Recommendations for Contraception: Examining the Role of Patients' Age and Race.

The literature suggests that women of different races are more or less likely to use certain contraceptive methods and patient race can influence which contraceptive recommendations a provider makes. To explore whether health care providers treat individuals of different races differently, we conducted a preliminary investigation on whether medical students recommended different contraceptive methods for hypothetical patients presenting with the same clinical features who only varied by race. Third- and fourth-year medical students (n=103) at the University of Hawai'i completed an online survey. Students read case studies about a 23-year-old and 36-year-old patient and then made contraceptive recommendations. All students reviewed the same scenarios, with the exception of the patient's name which was randomly assigned to represent one of five racial/ethnic groups (White, Chinese, Filipina, Native Hawaiian, and Micronesian). Recommendations were analyzed using χ2 tests and bivariate logistic regressions. For the younger patient, students were most likely to recommend intrauterine devices (IUDs), followed by the contraceptive pill and Etonogestrel implant; recommendations did not differ by race/ethnicity (P = .91). For the older patient, students were most likely to recommend IUDs or sterilization, and Micronesian women were more likely to receive sterilization recommendations compared to White women (60% versus 27%, P = .04). In summary, contraceptive recommendations, specifically the frequency of recommending sterilization varied by race. Our findings add to the literature exploring the role of a patient's race/ethnicity on recommendations for contraception and highlights the need for more studies exploring the etiology of health care disparities.

From Kaua'i to Hawai'i Island: Interisland Differences in Emergency Contraceptive Pill Availability.

Emergency contraceptive pills (ECPs) are medications used after unprotected intercourse, underprotected intercourse, or sexual assault to decrease the risk of pregnancy. Availability of ECPs in Hawai'i's retail pharmacies was last assessed in 2007, following over-the-counter access to levonorgestrel ECPs (LNG-ECP) for women age 18 years or older and prior to U.S. Food and Drug Administration (FDA) approval of prescription-only ulipristal acetate (UPA). We conducted a county-by-county subanalysis from a larger observational population-based study on statewide availability of ECPs in Hawai'i's pharmacies. In the original study, researchers called all 198 unique retail pharmacies in Hawai'i between December 2013 and June 2014. Only 3% of pharmacies had UPA immediately available on-site in the state, with UPA available on Kaua'i and O'ahu only. At least one form of LNG-ECPs was available in 82% of pharmacies in 2013-2014, roughly the same as 2007 (81%) (P=0.9) when Lana'i and Moloka'i lacked access. Currently, only Moloka'i lacks retail pharmacy access to ECPs. When controlling for general inflation, the 2013-2014 mean price for name brand LNG-ECP fell within the reported range of 2007 prices. Generic LNG-ECPs were substantially lower in price than name brand LNG-ECPs in 2007 and 2013-2014. Availability of UPA is limited and significantly lower compared to LNG-ECPs. Availability of LNG-ECPs statewide has remained stable and the arrival of generics has decreased prices.

Pharmacy access to ulipristal acetate in Hawaii: is a prescription enough?

OBJECTIVE: To determine pharmacy availability of ulipristal acetate (UPA) and compare to availability of levonorgestrel-containing emergency contraceptive pills (LNG-ECPs). METHODS: We conducted an observational population-based study utilizing a telephone-based secret shopper methodology. Researchers called all 198 unique retail pharmacies in Hawaii on December 2013-June 2014, representing themselves as patients and physicians. RESULTS: Only 2.6% of pharmacies had UPA immediately available, though 22.8% reported ability to order UPA. In contrast, 82.4% reported immediate availability of LNG-ECPs. No significant difference in availability was reported to patients and physicians. CONCLUSIONS: Availability of UPA is limited and significantly lower compared to LNG-ECPs. The study period did overlap with a change in distributor for UPA, likely capturing some disruption of the supply chain. IMPLICATIONS: Systems-based interventions are needed to address barriers to obtaining UPA.

Neuraxial blockade for external cephalic version: Cost analysis.

AIM: Neuraxial blockade (epidural or spinal anesthesia/analgesia) with external cephalic version increases the external cephalic version success rate. Hospitals and insurers may affect access to neuraxial blockade for external cephalic version, but the costs to these institutions remain largely unstudied. The objective of this study was to perform a cost analysis of neuraxial blockade use during external cephalic version from hospital and insurance payer perspectives. Secondarily, we estimated the effect of neuraxial blockade on cesarean delivery rates. METHODS: A decision-analysis model was developed using costs and probabilities occurring prenatally through the delivery hospital admission. Model inputs were derived from the literature, national databases, and local supply costs. Univariate and bivariate sensitivity analyses and Monte Carlo simulations were performed to assess model robustness. RESULTS: Neuraxial blockade was cost saving to both hospitals ($30 per delivery) and insurers ($539 per delivery) using baseline estimates. From both perspectives, however, the model was sensitive to multiple variables. Monte Carlo simulation indicated neuraxial blockade to be more costly in approximately 50% of scenarios. The model demonstrated that routine use of neuraxial blockade during external cephalic version, compared to no neuraxial blockade, prevented 17 cesarean deliveries for every 100 external cephalic versions attempted. CONCLUSIONS: Neuraxial blockade is associated with minimal hospital and insurer cost changes in the setting of external cephalic version, while reducing the cesarean delivery rate.

Cost analysis of immediate postabortal IUD insertion compared to planned IUD insertion at the time of abortion follow up.

BACKGROUND: Immediate postabortal intrauterine device (IUD) insertion decreases rates of repeat abortions. However, only one third of high-volume, non-hospital abortion providers in the United States offer immediate postabortal IUD placement. STUDY DESIGN: We conducted a cost analysis from a public payer perspective to evaluate the potential cost savings associated with a policy of immediate postabortal IUD insertion, compared to planned IUD insertion at the time of abortion follow up. Sensitivity analyses and Monte Carlo simulation were performed. RESULTS: Considering only direct costs of contraception and pregnancy-related care over 1 year, immediate postabortal IUD provision decreases public program expenditures by US$111 per woman compared to planned IUD placement at follow up. Over 5 years, the savings increases to $4296 per woman, when public health and social program costs are also considered. CONCLUSION: Immediate postabortal IUD insertion is cost saving from a public payer perspective, compared to planned insertion at the time of follow up. These savings are seen over a wide range of model inputs.