costs and benefits of IUD follow-up visits in the Mexican Social Security Institute, The

International Family Planning Perspectives, Mar 1999 by Hubacher, David, Cardenas, Carmen, Hernandez, Daniel, Cortes, Manuel, Janowitz, Barbara

Context: In some settings, clinicians routinely schedule IUD users for follow-up care, but little effort has been made to compare the health benefit of repeat visits with the costs to programs.

Methods: In a prospective study at eight clinics of the Mexican Social Security Institute, 713 new IUD users were instructed to return for either two or four visits in the first 12 months after insertion of the device. To estimate the health benefits and costs of each regimen, data were collected on the frequency of various medical interventions and the labor and material costs.

Results: Of the nearly 2, 000 visits made overall, 235 in the four-visit regimen and 159 in the two-visit regimen involved medical interventions to treat serious conditions; 53 and 29, respectively, were scheduled visits by women who had no .symptoms but were found to require medical care. Assuming that the program provides about 250,000 IUDs annually, costs would total $1.7 million for the four-visit and $900,000 for the two- visit regimen; the four-visit approach would generate 8,387 more visits involving medical interventions than the two-visit regimen, at a cost of $48 per visit.

Conclusions: Additional follow-up visits create an opportunity to diagnose and treat problems, and therefore provide increased safety for IUD users. However, a four-visit regimen costs much more than a two-visit approach.

Clinicians in many countries schedule periodic checkups for new acceptors of IUDs; though the worldwide prevalence of this practice is not known, regularly scheduled followup visits (as many as four in the first year after the device is inserted) are commonplace in a diverse range of settings.1 Most experts on family planning and IUDs recommend no more than two visits in the first year of use.2 However, other key sources do not specify the appropriate number of follow-up visits,3 and one recommends three revisits in the first year.4

How the recommended number of IUD follow-up visits is established is unclear; however, the rationale for frequent revisits may be grounded in clinical trial protocols or related to health providers' concern about their patients' developing pelvic inflammatory disease. Frequent follow-up visits may be intended to identify asymptomatic conditions requiring medical interventions, such as lower genital tract infections from Chlamydia trachomatis and early stages of clinical anemia. Clinicians' recommendations to IUD users may reflect either their institution's guidelines or their own sense of what represents appropriate health care.

Revisits entail costs to both clients (including clinic fees, transportation costs, lost wages and variable opportunity costs) and providers (in terms of draining overall resources and interfering with scheduling appointments for clients with medical needs). Consequently, regimens of frequent revisits should afford a clear and demonstrated health benefit before they are accepted as standard medical practice.

Research on IUD follow-up visits has been limited in scope and methodology. A reanalysis of clinical trial data found little medical benefit of routine follow-up vis its.5 However, the analysts relied on information drawn from case report forms and a secondhand medical interpretation of the clinic visit; in addition, they did not estimate the costs of the visits and compare them with the possible health benefits. In Ecuador, researchers interviewed returning IUD users to estimate (indirectly) the programmatic implications of different revisit norms; they found that reducing the number of follow-up visits would result in a small decrease in the number of problems detected, but also would lead to major cost savings and improvements in access to services.6

The study we describe in this article improves on previous efforts by using an experimental design to compare the medical benefit with the cost of routine follow-up care for IUD users obtaining services at the Mexican Social Security Institute (IMSS), Mexico's largest health care provider.7 When the study was launched, Mexican public health care institutions were operating under guidelines specifying three revisits in the first year postinsertion,8 but informal interviews with providers suggested that the guidelines were not being followed consistently and that many physicians often recommended four revisits in the first year of IUD use.

Our study was designed to answer both clinical and cost questions. The primary clinical question was whether more scheduled checkup visits increase the safety of IUD use. The key cost questions were how much each IUD follow-up visit costs IMSS and what the projected yearly costs to the institution are of maintaining recommended follow-up schedules. The answers to these questions can be used to compare the increased costs of more scheduled visits with the possible health benefits. Given that IUDs are the most widely used form of reversible contraception in Mexico, representing 22% of the method mix,9 the importance of this research to the country's family planning program is evident; indeed, this information is requisite for purposes of improving IUD services.