Tag Archives: ACOG

IUD Contraception Cost May Inhibit Use

A copper intrauterine device (IUD) retails for the equivalent of $20 in France. In the United States, it costs $860, Dr. Eve Espey says.

“This is highway robbery. It has to change,” she said during a talk on long-acting reversible contraception at the annual meeting of the American College of Obstetricians and Gynecologists (ACOG). “Honestly,” she sighed, “If you went to Home Depot and picked up the supplies to make yourself an IUD, what would it cost? Like, under $1.” (Not that she’s advocating that.)

Dr. Eve Espey (Sherry Boschert/IMNG Medical Media)

Strong words, and they’re not coming from just any frustrated physician. Dr. Espey is chair of ACOG’s Working Group on Long-Acting Reversible Contraception and a professor of ob.gyn. at the University of New Mexico, Albuquerque.

The high U.S. price may be one reason that only 6% of U.S. women using contraceptives choose an IUD, even though studies show it’s one of the most effective kinds of contraception, along with levonorgestrel intrauterine systems and contraceptive implants, the other two kinds of long-active reversible contraceptives.

Sure, the cost of a copper IUD may be somewhat less than $860 if the physician or patient has access to government prices or other discounts, but it still creates a financial burden for physicians to stock their shelves with IUDs, not to mention inadequate reimbursement from insurers, she said.

“I think that the emerging, biggest barrier to IUD and implant use in this country is price,” Dr. Espey said. “ACOG is really trying to work to make a dent in that, but I think that until we see a cheaper IUD, it’s going to be a barrier to increased usage.”

Dr. Espey reported having no financial disclosures.

There’s only one copper IUD approved for use in the United States, so I contacted the makers of the ParaGard IUD, Teva Women’s Health. The “typical cost” for one ParaGard is $754, according to the company’s vice president for corporate communications, Denise Bradley. She said that the ParaGard’s price is “below most other forms of female birth control,” that most insurance plans cover ParaGard, and that the company offers women whose insurers don’t cover the IUD the option of paying by monthly installments.

She didn’t respond directly to the question of whether ParaGard’s cost is a barrier to use, but said, “Teva Women’s Health believes that increased access to all forms of contraception is of critical importance to all women of reproductive age.” She declined to comment on price differences between copper IUDs in the United States and other countries.

Recent data show that when financial barriers are removed and women receive standardized information about contraceptive choices, many more choose long-acting reversible contraception. The Reproductive CHOICE Project recruited nearly 10,000 women in the St. Louis area who desired contraception, gave them standardized counseling, and provided contraceptives for free.

A copper IUD. (Photo courtesy flickr/+mara/Creative Commons)

Results from the first 4,167 women to complete a year of follow-up found that 71% chose a long-acting reversible contraceptive (45% the levonorgestrel intrauterine system, 13% the copper IUD, and 13% an implant), Dr. Espey said. Others chose contraceptive pills, vaginal rings, transdermal patches, or another method.

After 12 months of use, 80% of IUD users reported being somewhat or very satisfied, compared with 54% of pill, patch, or ring users, she said. Only 55% of pill, patch, or ring users were on the same choice of contraception after 1 year compared with 84% of IUD users, 83% of implant users, and 88% of women who got a levonorgestrel intrauterine system.

The investigators recently reported that there have been 334 unintended pregnancies in 7,486 participants. Those using the pill, patch or ring were 22 times more likely to experience contraceptive failure compared with participants on long-acting reversible contraceptives (N. Engl. J. Med. 2012:366:1998-2007).

Long-acting reversible contraception was equally effective in all age groups, but use of the pill, patch, or ring was strikingly less effective in participants younger than 21 years, who were nearly twice as likely to have an unintended pregnancy compared with older women using those same methods of birth control.

–Sherry Boschert (on Twitter @sherryboschert)

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Doctors Face Fallout from Adverse Events

When things go wrong medically or surgically – whether or not a mistake was made – two parties get hurt: the patient and the physician. It’s nice to see increasing attention on the effects of bad outcomes on physicians, as I reported in a previous post.

A new video helps ob.gyns. cope when things go wrong. (Sherry Boschert/IMNG Medical Media)

Here are the latest examples. The American College of Obstetricians and Gynecologists (ACOG) just released a new DVD that it is sending to all ob.gyn. residency program directors to view with their residents. Called “Healing Our Own: Adverse Events in Obstetrics and Gynecology,” the video features ob.gyns. describing the painful effects that adverse events have had on them, and how they recovered.

The video can be viewed in a members-only section of the ACOG website and it was shown in the Exhibit Hall during ACOG’s recent annual meeting.

Both members and non-members are welcome to join (for a fee) an ACOG-sponsored webinar on Adverse Events, Stress, and Litigation on July 10 at 1 p.m. Eastern Time. The webinar will address feelings of isolation, guilt, and shame that physicians commonly experience when bad things happen to their patients, feelings that only get exacerbated if the event leads to a lawsuit.

Ob.gyns. are the sixth most likely medical specialists to get sued regardless of whether a mistake was made, according to a 2011 report in the New England Journal of Medicine.

The stress created by adverse events is just a part of the higher than usual stress levels that physicians try to cope with every day. Tools like the American Medical Association’s A Physician’s Guide To Personal Health offer strategies for staying sane and healthy under stress. Non-profit groups like Medically Induced Trauma Support Services (MITSS) offer tools and templates for health care workers after adverse events, though they mainly focus on helping patients through the trauma. MITSS did post an extensive bibliography online for articles and resources related to the impact of adverse events on caregivers.

If you know of other medical specialty organizations like ACOG that are helping physicians cope with the fallout from adverse events, let us know and we’ll share the resources with our readers.

–Sherry Boschert (on Twitter @sherryboschert)

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Abortion Protests Absent at Ob.Gyn. Meeting

While covering the annual meeting of the American College of Obstetricians and Gynecologists, I noticed something similar to what I first reported in a blog post from ACOG’s 2010 meeting, when room numbers had been left out of the printed program intentionally – for security reasons – for sessions on abortion and even contraception.

There’s something very different about this year’s ACOG meeting, though. Anti-abortion and anti-contraception protesters who previously were camped outside with signs vilifying obstetricians for being “child haters” are nowhere to be seen this year. Is that a sign of the times? Or a difference between having the meeting in protest-crazy San Francisco in 2010 and this year’s meeting in more conservative San Diego?

Protesters outside ACOG’s annual meeting. (Sherry Boschert/IMNG Medical Media)

Don’t get me wrong. There still are protesters here calling obstetricians “sex criminals.” With anti-abortionists and anti-contraceptionists gone, all that were left were the anti-circumcisionists handing out cards with links to Web sites such as Doctors Opposing Circumcision (DOC).

That means there’s still a strong police presence at the doors to the convention center and workers diligently checking to see that people who come into the center are wearing registration badges.  I haven’t heard of any cases of anti-circumcisionists murdering ob.gyns. as some abortion opponents have done, though.

For the record, ACOG’s policy on circumcision is essentially the same as that of the American Academy of Pediatrics. They do not recommend routine circumcision for newborn males, but advise physicians to weigh the potential risks, benefits, and costs of circumcision with the newborn’s parents.

And looking at the ACOG program, I didn’t see “Room TBD” next to the two presentations on circumcision, one of which I’ll be reporting soon: “A Cost-effective Analysis of Male Circumcision for the Prevention of HIV in the United States.” The findings may surprise you. Stay tuned.

–Sherry Boschert

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Tears When a Patient Takes the Podium

From the annual meeting of the American College of Obstetricians and Gynecologists.

Mary Jo Codey (Photo courtesy of Robert Menendez Senatorial Office.)

When physicians invite patients who have become advocates to speak at medical conferences, there’s usually a good reason. I’ve learned a lot from hearing a panel of intersex people speak at a meeting of psychiatrists and psychologists, and I’ve always been moved by hearing people who are living with HIV and AIDS address physicians, whether in small grand rounds or at the International AIDS Conference.

My jaded professional demeanor was blown apart, though, when I heard Mary Jo Codey speak this week. My eyes teared up. The eyes of physicians all around me teared up. When she finished, thousands of ob.gyns. in the auditorium gave her a standing ovation.

Codey, an elementary school teacher who loved children, suffered postpartum depression with both of her two pregnancies. She described the agonizing ordeal she went through before she was diagnosed, the multiple failed antidepressants and electroshock therapy, the judgmental attitudes that made her blame herself, the desire to hurt her baby, the desire to kill herself.

“Nothing that has happened in my life was worse, not even breast cancer and a double mastectomy. They can’t even compare,” she said. Finally, treatment with a monoamine oxidase inhibitor restored her mental health. When her husband later became governor of New Jersey, she launched a statewide campaign to raise awareness about postpartum depression and to improve education and resources on the subject.

The president of the American College of Obstetricians and Gynecologists, Dr. Gerald F. Joseph Jr., has made postpartum and perinatal depression part of a “presidential initiative” that included release last fall of a joint report with the American Psychiatric Association on Management of Depression During Pregnancy. In early 2010, the College also released a committee report on screening for depression during and after pregnancy.

By focusing the entire opening plenary session of the annual meeting on this topic, he sent a message about the importance of getting ob.gyns. to wrap their minds around the issue of postpartum depression. And by having Mrs. Codey speak, he guaranteed that they wrapped their hearts around it, too.

—Sherry Boschert
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Why Do You Hate Children?

From the annual meeting of the American College of Obstetricians and Gynecologists.  

Protester's sign: "Why do you hate children?" Photo by Sherry Boschert.

 I encountered a weird, sad and somewhat frightening thing when covering the obstetricians’ and gynecologists’ big annual meeting this year — something I haven’t seen in my 20 years of medical news reporting, including many assignments to this very meeting.  

It took me awhile to recognize it. The first day, as I was trying to find the room number for a talk I wanted to cover, I noticed that there was a “mistake” in the program book. The room number for that particular session was missing. The next day, two more sessions that I wanted to cover had the same “problem” — no room number.  

So I asked for help from staff in the press office, and they seemed surprised to see these “errors” in the program too. But they knew who to call, and got me the room numbers, explaining that the omissions from the program were for “security” reasons.  

Then it hit me that the link between each of the “missing” sessions that I’d hoped to attend was that they all were about contraception. Not even abortion, mind you, just contraception.  

Throughout the meeting, protesters took up posts outside the convention center, haranguing attendees with shouts through bullhorns and enlarged anti-abortion signs and photos of fetuses, even one sign that accused these baby-loving physicians of hating children.  

I’ve seen that before, but never felt threatened. Perhaps I shouldn’t have felt so safe, considering that eight abortion providers have been murdered since 1993. Clearly, the meeting organizers were taking no chances. The fact that they felt they needed to protect contraception sessions is a sad sign of our violent times, and it occurred to me that the nervousness it generated in me must be something that many Ob.Gyns. live with every day.  

— Sherry Boschert (@sherryboschert on Twitter)
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Delivery Timing After PPROM Gets More Exact

From the annual meeting of the American College of Obstetricians and Gynecologists.   

Photo by flickr user MJTR (Creative Commons).

 A new study could help close the gap in varying opinions about when best to deliver a baby after preterm premature rupture of membranes (PPROM), or at least give physicians better information to use when counseling patients with PPROM. Deciding when to deliver after PPROM has always required balancing the desire to delay delivery in order to avoid problems associated with preterm births and the desire to deliver soon in order to avoid the risk of infection.   

Dr. Christopher Nold and his associates compared medical records and neonatal intensive care (NICU) data on 195 pregnancies with PPROM. They found that to avoid 95% of the complications of prematurity, it’s best to deliver after 34 weeks, 1 day of gestation. Babies whose delivery was delayed to 35 weeks spent much less time in the NICU. Both of those targets are later in gestation than some institutions choose for delivering pregnancies with PPROM. See more details in my story about the study.   

After Dr. Nold presented the findings, a physician in the audience asked the obvious question — which is it? Thirty-five weeks? Or 34 weeks, 1 day? Which would he choose for a woman with PPROM?   

Sorry, but there’s no pat answer to that question, at least not from this data, Dr. Nold replied. Still, the findings do give physicians more information when discussing with the mother the pros and cons of different delivery strategies. That’s definitely progress.   

I’d be interested in hearing from physicians who delivery babies — which would you choose, 34 weeks and 1 day, or 35 weeks, if you could delay a PPROM delivery that long? Read the full article, and let me know if you’d you rather reduce the risk of a complication of prematurity, or reduce NICU stay.   

— Sherry Boschert (@sherryboschert on Twitter)
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Whose Genes Are They?

Image courtesy of NCI

Yesterday a federal court ruled that the breast/ovarian cancer genes BRCA1 and BRCA2 are not patentable, invalidating seven patents for the only diagnostic test for mutations of these genes (BRACAnalysis). [See the New York Times story.]

The ruling has been long awaited and the implications are far reaching. At the heart of the matter is the question of whether patents for the identification of specific gene sequences stifles or promotes genetic research and development.

The case pitted the American Civil Liberties Union and the Public Patent Foundation (a not-for-profit organization affiliated with Benjamin N. Cardozo School of Law in New York) and individual cancer patients against Myriad Genetics and the University of Utah Research Foundation, which holds the patents for these gene sequences.

The ACLU—with amici curiae from the American Medical Association, the American Society of Human Genetics, the American College of Obstetricians and Gynecologists, the American College of Embryology, and the Medical Society of the State of New York—argued that genes cannot be patented and that such patents  restrict both scientific research and patients’ access to medical care. In particular, the plaintiffs argued that the patents constituted a monopoly and prevented women from independently confirming their test results.

Image courtesy of NIH

Myriad argued that without the ability to patent genetic sequences, there is no incentive to genetic investigation and the development of new diagnostic tests.  In the promised age of personalized medicine, such research and development represents not only improved patient care but also a burgeoning industry, in which millions of dollars are at stake. 

This story is far from over yet.  The company plans to appeal the ruling, in the meantime leaving other existing gene-based patents in limbo.

—Kerri Wachter ( @knwachter on Twitter)
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