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transcript
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• Please do not cite or referencePlease do not cite or reference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
• ConclusionsConclusions
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
• 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
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
• 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
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
Proportion age 30-34 (%)Proportion age 30-34 (%) 25.3325.33 1.561.56 21.5321.53 28.9428.94
Proportion age 35-39 (%)Proportion age 35-39 (%) 26.3726.37 1.051.05 20.1020.10 29.9429.94
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]**
4-5 Clinics4-5 Clinics 1.4851.485
[0.143]**[0.143]**
-1.260-1.260
[0.221]**[0.221]**
6-10 Clinics6-10 Clinics 1.9961.996
[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]
>15 Clinics>15 Clinics 0.0110.011
[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
2-3 Clinics2-3 Clinics 0.0460.046
[0.023][0.023]
0.0060.006
[0.006][0.006]
-0.009-0.009
[0.018][0.018]
4-5 Clinics4-5 Clinics 0.0630.063
[0.033][0.033]
0.0100.010
[0.0197][0.0197]
0.0200.020
[0.024][0.024]
6-10 Clinics6-10 Clinics 0.0180.018
[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]
>15 Clinics>15 Clinics 0.0160.016
[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
2-3 2-3 ClinicsClinics
-0.003-0.003
[0.013][0.013]
0.0060.006
[0.009][0.009]
4-5 4-5 ClinicsClinics
-0.018-0.018
[0.015][0.015]
-0.006-0.006
[0.011][0.011]
6-10 6-10 ClinicsClinics
-0.022-0.022
[0.016][0.016]
-0.009-0.009
[0.011][0.011]
11-15 11-15 ClinicsClinics
-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
2-3 2-3 ClinicsClinics
0.0090.009
[0.034][0.034]
0.0070.007
[0.018][0.018]
4-5 4-5 ClinicsClinics
-0.042-0.042
[0.039][0.039]
0.0380.038
[0.021]+[0.021]+
6-10 6-10 ClinicsClinics
-0.032-0.032
[0.041][0.041]
0.0150.015
[0.022][0.022]
11-15 11-15 ClinicsClinics
-0.031-0.031
[0.045][0.045]
-0.027-0.027
[0.027][0.027]
>15 >15 ClinicsClinics
-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
2-3 Clinics2-3 Clinics -0.087-0.087
[0.072][0.072]
-0.066-0.066
[0.070][0.070]
-0.094-0.094
[0.070][0.070]
4-5 Clinics4-5 Clinics -0.082-0.082
[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
2-3 Clinics2-3 Clinics -0.007-0.007
[0.011][0.011]
4-5 Clinics4-5 Clinics -0.030-0.030
[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
2-3 2-3 ClinicsClinics
0.0680.068
[0.025]**[0.025]**
-0.19-0.19
[0.011]+[0.011]+
4-5 4-5 ClinicsClinics
0.0610.061
[0.027]*[0.027]*
-0.033-0.033
[0.013]*[0.013]*
6-10 6-10 ClinicsClinics
0.0560.056
[0.028]*[0.028]*
-0.030-0.030
[0.013]*[0.013]*
11-15 11-15 ClinicsClinics
0.0330.033
[0.033][0.033]
-0.036-0.036
[0.016]*[0.016]*
>15 >15 ClinicsClinics
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
2-3 2-3 ClinicsClinics
0.2900.290
[0.081]**[0.081]**
-0.016-0.016
[0.028][0.028]
4-5 4-5 ClinicsClinics
0.2860.286
[0.089]**[0.089]**
0.0340.034
[0.033][0.033]
6-10 6-10 ClinicsClinics
0.2900.290
[0.094]**[0.094]**
0.0140.014
[0.035][0.035]
11-15 11-15 ClinicsClinics
0.1680.168
[0.110][0.110]
-0.051-0.051
[0.042][0.042]
>15 >15 ClinicsClinics
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
2-3 2-3 ClinicsClinics
0.2250.225
[0.178][0.178]
-0.166-0.166
[0.079]*[0.079]*
4-5 4-5 ClinicsClinics
0.3730.373
[0.194]+[0.194]+
-0.181-0.181
[0.094]+[0.094]+
6-10 6-10 ClinicsClinics
0.5400.540
[0.202]**[0.202]**
-0.205-0.205
[0.098]*[0.098]*
11-15 11-15 ClinicsClinics
0.5520.552
[0.239]**[0.239]**
-0.251-0.251
[0.118]*[0.118]*
>15 >15 ClinicsClinics
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
2-3 2-3 ClinicsClinics
0.0130.013
[0.030][0.030]
-0.011-0.011
[0.011][0.011]
4-5 4-5 ClinicsClinics
0.0060.006
[0.033][0.033]
-0.048-0.048
[0.013]**[0.013]**
6-10 6-10 ClinicsClinics
-0.019-0.019
[0.034][0.034]
-0.044-0.044
[0.014]**[0.014]**
11-15 11-15 ClinicsClinics
-0.110-0.110
[0.041]**[0.041]**
-0.064-0.064
[0.017]**[0.017]**
>15 >15 ClinicsClinics
-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]
4-5 4-5 ClinicClinicss
-0.019-0.019
[0.0120[0.0120
0.0180.018
[0.010]+[0.010]+
-0.016-0.016
[0.021][0.021]
6-10 6-10 ClinicClinicss
-0.025-0.025
[0.014]+[0.014]+
0.0250.025
[0.011]*[0.011]*
00
[0.020][0.020]
11-15 11-15 ClinicClinicss
-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]
Small Small (<120)(<120)
MediumMedium
(120-500)(120-500)
LargeLarge
(>500)(>500)
2-3 2-3 ClinicClinicss
0.0190.019
[0.025][0.025]
-0.021-0.021
[0.016][0.016]
0.0280.028
[0.022][0.022]
4-5 4-5 ClinicClinicss
0.0380.038
[0.033][0.033]
-0.027-0.027
[0.018][0.018]
0.0240.024
[0.026][0.026]
6-10 6-10 ClinicClinicss
0.0080.008
[0.038][0.038]
-0.010-0.010
[0.019][0.019]
0.0160.016
[0.024][0.024]
11-15 11-15 ClinicClinicss
-0.024-0.024
[0.046][0.046]
-0.049-0.049
[0.021]*[0.021]*
0.0520.052
[0.026]*[0.026]*
>15 >15 ClinicClinicss
-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
Small Small (<120)(<120)
MediumMedium
(120-500)(120-500)
LargeLarge
(>500)(>500)
2-3 2-3 ClinicClinicss
-0.162 -0.162 [0.109][0.109]
-0.054-0.054
[0.120][0.120]
-0.160-0.160
[0.170][0.170]
4-5 4-5 ClinicClinicss
0.0070.007
[0.126][0.126]
-0.207-0.207
[0.140][0.140]
0.0040.004
[0.210][0.210]
6-10 6-10 ClinicClinicss
-0.068-0.068
[0.139][0.139]
-0.081-0.081
[0.141][0.141]
-0.185-0.185
[0.184][0.184]
11-15 11-15 ClinicClinicss
-0.002-0.002
[0.175][0.175]
-0.060-0.060
[0.158][0.158]
-0.486-0.486
{0.202]*{0.202]*
>15 >15 ClinicClinicss
-0.038-0.038
[0.165][0.165]
-0.190-0.190
[0.158][0.158]
-0.297-0.297
[0.200][0.200]
Small Small (<120)(<120)
MediumMedium
(120-500)(120-500)
LargeLarge
(>500)(>500)
2-3 2-3 ClinicClinicss
-0.008-0.008
[0.018][0.018]
0.0110.011
[0.016][0.016]
-0.021-0.021
[0.021][0.021]
4-5 4-5 ClinicClinicss
-0.044-0.044
[0.021]*[0.021]*
0.0150.015
[0.018][0.018]
-0.056-0.056
[0.026]*[0.026]*
6-10 6-10 ClinicClinicss
-0.063-0.063
[0.023]**[0.023]**
0.0170.017
[0.018][0.018]
-0.044-0.044
[-/-23]+[-/-23]+
11-15 11-15 ClinicClinicss
-0.123-0.123
[0.029]**[0.029]**
-0.003-0.003
[0.021][0.021]
-0.048-0.048
[0.025]+[0.025]+
>15 >15 ClinicClinicss
-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