Revival of the IUD: Increased Use among U S Women
Increased Use among U.S. Women with Employer‐Sponsored Insurance, *
2002 2007
2002‐2007
Xin Xu, Maurizio Macaluso, Lijing Ouyang, Andrzej Kulczycki, Scott Grosse
* The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.
Overview
 Introduction
 Objectives of the Study
 Data and Methods
d
h d
 Results
 Discussions and Conclusions
Introduction
 The intrauterine device (IUD) is a safe, highly effective and long‐lasting, but reversible family planning method.
 Worldwide, the IUD is the most popular reversible contraceptive method used among women of reproductive age (United Nations, 2006).
)
 In European countries, 10‐26% of women of reproductive age had used IUDs (United Nations, 2006).
 Data
Data from the 2002 National Survey of Family Growth suggests that from the 2002 National Survey of Family Growth suggests that
only 2‐3% women of reproductive age in the United States had used IUDs (Mosher et al., 2004).
Introduction: (continued)
 Women who had recently used IUDs reported the highest rate of complete satisfaction among all reversible contraception users (Guttmacher telephone survey, 2004) .
 None
None of IUD users reported dissatisfaction (Guttmacher
of IUD users reported dissatisfaction (Guttmacher telephone telephone
survey, 2004).
 Limited
Limited information has been provided to demonstrate the trend of information has been provided to demonstrate the trend of
IUD insertions and related medical expenditure in the United States after 2002.
Overview
 Introduction
 Objectives of the Study
 Data and Methods
d
h d
 Results
 Discussions and Conclusions
Obj ti
Objectives of the Study
f th St d
 The objective of this study was to evaluate trends in the
p
in
incidence of IUD insertions and related medical expenditure
the United States from 2002 to 2007, among the female
population with employer-sponsored health insurance (ESI).
 Illustrate geographic and age variations in the incidence of IUD
insertions.
 Explore the differences in the use of the copper IUD versus the
LNG IUS.
LNG-IUS.
Overview
 Introduction
 Objectives of the Study
 Data and Methods
d
h d
 Results
 Discussions and Conclusions
D t
Data
 The
The MarketScan
MarketScan Commercial Claims and Encounter Enrolled Commercial Claims and Encounter Enrolled
Population database from 2002 to 2007.
 Limit
Limit the sample to females aged from 15 to 49 years old from large, the sample to females aged from 15 to 49 years old from large
self‐insured employers.
 Identify
Identify for IUD insertion procedures between Jan. 1, 2002 and Dec. for IUD insertion procedures between Jan 1 2002 and Dec
31, 2007 through a unique Current Procedural Terminology code (CPT code 58300).
 Used the codes of the Healthcare Common Procedure Coding System (HCPCS) for the claims of IUD devices (HCPCS code J7300 for the copper IUD and J7302 for the LNG‐IUS).
IU
d J 302 f h LNG IUS)
Methods
h d
Incidence Estimation: Annual IUD insertion rates for women of reproductive age with ESI from 2002 to 2007.
 The numerator was the annual number of women having at least one reimbursed IUD insertion.
 The denominator was the annual number of women under ESI plans with IUD insertion coverage.
Methods: continued
Methods: continued
The Definition of “Covered
The Definition of Covered Plans
Plans”::
 If the ESI plan was identifiable from the MarketScan Benefit Plan D i d t b
Design database (50%):
(50%)
(a) the insurance plan explicitly included the coverage for co t acept es ( 6%);
contraceptives (16%);
(b) at least one IUD insertion reimbursement had been documented for this insurance plan in a given year (34%).
 If the ESI plan was un‐identifiable from the MarketScan Benefit Plan Design database (50%):
The percent of women with IUD coverage in identifiable plan was applied to the insured women to estimate number of women covered.
Methods: continued
Methods: continued
St ti ti l M th d
Statistical Methods:

Extrapolating estimates to women of reproductive age with ESI in Extrapolating
estimates to women of reproductive age with ESI in
the U.S. Using MarketScan national weights generated from weighted samples from The Medical Expenditure Panel Survey.
l f
Th M di l E
dit
P
lS

All monetary terms have been inflated to 2007 dollars, using All
monetary terms have been inflated to 2007 dollars using
Consumer Price Index for medical care.
Overview
 Introduction
 Objectives of the Study
 Data and Methods
d
h d
 Results
 Discussions and Conclusions
IUD Insertion Rates: IUD
Insertion Rates:
2002‐2007
2002
2003
2004
2005
2006
2007
Women reimbursed
for IUD insertions
Women with ESI
plans that cover for
IUD Insertions
IUD Insertion
Incidence
(per 1,000 women)
70,851
93,723
118,859
,
158,880
228,912
306,592
34,148,034
35,264,344
36,266,253
,
,
36,162,818
36,563,812
36,857,678
2.07
2.66
3.28
4.39
6.26
8.32
 Close to 1 million women with ESI had IUD insertions in the United States between 2002 and 2007.
 The incidence of IUD insertions among women with ESI went up by approximately 3 times between 2002 and 2007.
The IUD Insertion Rates: The
IUD Insertion Rates:
2002 vs 2007
INCIDENCE_IN_2002
1
2
4
6
8
INCIDENCE_IN_2007
1
2
4
6
8
10
12
The Increases in IUD I
Insertion Rates, 2002‐2007
ti R t 2002 2007
GROWTH_BETWEEN_2002_TO_2007
0.165917 - 3.768999
6.635840 - 7.163263
4.228762 - 5.397326
7.213403 - 8.969595
5.461743 - 6.551244
9.222190 - 14.278881
AVERAGE_ANNUL_GROWTH_RATES
0.852157 - 27.653100
63.116162 - 78.696475
29.915576 - 44.754635
78.912750 - 112.243442
48.815133 - 61.519500
118.364514 - 357.974088
Results
 The IUD insertion incidence was relatively higher in border States.
The IUD insertion incidence was relatively higher in border States
 Except Hawaii (because of insufficient data) and other 3 states (North Dakota, Washington DC and Washington State), all states witnessed average annual growth rates of 25% or higher.
 The average annual growth rate ranged from 0.9% in North Dakota, to over 300.0% in Alabama, Arkansas, and West Virginia.
 The average annual growth rates were more pronounced in Southeastern states where IUD insertion incidences were quite low in 2002.
IUD Insertion rates by y
Quintiles
The within State difference in insertion rates between 2002 and 2007 (Per 1 000 women )
The within State difference in insertion rates between 2002 and 2007 (Per 1,000
14
13
12
11
10
9
8
US Average
Lowest 10 States
7
Lowmid 10 States
Mid 10 States
6
MidHigh 10 States
Highest 10 States
5
4
3
2
1
0
2002
2003
2004
2005
2006
2007
Results
 The
The increase in the IUD insertion incidence among states in upper increase in the IUD insertion incidence among states in upper
quintiles is the driven force of the nationally rapid growth.
 Among the 10 states in the first quintile, the insertion incidence increased from 3.0 in 2002 to 13.5 in 2007, roughly a 350% growth.
 Among the 10 states in the last quintile, the insertion incidence only increased from 2.3 to 5.6, representing approximately a 143.5% gro th
growth.
 The incidence among the states in the last quintile had hardly moved after 2005.
IUD Insertion Rates
by Age Groups
(Per 1 000 enrollees)
(Per 1,000
18.00
16.00
14.00
12.00
10.00
Ages 15‐24
Ages 25‐34
8 00
8.00
Ages 34‐44
Ages 45‐49
6.00
4 00
4.00
2.00
0.00
2002
2003
2004
2005
2006
2007
Results
 The growth rates of the incidences were very similar across age groups.
groups
 But the absolute age variations in the IUD insertion incidence in 2007
2007 were exaggerated because of the age difference in 2002.
t db
f th
diff
i 2002
 The IUD insertion incidence among the age group of 25‐34 went from 4 in 2002 to 16 in 2007.
Incidence Rates Incidence
Rates
the Copper IUD vs the LNG‐IUS
pp
(Per 1,000 enrollees)
9
8
7
6
5
the Incidence of IUD/IUS Patients
the Incidence of Copper IUD Patients 4
the Incidenceof LNG‐IUS Patients 3
2
1
0
2002
2003
2004
2005
2006
2007
Results
 The insertion incidence of the LNG‐IUS went from 0.5 in 2002 to 6.0 in 2007.
 The insertion incidence of the copper IUD went from 0.8 to 1.4.
 The LNG‐IUS represented 37% of all IUDs inserted in 2002, more than 50% in 2003, and over 80% in 2007.
 The age variations in this growth of the relative share of the LNG‐
IUS were very small.
Overview
 Introduction
 Objectives of the Study
 Data and Methods
d
h d
 Results
 Discussions and Conclusions
Strengths
 Illustrate
Illustrate the trend in IUD insertion Incidence from 2002 to 2007 the trend in IUD insertion Incidence from 2002 to 2007
using patient‐level claim data .
 The estimates represent 226.5 million women covered by ESI from 2002 to 2007.
 Demonstrate recent geographic and age variations in IUD insertions in the U.S. population.
 Reveal the difference in the insertion incidence of the copper IUD and the LNG‐IUS.  Estimate the medical expenditure associated with IUD insertions in the U S population with ESI
the U.S. population with ESI.
Limitations
 The denominator was estimated by assuming the percent of women y
g
p
with IUD coverage in un‐identifiable plans was identical to that of women that were identifiable.
 Missed female population who had ESI plans but did not have the coverage for IUD insertions (less than 10%).
 ESI plans might reimburse for the insertion procedure but not the p
prescription of the IUD device (underestimation of the insertion p
(
incidences of the copper IUD and the LNG‐IUS in the first two years).
 Provided
Provided limited information on the purpose of the IUD insertion. limited information on the purpose of the IUD insertion
Contraceptive or managing menstrual bleeding? Or a combination of both?
Conclusions
 The
The IUD insertion incidence among the population with ESI in the United IUD insertion incidence among the population with ESI in the United
States had increased remarkably from 2002 to 2007, although the overall incidence was still low.
 Substantial geographic and age disparity existed in the IUD insertion g
p
incidences during this time period.
 The total medical expenditure associated with IUD insertions in this population increased from 26 7 million in 2002 to 169 2 million in 2007
population increased from 26.7 million in 2002 to 169.2 million in 2007, representing a 533% growth.  Additi
Additional research is needed to understand whether the recent growth l
hi
d dt
d t d h th th
t
th
in IUD insertions and the state variations in the insertion incidence were p
p
related to differences in provider attitudes and local policies.