Willingness to pay for ovulation induction treatment in case of WHO II anovulation: a study using the contingent valuation method

The value of treatment for infertility: A systematic literature review of willingness-to-pay thresholds and approaches for determining the cost effectiveness of fertility therapies

Willingness to pay (WTP) for an infertility treatment is the maximum amount of money a patient is willing to pay per treatment, or to achieve a live birth or pregnancy. Such thresholds are important to determine the cost effectiveness of a treatment. A systematic review was conducted to identify and explore the studies that attempt to ascertain WTP for infertility and compare them with the cost-effectiveness studies that claimed to use WTP thresholds. For comparison, all the costs were converted and inflated to 2021 euros. The results demonstrated that there were no standard outcomes or WTP thresholds for an outcome/treatment, and the methodologies used vary. Cost-effectiveness studies either used the incremental cost-effectiveness ratio to imply a WTP threshold, or used thresholds that were previously accepted for a quality-adjusted life year outcome converted, inappropriately, to an infertility outcome. There is a need for further research by health economists to develop a consensus for the meaningful assessment of WTP for ART.

Determinants of willingness to pay for health services: a systematic review of contingent valuation studies

INTRODUCTION

Stated preference studies are a valuable tool to elicit respondents' willingness to pay (WTP) for goods or services, especially in situations where no market valuation exists. Contingent valuation (CV) is a widely used approach among stated-preference techniques for eliciting WTP if prices do not exist or do not reflect actual costs, for example, when services are covered by insurance. This review aimed to provide an overview of relevant factors determining WTP for health services to support variable selection.

METHODS

A comprehensive systematic literature search and review of CV studies assessing determinants of WTP for health services was conducted, including 11 electronic databases. Two of the authors made independent decisions on the eligibility of studies. We extracted all determinants used and related p values for the effect sizes (e.g. reported in regression models with WTP for a health service as outcome variable). Determinants were summarised in systematic evidence tables and structured by thematic domains.

RESULTS

We identified 2082 publications, of which 202 full texts were checked for eligibility. We included 62 publications on 61 studies in the review. Across all studies, we identified 22 WTP determinants and other factors from 5 thematic domains: sociodemographic characteristics, perceived threat, perceived benefit, perceived barriers, and other information.

CONCLUSION

Our review provides evidence on 22 relevant determinants of WTP for health services, which may be used for variable selection and as guidance for planning CV surveys. Endogeneity should be carefully considered before interpreting these determinants as causal factors and potential intervention targets.

How Do People with Experience of Infertility Value Different Aspects of Assistive Reproductive Therapy? Results from a Multi-Country Discrete Choice Experiment

Objectives

Assistive reproductive therapies can help those who have difficulty conceiving but different forms of assistive reproductive therapies are associated with different treatment characteristics. We undertook a large, multinational discrete choice experiment to understand patient preferences for assistive reproductive therapies.

Methods

We administered an online discrete choice experiment with persons who had experience with subfertility or assistive reproductive therapies in the USA, UK, the Nordic region (Denmark, Norway, Sweden, Finland), Spain, and China. Attributes encouraged trade-offs between effectiveness, risk of adverse effects, treatment (dis)comfort, (in)convenience, cost per cycle and shared decision making. We used multinomial logit and mixed-logit models to estimate preferences and attribute importance by country/region, and estimated willingness to pay for changes in attribute levels.

Results

A total of 7565 respondents participated. Mixed logit had a better fit than multinomial logit across all samples. Preferences moved in expected directions across all samples, but the relative importance of attributes differed between countries. Willingness to pay was greatest for improvements in effectiveness and a greater degree of shared decision making, and we observe a substantial ‘option value’ independent of treatment characteristics. Unexpectedly, preferences over cost were insignificant in the Chinese sample, limiting the use of willingness to pay in this sample.

Conclusions

Respondents balanced concerns for effectiveness with other considerations, including the cost and (dis)comfort of treatment, and the degree of shared decision making, but there is also substantial option value independent of treatment characteristics, demonstrating value of assistive reproductive therapies to individuals with experience of subfertility. We hypothesise that price insensitivity in the Chinese sample may reflect a degree of social desirability bias.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-021-00563-7.

Is the public supportive and willing to pay for a national assistive reproductive therapies programme? Results from a multicountry survey

OBJECTIVES

To understand attitudes towards infertility and willingness to pay (WTP) towards a publicly funded national assistive reproductive therapies (ART) programme.

DESIGN

Attitudes survey with dichotomous and open-ended WTP questions.

SETTING

Online survey administered in the USA, UK, Norway, Sweden, Finland, Denmark and China.

PARTICIPANTS

7945 respondents, analysed by country. Nordic respondents were pooled into a regionally representative sample.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measures were proportion of sample agreeing with different infertility-related and ART-related value statements and supporting a monthly contribution to fund a national ART programme, expressed in local currency. Secondary outcome measure was maximum WTP.

RESULTS

Across the nationally representative samples, 75.5% of all respondents agreed with infertility as a medical condition and 82.3% and 83.7% with ART eligibility for anyone who has difficulty having a baby or a medical problem preventing them from having a baby, respectively. 56.4% of respondents supported a defined monthly contribution and 73.9% supported at least some additional contribution to fund a national ART programme. Overall, converting to euros, median maximum WTP was €3.00 and mean was €15.47 (95% CI 14.23 to 16.72) per month. Maximum WTP was highest in China and the USA and lowest in the European samples.

CONCLUSIONS

This large, multicountry survey extends our understanding of public attitudes towards infertility and fertility treatment beyond Europe. It finds evidence that a majority of the public in all sampled countries/regions views infertility as a treatable medical condition and supports the idea that all infertile individuals should have access to treatments that improve the chance of conception. There was also strong agreement with the idea that the desire for children is a basic human need. WTP questions showed that a majority of respondents supported a monthly contribution to fund a national ART programme, although there is some evidence of an acquiescence bias that may overstate support among specific samples.

An exploratory study to estimate cost-effectiveness threshold value for life saving treatments in western Iran

Background

Cost-effectiveness analysis provides a crucial means for evidence-informed decision-making on resource allocation. This study aims to elicit individuals' willingness to pay (WTP) for one additional quality-adjusted life-year (QALY) gained from life-saving treatment and associated factors in Kermanshah city, western Iran.

Methods

We conducted a cross-sectional study on a total of 847 adults aged 18 years and above to elicit their WTP for one additional QALY gained by oneself and a family member using a hypothetical life-saving treatment. We used a multistage sampling technique to select the samples, and the Iranian version of EQ-5D-3L, and visual analogue scale (VAS) measures to obtain the participants’ health utility value. The Tobit regression model was used to identify the factors affecting WTP per QALY values.

Results

The mean WTP value and standard deviation (SD) was US$ 862 (3,224) for the respondents. The mean utility values using EQ-5D-3L and VAS methods for respondents were 0.779 and 0.800, respectively. Besides, the WTP for the additional QALY gained by the individual participants using the EQ-5D-3L and VAS methods were respectively US$ 1,202 and US$ 1,101, while the estimated value of the family members was US$ 1,355 (SD = 3,993). The Tobit regression models indicated that monthly income, education level, sex, and birthplace were statistically significantly associated (p < 0.05) with both the WTP for the extra QALY values using the EQ-5D-3L and the VAS methods. Educational level and monthly income also showed statistically significant relationships with the WTP for the additional QALY gained by the family members (p < 0.05).

Conclusion

Our findings indicated that the participants' WTP value of the additional QALY gained from the hypothetical life-saving treatment was in the range of 0.20–0.24 of the gross domestic product (GDP) per capita of Iran. This value is far lower than the World Health Organization (WHO) recommended CE threshold value of one. This wide gap reflects the challenges the health system is facing and requires further research for defining the most appropriate CE threshold at the local level.

Web Comparison of Three Contingent Valuation Techniques in Women of Childbearing Age: The Case of Ovulation Induction in Quebec

Background

In Canada, 11.5% to 15.7% of couples suffer from infertility. Anovulation, or failed ovulation, is one of the main causes of infertility in women. In Quebec, the treatment for ovulation induction and other services related to assisted reproductive technology (ART) have been partially reimbursed by the government since 2010.

Objective

This study aimed to compare the willingness to pay (WTP) of women of childbearing age to receive drug treatment in the event of failed ovulation according to 3 different contingent valuation methods.

Methods

The following elicitation techniques were used: simple bid price dichotomous choice (DC), followed by an open-ended question (DC-OE), and a simplified multiple-bounded discrete choice (MBDC). Each participant was randomly assigned to 1 of 3 elicitation techniques. Bid prices ranged from Can $200 to Can $5000. Of the 7 bid prices, 1 was randomly proposed to each participant in the DC and DC-OE groups. For the DC-OE group, if the answer to the DC bid price was no, respondents were asked what was the maximum amount they were willing to pay. For the MBDC group, each respondent was offered an initial bid price of Can $1500, and the subsequent bid price offer increased or decreased according to the answer provided. “Do not know” responses were considered as a “no”, and each individual was questioned as to their certainty after each choice. WTP values were estimated using probit and bivariate models; the Welsh and Poe model was also performed for the MBDC group.

Results

The survey was conducted from 2009 to 2010 with a total sample of 680 women. Analyses were performed on 610 respondents (199 DC, 230 DC-OE, and 181 MBDC). Of the 70 respondents who were excluded, 6 did not meet the age criterion, 45 had an annual income less than Can $2500, and 19 did not respond to the WTP question. Mean WTP values were Can $4033.26, Can $1857.90, and Can $1630.63 for DC, DC-OE, and MBDC, respectively. The WTP for MBDC “definitely yes” and “probably yes” values were Can $1516.73 and Can $1871.22, respectively. The 3 elicitation techniques provided WTP value differences that were statistically significant (P<.01). The MBDC was the most accurate method, with a lower confidence interval (Can $557) and a lower (CI/mean) ratio (0.34).

Conclusions

A positive WTP for ovulation induction was found in Quebec. Adding a follow-up question resulted in more accurate WTP values. The MBDC technique provided a more accurate estimate of the WTP with a smaller and, therefore, more efficient confidence interval. To help decision making and improve the effectiveness of the fiscal policy related to the ART program, the WTP value elicited with the MBDC technique should be used.

Willingness to pay for family education and counselling services provided by critical care advanced practice nurses

Aim

The aim of this study was to estimate the economic value of a family education and counselling service provided by critical care advanced practice nurses in South Korea utilizing a contingent valuation approach.

Methods

A double‐bounded dichotomous choice contingent valuation method was utilized to estimate the public's willingness to pay value for an education and counselling service provided by critical care advanced practice nurses. A web‐based self‐administered survey was conducted.

Results

Median willingness to pay was 43 112 Korean won (35 US dollars). Higher income and younger age were associated with higher willingness to pay.

Conclusion

This study captured the economic value of an education and counselling service provided by critical care advanced practice nurses that is not on the benefit list under the fee‐for‐service system of the Korean National Health System. Policy makers should consider including such services in the health care system.

What is already known about this topic?

Patients in intensive care units and their family members need education and counselling.

Nurses and physicians recognize the importance of the education and counselling services provided by critical care advanced practice nurses.

No studies have evaluated the economic value of the family education and counselling services provided by critical care advanced practice nurses.

What this paper adds?

The Korean people in this study recognized the economic value of a service provided by critical care advanced practice nurses.

Income and age were found to be factors related to the economic value of the education service provided by critical care advanced practice nurses.

The implications of this paper:

This study captured the economic value of an education and counselling service provided by critical care advanced practice nurses, the fee for which is not reimbursed by the current Korean health care fee‐for‐service system.

Policy makers should consider the public perception of the economic value of the education and counselling services provided by critical care advanced practice nurses when determining the benefits and the prices of services included in the Korean National Health Insurance System.

Willingness to pay for antiretroviral drugs among HIV and AIDS clients in south-east Nigeria

BACKGROUND

The current trend of withdrawal of donor support for HIV/AIDS treatment in Nigeria may require that the cost of antiretroviral drugs be borne in part by infected people and their families.

OBJECTIVE

This study was conducted to determine the economic value for free antiretroviral drugs (ARVs) expressed by clients receiving treatment for HIV/AIDS in a tertiary hospital.

STUDY METHOD

The contingent valuation method was used to elicit the values attached to free ARVs from people living with HIV/AIDS that were receiving care in a public tertiary hospital in south-east Nigeria. Exit poll using a pre-tested questionnaire was undertaken with adult clients on treatment. The bidding game technique was used to elicit their willingness to pay (WTP) for ARVs for themselves and members of their households. Ordinary least squares (OLS) multiple regression analysis was used to test the construct validity of elicited WTP amounts.

RESULTS

About a third of the respondents were willing to pay for a monthly supply of ARVs for themselves and household members. The mean WTP for monthly supply of ARVs for self was US$15.32 and for household member was US$15.26 (1US$=₦160). OLS regression analysis showed that employment status and higher socio-economic status were positively associated with higher WTP. OLS showed that age and transport cost per clinic visit were negatively related to WTP. Knowing the risks of not adhering to treatment protocol was positively related to WTP.

CONCLUSION

The respondents positively valued the free ARVs. This calls for greater financial support for the sustainable provision of the treatment service. However, holistic financing mechanisms should be explored to ensure sustained funding in the event of complete withdrawal of donor support.

Willingness to pay and the sensitivity of willingness to pay for interdisciplinary musculoskeletal clinics: a contingent valuation study in Quebec, Canada

Orthopedics is a discipline that requires a continuum of care in close collaboration with physicians, nurses, and healthcare professionals to ensure effective rehabilitation. In some cases, the wait time for a consultation may be very long, which can jeopardize the patient's rehabilitation and sometimes even cause complications that lead to a loss of autonomy. In Quebec, there is a severe shortage of healthcare professionals-and of orthopedic surgeons, in particular-specializing in musculoskeletal problems. To address this problem, public managers have decided to establish interdisciplinary musculoskeletal clinics in regions outside the two major cities of Montréal and Québec. The major benefits of these clinics are that they reduce the wait time for consultation and treatment while maintaining service quality. Although their benefits are certain, these clinics remain threatened by relatively high initial costs. This study's objective is to evaluate whether the population of Quebec has a quantifiable willingness to pay (WTP) to establish these clinics. To our knowledge, this is the first study of its kind either in the province of Quebec or elsewhere. We selected 3822 subjects randomly within the target population using Internet surveys, telephone surveys and self-administered paper surveys as our methods of recruitment. Three payment vehicles were used and each participant was randomly allocated among these: tax, donation or lump-sum fee. A contingent valuation question using a referendum format with the option "don't know" was used. Econometric estimates were performed using probit and Wang's models. Our results indicate that the population of Quebec may potentially have a mean WTP of 42.3 Canadian dollars per person for such clinics, which would enable a mean reduction from 12 to 4 months of wait time. However, the WTP is found to be very sensitive to the survey mode and the payment vehicle used: about 1.2-2 times more important in the tax and the lump-sum fee scenarios than in the donation scenario, and about 3-4 times less important in the Internet survey than in the telephone or self-administered paper surveys. In addition, this amount was strongly affected by the introduction of a new governmental health-related policy that arose during the survey and led to a minimal drop in WTP of about 30-50 %. This strong sensitivity led us to the three following recommendations for future contingent valuation studies: (1) favour Internet surveys, (2) use a payment vehicle that limit uncertainty in the WTP answer and allow to socialize benefits, as the tax scenario in our study, and (3) strictly apply the "divide by 2" rule of the NOAA panel.

A Comparison of Web and Telephone Responses From a National HIV and AIDS Survey

BACKGROUND

Response differences to survey questions are known to exist for different modes of questionnaire completion. Previous research has shown that response differences by mode are larger for sensitive and complicated questions. However, it is unknown what effect completion mode may have on HIV and AIDS survey research, which addresses particularly sensitive and stigmatized health issues.

OBJECTIVES

We seek to compare responses between self-selected Web and telephone respondents in terms of social desirability and item nonresponse in a national HIV and AIDS survey.

METHODS

A survey of 2085 people in Canada aged 18 years and older was conducted to explore public knowledge, attitudes, and behaviors around HIV and AIDS in May 2011. Participants were recruited using random-digit dialing and could select to be interviewed on the telephone or self-complete through the Internet. For this paper, 15 questions considered to be either sensitive, stigma-related, or less-sensitive in nature were assessed to estimate associations between responses and mode of completion. Multivariate regression analyses were conducted for questions with significant (P≤.05) bivariate differences in responses to adjust for sociodemographic factors. As survey mode was not randomly assigned, we created a propensity score variable and included it in our multivariate models to control for mode selection bias.

RESULTS

A total of 81% of participants completed the questionnaire through the Internet, and 19% completed by telephone. Telephone respondents were older, reported less education, had lower incomes, and were more likely from the province of Quebec. Overall, 2 of 13 questions assessed for social desirability and 3 of 15 questions assessed for item nonresponse were significantly associated with choice of mode in the multivariate analysis. For social desirability, Web respondents were more likely than telephone respondents to report more than 1 sexual partner in the past year (fully adjusted odds ratio (OR)=3.65, 95% CI 1.80-7.42) and more likely to have donated to charity in the past year (OR=1.63, 95% CI 1.15-2.29). For item nonresponse, Web respondents were more likely than telephone respondents to have a missing or "don't know" response when asked about: the disease they were most concerned about (OR=3.02, 95% CI 1.67-5.47); if they had ever been tested for HIV (OR=8.04, 95% CI 2.46-26.31); and when rating their level of comfort with shopping at grocery store if the owner was known to have HIV or AIDS (OR=3.11, 95% CI 1.47-6.63).

CONCLUSION

Sociodemographic differences existed between Web and telephone respondents, but for 23 of 28 questions considered in our analysis, there were no significant differences in responses by mode. For surveys with very sensitive health content, such as HIV and AIDS, Web administration may be subject to less social desirability bias but may also have greater item nonresponse for certain questions.

Mono-ovulation in women with polycystic ovary syndrome: a clinical review on ovulation induction

Polycystic ovary syndrome (PCOS) affects 5-10% of women of reproductive age and is the most common cause of anovulatory infertility. The treatment approaches to ovulation induction vary in efficacy, treatment duration and patient friendliness. The aim was to determine the most efficient, evidence-based method to achieve mono-ovulation in women diagnosed with PCOS. Publications in English providing information on treatment, efficacy and complication rates were included until September 2015. Systematic reviews, meta-analyses and randomized controlled trials were favoured over cohort and retrospective studies. Clomiphene citrate is recommended as primary treatment for PCOS-related infertility. It induces ovulation in three out of four patients, the risk of multiple pregnancies is modest and the treatment is simple and inexpensive. Gonadotrophins are highly efficient in a low-dose step-up regimen. Ovulation rates are improved by lifestyle interventions in overweight women. Metformin may improve the menstrual cycle within 1-3 months, but does not improve the live birth rate. Letrozole is effective for ovulation induction, but is an off-label drug in many countries. Ovulation induction in women with PCOS should be individualized with regard to weight, treatment efficacy and patient preferences with the aim of achieving mono-ovulation and subsequently the birth of a singleton baby.