Cost-effectiveness of provision of contraceptive implants to adolescents at school based health centers
Awarded 2018
Complex Family Planning Fellowship Research
Chi-Son Kim, MD, MPH
Icahn School of Medicine at Mount Sinai

Despite recent improvements the US still has the highest rate of teen pregnancy among high-income countries. Teen pregnancy and childbirth cause significant immediate and long-term socioeconomic burden and health disparities for teen parents and their children. In 2010, teen pregnancy and childbirth cost the United States $9.4 billion taxpayer dollars. Long acting reversible contraceptives, including intrauterine devices and contraceptive implants, are recommended as first line in adolescents. To increase access to LARC for adolescents, the New York City Department of Health has mandated that both contraceptive implants and intrauterine devices be made available in school-based health centers (SBHCs). Many SBHCs in the city are first implementing contraceptive implant provision as the easier of the two types of methods for providers new to LARC placement. Studies have shown that the rate of early discontinuation at less than or equal to 1 year of use for the implant is about 20-25%. But in practice there is still concern among providers that provision of LARC to adolescents waste resources and health care dollars. We hypothesized that immediate provision of the implants in schools will be cost-effective compared to the usual model of referral to a free-standing clinic, as it will allow higher proportion of adolescents to initiate this method, compared to the referral where some adolescents may be lost to follow-up.
We developed a microsimulation model of teen pregnancy using the public payer perspective over a 3-year time horizon. Model inputs were derived from literature review and retrospective chart review. We performed 1-way, 2-way, and probabilistic sensitivity analysis to make sure our results are robust.
Immediate provision in school cost $204 more per person upfront, but it prevents 65 pregnancies per 1,000 adolescents compared to the referral system. The incremental cost effectiveness ratio (ICER) for implementing in-school provision was $3,161 more per additional pregnancy prevented and was less than $18,828 willingness-to-pay.
Bringing the healthcare delivery system to in-school is cost-effective. This patient-centered model should be expanded to other SBHC locations.