A study examines the impact of Obamacare on how much women have to spend for contraceptives. Plus, do smoking and preterm delivery increase the risk of cardiovascular disease? And: Are the benefits of mammograms overblown?
An analysis of claims data from a national insurer shows that the Affordable Care Act (ACA) has translated into lower out-of-pocket costs for contraception for women. Since 2008, on average, users of oral contraceptives (OCs) have saved $255 annually and women who use intrauterine devices (IUDs) have saved $248, a 20% drop, according to the report in Health Affairs.
Researchers from The Wharton School at the University of Pennsylvania say their findings, spanning the period from June 2012 to June 2013 and reflecting costs for 8 categories of contraceptives, suggest that women’s out-of-pocket savings are even higher than that estimated in a recent industry report. They caution that the numbers “should be interpreted as short-term changes in out-of-pocket spending only and should not be used for long-term estimates of out-of-pocket spending reductions.”
Nevertheless, analysis of month-level observations for 790,895 women aged 13 to 45 enrolled in private health insurance for at least 1 month during the study period showed a significant drop in the cost of contraception. In the year for which data were assessed, the average adjusted per claim out-of-pocket cost for an OC prescription fell from $33.58 to $19.84 and for an IUD insertion from $293.28 to $145.24, declines of 38% and 68%, respectively.
For the other 6 categories of contraceptives examined, the authors also reported declines in cost, ranging from 93% for emergency contraception to 84% for diaphragms or cervical caps, 72% for the implant, 68% for injection, and only 2% and 3%, respectively, for the ring and the patch.
The sample analyzed included women in all 50 states and the District of Columbia and looked at claims for contraception provided by a pharmacy and in a physician office. Cost-sharing for physician appointments or costs of IUD or implant removals were not included in the analysis.
The results, the authors said, “suggest that the mandate has led to large reductions in total out-of-pocket spending on contraceptives and that these price changes are likely to be salient for women with private health insurance.”
Smoking, preterm birth and maternal health
Smoking and preterm birth appear to have a synergistic effect on risk of maternal cardiovascular disease (CVD), according to a new Australian study.
Researchers linked birth records from 902,008 mothers who delivered singleton infants between 1994 and 2011 in New South Wales, Australia to mothers’ later CVD hospitalization or death. In an attempt to rule out the immediate effects of pregnancy on maternal CVD, women who had a CVD event prior to their final birth and women who had a CVD even within 42 days of their final birth were excluded from the study, as were women who had died before follow-up began. Cox proportional hazard regression models were used to assess the association between preterm birth and maternal prenatal smoking with the first occurrence of CVD.
The median age of the cohort was 31 years (interquartile range [IQR]: 27 -35). Of them, 76,204 (8.5%) women had a history of preterm birth, 171,370 (19%) had smoked, and 21,442 (2.4%) had given birth prematurely and smoked. Median follow-up time was 7.3 years (IQR: 3.0 – 12.8), covering more than 7.2 million person-years at risk. During the follow-up, a first CVD event developed in 4966 women, which resulted in 4930 hospitalizations and 36 deaths. The overall crude incidence rate for a first CVD event was 67 per 100,000 person years at risk.
Risk of CVD was nearly 4 times higher (95% CI 3.23 – 4.69) in mothers who had ever smoked and given birth extremely prematurely (20-33 weeks’ gestation) than in non-smoking women with term births. Risk of CVD was roughly 3 times higher (95% CI 2.76 – 3.66) for smokers with a moderate preterm birth (34-36 weeks’ gestation) that in women with no smoking history and term births. Having 2 or more preterm births and a history of smoking also increased the risk of CVD when compared with just 1 preterm birth and a history of smoking (hazard ratios 4.47 and 3.20, respectively).
Unmeasured risk factors such as maternal obesity and maternal hypertension were considered one of the study’s limitations. The makeup of the cohort-relatively young women-and short follow-up period also were considered limitations.
Investigators concluded that a synergistic relationship between smoking and preterm birth may have a negative impact on a woman’s future risk of CVD. They believe that the findings highlight the need for careful documentation of gestational age and any prenatal smoking habits to target screenings.
Are the benefits of mammography overstated?
A new review of the Swedish randomized trials that have long influenced use of mammography for breast cancer screening may call into question the benefits of the technology.
Researchers from the University of Strathclyde Institute of Public Health compared how relative risk of cancer death was calculated in the 5 Swedish trials versus in 17 trials of screening for other cancers. They identified when the screening was offered to just the screening group versus when screening times were the same for both the screened and control groups. Investigators also looked at which cancer deaths were used for computing the relative risk of cancer deaths.
In the 5 Swedish trials, the relative risk calculations had used deaths due to any breast cancers found during the intervention period plus those in women in the control group whose disease was found at first screening. When the added breast cancer deaths were properly reallocated to the post-intervention periods of control groups, relative risks of 0.86 (0.75; 0.97) and 0.83 (0.71; 0.97) were found for cancers located during the intervention period and in the post-intervention period, respectively. This change in risk reduction indicates a constant reduction in breast cancer death risk over the course of follow-up, regardless of screening.
Also read: The high cost of routine mammography in younger women
The investigators concluded that unconventional statistical methods in the Swedish trials led to overestimation of mammography’s contribution to reducing risk of death due to breast cancer. They believe that the risk reduction seen in the original trials was likely a function of a design that optimized awareness and medical management of women allocated to the screening groups.