Hospital utilization, costs and mortality rates during the first 5 years of life: a population study of ART and non-ART singletons.

STUDY QUESTION: Do singletons conceived following assisted reproduction technologies (ARTs) have significantly different hospital utilization, and therefore costs, compared with non-ART children during the first 5 years of life? SUMMARY ANSWER: ART singletons have longer hospital birth-admissions and a small increased risk of re-admission during the first 5 years of life resulting in higher costs of hospital care. WHAT IS KNOWN ALREADY: ART singletons are at greater risk of adverse perinatal outcomes compared with non-ART singletons. Long-term physical and mental health outcomes of ART singletons are generally reassuring. There is a scarcity of information on health service utilization and the health economic impact of ART conceived children. STUDY DESIGN, SIZE, DURATION: A population cohort study using linked birth, hospital and death records. Perinatal outcomes, hospital utilization and costs, and mortality rates were compared for non-ART and ART singletons to 5 years. Adjustments were made for maternal age, parity, sex, birth year, socioeconomic status and funding source. Australian Diagnosis Related Groups cost-weights were used to derive costs. All costs are reported in 2009/2010 Australian dollars. PARTICIPANTS/MATERIALS, SETTING, METHODS: All babies born in Western Australia between 1994 and 2003 were included; 224 425 non-ART singletons and 2199 ART conceived singletons. Hospital admission and death records in Western Australia linked to 2008 were used. MAIN RESULTS AND THE ROLE OF CHANCE: Overall, ART singletons had a significantly longer length of stay during the birth-admission (mean difference 1.8 days, P < 0.001) and a 20% increased risk of being admitted during the first 5 years of life. The average adjusted difference in hospital admission costs up to 5 years of age was $2490, with most of the additional cost occurring during the birth-admission ($1473). The independent residual cost associated with ART conception was $342 during the birth-admission and an additional $548 up to 5 years of age, indicating that being conceived as an ART child predicts not only higher birth-admission costs but excess costs to at least 5 years of age. LIMITATIONS, REASONS FOR CAUTION: This study could not investigate the impact of different ART practices and techniques on perinatal outcomes or hospital utilization, nor could it adjust for parental characteristics such as cause of infertility and treatment-seeking behaviour. This study related to ART treatment undertaken before 2003. WIDER IMPLICATIONS OF THE FINDINGS: Clinicians and patients should be aware of the risk of poorer perinatal outcomes and increased hospitalization of ART singletons compared with non-ART singletons. These differences are significant enough to affect health-care resource consumption, but are substantially and significantly less than those associated with ART multiple birth infants. Understanding the short- and long-term health services and economic impact of ART is important for setting the research agenda in ART, for informing economic evaluations of infertility and treatment strategies, and for providing an important input to clinical and administrative decision making. STUDY FUNDING/COMPETING INTEREST(S): No specific funding was used to undertake this study and the authors report no conflicts of interest. A number of the authors receive Research Grants to their institutions from the Australian Government. G.M.C. receives grant support to her institution from the Australian Government, Australian Research Council (ARC) Linkage Grant No LP1002165; ARC Linkage Grant Partner Organisations are IVFAustralia, Melbourne IVF and Queensland Fertility Group. V.P.H. is employed as an Economics Research Associate on the same grant. TRIAL REGISTRATIONS NUMBER: NA.

Socioeconomic disparities in access to ART treatment and the differential impact of a policy that increased consumer costs.

STUDY QUESTION: What was the impact on access to assisted reproductive technology (ART) treatment by different socioeconomic status (SES) groups after the introduction of a policy that increased patient out-of-pocket costs? SUMMARY ANSWER: After the introduction of a policy that increased out-of-pocket costs in Australia, all SES groups experienced a similar percentage reduction in fresh ART cycles per 1000 women of reproductive age. Higher SES groups experienced a progressively greater reduction in absolute numbers of fresh ART cycles due to existing higher levels of utilization. WHAT IS KNOWN ALREADY: Australia has supportive public funding arrangements for ARTs. Policies that substantially increase out-of-pocket costs for ART treatment create financial barriers to access and an overall reduction in utilization. Data from the USA suggests that disparities exist in access to ART treatment based on ethnicity, education level and income. STUDY DESIGN, SIZE, DURATION: Time series analysis of utilization of ART, intrauterine insemination (IUI) and clomiphene citrate by women from varying SES groups before and after the introduction of a change in the level of public funding for ART. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women undertaking fertility treatment in Australia between 2007 and 2010. MAIN RESULTS AND THE ROLE OF CHANCE: Women from higher SES quintiles use more ART treatment than those in lower SES quintiles, which likely reflects a greater ability to pay for treatment and a greater need for ART treatment as indicated by the trend to later childbearing. In 2009, 10.13 and 5.17 fresh ART cycles per 1000 women of reproductive age were performed in women in the highest and lowest SES quintiles respectively. In the 12 months after the introduction of a policy that increased out-of-pocket costs from ∼$1500 Australian dollars (€1000) to ∼$2500 (€1670) for a fresh IVF cycle, there was a 21-25% reduction in fresh ART cycles across all SES quintiles. The absolute reduction in fresh ART cycles in the highest SES quintile was double that in the lowest SES quintile. LIMITATIONS, REASONS FOR CAUTION: In this study, SES was based on the average relative socioeconomic advantage and disadvantage of small geographic areas, and therefore may not reflect the SES of an individual. Additionally, the policy impact was limited to the 12 months following its introduction, and may not reflect longer term trends in ART treatment. WIDER IMPLICATIONS OF THE FINDINGS: While financial barriers are an important obstacle to equitable access to ARTs, socioeconomic differences in utilization are likely to persist in countries with supportive public funding, due in part to differences in childbearing patterns and treatment seeking behaviour. Policy makers should be informed of the impact that changes in the level of cost subsidization have on access to ART treatment by different socioeconomic groups. STUDY FUNDING/COMPETING INTEREST(S): G.M.C. receives grant support to her institution from the Australian Government, Australian Research Council (ARC) Linkage Grant No LP1002165; ARC Linkage Grant Partner Organisations are IVFAustralia, Melbourne IVF and Queensland Fertility Group. V.P.H. is employed as an Economics Research Associate on the same grant. P.J.I. is Medical Director of the IVF Clinic, IVFAustralia and has a financial interest in the parent group, Virtus. TRIAL REGISTRATION NUMBER: N/A.