Volume 23, Number 1—January 2017
Cost-effectiveness of Increasing Access to Contraception during the Zika Virus Outbreak, Puerto Rico, 2016
|Parameter||No. ZAM cases prevented||Incremental intervention cost, millions||Zika virus–associated cost avoided, millions||Total incremental cost,† millions||Cost per HLY gained||Additional cost avoided from UP, millions|
|% Women receiving contraceptive services from healthcare provider; main scenario, 50% of no method users, 60% of less-effective method users, and 100% of moderately effective method users|
|30% of no method users‡||22||$32.4||$55.8||–$23.5||CS||$34.6|
|70% of no method users||29||$34.6||$74.5||–$39.9||CS||$46.1|
|30% of less-effective method users||19||$26.0||$50.0||–$24.0||CS||$31.0|
|80% of less-effective method users
|% Women receiving contraceptive services as in NSFG 2011–2013§||16||$25.2||$40.6||–$15.4||CS||$25.1|
|% Women willing to change to more effective method;¶ main scenario value: 50%|
|% Women receiving contraceptive services from healthcare provider as in NSFG 2011–2013 with 30% of them willing to change to a new method
|Use of highly effective methods among switchers; main value 50%|
|Contraception switching pattern reported in Colorado Family Planning Initiative#
|Dual-method use; 30% of moderately effective method users in main scenario|
|20% of moderately effective users||24||33.1||61.3||–$28.2||CS||$38.0|
|50% of moderately effective users
|Contraception use distribution at baseline|
|As reported in 2002 BRFSS survey**||30||33.6||−78.4||–$44.8||CS||$48.6|
|As in Title X clinics in 2014††
|Rate of ZAM among all live-born infants; main scenario value 58/10,000|
|Lifetime costs for microcephaly; main scenario value $3.8 million|
|Termination of pregnancy with ZAM|
|Cost of the program other than providing the contraception at no cost to patients; main scenario value $39/person|
|Annualized LARC device cost||25||$17.5||$65.2||–$47.7||CS||$40.4|
|Puerto Rico costs§§
*BRFSS, Behavioral Risk Factor Surveillance System; CN, cost-neutral; CS, cost-saving; HLY, healthy life years; LARC, long-acting reversible contraceptive; NSFG, National Survey of Family Growth; UP, unwanted pregnancy; ZAM, Zika virus–associated microcephaly.
†Total incremental cost is the additional cost of contraception minus Zika virus–associated cost avoided.
‡30% of no contraception users, 60% of less-effective contraceptive method users, 100% of moderately effective contraceptive method users seeking contraceptive services from healthcare provider during the Zika virus outbreak.
§Based on NSFG 2011–2013, among women of reproductive age who are sexually active, did not intend to become pregnant, and were not using permanent contraceptive methods, 21% of no contraception users, 33% of less-effective contraceptive method users, 97% of moderately effective contraceptive method users, and 94% of dual-method users had at least 1 contraceptive service visit in the last 12 months (in total 50%).
¶Based on Title X Family Planning annual report for 2007–2015 in Colorado, 30% of clients who visited Title X clinics switched to a new method.
#Eighteen percentage points of users of moderately effective methods are assumed to switch to highly effective methods, of whom 21% were dual-method users.
**Contraception distribution in Puerto Rico in 2002 15.9% no method, 41.6% less-effective methods, 40.2% moderately effective methods, and 2.4% highly effective methods.
††In 2014, in Title X clinics in Puerto Rico, 20% of women at risk for unintended pregnancy used less-effective methods, 77% used moderately effective methods, and 2% used highly effective methods.
‡‡Intervention cost equals to the medical savings from ZAM cases prevented.
§§Conversion factor of 0.36 applied to pregnancy and ZAM medical costs based on the ratio of per capita medical expenditure in Puerto Rico and in the United States in 2012 as in Portela et al. 2015 (32); conversion factor of 0.72 applied to costs of supportive care for live-born infants with ZAM, based on the ratio of annual salary for assistant nurses in Puerto Rico and in the United States (33).
- Rasmussen SA, Jamieson DJ, Honein MA, Petersen LR. Zika virus and birth defects—reviewing the evidence for causality. N Engl J Med. 2016;374:1981–7.
- Tepper NK, Goldberg HI, Bernal MI, Rivera B, Frey MT, Malave C, et al. Estimating contraceptive needs and increasing access to contraception in response to the Zika virus disease outbreak—Puerto Rico, 2016. MMWR Morb Mortal Wkly Rep. 2016;65:311–4.
- Oster AM, Russell K, Stryker JE, Friedman A, Kachur RE, Petersen EE, et al. Update: interim guidance for prevention of sexual transmission of Zika virus—United States, 2016. MMWR Morb Mortal Wkly Rep. 2016;65:323–5.
- Centers for Disease Control and Prevention. Zika virus disease in the United States, 2015–2016 [cited 2016 May 3]. http://www.cdc.gov/zika/geo/united-states.html
- Ellington SR, Devine O, Bertolli J, Martinez Quiñones A, Shapiro-Mendoza CK, Perez-Padilla J, et al. Estimating the number of pregnant women infected with Zika virus and expected infants with microcephaly following the Zika outbreak in Puerto Rico, 2016. JAMA Pediatr. 2016 Aug 19 [Epub ahead of print].
- Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008–2011. N Engl J Med. 2016;374:843–52.
- Trussell J. Overstating the cost savings from contraceptive use. Eur J Contracept Reprod Health Care. 2008;13:219–21.
- Bensyl DM, Iuliano DA, Carter M, Santelli J, Gilbert BC. Contraceptive use—United States and territories, Behavioral Risk Factor Surveillance System, 2002. MMWR Surveill Summ. 2005;54:1–72.
- Secura GM, Allsworth JE, Madden T, Mullersman JL, Peipert JF. The Contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception. Am J Obstet Gynecol. 2010;203:115.e1–7.
- Trussell J. Contraceptive failure in the United States. Contraception. 2011;83:397–404.
- Sedgh G, Singh S, Henshaw SK, Bankole A. Legal abortion worldwide in 2008: levels and recent trends. Int Perspect Sex Reprod Health. 2011;37:84–94.
- Singh S, Sedgh G, Hussain R. Unintended pregnancy: worldwide levels, trends, and outcomes. Stud Fam Plann. 2010;41:241–50.
- Cragan JD, Gilboa SM. Including prenatal diagnoses in birth defects monitoring: Experience of the Metropolitan Atlanta Congenital Defects Program. Birth Defects Res A Clin Mol Teratol. 2009;85:20–9.
- Centers for Disease Control and Prevention. Outcomes of pregnancies with laboratory evidence of possible Zika virus infection in the United States, 2016 [cited 2016 Jul 26]. https://www.cdc.gov/zika/geo/pregnancy-outcomes.html
- Grosse SD, Ouyang L, Collins JS, Green D, Dean JH, Stevenson RE. Economic evaluation of a neural tube defect recurrence-prevention program. Am J Prev Med. 2008;35:572–7.
- Trussell J, Hassan F, Lowin J, Law A, Filonenko A. Achieving cost-neutrality with long-acting reversible contraceptive methods. Contraception. 2015;91:49–56.
- Truven Health Analytics. The cost of having a baby in the United States [cited 2016 May 16]. http://transform.childbirthconnection.org/wp-content/uploads/2013/01/Cost-of-Having-a-Baby1.pdf
- Biggio JR Jr, Morris TC, Owen J, Stringer JS. An outcomes analysis of five prenatal screening strategies for trisomy 21 in women younger than 35 years. Am J Obstet Gynecol. 2004;190:721–9.
- Santelli JS, Lindberg LD, Finer LB, Singh S. Explaining recent declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use. Am J Public Health. 2007;97:150–6.
- Oduyebo T, Petersen EE, Rasmussen SA, Mead PS, Meaney-Delman D, Renquist CM, et al. Update: interim guidelines for health care providers caring for pregnant women and women of reproductive age with possible Zika virus exposure—United States, 2016. MMWR Morb Mortal Wkly Rep. 2016;65:122–7.
- Fleming-Dutra KE, Nelson JM, Fischer M, Staples JE, Karwowski MP, Mead P, et al. Update: interim guidelines for health care providers caring for infants and children with possible Zika virus infection—United States, February 2016. MMWR Morb Mortal Wkly Rep. 2016;65:182–7.
- Martines RB, Bhatnagar J, Keating MK, Silva-Flannery L, Muehlenbachs A, Gary J, et al. Notes from the field: evidence of Zika virus infection in brain and placental tissues from two congenitally infected newborns and two fetal losses—Brazil, 2015. MMWR Morb Mortal Wkly Rep. 2016;65:159–60.
- Hamilton BE, Martin JA, Osterman MJ, Curtin SC, Matthews TJ. Births: Final Data for 2014. Natl Vital Stat Rep. 2015;64:1–64.
- Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: final data for 2002. Natl Vital Stat Rep. 2003;52:1–113.
- Riehman KS, Sly DF, Soler H, Eberstein IW, Quadagno D, Harrison DF. Dual-method use among an ethnically diverse group of women at risk of HIV infection. Fam Plann Perspect. 1998;30:212–7.
- Besnard M, Eyrolle-Guignot D, Guillemette-Artur P, Lastère S, Bost-Bezeaud F, Marcelis L, et al. Congenital cerebral malformations and dysfunction in fetuses and newborns following the 2013 to 2014 Zika virus epidemic in French Polynesia. Euro Surveill. 2016;21:30181.
- Alfaro-Murillo JA, Parpia AS, Fitzpatrick MC, Tamagnan JA, Medlock J, Ndeffo-Mbah ML, et al. A cost-effectiveness tool for informing policies on Zika virus control. PLoS Negl Trop Dis. 2016;10:e0004743.
- Broyles RS, Tyson JE, Swint JM. Have Medicaid reimbursements been a credible measure of the cost of pediatric care? Pediatrics. 1997;99:E8.
- Trussell J, Lalla AM, Doan QV, Reyes E, Pinto L, Gricar J. Cost effectiveness of contraceptives in the United States. Contraception. 2009;79:5–14.
- Arroyo MP. Contraceptive access due to Zika threat. Elnuevodia [cited 2016 Aug 4]. http://www.elnuevodia.com/english/english/nota/contraceptiveaccessduetozikathreat-2227239
- Fowler C, Gable J, Wang J, Lasater B. Title X family planning annual report: 2014 national summary. Research Triangle Park (NC): RTI International; 2015.
- Portela M, Sommers BD. On the Outskirts of national health reform: a comparative assessment of health insurance and access to care in Puerto Rico and the United States. Milbank Q. 2015;93:584–608.
- Bureau of Labor Statistics. May 2015 state occupational employment and wage estimates: Puerto Rico [cited 2016 Jul 20]. http://www.bls.gov/oes/current/oes_pr.htm
- Bureau of Economic Analysis. Table 2.5.4. Price indexes for personal consumption expenditures by function [cited 2016 Aug 5]. http://www.bea.gov/iTable/iTable.cfm?reqid=9&step=3&isuri=1&903=69#reqid=9&step=3&isuri=1&903=73
- Grosse SD. Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold. Expert Rev Pharmacoecon Outcomes Res. 2008;8:165–78.
- McGann PT, Grosse SD, Santos B, de Oliveira V, Bernardino L, Kassebaum NJ, et al. A cost-effectiveness analysis of a pilot neonatal screening program for sickle cell anemia in the Republic of Angola. J Pediatr. 2015;167:1314–9.
- Burlone S, Edelman AB, Caughey AB, Trussell J, Dantas S, Rodriguez MI. Extending contraceptive coverage under the Affordable Care Act saves public funds. Contraception. 2013;87:143–8.
- Frost JJ, Sonfield A, Zolna MR, Finer LB. Return on investment: a fuller assessment of the benefits and cost savings of the US publicly funded family planning program. Milbank Q. 2014;92:696–749.
- Center for Work Force Studies. 2015 state physician workforce data book. Washington: Association of American Medical Colleges; 2015.
- Bishaw A, Fontenot K. Poverty: 2012 and 2013 [cited 2016 May 20]. https://www.census.gov/content/dam/Census/library/publications/2014/acs/acsbr13-01.pdf