergency contraceptive pills obtained directly from a pharmacist.

Methods. We used a decision model to compare outcomes for private and public payers following unprotected intercourse from.

Results. Obtaining emergency contraceptive pills from a pharmacy, compared with obtaining them from a physician or clinic, resulted in a $158 (95% confidence interval (CI) = $76, $269) reduction in costs for private payers and a $48 (95% CI = $16, $93) reduction for public payers.

Conclusions. Our findings suggest that under varied assumptions, obtaining emergency contraceptive pills directly from a pharmacist reduces the number of unintended pregnancies and is cost saving.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 References
 
Unintended pregnancy is a significant public health problem. In the United States, 49% of pregnancies are unintended, with 48% of women aged 15 to 44 having at least 1 unintended pregnancy at some time in their lives.1

The Yuzpe regimen (100 µg ethinyl estradiol and 0.50 mg levonorgestrel or 1.0 mg norgestrel per dose given in 2 doses) of emergency contraceptive pills is an effective method of preventing unintended pregnancies when started within 72 hours of unprotected intercourse. Because of this narrow window of effectiveness, typical prescription delivery patterns can make emergency contraceptive pills an inaccessible postcoital contraceptive option.

In 1997, several collaborators in Washington State undertook a pilot project to reduce the number of unintended pregnancies; they developed a prescribing protocol that allowed women to obtain emergency contraceptive pills directly from a pharmacist without having to visit a physician or clinic. Thus, women were able to obtain emergency contraceptive pills outside of normal clinic hours, facilitating the use of the regimen within 72 hours of unprotected sex.2 The pharmacist-prescribed emergency contraceptive pills regimen included pills from one of several varieties of oral contraceptives, an antiemetic agent, and counseling. Details of the project have been reported elsewhere.3

We modeled the attributable effect of the Yuzpe emergency contraceptive pills regimen on the costs and risks of unintended pregnancy among women obtaining it directly from a pharmacist.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 References
 
Decision Model
We modeled the costs and outcomes of the decision to use or not to use emergency contraceptive pills obtained from a pharmacy after an unprotected act of intercourse (Figure 1Go). The time horizon of the analysis was 9 months (i.e., the time to birth following an unintended conception). The model parameters and their corresponding ranges explored in the sensitivity analysis were derived from the literature and other sources (Table 1Go). We considered costs, updated to 1998 dollars,4 from both a private and a public third-party payer perspective. The cost estimates for each of the unintended pregnancy outcomes included all costs incurred from the time of conception through the outcome of the pregnancy.5,6 We did not discount costs or outcomes, because the time frame of interest spanned less than a 1-year period.



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  		FIGURE 1— Decision model for use or nonuse of emergency contraceptive pills obtained from a pharmacy after an unprotected act of intercourse.

 

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  		TABLE 1— Parameters and Costs Used in the Decision Analysisa
 
Sensitivity Analysis
A Monte Carlo simulation was used to perform a multivariate sensitivity analysis to assess the degree of uncertainty.7 The uncertainty in each estimate was modeled with a probability distribution that was based on the range of values given in Table 1Go.8 When published sources were not available, we varied probabilities and costs by 25% unless otherwise noted. We assumed that risk estimates followed a logistic–normal distribution and that costs followed a normal distribution.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 References
 
The incidence of pregnancy was reduced from 4.9% in the group not obtaining emergency contraceptive pills from a pharmacy (some obtained emergency contraceptive pills from a physician) to 1.8% in the group that did, for an absolute difference of 3.1% (95% confidence interval (CI) = 1.1%, 5.3%). In the private payer analysis, obtaining emergency contraceptive pills from a pharmacy resulted in a $158 (95% CI = $76, $269) reduction in cost per woman having unprotected intercourse. In the public payer analysis, obtaining emergency contraceptive pills from a pharmacy resulted in a $48 (95% CI = $16, $93) reduction in cost per woman having unprotected intercourse.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 References
 
The results of our analysis suggested that obtaining emergency contraceptive pills directly from a pharmacist reduced the number of unintended pregnancies and was cost saving relative to outcomes in the absence of the pharmacy service. Private payers could expect to save $158, and public payers could expect to save $48 in unintended pregnancy costs per woman having unprotected sex.

The extent of cost savings varied depending on the estimates used in the analysis. Although dedicated progestin-only emergency contraceptive pills were not available during the pilot project, recent studies have indicated that the progestin-only method may have greater efficacy. Incorporating progestin-only emergency contraceptive pill effectiveness and nausea estimates (85% and 23%, respectively)9 into the analysis changes the cost savings to $179 per woman for private payers and $57 per woman for public payers. Incorporating the recently reported lower estimates of effectiveness (57%) of the Yuzpe regimen9 reduces the cost savings to $119 for private payers and $32 for public payers.

The cost savings also may vary depending on the choice of modeling assumptions. The time horizon for this analysis was only 9 months, and we did not consider the costs of future pregnancies. Many unintended pregnancies are simply mistimed rather than unwanted (i.e., the woman planned to conceive in the future vs not wanting to become pregnant in the future); thus, some of the women seeking emergency contraceptive pills would have become intentionally pregnant at a later time, potentially reversing the cost savings depending on the assumptions used.

The analysis was conservative because we assumed that the effectiveness of emergency contraceptive pills was the same whether women obtained the regimen from a physician or from a pharmacist. A recent trial showed that even within the 72-hour window, the efficacy of emergency contraceptive pills diminishes over time.9 Because pharmacies generally are more accessible than physicians are, the average effectiveness of emergency contraceptive pills may actually be greater when obtained from a pharmacy.

Indirect costs such as time lost from work and the psychologic effect of an unintended pregnancy were not taken into account. Nor did we consider benefits derived from obtaining emergency contraceptive pills from a physician or clinic. Potentially, women obtaining emergency contraceptive pills from a physician would have the opportunity to receive cancer or sexually transmitted disease screening at the same visit. To promote and facilitate entry into the health care system for women receiving the regimen directly from pharmacists, counseling included referrals to local clinics, with pharmacists occasionally calling for appointments on behalf of the patient.


   CONCLUSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
References
 
Unintended pregnancy is a substantial problem in the United States. Because of their drug expertise, pharmacists are highly qualified to prescribe emergency contraceptive pills and expand the network of contraceptive resources. Pharmacies are unique in that they are highly accessible, allowing women to obtain the time-sensitive regimen quickly and easily. We found that obtaining emergency contraceptive pills directly from a pharmacist following an act of unprotected intercourse is cost saving when modeled under varied assumptions. Decision makers may consider implementing similar programs elsewhere to reduce the burden of unintended pregnancy and its associated costs.


   Acknowledgments
 
The authors thank the David and Lucile Packard Foundation for funding the study.

The authors acknowledge and thank Jane Hutchings, Tim Fuller, Don Downing, Jennifer Winkler, Holly Carlton, Rod Shafer, and James Trussell for their contributions to the study.


   Footnotes
 
K. D. Marciante designed the model, analyzed the data, and wrote the paper. J. S. Gardner planned the study. D. L. Veenstra supervised the data analysis. S. D. Sullivan supervised study methodology. J. S. Gardner, D. L. Veenstra, and S. D. Sullivan assisted with study design and contributed to the writing of the paper.

Peer Reviewed

Accepted for publication October 23, 2000.


   References
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 References
 
1. Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect.1998;30:24–29.[Medline]

2. Wells ES, Hutchings J, Gardner JS, et al. Using pharmacies in Washington State to expand access to emergency contraception. Fam Plann Perspect.1998;30:288–290.[Medline]

3. Hutching J, Winkler JL, Fuller TS, et al. When the morning after is Sunday: pharmacist prescribing of emergency contraceptive pills. J Am Womens Assoc.1998;53(5 suppl 2):230–232.

4. US Dept of Labor, Bureau of Labor Statistics. Consumer Price Index: December 1998. Available at: http://stats.bls.gov/cpihome.htm. Accessed October 10, 1999.

5. Trussell J, Leveque JA, Koenig JD, et al. The economic value of contraception: a comparison of 15 methods. Am J Public Health.1995;85:494–503.[Abstract/Free Full Text]

6. Trussell J, Koenig J, Ellertson C, Stewart F. Preventing unintended pregnancy: the cost-effectiveness of three methods of emergency contraception. Am J Public Health.1997;87:932–937.[Abstract/Free Full Text]

7. Krahn MD, Naglie G, Naimark D, Redelmeier DA, Detsky AS. Primer on medical decision analysis. Med Decis Making.1991;17:142–151.

8. Doubilet P, Begg CB, Weinstein MC, Braun P, McNeil BJ. Probabilistic sensitivity analysis using Monte Carlo simulation: a practical approach. Med Decis Making.1985;5:157–177.

9. WHO Task Force on Postovulatory Methods of Fertility Regulation. Randomised controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet.1998;352:428–433.[Medline]

10. Trussell J, Rodriguez G, Ellertson C. New estimates of the effectiveness of the Yuzpe regimen of emergency contraception. Contraception.1998;57:363–369.[Medline]

11. Washington State Department of Health. Pregnancy statistics, Washington State residents, 1974–1998. Available at: http://www.doh.wa.gov/EHSPHL/CHS/default.htm#Abortion. Accessed August 16, 1999.

12. US Dept of Labor, Bureau of Labor Statistics. National Compensation Survey Seattle-Tacoma-Bremerton, Washington. December 1997. Available at: http://stats.bls.gov/compub.htm#WA. Accessed October 5, 1999.

13. Drug Topics Red Book. Montvale, NJ: Medical Economics Co Inc; 1998.




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