目标:在高收入国家中,哪些辅助生殖技术(ART)干预措施具有成本效益,哪些不具有成本效益?
结论:在经济评估中评估的所有ART干预措施中,大多数高成本干预措施,包括一般人群的非整倍体(PGT-A)的植入前遗传学检测和原因不明的不孕症的ICSI,由于有效性的提高很小或没有提高,因此不太可能具有成本效益。
背景:降低成本以增加获取的方法已被确定为未来不孕症研究的研究重点。在全球常规临床实践中实施越来越多的ART干预措施,在对经济评估的证据进行强有力的评估之前。在高质量研究中已经评估了一些研究比较的临床有效性程度,允许围绕成本效益做出更多信息的决策。
方法:我们进行了系统评价并检索了七个数据库(MEDLINE,pubmed,EMBASE,Cochrane,ECONLIT,Scopus,andCINAHL)用于研究ART干预对不孕症的干预措施以及经济评估部分(成本效益,成本效益,成本效用,或成本最小化评估),在高收入国家,自2011年1月发布。最后一次搜索是2022年6月22日。
方法:两名独立审稿人评估了出版物,并包括了符合资格标准的出版物。对研究进行了检查,以评估所研究干预措施的成本效益,以及研究的报告质量。还注意到选择的结果衡量标准和付款人观点。报告的完整性是根据综合卫生经济评估报告标准进行评估的。根据所研究的干预措施,呈现并总结结果。
结果:该综述包括在11个高收入国家进行的40项研究。大多数研究(n=34)包括成本效益分析。ART干预包括药物或控制性卵巢刺激策略(n=15),IVF(n=9),PGT-A(n=7),单胚胎移植(n=5),ICSI(n=3),和冷冻所有胚胎移植(n=1)。活产是最常见的主要结局(n=27),3项研究报告了质量调整生命年.85%(n=34)的研究使用了健康资助者的观点。纳入的研究均未测量患者对治疗的偏好。与没有PGT-A管理的IVF周期相比,PGT-A是否能提高妊娠率仍然不确定。因此无法证明这种干预措施的成本效益。同样,与IVF周期中的标准受精相比,非男性因素不育症的ICSI似乎在临床上无效,因此不具有成本效益。诸如使用生物类似物或HMG进行卵巢刺激之类的干预措施更便宜,但会损害临床有效性。
结论:缺乏基于偏好和标准化的结果限制了研究结果的可比性。为某些干预措施提供的有效性证据的选择并不总是基于高质量的随机试验和系统评价。此外,对个人和国家资助者支付治疗不孕症的门槛的意愿了解不足。报告分数的质量各不相同,这可能会增加成本效益结果的不确定性。
结论:在个人和人群水平上,投资帮助使用ART的不育者的策略是合理的。这种系统评价可以帮助ART资助者决定如何进行最佳投资,以最大限度地提高健康儿童分娩的可能性。
背景:这项研究没有资金支持。E.C.和R.W.通过他们的研究金计划(ECGNT1159536,RW2021/GNT2009767)获得国家健康与医学研究委员会(NHMRC)的薪水支持。M.D.-T.报告法哈德国王医学院的咨询费。所有其他作者都没有竞争利益可声明。
背景:ProsperoCRD42021261537.
OBJECTIVE: Which assited reproductive technology (
ART) interventions in high-income countries are cost-effective and which are not?
CONCLUSIONS: Among all
ART interventions assessed in economic evaluations, most high-cost interventions, including preimplantation genetic testing for aneuploidy (PGT-A) for a general population and ICSI for unexplained infertility, are unlikely to be cost-effective owing to minimal or no increase in effectiveness.
BACKGROUND: Approaches to reduce costs in order to increase access have been identified as a research priority for future infertility research. There has been an increasing number of ART interventions implemented in routine clinical practice globally, before robust assessments of evidence on economic evaluations. The extent of clinical effectiveness of some studied comparisons has been evaluated in high-quality research, allowing more informative decision making around cost-effectiveness.
METHODS: We performed a systematic
review and searched seven databases (MEDLINE, PUBMED, EMBASE, COCHRANE, ECONLIT, SCOPUS, and CINAHL) for studies examining ART interventions for infertility together with an economic evaluation component (cost-effectiveness, cost-benefit, cost-utility, or cost-minimization assessment), in high-income countries, published since January 2011. The last search was 22 June 2022.
METHODS: Two independent reviewers assessed publications and included those fulfilling the eligibility criteria. Studies were examined to assess the cost-effectiveness of the studied intervention, as well as the reporting quality of the study. The chosen outcome measure and payer perspective were also noted. Completeness of reporting was assessed against the Consolidated Health Economic Evaluation Reporting Standard. Results are presented and summarized based on the intervention studied.
RESULTS: The
review included 40 studies which were conducted in 11 high-income countries. Most studies (n = 34) included a cost-effectiveness analysis. ART interventions included medication or strategies for controlled ovarian stimulation (n = 15), IVF (n = 9), PGT-A (n = 7), single embryo transfer (n = 5), ICSI (n = 3), and freeze-all embryo transfer (n = 1). Live birth was the mostly commonly reported primary outcome (n = 27), and quality-adjusted life years was reported in three studies. The health funder perspective was used in 85% (n = 34) of studies. None of the included studies measured patient preference for treatment. It remains uncertain whether PGT-A improves pregnancy rates compared to IVF cycles managed without PGT-A, and therefore cost-effectiveness could not be demonstrated for this intervention. Similarly, ICSI in non-male factor infertility appears not to be clinically effective compared to standard fertilization in an IVF cycle and is therefore not cost-effective. Interventions such as use of biosimilars or HMG for ovarian stimulation are cheaper but compromise clinical effectiveness.
CONCLUSIONS: Lack of both preference-based and standardized outcomes limits the comparability of results across studies. The selection of efficacy evidence offered for some interventions for economic evaluations is not always based on high-quality randomized trials and systematic reviews. In addition, there is insufficient knowledge of the willingness to pay thresholds of individuals and state funders for treatment of infertility. There is variable quality of reporting scores, which might increase uncertainty around the cost-effectiveness results.
CONCLUSIONS: Investment in strategies to help infertile people who utilize ART is justifiable at both personal and population levels. This systematic
review may assist
ART funders decide how to best invest to maximize the likelihood of delivery of a healthy child.
BACKGROUND: There was no funding for this study. E.C. and R.W. receive salary support from the National Health and Medical Research Council (NHMRC) through their fellowship scheme (EC GNT1159536, RW 2021/GNT2009767). M.D.-T. reports consulting fees from King Fahad Medical School. All other authors have no competing interests to declare.
BACKGROUND: Prospero CRD42021261537.