Re-Examining Genetic Screening and Oral Contraceptives: A Patient-Centered Review.

The World Health Organization classifies combined hormonal contraception as an unacceptable health risk in the presence of a known thrombogenic mutation but advises against routine thrombophilia screening before initiating combined oral contraceptives (COCs) on the grounds of high screening costs and low prevalence. From the perspective of patient-centered care, we examine cost, prevalence, and other published arguments for and against thrombophilia screening before initiating COCs. Our patient-centered review draws on relevant empirical evidence concerning the advantages and disadvantages of thrombophilia screening, while placing the discussion in the broader context of evolving attitudes toward genetic testing and a shifting policy landscape that provides many women direct access to COCs and/or thrombophilia screening. Given variation in prior probabilities of thrombophilia, expected exposure to other risk factors for venous thromboembolism, attitudes towards risk, expected reactions to a positive test result, ability to pay, and concerns about genetic discrimination, we conclude that the current one-size-fits-most approach is not consistent with patient-centered care. Instead, we advocate for greater patient and provider education concerning the implications of thrombophilia screening. Moreover, we recommend offering patients optional thrombophilia screening before initiating COCs.

Economic Evaluations of Thrombophilia Screening Prior to Prescribing Combined Oral Contraceptives: A Systematic and Critical Review.

BACKGROUND: Combined oral contraceptives (COCs) increase the risk of venous thromboembolism (VTE), particularly among women with inherited clotting disorders. The World Health Organization classifies combined hormonal contraception as an "unacceptable health risk" for women with thrombogenic mutations but advises against universal thrombophilia screening before prescribing COCs given the low prevalence of thrombophilia and high screening costs. OBJECTIVE: Through the lens of lifetime costs and benefits, this paper systematically and critically reviews all published economic evaluations of thrombophilia screening prior to prescribing COCs. METHODS: We searched relevant databases for economic evaluations of thrombophilia screening before prescribing COCs. After extracting the key study characteristics and economic variables, we evaluated each article using the Quality of Health Economic Studies (QHES) and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) instruments. RESULTS: Seven economic evaluations of thrombophilia screening before prescribing COCs met our inclusion criteria. Only the two economic evaluations focusing exclusively on selective screening exceeded the 75-point threshold for high-quality economic studies based on the QHES instrument, whereas only one of these exceeded the 85% CHEERS threshold. Only three of the seven economic evaluations performed sensitivity analysis on key parameters. Most studies underestimated the benefits of thrombophilia screening by comparing one-time costs of genetic screening against benefits per person-year, thus implicitly assuming a 1-year duration of COC use, neglecting the long-term implications of VTE and/or neglecting the lifetime benefits of awareness of inherited thrombophilia. CONCLUSION: Our review highlights the lack of methodologically rigorous economic evaluations of universal thrombophilia screening before prescribing COCs.

Increased risks of needing long-term care among older adults living with same-sex partners.

OBJECTIVES: We examined whether older individuals living with same-sex partners face greater risks of needing long-term care than their counterparts living with different-sex partners or spouses. METHODS: With data on older couples (at least 1 individual aged 60 years or older) from the 2009 American Community Survey, we estimated logistic regression models of 2 activity limitations that signal a long-term care need: difficulty dressing or bathing and difficulty doing errands alone. RESULTS: When we controlled for age, race/ethnicity, and education, older women who lived with female partners were statistically significantly more likely than those who lived with male partners or spouses to have difficulty dressing or bathing. Older men who lived with male partners were statistically significantly more likely than those who lived with female spouses or partners to need assistance with errands. CONCLUSIONS: Older individuals living with same-sex partners face greater risks of needing long-term care than those living with different-sex partners or spouses, but the role of relationship status differs by gender. These findings suggest more broadly that older gay men and lesbians may face greater risks of needing long-term care than their heterosexual counterparts.