Determinants of the economic burden of ART on the Italian NHS : insights from the Lombardy region

With the rising spread of Assisted Reproductive Technology (ART), it becomes imperative to understand the determinants of resource utilization in ART versus spontaneous pregnancies to enhance policies directed to pregnancy care. The focus of our study is to examine the costs associated with ART from the perspective of the Italian NHS and to investigate in depth the contributing social and clinical factors. Using the healthcare informative system of Lombardy, a Region of Northern Italy, we gathered individual-level information for a cohort of women who experienced either spontaneous pregnancies or pregnancies following ART from 2007 until 2020. The information covered multiple healthcare services, and we used a propensity score matching technique to match couples of ART/No ART women based on a comprehensive set of confounders. We then applied statistical tests and regression models to identify the impact of ART on the reported cost differences. Our cohort was composed of 44652 women and results revealed significantly higher costs for ART pregnancies, especially in terms of hospital admissions (additional 1611€, 95% CI 1558-1666) and drug prescriptions (additional 216 €, CI 95% 204-228) occurring before delivery. In-depth analysis showed for ART pregnancies, i) a higher likelihood of incur- ring expenses related to complications and ii) higher costs associated with two established clinical practices that lack scientific evidence supporting their efficacy. Our study sheds light on the complex interplay of clinical and social factors influencing the ART burden, emphasizing the importance of tailored support and evidence-based practices in optimizing outcomes and resource allocation. Key points • From the NHS perspective, ART pregnancies, compared to spontaneous pregnancies, mainly result in higher costs (especially in terms of hospital admissions and drug prescriptions occurring before delivery), even though they cor- respond to lower specialistic visits; • The probability of spending for services related to complications is higher for ART pregnancies compared to spon- taneous pregnancies, thus confirming the higher risk, regardless of single or twin pregnancy, of several obstetric and perinatal complications; • The higher costs in pregnancies following ART due to two consolidated clinical practices not supported by scientific evidence (aspirin and progestogen prescriptions) call for reflection on the unmet need of women experiencing ART in terms of emotional and psychological support