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In-vitro fertilization pregnancies and perinatal health in Finland 1991-1993 |
Gissler M, Silverio M M, Hemminki E |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology In-vitro fertilization (IVF).
Economic study type Cost-effectiveness analysis.
Study population Pregnancies resulting in newborn babies.
Setting Primary care. The economic study was carried out in Finland.
Dates to which data relate The recorded data for costs and effectiveness were from 1991-1993, and prices were from the same years.
Source of effectiveness data Effectiveness data were derived from a single study.
Link between effectiveness and cost data The study sample used for costing, which was undertaken retrospectively, was the same as that used for the effectiveness study.
Study sample Power calculations were not used to determine the sample size. There were 1,015 cases of IVF pregnancies ending in 1,332 newborns versus 190,697 cases of non-IVF pregnancies resulting in 191,712 newborns.
Study design This was a multicentre, case-control study carried out in Finland. The duration of follow up was one week after birth.
Analysis of effectiveness The analysis was based on intention to treat. The primary health outcomes used were divided in two categories: mothers' outcomes and infants' outcomes. The mothers' outcomes consisted of hospital treatment during pregnancy, mother in the hospital 7 days or more, and Caesarean section. The infants' outcomes included gestation length less than 37 weeks, birth weight less than 2500g, 1 minute Apgar score 0-6, newborn stay in hospital for 7 or more days, and perinatal mortality. The groups were subject to an adjustment for the mother's background, the variables being as follows: county, age, smoking, marital status, previous pregnancies and previous deliveries.
Effectiveness results The odds ratios of the IVF group outcomes relative to the control group, after adjusting for mother's background variables, were as follows (95% CI in parentheses):
hospital treatment during pregnancy, 4.96 (95% CI: 4.43 - 5.55);
mother in the hospital 7 or more days, 2.21 (95% CI: 1.98 - 2.47);
Caesarean section, 2.72 (95% CI: 2.43 - 3.04);
gestation length less than 37 weeks, 8.16 (95% CI: 7.25-9.18);
birth weight less than 2500 g, 8.98 (95% CI: 7.94 - 10.2);
1 minute Apgar score 0-6, 2.54 (95% CI: 2.14 - 3.02);
newborn in hospital 7 or more days, 4.10 (95% CI: 3.63 - 4.63);
and perinatal mortality 3.65 (95% CI: 2.63 - 5.09).
Clinical conclusions All indicators, excluding mother's treatment in the hospital for longer than 7 days after the delivery, showed that IVF mothers used more health care services. The infant outcomes for Finnish IVF newborns were much worse than for other newborns. This was true both for singletons and multiples, and after adjusting for mothers' background characteristics.
Measure of benefits used in the economic analysis No summary benefit measure was identified in the economic study, and only separate clinical outcomes were reported.
Direct costs Only costs (not resource use) were reported. Operating costs, costs of complications and overhead costs were included. The boundary adopted was the patient (in the case of private clinic) or the third-party payer (municipalities, in the case of public clinics). The estimation of costs was based on actual dataand standard prices. Questionnaires were sent to hospitals in 1992-93 for clinic specified costs, while the costs after induction of pregnancy were estimated by using the national mean costs of the hospital treatment. Data for the use of antenatal care, mother's hospitalizations, Caesarean sections and short-term infant treatments were obtained from the Finnish Medical Birth Register (MBR). The currency transformations were based on the official mean rates in 1991-1993 given by the Commission of the European Union.
Currency European currency units (ECU).
Estimated benefits used in the economic analysis Cost results Only the total costs of IVF cycles and other costs of IVF treatment during the study period in Finland were reported. The corresponding values were 8.6-11.4 million ECU and ~2.9 million ECU, respectively. Furthermore, it was reported that "the antenatal care costs were estimated to be 38% higher, the hospitalisation costs before childbirth 190% and after childbirth 94%, delivery costs 33%, and short-term infant treatment costs 107% higher for an IVF pregnancy than for other pregnancies".
Synthesis of costs and benefits The average cost per successful birth was calculated. The cost per successful live birth was ECU16,906 for the IVF pregnancies versus ECU3,130 for other pregnancies.
Authors' conclusions "All indicators, excluding mother's treatment in the hospital (more than) 7 days after the delivery, showed that IVF mothers used more health care services. The infant outcomes for Finnish IVF newborns were much worse than for other newborns. This was true both for singletons and multiples, and after adjusting for mothers' background characteristics". "The couples planning to use IVF treatment should be conscious of the risk present in using IVF, although the desire to have a child may be stronger than the probable risks". "The health care costs for one IVF newborn from induction of pregnancy until the age of 7 days was 5.4 fold compared to other newborns. The subsequent health of IVF children has to be further studied to more fully assess the health impact of IVF".
CRD COMMENTARY - Selection of comparators The reason for the choice of the comparator is clear. Validity of estimate of measure of benefit Despite some missing data and the possibility of errors, the effectiveness results are likely to be internally valid due to large study sample. Validity of estimate of costs Resource utilisation was not fully reported separately from the costs and, as the authors pointed out, indirect costs were not considered. Other issues Given that the authors stated that "The couples planning to use IVF treatment should be conscious of the risk present in using IVF, although the desire to have a child may be stronger than the probable risks", it would appear that a cost-utility analysis may have been a more appropriate study type in this context than a cost-effectiveness analysis. Bibliographic details Gissler M, Silverio M M, Hemminki E. In-vitro fertilization pregnancies and perinatal health in Finland 1991-1993. Human Reproduction 1995; 10(7): 1856-1861 Indexing Status Subject indexing assigned by NLM MeSH Female; Fertilization in Vitro; Fetus /physiology; Finland; Health Care Costs; Health Services /utilization; Health Status; Humans; Infant Care /economics; Infant, Newborn /physiology; Postpartum Period; Pregnancy; Pregnancy Outcome; Pregnancy, Multiple; Registries AccessionNumber 21995000977 Date bibliographic record published 31/07/1999 Date abstract record published 31/07/1999 |
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