effects of competition on infertility treatment outcomes melinda henne research in progress seminar...

Effects of Competition on Effects of Competition on Infertility Treatment Infertility Treatment

OutcomesOutcomes

Melinda HenneMelinda HenneResearch In Progress SeminarResearch In Progress Seminar

Stanford UniversityStanford UniversityJune 1, 2005June 1, 2005

Research In ProgressResearch In Progress

• Results are preliminaryResults are preliminary

• Please do not cite or referencePlease do not cite or reference

AcknowledgementsAcknowledgements

• Kate BundorfKate Bundorf

• Laurence BakerLaurence Baker

• Jia ChanJia Chan

• Shannon McConnvilleShannon McConnville

OutlineOutline

• Multiple Births and ART overviewMultiple Births and ART overview• Literature on CompetitionLiterature on Competition• ModelModel

– Definition of MarketDefinition of Market– Measure of CompetitionMeasure of Competition– EquationsEquations

• ResultsResults• ConclusionsConclusions

OutlineOutline

• Multiple Births and ART overviewMultiple Births and ART overview• Literature on CompetitionLiterature on Competition

• ModelModel– Definition of MarketDefinition of Market– Measure of CompetitionMeasure of Competition– EquationsEquations

• ResultsResults

• ConclusionsConclusions

Trends in multiple birth Trends in multiple birth ratesrates

0

50

100

150

200

250

300

350

Twins/10,000 deliveries HOM/100,000 deliveries

Increasing utilization of ART in the Increasing utilization of ART in the U.S.U.S.

0

20000

40000

60000

80000

100000

120000

140000

Cycles Births Multiple Births

Trends in ART Birth RatesTrends in ART Birth Rates

00.050.1

0.150.2

0.250.3

0.350.4

0.45

Births/ Cycle Multiples/ Cycle Multiples/ Birth

ART CycleART Cycle

3 weeksBirth Control Pills

2-3 weeksDaily shots

frequent office visits

Egg Retrieval

3-5 days

Embryo Transfer

2 weeksProgesterone Treatment

(shots, vaginal)

Pregnancy Test

$10,000-$15,000$10,000-$15,000

Number of ART Clinics in United Number of ART Clinics in United StatesStates

50100150200250300350400450

Clinics Statistical Areas with Clinics

Fertility Inc.: Clinics Race to Lure Fertility Inc.: Clinics Race to Lure ClientsClients

• ““Infertility has become a big, fiercely competitive Infertility has become a big, fiercely competitive business, with a billion dollars in revenues and with business, with a billion dollars in revenues and with more and more doctors fighting for a limited number more and more doctors fighting for a limited number of patients. The growth of the field has been fueled by of patients. The growth of the field has been fueled by rising success rates and increased demand from rising success rates and increased demand from patients . . .”patients . . .”

• ““critics say, they may implant too many embryos . . .”critics say, they may implant too many embryos . . .”

• ““Since most patients pay with their own Since most patients pay with their own money . . .fertility specialists say that if they want to money . . .fertility specialists say that if they want to survive, they have to get the attention of both survive, they have to get the attention of both patients and referring doctors”patients and referring doctors”

New York Times, January 1, 2002New York Times, January 1, 2002

OutlineOutline

• Multiple Births and ART overviewMultiple Births and ART overview

• Literature on CompetitionLiterature on Competition• ModelModel

– Definition of Market Definition of Market – Measure of CompetitionMeasure of Competition– EquationsEquations

• ResultsResults


Competition in HealthcareCompetition in Healthcare

• Hospital BasedHospital Based

• Emergent or Urgent CareEmergent or Urgent Care– Mortality after AMIMortality after AMI– Mortality from PneumoniaMortality from Pneumonia

• EffectsEffects– Lower costs, increased quality, decreased Lower costs, increased quality, decreased

mortality, improved efficiencymortality, improved efficiency– Excess capacity, higher costs, worse outcomes Excess capacity, higher costs, worse outcomes

SteinerSteiner

• Cross sectional analysis, 2000Cross sectional analysis, 2000• Competition AreaCompetition Area

−Metropolitan Statistical Area or CountyMetropolitan Statistical Area or County• Competition (low {1-2}, intermediate Competition (low {1-2}, intermediate

{2-7}, high{>7}){2-7}, high{>7})• Demand (low {<130,000}, intermediate Demand (low {<130,000}, intermediate

{130,000-600,000}, high {>600,000}){130,000-600,000}, high {>600,000})• ConclusionConclusion

−As competition increased, the percentage of As competition increased, the percentage of high-order multiple pregnancies decreasedhigh-order multiple pregnancies decreased

20022002

Hamilton and McManusHamilton and McManus

• Time-series analysis, 1995-2000Time-series analysis, 1995-2000• Competition area—Combined or Metropolitan Competition area—Combined or Metropolitan

Statistical AreaStatistical Area• CompetitionCompetition

– HHIHHI– Clinics (dichotomous—monopoly or not)Clinics (dichotomous—monopoly or not)

• Demographic controlsDemographic controls• ConclusionConclusion

– Clinics in areas with more than one clinic transfer Clinics in areas with more than one clinic transfer fewer embryos and have lower multiple birth ratesfewer embryos and have lower multiple birth rates

2004, 20052004, 2005

OutlineOutline


• Literature on CompetitionLiterature on Competition

• ModelModel– Definition of MarketDefinition of Market– Measure of CompetitionMeasure of Competition– EquationsEquations

• ResultsResults


Questions??Questions??

• What happens to clinic volume with more What happens to clinic volume with more clinics in an area?clinics in an area?

• Are practices different when there is more Are practices different when there is more competition?competition?– How do clinics try to improve birth rates?How do clinics try to improve birth rates?

• Do clinics transfer more embryos?Do clinics transfer more embryos?• Do clinics cherry pick patients?Do clinics cherry pick patients?

– How do clinics try to reduce multiple birth rates?How do clinics try to reduce multiple birth rates?• Do clinics sacrifice birth rates for this goal?Do clinics sacrifice birth rates for this goal?• Do clinics transfer fewer embryos?Do clinics transfer fewer embryos?• Do clinics have to take all patients, regardless of Do clinics have to take all patients, regardless of

prognosis?prognosis?

A

C

B

Fixed Radius

1. Number of Clinics

D

E

Competition AreaCompetition AreaGeographic Area

BA

C

E

D

1. Number of clinics2. HHI

Location of ART clinics in U.S in Location of ART clinics in U.S in 20022002

SART, SART, 20022002

OutlineOutline


• Literature on CompetitionLiterature on Competition

• ModelModel– Definition of MarketDefinition of Market

– Measure of CompetitionMeasure of Competition– EquationsEquations

• ResultsResults


Measure of CompetitionMeasure of Competition

• Number of clinics within defined areaNumber of clinics within defined area– ContinuousContinuous

• Positive skew (log transformed)Positive skew (log transformed)

– Categorical definitions (monopoly, low Categorical definitions (monopoly, low competition{2-3}, low-medium competition {4-competition{2-3}, low-medium competition {4-5}, high-medium competition {6-10}, high 5}, high-medium competition {6-10}, high competition {11-15}, very high competition competition {11-15}, very high competition {16+}){16+})

• Herfindahl-Hirschman Index (HHI)Herfindahl-Hirschman Index (HHI)– Sum of market shares Sum of market shares – Captures both the size and number of competitorsCaptures both the size and number of competitors

OutlineOutline

• Multiple Births and ART overviewMultiple Births and ART overview• Literature on CompetitionLiterature on Competition

•ModelModel– Measure of CompetitionMeasure of Competition– Definition of MarketDefinition of Market

– EquationsEquations• ResultsResults• ConclusionsConclusions

Dependent VariablesDependent Variables

• Cycles performed—positive skew Cycles performed—positive skew (log (log transformed)transformed)

• Births per Cycle—NormalBirths per Cycle—Normal

• Multiples per Cycles—NormalMultiples per Cycles—Normal

• Multiples per Birth—NormalMultiples per Birth—Normal

• Number of Embryos Transferred—Number of Embryos Transferred—NormalNormal

• Proportion of young patients—NormalProportion of young patients—Normal

Summary StatisticsSummary Statistics

MeanMean S.D.S.D. MinMin MaxMax

CyclesCycles

(lCycles)(lCycles)206.71206.71

(4.55)(4.55)276.05276.05

(1.07)(1.07)00

(0)(0)33283328

(8.11)(8.11)

Births/CycleBirths/Cycle 0.210.21 0.090.09 00 11

Multiples/CycleMultiples/Cycle 0.080.08 0.060.06 00 11

Multiples/BirthMultiples/Birth 0.340.34 0.170.17 00 11

Embryos TransferredEmbryos Transferred 3.633.63 0.770.77 11 7.597.59

Embryos Transferred Embryos Transferred (<35)(<35)

3.473.47 0.800.80 11 9.79.7

Embryos Transferred Embryos Transferred (35+)(35+)

3.643.64 0.750.75 11 7.597.59

Proportion of Patients Proportion of Patients <35<35

0.460.46 0.120.12 00 11

Independent VariablesIndependent Variables• Measure of Measure of

CompetitionCompetition

• Year, Market Fixed Year, Market Fixed EffectsEffects

• Clinic CharacteristicsClinic Characteristics– SizeSize– Years in BusinessYears in Business

• Time varying market Time varying market characteristicscharacteristics– PopulationPopulation– Minority RateMinority Rate– IncomeIncome– Unemployment RateUnemployment Rate– EducationEducation

• InstrumentsInstruments– Non-federal MDsNon-federal MDs– Medical SchoolsMedical Schools– Number of HospitalsNumber of Hospitals

Summary statisticsSummary statisticsMeanMean S.D.S.D. Min. Min. Max.Max.

Women age 25-44 (1000)Women age 25-44 (1000) 291.30291.30 474.24474.24 10.3010.30 3465.803465.80

Proportion age 25-29 (%)Proportion age 25-29 (%) 23.6223.62 1.971.97 17.0717.07 36.1336.13



Minority Rate (%)Minority Rate (%) 22.9122.91 14.4514.45 1.601.60 79.7379.73

Per Capita Income ($1000)Per Capita Income ($1000) 27.3827.38 3.763.76 18.4118.41 48.4848.48

Unemployment Rate (%)Unemployment Rate (%) 5.275.27 3.983.98 1.321.32 43.5243.52

Proportion with College DegreeProportion with College Degree 24.0224.02 5.615.61 12.2612.26 42.1542.15

Number of non-Federal MDsNumber of non-Federal MDs 4293.14293.166

9262.109262.10 120120 85,77385,773

Presence of Medical SchoolPresence of Medical School 0.680.68 0.470.47 00 11

Number of HospitalsNumber of Hospitals 31.4831.48 41.4241.42 11 294294

Expanded market and individual clinic Expanded market and individual clinic volumevolume

X = vector of market-X = vector of market-time characteristicstime characteristics

FE = market and year FE = market and year fixed effectsfixed effects

Instruments for clinicsInstruments for clinics– Non-federal MDsNon-federal MDs– Medical SchoolsMedical Schools– Number of HospitalsNumber of Hospitals

PossibilitiesPossibilities– 11, , 11 >>00

– >>0, 0, 11 <<00

Cycles/1000m,t = + 1*Clinicsm,t + 2*Xm,t + 3*FE +

Cyclesc,m,t = + 1*Clinicsm,t + 2*Xm,t + 3 *FE +

Does competition affect treatment and Does competition affect treatment and outcomes?outcomes?

Y = outcomeY = outcomeC = measure of C = measure of

competitioncompetitionX = vector of market-X = vector of market-

year characteristicsyear characteristicsF = market and year F = market and year

fixed effectsfixed effects

Yc,m,t = + 1*Cc,m,t + 2*Xm,t + 3 * FE +

OutlineOutline

• Multiple Births and ART overviewMultiple Births and ART overview• Literature on CompetitionLiterature on Competition• ModelModel

– Measure of CompetitionMeasure of Competition– Definition of MarketDefinition of Market– EquationsEquations

• ResultsResults• ConclusionsConclusions

Number of Cycles PerformedNumber of Cycles Performed(log transformed)(log transformed)

ln(Cycles)/1000ln(Cycles)/1000 ln(Cycles)/Clinicln(Cycles)/Clinic

ln (Clinics)ln (Clinics) 1.2861.286

(0.100)**(0.100)**

-1.005-1.005

[0.185]**[0.185]**

2-3 Clinics2-3 Clinics 0.9920.992

[0.102]**[0.102]**

-0.810-0.810

[0.175]**[0.175]**


[0.143]**[0.143]**

-1.260-1.260

[0.221]**[0.221]**


[0.168]**[0.168]**

-1.506-1.506

[0.271]**[0.271]**

11-15 Clinics11-15 Clinics 2.2132.213

[0.199]**[0.199]**

-1.687-1.687

[0.319]**[0.319]**

>15 Clinics>15 Clinics 2.5812.581

[0.266]**[0.266]**

-2.000-2.000

[0.339]**[0.339]**

Clinic volume compared to market Clinic volume compared to market volumevolume

-3

-2

-1

0

1

2

3

2-3 4-5 6-10 11-15 >15

Market Clinic

Number of Number of ClinicsClinics

ln(N

um

ber

of

ln(N

um

ber

of

Cycl

es)

Cycl

es)

Mean ln(Cycles)/1000 = Mean ln(Cycles)/1000 = 1.041.04

Mean ln(Cycles) = 4.55Mean ln(Cycles) = 4.55

Births Per CycleBirths Per CycleCSACSA Radius 20Radius 20 Radius 50Radius 50

2-3 Clinics2-3 Clinics -0.004-0.004

[0.008][0.008]

0.0060.006

[0.006][0.006]

0.0090.009

[0.008][0.008]

4-5 Clinics4-5 Clinics -0.014 -0.014 [0.011][0.011]

-0.010-0.010

[0.008][0.008]

0.0060.006

[0.011][0.011]

6-10 Clinics6-10 Clinics -0.001-0.001

[0.013][0.013]

-0.010-0.010

[0.010][0.010]

0.0060.006

[0.013][0.013]

11-15 Clinics11-15 Clinics -0.010-0.010

[0.016][0.016]

-0.014-0.014

[0.010][0.010]

-0.010-0.010

[0.015][0.015]


[0.018][0.018]

-0.033-0.033

[0.011]**[0.011]**

-0.015-0.015

[0.017][0.017]

F-testF-test 0.970.97

(0.436)(0.436)

3.793.79

(P = 0.002)(P = 0.002)

1.471.47

(P = 0.195)(P = 0.195)

Multiples per BirthMultiples per BirthCSACSA Radius 20Radius 20 Radius 50Radius 50


[0.023][0.023]

0.0060.006

[0.006][0.006]

-0.009-0.009

[0.018][0.018]


[0.033][0.033]

0.0100.010

[0.0197][0.0197]

0.0200.020

[0.024][0.024]


[0.040][0.040]

0.0010.001

[0.019][0.019]

-0.024-0.024

[0.028][0.028]

11-15 11-15 ClinicsClinics

0.0140.014

[0.049][0.049]

-0.027-0.027

[0.022][0.022]

-0.036-0.036

[0.034][0.034]


[0.054][0.054]

-0.055-0.055

[0.024]*[0.024]*

-0.057-0.057

[0.037][0.037]

F-testF-test 1.471.47

(0.195)(0.195)

2.372.37

(P = 0.037)(P = 0.037)

1.21 1.21

(P = 0.300)(P = 0.300)

Mandatory ReportingMandatory Reporting

Before Before 19951995

After After 19951995


-0.003-0.003

[0.013][0.013]

0.0060.006

[0.009][0.009]


-0.018-0.018

[0.015][0.015]

-0.006-0.006

[0.011][0.011]


-0.022-0.022

[0.016][0.016]

-0.009-0.009

[0.011][0.011]


-0.022-0.022

[0.017][0.017]

-0.017-0.017

[0.014][0.014]

>15 >15 ClinicsClinics

-0.088-0.088

[0.032]**[0.032]**

-0.030-0.030

[0.013]*[0.013]*

Multiples Per BirthMultiples Per BirthBirths Per CycleBirths Per CycleBefore Before 19951995

After After 19951995


0.0090.009

[0.034][0.034]

0.0070.007

[0.018][0.018]


-0.042-0.042

[0.039][0.039]

0.0380.038

[0.021]+[0.021]+


-0.032-0.032

[0.041][0.041]

0.0150.015

[0.022][0.022]


-0.031-0.031

[0.045][0.045]

-0.027-0.027

[0.027][0.027]


-0.124-0.124

[0.083][0.083]

-0.041-0.041

[0.026][0.026]

Embryos TransferredEmbryos TransferredOverallOverall Under 35Under 35 Over 35Over 35


[0.072][0.072]

-0.066-0.066

[0.070][0.070]

-0.094-0.094

[0.070][0.070]


[0.085][0.085]

-0.005-0.005

[0.082][0.082]

-0.065-0.065

[0.082][0.082]

6-10 Clinics6-10 Clinics -0.063-0.063

[0.089][0.089]

0.0440.044

[0.086][0.086]

-0.068-0.068

[0.086][0.086]

11-15 Clinics11-15 Clinics -0.085-0.085

[0.107][0.107]

-0.029-0.029

[0.104][0.104]

-0.098-0.098

[0.104][0.104]

>15 Clinics>15 Clinics -0.108-0.108

[0.104][0.104]

0.1280.128

[0.101][0.101]

-0.136-0.136

[0.102][0.102]

F-TestF-Test 0.390.39

(P = 0.856)(P = 0.856)

1.641.64

(P = 0.146)(P = 0.146)

0.560.56

(P = 0.733)(P = 0.733)

Patient SelectionPatient SelectionProportion of Patients <35Proportion of Patients <35


[0.011][0.011]


[0.013][0.013]

6-10 Clinics6-10 Clinics -0.038-0.038

[0.014]**[0.014]**

11-15 Clinics11-15 Clinics -0.073-0.073

[0.016]**[0.016]**

>15 Clinics>15 Clinics -0.069-0.069

[0.016]**[0.016]**

Age of ClinicAge of Clinic

NewNew

(1-2 (1-2 Years)Years)

OldOld


0.0680.068

[0.025]**[0.025]**

-0.19-0.19

[0.011]+[0.011]+


0.0610.061

[0.027]*[0.027]*

-0.033-0.033

[0.013]*[0.013]*


0.0560.056

[0.028]*[0.028]*

-0.030-0.030

[0.013]*[0.013]*


0.0330.033

[0.033][0.033]

-0.036-0.036

[0.016]*[0.016]*


0.0090.009

[0.032][0.032]

-0.050-0.050

[0.016]**[0.016]**

Multiples Per BirthMultiples Per BirthBirths Per CycleBirths Per Cycle

New (1-New (1-2 Years)2 Years)

OldOld


0.2900.290

[0.081]**[0.081]**

-0.016-0.016

[0.028][0.028]


0.2860.286

[0.089]**[0.089]**

0.0340.034

[0.033][0.033]


0.2900.290

[0.094]**[0.094]**

0.0140.014

[0.035][0.035]


0.1680.168

[0.110][0.110]

-0.051-0.051

[0.042][0.042]


0.1810.181

[0.105]+[0.105]+

0.0170.017

[0.040][0.040]

Age of ClinicAge of Clinic

NewNew

(1-2 (1-2 Years)Years)

OldOld


0.2250.225

[0.178][0.178]

-0.166-0.166

[0.079]*[0.079]*


0.3730.373

[0.194]+[0.194]+

-0.181-0.181

[0.094]+[0.094]+


0.5400.540

[0.202]**[0.202]**

-0.205-0.205

[0.098]*[0.098]*


0.5520.552

[0.239]**[0.239]**

-0.251-0.251

[0.118]*[0.118]*


0.6100.610

[0.234]**[0.234]**

-0.311-0.311

[0.114]**[0.114]**

Proportion of young Proportion of young patientspatients

Embryos TransferredEmbryos Transferred

New (1-New (1-2 Years)2 Years)

OldOld


0.0130.013

[0.030][0.030]

-0.011-0.011

[0.011][0.011]


0.0060.006

[0.033][0.033]

-0.048-0.048

[0.013]**[0.013]**


-0.019-0.019

[0.034][0.034]

-0.044-0.044

[0.014]**[0.014]**


-0.110-0.110

[0.041]**[0.041]**

-0.064-0.064

[0.017]**[0.017]**


-0.107-0.107

[0.040]**[0.040]**

-0.058-0.058

[0.016]**[0.016]**

Size of ClinicSize of Clinic

Small Small (<120)(<120)

MediumMedium

(120-500)(120-500)

LargeLarge

(>500)(>500)

2-3 2-3 ClinicClinicss

00

[0.010][0.010]

0.0210.021

[0.009]*[0.009]*

-0.018-0.018

[0.018][0.018]


-0.019-0.019

[0.0120[0.0120

0.0180.018

[0.010]+[0.010]+

-0.016-0.016

[0.021][0.021]


-0.025-0.025

[0.014]+[0.014]+

0.0250.025

[0.011]*[0.011]*

00

[0.020][0.020]


-0.026-0.026

[0.018][0.018]

0.0190.019

[0.012][0.012]

0.0040.004

[0.021][0.021]

>15 >15 ClinicClinicss

-0.042-0.042

[0.019]*[0.019]*

-0.007-0.007

[0.014][0.014]

-0.023-0.023

[0.022][0.022]


MediumMedium

(120-500)(120-500)

LargeLarge

(>500)(>500)


0.0190.019

[0.025][0.025]

-0.021-0.021

[0.016][0.016]

0.0280.028

[0.022][0.022]


0.0380.038

[0.033][0.033]

-0.027-0.027

[0.018][0.018]

0.0240.024

[0.026][0.026]


0.0080.008

[0.038][0.038]

-0.010-0.010

[0.019][0.019]

0.0160.016

[0.024][0.024]


-0.024-0.024

[0.046][0.046]

-0.049-0.049

[0.021]*[0.021]*

0.0520.052

[0.026]*[0.026]*


-0.079-0.079

[0.050][0.050]

-0.049-0.049

[0.024]*[0.024]*

0.030.03

[0.027][0.027]

Births per CycleBirths per Cycle Multiples per BirthMultiples per Birth

Size of ClinicSize of Clinic


MediumMedium

(120-500)(120-500)

LargeLarge

(>500)(>500)


-0.162 -0.162 [0.109][0.109]

-0.054-0.054

[0.120][0.120]

-0.160-0.160

[0.170][0.170]


0.0070.007

[0.126][0.126]

-0.207-0.207

[0.140][0.140]

0.0040.004

[0.210][0.210]


-0.068-0.068

[0.139][0.139]

-0.081-0.081

[0.141][0.141]

-0.185-0.185

[0.184][0.184]


-0.002-0.002

[0.175][0.175]

-0.060-0.060

[0.158][0.158]

-0.486-0.486

{0.202]*{0.202]*


-0.038-0.038

[0.165][0.165]

-0.190-0.190

[0.158][0.158]

-0.297-0.297

[0.200][0.200]


MediumMedium

(120-500)(120-500)

LargeLarge

(>500)(>500)


-0.008-0.008

[0.018][0.018]

0.0110.011

[0.016][0.016]

-0.021-0.021

[0.021][0.021]


-0.044-0.044

[0.021]*[0.021]*

0.0150.015

[0.018][0.018]

-0.056-0.056

[0.026]*[0.026]*


-0.063-0.063

[0.023]**[0.023]**

0.0170.017

[0.018][0.018]

-0.044-0.044

[-/-23]+[-/-23]+


-0.123-0.123

[0.029]**[0.029]**

-0.003-0.003

[0.021][0.021]

-0.048-0.048

[0.025]+[0.025]+


-0.097-0.097

[0.028]**[0.028]**

-0.018-0.018

[0.021][0.021]

-0.100-0.100

[0.025]*[0.025]*

Embryos TransferredEmbryos TransferredProportion of young Proportion of young

patientspatients

Results SummaryResults Summary

• As more clinics enter an area, the market As more clinics enter an area, the market is expanded, but each individual clinic is expanded, but each individual clinic performs fewer cyclesperforms fewer cycles

• Outcome differences are observed in a Outcome differences are observed in a narrow radiusnarrow radius

• Embryo transfer practices do not appear Embryo transfer practices do not appear to be affected by the number of to be affected by the number of neighboring clinicsneighboring clinics

• Clinics with many neighbors are less able Clinics with many neighbors are less able to select for patients with higher liklihood to select for patients with higher liklihood of successof success

Results Summary-2Results Summary-2

• Young clinicsYoung clinics– Have higher birth rates and multiple birth ratesHave higher birth rates and multiple birth rates– Have a smaller proportion of young patientsHave a smaller proportion of young patients– Transfer more embryos per cycleTransfer more embryos per cycle

• Small clinics and large clinicsSmall clinics and large clinics– Have a smaller proportion of young patientsHave a smaller proportion of young patients– Have lower birth rates, but higher multiple birth Have lower birth rates, but higher multiple birth

ratesrates– Small clinics transfer more embryos per cycleSmall clinics transfer more embryos per cycle– Large clinics transfer fewer embryos per cycleLarge clinics transfer fewer embryos per cycle

ConclusionsConclusions

• The definition of the market is vital to determine The definition of the market is vital to determine the impact of competition among IVF clinicsthe impact of competition among IVF clinics

• Patient selection probably plays a more Patient selection probably plays a more significant impact on outcomes than differences significant impact on outcomes than differences in practice behaviorin practice behavior

• Mandatory reporting of success rates may Mandatory reporting of success rates may influence practice patterns and patient selectioninfluence practice patterns and patient selection

• Clinic characteristics influence outcomes and Clinic characteristics influence outcomes and may confound results of previous competition in may confound results of previous competition in IVF studiesIVF studies

effects of competition on infertility treatment outcomes melinda henne research in progress seminar...

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