Exploring the role of a facilitator in supporting family carers when embedding the iSupport for Dementia programme in care services: A qualitative study.

AIMS: To explore stakeholders' perceptions of a facilitator's role in supporting carers when embedding iSupport for Dementia psychoeducation program, in care services. METHODS: A qualitative descriptive study design was applied. Data were collected from workshops and interviews with carers of people living with dementia (PLWD)and with health and social care professionals from two tertiary hospitals and two community aged care organisations across three Australian states between October 2021 and March 2022. A thematic analysis was used to analyse data. The COREQ guideline was followed to report our findings. RESULTS: A total of 30 family carers and 45 health and social care professionals participated in the study. Three main themes and seven subthemes were identified from the data. We described the main themes as (1) the facilitator's role at the time of dementia diagnosis, (2) the facilitator's role throughout the everyday dementia care journey and (3) the facilitator's role during transition moments. CONCLUSIONS: Caring for family members with dementia is demanding and stressful for carers. Embedding a facilitator-enabled iSupport for Dementia program in hospital and community aged care settings has the potential to mitigate sources of stress associated with care recipient factors, carer factors and care service factors, and improve the health and well-being of carers and those for whom they care. RELEVANCE TO CLINICAL PRACTICE: Our findings will inform the establishment of iSupport facilitators appointed by dementia care providers in hospital and community care settings and help determine their roles and responsibilities in delivering the iSupport program. Our findings relate to nurse-led and coordinated dementia care in hospital and community aged care settings. PATIENT OR PUBLIC CONTRIBUTION: This study was co-designed with stakeholders from two aged care organisations and two tertiary hospitals. The study participants were staff employed by these organisations and carers of PLWD who were service users.

Matters of care and the good death - rhetoric or reality?

PURPOSE OF REVIEW: The notion of a 'good death' is central to hospice and palliative care philosophy. This review interrogates social imaginaries of the 'good death' in the context of current global, health and sociopolitical challenges. RECENT FINDINGS: Research literature and policy documents across fields continue to place emphasis on the 'good death'. As part of the equity turn in palliative care, there is a growing body of work highlighting the diverse perspectives of people whose voices were heretofore not understood. Inequities are evident not only in terms of who has access to a 'good death' but also related to the effects of the dominant 'good death' script itself. SUMMARY: There is increasing evidence that pursuit of the 'good death' narrative may be counter to supporting people as they are living and dying. The authors instead argue for a research, policy and practice shift to 'matters of care'.

Inter- and Intra-Observer Agreement Between Embryologists for Cytoplasmic String Assessment in Day 5/6 Human Blastocysts.

To investigate inter- and intra-observer agreement in the assessment of cytoplasmic string (CS) by embryologists on day 5/6 human blastocysts using the EmbryoViewer software. This was a prospective study involving five embryologists working between 2019 and 2020. Inter-observer agreement was calculated using assessments performed on 104 day 5/6 blastocysts regarding the presence, number, and location of CS and CS vesicle activity using timelapse videos. Intra-observer agreement was calculated when the same embryologists repeated the observations after a month's break. Inter- and intra-observer agreement was assessed using Fleiss' kappa coefficient and the intra-class correlation coefficient (ICC). The inter-observer agreement on the presence of CS (kappa: 0.477, 95% CI: 0.301-0.639) and their vesicles (kappa: 0.494, 95% CI: 0.345-0.643) was moderate, while the specific characteristics of CS assessment ranged from fair to moderate (kappa scores between: 0.157 and 0.563). The intra-observer agreement indicated an improvement on the level of agreement (kappa scores between: 0.162 and 0.795) compared to the inter-observer agreement. This study has shown a moderate level of inter- and intra-observer agreement when assessing day 5/6 human blastocysts for the presence of CS and their vesicles. When the specific characteristics of CS assessment occurred (such as the number of CS/vesicles) a slight to moderate level of agreement was seen among the embryologists. Agreement of specific characteristics of CS was not optimal, suggesting the need for further training using specifically designed CS quality assurance programme (QAP) modules, to determine if inter- and intra-observer agreement can be improved.

Detection of early allograft dysfunction at 30 min of reperfusion in liver transplantation: An intraoperative diagnostic tool with real time assessment of graft function.

INTRODUCTION: During the anhepatic phase of liver transplantation (LT), fibrinolytic activity increases, since the liver clears tissue plasminogen activator (tPA). We hypothesize that patients who fail to reduce fibrinolytic activity following graft reperfusion will have an increased rate of early allograft dysfunction (EAD). METHODS: Assessment of fibrinolysis in liver transplant recipients was quantified with thrombelastography (TEG) LY30. Changes in LY30 were assessed after graft reperfusion. The 30-min post-reperfusion LY30 was subtracted from the anhepatic LY30 quantifying fibrinolytic changes (delta-LY30). RESULTS: Seventy-three primary LT patients were included in the analysis. Receiver operating characteristic curve (ROC) analysis identified an inflection point of delta-LY30-5.3% as a risk factor for EAD. EAD occurred in 44% of these patients compared to 5% in high delta-LY30 (p = 0.002). CONCLUSION: LT recipients that develop hyperfibrinolysis who fail to reduce fibrinolytic activity 30 min after graft reperfusion had an EAD rate 8-fold higher than patients who had a large reduction in LY30 following reperfusion.

Validity and reliability evidence of a point of care assessment of salivary cortisol and α-amylase: a pre-registered study.

PURPOSE: The iPro Cube is a small portable point-of-care device designed to analyse salivary markers of stress in a user-friendly manner (e.g., fast, convenient). Our aim was to test the reliability and validity of the iPro Cube to measure salivary cortisol and α-amylase as compared to the common laboratory standard method (ELISA immunoassay) prior to and after moderate intensity exercise. METHODS: The study was a repeated measures, pre-registered design, and statistical framework that incorporated prior knowledge directly into the estimation process. Twenty-nine individuals (age = 27.4 ± 6.6 y; body-mass = 70.8 ± 11.3 kg; height = 1.74 ± 0.92 m; 18 males) completed a single PWC75%HRmax, with repeated measures of salivary cortisol and -amylase pre, immediately post, and 30 min post-exercise. RESULTS: Correlation between the iPro Cube and laboratory-based assessments of salivary cortisol was moderate-to-large (0.53 > r < 0.81) across all three testing points. In contrast, correlation between the iPro Cube and laboratory-based assessments of -amylase was small-to-moderate (0.25 > r < 0.46). We found a large correlation between duplicate samples of iPro Cube cortisol assessment (0.75 > r < 0.82), and a moderate-to-large correlation for -amylase (0.51> r < 0.77). CONCLUSIONS: The iPro Cube is capable of taking measures of salivary cortisol that are moderately correlated to values obtained via ELISA immunoassay, however the unit underestimates salivary cortisol and overestimates salivary -amylase at rest and post-moderate intensity exercise. It is recommended that researchers continue using standard laboratory techniques to assess these salivary stress markers.

Infertility management in women and men attending primary care-patient characteristics, management actions and referrals.

STUDY QUESTION: How did general practitioners (GPs) (family physicians) manage infertility in females and males in primary care between 2000 and 2016? SUMMARY ANSWER: The number of GP infertility consultations for females increased 1.6 folds during the study period, with 42.9% of consultations resulting in a referral to a fertility clinic or specialist, compared to a 3-fold increase in the number of consultations for men, with 21.5% of consultations resulting in a referral. WHAT IS KNOWN ALREADY: Infertility affects one in six couples and is expected to increase with the trend to later childbearing and reports of declining sperm counts. Despite GPs often being the first contact for infertile people, very limited information is available on the management of infertility in primary care. STUDY DESIGN, SIZE, DURATION: Data from the Bettering the Evaluation and Care of Health programme were used, which is a national study of Australian primary care (general practice) clinical activity based on 1000 ever-changing, randomly selected GPs involved in 100 000 GP-patient consultations per year between 2000 and 2016. PARTICIPANTS/MATERIALS, SETTING, METHODS: Females and males aged 18-49 years attending GPs for the management of infertility were included in the study. Details recorded by GPs included patient characteristics, problems managed and management actions (including counselling/education, imaging, pathology, medications and referrals to specialists and fertility clinics). Analyses included trends in the rates of infertility consultations by sex of patient, descriptive and univariate analyses of patient characteristics and management actions and multivariate logistic regression to determine which patient and GP characteristics were independently associated with increased rates of infertility management and referrals. MAIN RESULTS AND THE ROLE OF CHANCE: The rate of infertility consultations per capita increased 1.6 folds for women (17.7-28.3 per 1000 women aged 18-49 years) and 3 folds for men over the time period (3.4-10.2 per 1000 men aged 18-49 years). Referral to a fertility clinic or relevant specialist occurred in 42.9% of female infertility consultations and 21.5% of male infertility consultations. After controlling for age and other patient characteristics, being aged in their 30s, not having income assistance, attending primary care in later years of the study and coming from a non-English-speaking background, were associated with an increased likelihood of infertility being managed in primary care. In female patients, holding a Commonwealth concession card (indicating low income), living in a remote area and having a female GP all indicated a lower adjusted odds of referral to a fertility clinic or specialist. LIMITATIONS, REASONS FOR CAUTION: Data are lacking for the period of infertility and infertility diagnosis, which would provide a more complete picture of the epidemiology of treatment-seeking behaviour for infertility. Australia's universal insurance scheme provides residents with access to a GP, and therefore these findings may not be generalizable to other settings. WIDER IMPLICATIONS OF THE FINDINGS: This study informs public policy on how infertility is managed in primary care in different patient groups. Whether the management actions taken and rates of secondary referral to a fertility clinic or specialist are appropriate warrants further investigation. The development of clinical practice guidelines for the management of infertility would provide a standardized approach to advice, investigations, treatment and referral pathways in primary care. STUDY FUNDING/COMPETING INTEREST(S): This paper is part of a study being funded by an Australian National Health and Medical Research Council project grant APP1104543. G.C. reports that she is an employee of The University of New South Wales (UNSW) and Director of the National Perinatal Epidemiology and Statistics Unit (NPESU), UNSW. The NPESU manages the Australian and New Zealand Assisted Reproductive Technology Database on behalf of the Fertility Society of Australia. W.L. reports being a part-time paid employee and minor shareholder of Virtus Health, a fertility company. R.N. reports being a small unitholder in a fertility company, receiving grants for research from Merck and Ferring and speaker travel grants from Merck. TRIAL REGISTRATION NUMBER: NA.

Avoiding costly hospitalisation at end of life: findings from a specialist palliative care pilot in residential care for older adults.

OBJECTIVES: Specialist palliative care is not a standardised component of service delivery in nursing home care in Australia. Specialist palliative care services can increase rates of advance care planning, decrease hospital admissions and improve symptom management in such facilities. New approaches are required to support nursing home residents in avoiding unnecessary hospitalisation and improving rates of dying in documented preferred place of death. This study examined whether the addition of a proactive model of specialist palliative care reduced resident transfer to the acute care setting, and achieved a reduction in hospital deaths. METHODS: A quasi-experimental design was adopted, with participants at 4 residential care facilities. The intervention involved a palliative care nurse practitioner leading 'Palliative Care Needs Rounds' to support clinical decision-making, education and training. Participants were matched with historical decedents using propensity scores based on age, sex, primary diagnosis, comorbidities and the Aged Care Funding Instrument rating. Outcome measures included participants' hospitalisation in the past 3 months of life and the location of death. RESULTS: The data demonstrate that the intervention is associated with a substantial reduction in the length of hospital stays and a lower incidence of death in the acute care setting. While rates of hospitalisation were unchanged on average, length of admission was reduced by an average of 3.22 days (p<0.01 and 95% CI -5.05 to -1.41), a 67% decrease in admitted days. CONCLUSIONS: The findings have significant implications for promoting quality outcomes through models of palliative care service delivery in residential facilities.

Equity in disease prevention: Vaccines for the older adults - a national workshop, Australia 2014.

On the 20th June, 2014 the National Health and Medical Research Council's Centre for Research Excellence in Population Health "Immunisation in under Studied and Special Risk Populations", in collaboration with the Public Health Association of Australia, hosted a workshop "Equity in disease prevention: vaccines for the older adults". The workshop featured international and national speakers on ageing and vaccinology. The workshop was attended by health service providers, stakeholders in immunisation, ageing, primary care, researchers, government and non-government organisations, community representatives, and advocacy groups. The aims of the workshop were to: provide an update on the latest evidence around immunisation for the older adults; address barriers for prevention of infection in the older adults; and identify immunisation needs of these groups and provide recommendations to inform policy. There is a gap in immunisation coverage of funded vaccines between adults and infants. The workshop reviewed provider misconceptions, lack of Randomised Control Trials (RCT) and cost-effectiveness data in the frail elderly, loss of autonomy, value judgements and ageism in health care and the need for an adult vaccination register. Workshop recommendations included recognising the right of elderly people to prevention, the need for promotion in the community and amongst healthcare workers of the high burden of vaccine preventable diseases and the need to achieve high levels of vaccination coverage, in older adults and in health workers involved in their care. Research into new vaccine strategies for older adults which address poor coverage, provider attitudes and immunosenescence is a priority. A well designed national register for tracking vaccinations in older adults is a vital and basic requirement for a successful adult immunisation program. Eliminating financial barriers, by addressing inequities in the mechanisms for funding and subsidising vaccines for the older adults compared to those for children, is important to improve equity of access and vaccination coverage. Vaccination coverage rates should be included in quality indicators of care in residential aged care for older adults. Vaccination is key to healthy ageing, and there is a need to focus on reducing the immunisation gap between adults and children.

Socio-economic disparities in access to assisted reproductive technologies in Australia.

Women from disadvantaged socio-economic groups access assisted reproductive technology treatment less than women from more advantaged groups. However, women from disadvantaged groups tend to start families younger, making them less likely to suffer from age-related subfertility and potentially have less need for fertility treatment. Whether socio-economic disparities in access to assisted reproductive technology treatment persist after controlling for the need for treatment, has not been previously explored. This population based study demonstrates that socio-economic disparities in access to assisted reproductive technology treatment persist after adjusting for several confounding factors, including age at first birth (used as a measure of delayed childbearing, hence a proxy for need for fertility treatment), geographic remoteness and Australian jurisdiction. Assisted reproductive technology access progressively decreased as socio-economic quintiles became more disadvantaged, with a 15.8% decrease in access in the most disadvantaged quintile compared with the most advantaged quintile after controlling for confounding factors. The adjusted rate of access to assisted reproductive technology treatment also decreased by 12.3% for women living in regional and remote areas compared with those in major cities. These findings indicate that financial and sociocultural barriers to assisted reproductive technology treatment remain in disadvantaged groups after adjusting for need.

End-of-life care: Proactive clinical management of older Australians in the community.

BACKGROUND: Due to the changing demographics of ageing and death in Australia, general practitioners (GPs) are caring for greater numbers of people with advanced chronic conditions that will soon lead to death. GPs play a pivotal role in proactively preparing these people for end of life. OBJECTIVE: This article introduces GPs to a framework of care, based on a palliative care approach, which supports proactive management of end-of-life care for older Australians living in the community. DISCUSSION: Embedding the above framework into routine practice can help GPs deliver care, aligned with patients' preferences, at the right time and in the right place. Experience has shown that implementing proactive management of end-of-life care can increase satisfaction with GP care and help GPs meet the clinical, legal and ethical challenges associated with caring for older patients with advanced progressive conditions.

Development of a Competence-Based Spine Surgery Fellowship Curriculum Set of Learning Objectives in Canada.

STUDY DESIGN: Modified-Delphi expert consensus method. OBJECTIVE: The aim of this study was to develop competence-based spine fellowship curricula as a set of learning goals through expert consensus methodology in order to provide an educational tool for surgical educators and trainees. Secondarily, we aimed to determine potential differences among specialties in their rating of learning objectives to defined curriculum documents. SUMMARY OF BACKGROUND DATA: There has been recent interest in competence-based education in the training of future surgeons. Current spine fellowships often work on a preceptor-based model, and recent studies have demonstrated that graduating spine fellows may not necessarily be exposed to key cognitive and procedural competencies throughout their training that are expected of a practicing spine surgeon. METHODS: A consensus group of 32 spine surgeons from across Canada was assembled. A modified-Delphi approach refined an initial fellowship-level curriculum set of learning objectives (108 cognitive and 84 procedural competencies obtained from open sources). A consensus threshold of 70% was chosen with up to 5 rounds of blinded voting performed. Members were asked to ratify objectives into either a general comprehensive or focused/advanced curriculum. RESULTS: Twenty-eight of 32 consultants (88%) responded and participated in voting rounds. Seventy-eight (72%) cognitive and 63 (75%) procedural competency objectives reached 70% consensus in the first round. This increased to 82 cognitive and 73 procedural objectives by round 4. The final curriculum document evolved to include a general comprehensive curriculum (91 cognitive and 53 procedural objectives), a focused/advanced curriculum (22 procedural objectives), and a pediatrics curriculum (22 cognitive and 9 procedural objectives). CONCLUSION: Through a consensus-building approach, the study authors have developed a competence-based curriculum set of learning objectives anticipated to be of educational value to spine surgery fellowship educators and trainees. To our knowledge, this is one of the first nationally based efforts of its kind that is also anticipated to be of interest by international colleagues.

The rapidly escalating cost of treating colorectal cancer in Australia.

AIMS: Considerable progress in cancer treatment is leading to better outcomes, but the cost of therapy is placing increasing pressure on the health system. Understanding the real-world cost of therapies for each stage will become increasingly important in informing treatment selection and health policy. METHODS: To explore the cost of treating colorectal cancer in the modern era, data were entered onto a prospective database at four hospitals. We estimated the impact of bevacizumab by using data from July 2009, and projected the likely impact of the recent listing of cetuximab. The utility of these data for estimating the cost-effectiveness of treatment was explored. RESULTS: Cancer stage and age at diagnosis were major determinants of treatment received and the associated cost. The cost of early stage disease has not substantially changed whereas therapies such as oxaliplatin and irinotecan were significant contributors to substantial increases in stage IV disease, now $71,156 per patient. Bevacizumab has added at least $10,247 per patient and we estimate that cetuximab will add a further $12,022. An exploratory analysis of the cost-effectiveness of oxaliplatin for adjuvant therapy of stage III colon cancer suggests that this is well within the accepted range. CONCLUSION: These data suggest that recent progress in the treatment of later stages of colorectal cancer is being achieved at significant financial cost. The increased costs of managing later stages of disease make an investment in prevention and early detection ever more attractive.

Hospital costs of multiple-birth and singleton-birth children during the first 5 years of life and the role of assisted reproductive technology.

IMPORTANCE: The unprecedented increase in multiple births during the past 3 decades is a major public health concern and parallels the uptake of medically assisted conception. The economic implications of such births are not well understood. OBJECTIVES: To conduct a comprehensive economic and health services assessment of the frequency, duration, and cost of hospital admissions during the first 5 years of life for singleton, twin, and higher-order multiple (HOM) children and to examine the contribution of assisted reproductive technology (ART) to the incidence and cost of multiple births. DESIGN, SETTING, AND PARTICIPANTS: A retrospective population cohort study using individually linked birth, hospital, and death records among 233,850 infants born in Western Australia between October 1993 and September 2003, and followed up to September 2008. EXPOSURES: Multiple-gestation delivery and ART conception. MAIN OUTCOMES AND MEASURES: Odds of stillbirth, prematurity and low birth weight, frequency and length of hospital admissions, the mean costs by plurality, and the independent effect of prematurity on childhood costs. RESULTS: Of 226,624 singleton, 6941 twin, and 285 HOM infants, 1.0% of singletons, 15.4% of twins, and 34.7% of HOM children were conceived following ART. Compared with singletons, twins and HOMs were 3.4 and 9.6 times, respectively, more likely to be stillborn and were 6.4 and 36.7 times, respectively, more likely to die during the neonatal period. Twins and HOMs were 18.7 and 525.1 times, respectively, more likely to be preterm, and 3.6 and 2.8 times, respectively, more likely to be small for gestational age. The mean hospital costs of a singleton, twin, and HOM child to age 5 years were $2730, $8993, and $24,411 (in 2009-2010 US dollars), respectively, with cost differences concentrated in the neonatal period and during the first year of life. Almost 15% of inpatient costs for multiple births could have been avoided if ART twins and HOMs had been born as singletons. CONCLUSIONS AND RELEVANCE: Compared with singletons, multiple-birth infants consume significantly more hospital resources, particularly during the neonatal period and first year of life. A significant proportion of the clinical and economic burden associated with multiple births can be prevented through single-embryo transfer. Increasing ART use worldwide and persistently high ART multiple-birth rates in several countries highlight the need for strategies that encourage single-embryo transfer. The costs from this study can be generalized to other settings.

The impact of consumer affordability on access to assisted reproductive technologies and embryo transfer practices: an international analysis.

OBJECTIVE: To systematically quantify the impact of consumer cost on assisted reproduction technology (ART) utilization and numbers of embryos transferred. DESIGN: Ordinary least squared (OLS) regression models were constructed to measure the independent impact of ART affordability-measured as consumer cost relative to average disposable income-on ART utilization and embryo transfer practices. SETTING: Not applicable. PATIENT(S): Women undergoing ART treatment. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): OLS regression coefficient for ART affordability, which estimates the independent effect of consumer cost relative to income on utilization and number of embryos transferred. RESULT(S): ART affordability was independently and positively associated with ART utilization with a mean OLS coefficient of 0.032. This indicates that, on average, a decrease in the cost of a cycle of 1 percentage point of disposable income predicts a 3.2% increase in utilization. ART affordability was independently and negatively associated with the number of embryos transferred, indicating that a decrease in the cost of a cycle of 10 percentage points of disposable income predicts a 5.1% increase in single-embryo transfer cycles. CONCLUSION(S): The relative cost that consumers pay for ART treatment predicts the level of access and number of embryos transferred. Policies that affect ART funding should be informed by these findings to ensure equitable access to treatment and clinically responsible embryo transfer practices.

Acupuncture to improve live birth rates for women undergoing in vitro fertilization: a protocol for a randomized controlled trial.

BACKGROUND: IVF is a costly treatment option for women, their partners, and the public. Therefore new therapies that improve reproductive and health outcomes are highly desirable. There is a growing body of research evaluating the effect of acupuncture administered during IVF, and specifically on the day of embryo transfer (ET). Many trials are heterogeneous and results inconsistent. There remains insufficient evidence to determine if acupuncture can enhance live birth rates when used as an adjunct to IVF treatment.The study will determine the clinical effectiveness of acupuncture with improving the proportion of women undergoing IVF having live births. Other objectives include: determination of the cost effectiveness of IVF with acupuncture; and examination of the personal and social context of acupuncture in IVF patients, and examining the reasons why the acupuncture may or may not have worked. METHODS: We will conduct a randomized controlled trial of acupuncture compared to placebo acupuncture.Inclusion criteria include: women aged less than 43 years; undergoing a fresh IVF or ICSI cycle; and restricted to women with the potential for a lower live birth rate defined as two or more previous unsuccessful ETs; and unsuccessful clinical pregnancies of quality embryos deemed by the embryologist to have been suitable for freezing by standard criteria. Women will be randomized to acupuncture or placebo acupuncture. Treatment is administered on days 6 to 8 of the stimulated cycle and two treatments on the day of ET. A non-randomized cohort of women not using acupuncture will be recruited to the study. The primary study outcome is the proportion of women reporting a live birth. Secondary outcomes include the proportion of women reporting a clinical pregnancy miscarriage prior to 12 weeks, quality of life, and self-efficacy. The sample size of the study is 1,168 women, with the aim of detecting a 7% difference in live births between groups (P = 0.05, 80% power). DISCUSSION: There remains a need for further research to add significant new knowledge to defining the exact role of certain acupuncture protocols in the management of infertility requiring IVF from a clinical and cost-effectiveness perspective. CLINICAL TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry ACTRN12611000226909.

Barriers to conducting clinical research in reproductive medicine: Australia and the United Kingdom.

There are several major barriers to research in reproductive medicine in the United Kingdom and Australia. In Australia these mainly reflect income disparity between research and private practice whereas in United Kingdom they reflect the consequences of the economic downturn.

Is in vitro fertilisation more effective than stimulated intrauterine insemination as a first-line therapy for subfertility? A cohort analysis.

OBJECTIVE: To compare a strategy of two cycles of intrauterine insemination with controlled ovarian hyperstimulation (IUI/COH) vs one in vitro fertilisation (IVF) treatment programme (one fresh plus associated frozen embryo cycles) in couples presenting with unexplained, mild male or mild female subfertility. METHODS: A retrospective cohort design was used and analysed according to intention-to-treat principles. A total of 272 couples underwent an intended course of two cycles of IUI/COH and 176 couples underwent one IVF treatment programme. RESULTS: The cumulative live birth rate (CLBR) per couple for the IUI/COH group was 27.6% compared to 39.2% for the IVF group (P = 0.01). The mean time to pregnancy was 69 days in the IUI/COH group compared to 44 days in the IVF group (P = 0.02). The IVF programme was costlier, with an incremental cost-effectiveness ratio for an additional live birth in the range of $39,637-$46,325. The multiple delivery rate was 13.3% in the IUI/COH group compared to 10.1% in the IVF group (P = 0.55). One set of triplets and one set of quadruplets followed IUI/COH treatment. CONCLUSIONS: One IVF treatment programme was more effective, but costlier than an intended course of two cycles of IUI/COH. With consistently higher success rates, shorter times to pregnancy and a trend to less higher order multiple pregnancies, this study supports the view that IVF is now potentially safer and more clinically effective than IUI/COH as a first-line therapy for subfertility.

The economic impact of assisted reproductive technology: a review of selected developed countries.

OBJECTIVE: To compare regulatory and economic aspects of assisted reproductive technologies (ART) in developed countries. DESIGN: Comparative policy and economic analysis. PATIENT(S): Couples undergoing ART treatment in the United States, Canada, United Kingdom, Scandinavia, Japan, and Australia. OUTCOME MEASURE(S): Description of regulatory and financing arrangements, cycle costs, cost-effectiveness ratios, total expenditure, utilization, and price elasticity. RESULT(S): Regulation and financing of ART share few general characteristics in developed countries. The cost of treatment reflects the costliness of the underlying healthcare system rather than the regulatory or funding environment. The cost (in 2006 United States dollars) of a standard IVF cycle ranged from $12,513 in the United States to $3,956 in Japan. The cost per live birth was highest in the United States and United Kingdom ($41,132 and $40,364, respectively) and lowest in Scandinavia and Japan ($24,485 and $24,329, respectively). The cost of an IVF cycle after government subsidization ranged from 50% of annual disposable income in the United States to 6% in Australia. The cost of ART treatment did not exceed 0.25% of total healthcare expenditure in any country. Australia and Scandinavia were the only country/region to reach levels of utilization approximating demand, with North America meeting only 24% of estimated demand. Demand displayed variable price elasticity. CONCLUSION(S): Assisted reproductive technology is expensive from a patient perspective but not from a societal perspective. Only countries with funding arrangements that minimize out-of-pocket expenses met expected demand. Funding mechanisms should maximize efficiency and equity of access while minimizing the potential harm from multiple births.

Success rates and cost of a live birth following fresh assisted reproduction treatment in women aged 45 years and older, Australia 2002-2004.

BACKGROUND: The aim of this study was to calculate assisted reproductive technology (ART) success rates for fresh autologous and donor cycles in women aged > or = 45 and the resultant cost per live birth. METHODS: We performed a retrospective population-based study of 2339 ART cycles conducted in Australia, 2002-2004 to women aged > or = 45 years. The cost-outcome study was performed on fresh autologous treatment cycles. RESULTS: There were 1101 fresh autologous cycles initiated in women aged > or = 45, with a pregnancy rate of 1.9 per 100 initiated cycles. There were 21 women who achieved a clinical pregnancy with 15 (71%) ending in early pregnancy loss and 6 in live singleton births. The live birth rate following fresh autologous initiated cycles was 0.5% [95% confidence interval (CI): 0.1-1.0%]. Fresh donor recipients had an higher live birth rate of 19.1% (95% CI: 15.1-23.2) (odds ratio 43.2; 95% CI: 18.6-100.3) compared with women having fresh autologous cycles. The average cost of a live birth following fresh autologous cycles was 753,107 euros. CONCLUSIONS: The success rate of fresh autologous treatment for women aged > or = 45 years was < 1%. The very high cost of a live birth reflects a treatment failure rate of > 99%. The ART profession should counsel patients of the reality of the technology before the patients consent to treatment.

Babies born after ART treatment cost more than non-ART babies: a cost analysis of inpatient birth-admission costs of singleton and multiple gestation pregnancies.

BACKGROUND: Currently, about one-third of infants born after assisted reproductive technology (ART) worldwide are twins or triplets. This study compared the inpatient birth-admission costs of singleton and multiple gestation ART deliveries to non-ART deliveries. METHODS: A cohort of 5005 mothers and 5886 infants conceived following ART treatment were compared to 245 249 mothers and 248 539 infants in the general population. Birth-admission costs were calculated using Australian Refined Diagnosis Related Groups and weighted national average costs (2003-2004 euro). RESULTS: ART infants were 4.4 times more likely to be low birthweight (LBW) compared with non-ART infants, translating into 89% higher birth-admission costs (euro2,832 and euro1,502, respectively). ART singletons were also more likely to be LBW compared with non-ART singletons, translating into 31% higher birth-admission costs (euro1,849 and euro1,415, respectively). After combining infant and maternal admission costs, the average cost of an ART singleton delivery was euro4,818 compared with euro13 890 for ART twins and euro54 294 for ART higher order multiples. Findings were not sensitive to changes in casemix. CONCLUSIONS: The poorer neonatal outcomes of ART singletons compared with non-ART singletons are significant enough to impact healthcare resource consumption. The high costs associated with ART multiple births add to the overwhelming clinical and economic evidence in support of single embryo transfer.