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Efficacy and Cost-Benefit of Onsite Contraceptive Services With and Without Incentives Among Women With Opioid Use Disorder at High Risk for Unintended Pregnancy: A Randomized Clinical Trial.
JAMA Psychiatry ( IF 22.5 ) Pub Date : 2021-10-01 , DOI: 10.1001/jamapsychiatry.2021.1715
Sarah H Heil 1, 2 , Heidi S Melbostad 2 , Alexis K Matusiewicz 1 , Catalina N Rey 1, 3 , Gary J Badger 4 , Donald S Shepard 5 , Stacey C Sigmon 1, 2 , Lauren K MacAfee 6 , Stephen T Higgins 1, 2
Affiliation  

Importance Rates of in utero opioid exposure continue to increase in the US. Nearly all of these pregnancies are unintended but there has been little intervention research addressing this growing and costly public health problem. Objective To test the efficacy and cost-benefit of onsite contraceptive services with and without incentives to increase prescription contraceptive use among women with opioid use disorder (OUD) at high risk for unintended pregnancy compared with usual care. Design, Setting, and Participants A randomized clinical trial of 138 women ages 20 to 44 years receiving medication for OUD who were at high risk for an unintended pregnancy at trial enrollment between May 2015 and September 2018. The final assessment was completed in September 2019. Data were analyzed from October 2019 to March 2021. Participants received contraceptive services at a clinic colocated with an opioid treatment program. Interventions Participants were randomly assigned to receive 1 of 3 conditions: (1) usual care (ie, information about contraceptive methods and community health care facilities) (n = 48); (2) onsite contraceptive services adapted from the World Health Organization including 6 months of follow-up visits to assess method satisfaction (n = 48); or (3) those same onsite contraceptive services plus financial incentives for attending follow-up visits (n = 42). Main Outcomes and Measures Verified prescription contraceptive use at 6 months with a cost-benefit analysis conducted from a societal perspective. Results In this randomized clinical trial of 138 women (median age, 31 years [range, 20-44 years]), graded increases in verified prescription contraceptive use were seen in participants assigned to usual care (10.4%; 95% CI, 3.5%-22.7%) vs contraceptive services (29.2%; 95% CI, 17.0%-44.1%) vs contraceptive services plus incentives (54.8%; 95% CI, 38.7%-70.2%) at the 6-month end-of-treatment assessment (P < .001 for all comparisons). Those effects were sustained at the 12-month final assessment (usual care: 6.3%; 95% CI, 1.3%-17.2%; contraceptive services: 25.0%; 95% CI, 13.6%-39.6%; and contraceptive services plus incentives: 42.9%; 95% CI, 27.7%-59.0%; P < .001) and were associated with graded reductions in unintended pregnancy rates across the 12-month trial (usual care: 22.2%; 95% CI, 11.2%-37.1%; contraceptive services: 16.7%; 95% CI, 7.0%-31.4%; contraceptive services plus incentives: 4.9%; 95% CI, 0.6%-15.5%; P = .03). Each dollar invested yielded an estimated $5.59 (95% CI, $2.73-$7.91) in societal cost-benefits for contraceptive services vs usual care, $6.14 (95% CI, $3.57-$7.08) for contraceptive services plus incentives vs usual care and $6.96 (95% CI, $0.62-$10.09) for combining incentives with contraceptive services vs contraceptive services alone. Conclusions and Relevance In this randomized clinical trial, outcomes with both onsite contraceptive service interventions exceeded those with usual care, but the most efficacious, cost-beneficial outcomes were achieved by combining contraceptive services with incentives. Colocating contraceptive services with opioid treatment programs offers an innovative, cost-effective strategy for preventing unintended pregnancy. Trial Registration ClinicalTrials.gov Identifier: NCT02411357.

中文翻译:

在意外怀孕高风险的阿片类药物使用障碍女性中,有无激励措施的现场避孕服务的疗效和成本效益:一项随机临床试验。

在美国,子宫内阿片类药物暴露的重要性继续增加。几乎所有这些怀孕都是无意的,但很少有干预研究解决这一日益严重且代价高昂的公共卫生问题。目的 与常规护理相比,在意外怀孕高风险的阿片类药物使用障碍 (OUD) 女性中,测试有无激励措施的现场避孕服务的有效性和成本效益,以增加处方避孕药的使用。设计、设置和参与者 一项随机临床试验对 2015 年 5 月至 2018 年 9 月期间接受 OUD 药物治疗的 138 名年龄在 20 至 44 岁的女性进行随机临床试验,这些女性在试验入组时意外怀孕的风险很高。最终评估于 2019 年 9 月完成。数据分析时间为 2019 年 10 月至 2021 年 3 月。参与者在与阿片类药物治疗计划位于同一地点的诊所接受避孕服务。干预 参与者被随机分配接受 3 种情况中的一种:(1)常规护理(即有关避孕方法和社区卫生保健设施的信息)(n = 48);(2) 改编自世界卫生组织的现场避孕服务,包括 6 个月的随访以评估方法满意度(n = 48);或 (3) 那些相同的现场避孕服务加上参加随访的经济奖励 (n = 42)。主要结果和措施 从社会角度进行了成本效益分析,验证了 6 个月时的处方避孕药使用情况。结果 在这项包含 138 名女性(中位年龄,31 岁 [范围,20-44 岁])的随机临床试验中,在分配到常规护理(10.4%;95% CI,3.5%-22.7%)vs 避孕服务(29.2%;95% CI,17.0%-44.1%)vs 避孕服务加6 个月治疗结束评估时的激励(54.8%;95% CI,38.7%-70.2%)(所有比较 P < .001)。这些影响在 12 个月的最终评估中得以维持(常规护理:6.3%;95% CI,1.3%-17.2%;避孕服务:25.0%;95% CI,13.6%-39.6%;避孕服务加激励措施: 42.9%;95% CI,27.7%-59.0%;P < .001)并与在 12 个月的试验中意外怀孕率逐步降低相关(常规护理:22.2%;95% CI,11.2%-37.1% ;避孕服务:16.7%;95% CI,7.0%-31.4%;避孕服务加激励措施:4.9%;95% CI,0.6%-15.5%;P = .03)。每投入一美元,避孕服务与常规护理的社会成本效益估计为 5.59 美元(95% CI,2.73-7.91 美元),避孕服务加奖励与常规护理的社会成本效益为 6.14 美元(95% CI,3.57-7.08 美元),6.96 美元(95 % CI,0.62-10.09 美元)将激励措施与避孕服务相结合与单独避孕服务相结合。结论和相关性 在这项随机临床试验中,两种现场避孕服务干预的结果都超过了常规护理的结果,但通过将避孕服务与激励措施相结合,实现了最有效、最具成本效益的结果。将避孕服务与阿片类药物治疗计划相结合,为预防意外怀孕提供了一种创新的、具有成本效益的策略。试验注册 ClinicalTrials.gov 标识符:NCT02411357。59 (95% CI, $2.73-$7.91) 避孕服务与常规护理的社会成本效益,6.14 美元 (95% CI, $3.57-7.08) 避孕服务加奖励与常规护理和 $6.96 (95% CI, $0.62-$10.09) ) 将激励措施与避孕服务相结合,而不是单独使用避孕服务。结论和相关性 在这项随机临床试验中,两种现场避孕服务干预的结果都超过了常规护理,但将避孕服务与激励措施相结合实现了最有效、最具成本效益的结果。将避孕服务与阿片类药物治疗计划相结合,为预防意外怀孕提供了一种创新的、具有成本效益的策略。试验注册 ClinicalTrials.gov 标识符:NCT02411357。59 (95% CI, $2.73-$7.91) 避孕服务与常规护理的社会成本效益,6.14 美元 (95% CI, $3.57-7.08) 避孕服务加奖励与常规护理和 $6.96 (95% CI, $0.62-$10.09) ) 将激励措施与避孕服务相结合,而不是单独使用避孕服务。结论和相关性 在这项随机临床试验中,两种现场避孕服务干预的结果都超过了常规护理的结果,但通过将避孕服务与激励措施相结合,实现了最有效、最具成本效益的结果。将避孕服务与阿片类药物治疗计划相结合,为预防意外怀孕提供了一种创新的、具有成本效益的策略。试验注册 ClinicalTrials.gov 标识符:NCT02411357。91)在避孕服务与常规护理的社会成本效益中,6.14 美元(95% CI,3.57-7.08 美元)用于避孕服务加激励与常规护理,以及 6.96 美元(95% CI,0.62-10.09 美元)将激励与避孕服务相结合与仅提供避孕服务。结论和相关性 在这项随机临床试验中,两种现场避孕服务干预的结果都超过了常规护理,但将避孕服务与激励措施相结合实现了最有效、最具成本效益的结果。将避孕服务与阿片类药物治疗计划相结合,为预防意外怀孕提供了一种创新的、具有成本效益的策略。试验注册 ClinicalTrials.gov 标识符:NCT02411357。91)在避孕服务与常规护理的社会成本效益中,6.14 美元(95% CI,3.57-7.08 美元)用于避孕服务加激励与常规护理,以及 6.96 美元(95% CI,0.62-10.09 美元)将激励与避孕服务相结合与仅提供避孕服务。结论和相关性 在这项随机临床试验中,两种现场避孕服务干预的结果都超过了常规护理,但将避孕服务与激励措施相结合实现了最有效、最具成本效益的结果。将避孕服务与阿片类药物治疗计划相结合,为预防意外怀孕提供了一种创新的、具有成本效益的策略。试验注册 ClinicalTrials.gov 标识符:NCT02411357。08) 用于避孕服务加奖励与常规护理,以及 6.96 美元(95% CI,0.62-10.09 美元)将奖励与避孕服务相结合与单独使用避孕服务。结论和相关性 在这项随机临床试验中,两种现场避孕服务干预的结果都超过了常规护理的结果,但通过将避孕服务与激励措施相结合,实现了最有效、最具成本效益的结果。将避孕服务与阿片类药物治疗计划相结合,为预防意外怀孕提供了一种创新的、具有成本效益的策略。试验注册 ClinicalTrials.gov 标识符:NCT02411357。08) 用于避孕服务加奖励与常规护理,以及 6.96 美元(95% CI,0.62-10.09 美元)将奖励与避孕服务相结合与单独使用避孕服务。结论和相关性 在这项随机临床试验中,两种现场避孕服务干预的结果都超过了常规护理的结果,但通过将避孕服务与激励措施相结合,实现了最有效、最具成本效益的结果。将避孕服务与阿片类药物治疗计划相结合,为预防意外怀孕提供了一种创新的、具有成本效益的策略。试验注册 ClinicalTrials.gov 标识符:NCT02411357。两种现场避孕服务干预的结果都超过了常规护理,但通过将避孕服务与激励措施相结合,实现了最有效、最具成本效益的结果。将避孕服务与阿片类药物治疗计划相结合,为预防意外怀孕提供了一种创新的、具有成本效益的策略。试验注册 ClinicalTrials.gov 标识符:NCT02411357。两种现场避孕服务干预的结果都超过了常规护理,但通过将避孕服务与激励措施相结合,实现了最有效、最具成本效益的结果。将避孕服务与阿片类药物治疗计划相结合,为预防意外怀孕提供了一种创新的、具有成本效益的策略。试验注册 ClinicalTrials.gov 标识符:NCT02411357。
更新日期:2021-07-14
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