Healthcare use among U.S. women aged 45 and older: total costs and costs for selected postmenopausal health risks

The purpose of this study is to estimate the level of healthcare use and costs incurred by postmenopausal women overall and for these selected conditions: cardiovascular disease, osteoporosis, breast cancer, and gynecological cancers. National healthcare survey and discharge data were used to estimate healthcare use by women aged 45 and older. Clinical Classification for Health Policy Research (CCHPR) codes were used to identify patients whose primary diagnosis or procedure corresponded with the selected conditions. National weights were used to estimate resource use. Treatment costs were estimated using cost/charge ratios or the Medicare fee schedule to calculate costs for each individual procedure. Estimated total annual medical care treatment costs for women 45 and older were about $186 billion in 1997 dollars, including about $60.4 billion for cardiovascular disease, $12.9 billion for osteoporosis, and $5.0 billion for breast and gynecological cancers. For each condition, estimated resource use and costs are reported for hospitalization, outpatient, nursing home, and home healthcare services. Resource use and costs are also reported by age and expected source of payment. The economic burden of disease for conditions commonly affecting postmenopausal women is substantial. Prior research establishes that hormone replacement therapy (HRT) may be effective in reducing the burden of disease among women who continue preventive therapy for many years, but few at-risk women do so. New alternatives for prevention, such as selective estrogen receptor modulators (SERMs), may be effective in reducing the burden of disease among postmenopausal women.

[Costs of different intervention strategies to prevent hip fractures]

The cost of primary prevention and the number of hip fractures prevented was compared in different scenarios. Primary prevention with hormonal replacement therapy (HRT) in women over the age of 50 years, secondary prevention with HRT in women over 50 years with low bone mineral on screening, use of external hip protectors in nursing home residents, use of calcium and vitamin D in nursing home residents and tertiary prevention with bisphosphonates (alendronate) or external hip protectors in subjects with a previous hip fracture were evaluated. External hip protectors or calcium plus vitamin D were cheap in nursing home residents. The economic cost of bisphosphonate treatment was high even in tertiary prevention in the high risk group with previous hip fracture. It was doubtful whether potential savings in prevention would out-weigh the cost in younger individuals even in high-risk groups.

Etidronate and alendronate in the treatment of postmenopausal osteoporosis

OBJECTIVE

To review the clinical trials evaluating the efficacy of etidronate and alendronate in the treatment of established postmenopausal osteoporosis.

DATA SOURCE

A MEDLINE search was performed (from 1966 through September 1998) using the search terms bisphosphonates, etidronate, alendronate, and postmenopausal osteoporosis. English-language articles were considered for review.

STUDY SELECTION AND DATA EXTRACTION

Prospective, randomized, double-blind, placebo-controlled clinical trials using fracture as an end point were selected to review the efficacy of etidronate and alendronate in the treatment of postmenopausal osteoporosis. Results for the outcomes of bone mineral density (BMD) and fracture are summarized.

DATA SYNTHESIS

Etidronate and alendronate increase spinal BMD in postmenopausal women with osteoporosis. In one study, etidronate decreased the number of women sustaining new radiographic vertebral fractures over two years, but this effect was lost after three years of treatment. Alendronate reduces the number of radiographic vertebral fractures in postmenopausal women with a low bone mass. In women with preexisting fractures, alendronate decreases the number of patients with radiographic vertebral fractures, clinical (i.e., symptomatic vertebral and nonvertebral) fractures, and hip fractures. A significant reduction in the overall number of nonvertebral fractures has not been demonstrated in clinical trials evaluating either alendronate or etidronate.

CONCLUSIONS

No studies have directly compared the efficacy of alendronate and etidronate and the results of long-term clinical trials (i.e., >5 y) have not been published. Based on the results obtained in clinical trials using fracture as an end point, alendronate appears to be the bisphosphonate of choice. Safety profiles and cost should also be considered in the choice of etidronate or alendronate for the treatment of postmenopausal osteoporosis.

[Prevention of osteoporosis and its economic aspects]

Osteoporosis is a skeletal disease which deteriorates bone tissue and lowers its density. Bone fragility induces fractures of the hip, vertebrae and distal radius. These fractures occur mainly to women after their menopause due to important postmenopausal changes in bone metabolism. Osteoporosis and related fractures are a major public health issue, as the upcoming population aging will sharply increase their incidence. For the time being prevention of osteoporosis is at a crossroads in France. One way would be to treat the entire postmenopause female population with hormone substitution to avoid the incidence to one third among them: the cost would be very high and, for the time being, the risk/benefit ratio is not well known (we do not know the risks of a treatment lasting 20 or 25 years). The other way would be to implement only reliable diagnostic programs without generalized hormone treatment: such an option might lead to a sharp increase of the disease incidence, causing a high cost both in social and financial terms.

Health-related quality of life in economic evaluations for osteoporosis: whose values should we use?

OBJECTIVE

To determine whether the source of preference scores has an impact on the cost-effectiveness of osteoporosis interventions.

METHODS

Three groups of subjects aged > or =50 years--199 women without fractures and 183 women with osteoporotic fractures-were studied at two major medical centers. Medical history and comorbidity data were obtained from review of medical records. Health status was measured using the Medical Outcomes Study SF-36. Two preference-classification systems (i.e., quality of well-being scores estimated from SF-36 subscales and the Health Utilities Index) were also used. Preferences for current health and for hypothetical health states were assessed using a time tradeoff and implemented with a computer-based utility instrument (U-Titer). Wilcoxon's rank-sum and signed-rank tests were used to compare preferences for current health among women with osteoporotic fractures with 1) directly assessed preferences for osteoporosis health states delineated by outcome descriptions and 2) preference scores obtained from the preference-classification systems. The potential impact of the source of the preference scores was estimated using a Markov state-transition model.

RESULTS

The preference scores for hypothetical osteoporosis health states of the non-fracture subjects were approximately 50% lower than those of the women who had actually experienced the health state. Differences of this magnitude would change the estimated cost-effectiveness of a 15-year intervention (which for approximately $280 per year prevents hip fracture about as well as hormone-replacement therapy) from $25,000 per QALY gained when non-fracture subjects' preferences were used to $94,000 per QALY gained when fracture subjects' preferences were used. Preferences estimated using the Health Utilities Index and those directly measured in fracture subjects using the time tradeoff did not differ significantly.

CONCLUSIONS

The Health Utilities Index preference-classification system may provide an efficient and inexpensive alternative to direct utility assessment in this patient group. However, there are important differences in the valuation of health states by women who have experienced osteoporotic fractures compared with women who have not. Cost-utility analyses based solely on fracture patients' preferences for osteoporotic health states may undervalue prevention.

[Economic aspects of osteoporosis]

BACKGROUND

The objective of this study was to evaluate expenditures and efficacy of osteoporosis treatment in the Czech Republic (CZ) (1.38 million women and 0.99 million men > 55 years of age).

METHODS AND RESULTS

Demographic data, incidence of hip fractures and prevalence of osteoporosis and osteopenia in Czech women and men, cost burden to healthcare agencies due to hip fractures and costs of diagnostic procedures, preventive measures and therapies of osteoporosis were obtained from published data and from database of the main health insurance agency (VZP) and the State Institute for Drug Control. The direct costs for treatment of hip fractures in the CZ in 1997 averaged Kc (Czech Crown) 2.5 billion, diagnosis of osteoporosis, Kc 150 million, prevention of osteoporosis using hormone replacement therapy, Kc 66 million, and treatments of osteoporosis which has been applied to less than 5% of osteoporosis patients, 482 million. However, despite the continuously increasing expenditures for treatments of osteoporosis, the incidence of hip fractures doubled in the last 10 years. This is mainly due to increased life expectancy in Czech women and men.

CONCLUSIONS

The results of this first economic evaluation of diagnosis, treatment and consequences of osteoporosis in the CZ indicate a need for conceptual decisions in both treatment and prevention of osteoporosis.

Cost effectiveness of multi-therapy treatment strategies in the prevention of vertebral fractures in postmenopausal women with osteoporosis

OBJECTIVE

The aim of this study was to evaluate the cost effectiveness of multi-therapy treatment strategies in the prevention of vertebral fractures in postmenopausal women with osteoporosis.

DESIGN

A retrospective, incremental cost-effectiveness analysis was conducted from a societal perspective. It compared 9 treatment strategies over 3 years and incorporated the willingness of patients to initiate and continue each therapy.

MAIN OUTCOME MEASURES AND RESULTS

Four nondominated strategies formed the efficient frontier in the following order: (i) calcium-->no therapy; (ii) ovarian hormone therapy (OHT)-->calcium-->no therapy [166 Canadian dollars ($Can)]; (iii) OHT-->etidronate-->calcium-->no therapy ($Can2331); and (iv) OHT-->alendronate-->calcium-->no therapy ($Can40,965). The figures in parentheses are the incremental costs per vertebral fracture averted to move to that strategy from the previous strategy for patients who had undergone a hysterectomy.

CONCLUSIONS

We identified 4 efficient multi-therapy strategies for the treatment of vertebral osteoporosis in postmenopausal women, 2 of which were consistent with the practice guidelines of the Osteoporosis Society of Canada. Decision-makers may select from among these efficient strategies on the basis of incremental cost effectiveness.

[Bone-specific treatment design in the treatment of postmenopausal osteoporosis. Pharmaco-economic aspects]

Fairly new economic evaluations were, so far, properly conducted in the field of prevention and treatment of osteoporosis. This lack of studies is likely to be related to the pathophysiology and the natural course of the disease, the small number of disease-specific instruments allowing the evaluation of quality of life changes following fractures and the frequent interaction of osteoporotic treatments with other body systems. Notwithstanding a lot of efforts have to be brought before economic evaluations in osteoporosis become a key determinant of Public Health strategies, it remains of prime interest to promote this type of research taking into account the importance of the social, human and economic burden of this disease.

[Risks, benefits and costs of hormone replacement therapy in menopause]

Hormone replacement therapy (HRT) acts both as an effective treatment of menopausal symptoms and genital atrophy, and as an effective prevention of osteoporosis. It is also probably cardioprotective and potentially preventing cerebrovascular disease. The risk of oestrogen-induced endometrial cancer is eliminated by the addition of a progestin. An increase in breast cancer risk is however possible after 10 years or more of HRT use. This multifactorial risk-benefit balance altogether with other variables (numerous and expensive hormonal therapies, low compliance of postmenopausal women, need for monitoring, therapy-related adverse events) explain why so few global pharmaco-economic appraisals have been devoted to HRT. Computer model studies have been set up to study hypothetical cohorts of menopausal women treated for 5-10 years or more, comprising hysterectomized women (receiving an estrogen alone) and non hysterectomized women (receiving an oestrogen-progestogen therapy) compared with untreated controls. Treatment of hysterectomized women as well as non hysterectomized symptomatic menopausal women appears relatively cost-effective. In terms of mortality and morbidity, a reduction in cardiovascular disease risk and, to a smaller extent, in osteoporosis has a strikingly greater impact than the small increase in breast cancer risk related to HRT use. A significant increase in life expectancy seems associated with long-term use and the quality-adjusted life years gain, is particularly impressive, as quality of life appears distinctly improved by HRT utilization. In the future, this beneficial cost-effectiveness equation will probably be optimized thanks to the introduction of alternative and innovative replacement therapies allowing longer treatment periods without increasing the risk of breast cancer.

Osteoporosis: review of the evidence for prevention, diagnosis and treatment and cost-effectiveness analysis. Executive summary

This report describes evidence for the diagnosis, prevention, and treatment of osteoporosis in postmenopausal healthy white women. Osteoporosis is becoming an increasingly important public health problem as our population ages. Although it is partially preventable, fractures related to osteoporosis are still common. Because of the economic and social burdens, comprehensive prevention programs are needed. Insufficient data prevent development of comparable analyses for men or nonwhite women. Discussed are the effectiveness, risks, and costs of diagnostic tests and treatments, the probabilities that women will have osteoporosis-related fractures, and the effects of various factors on these probabilities. Hormone replacement therapy is considered most cost-effective; women who refuse hormone replacement can consider bisphosphonates (alendronate) and calcitonin. Nomograms are presented for guiding treatment and testing decisions for individual patients. The following public health measures are recommended: Ensure that adults receive the optimal daily intake of calcium--between 1000 mg and 1500 mg; ensure that people at risk for vitamin D deficiency receive 400 IU to 800 IU of vitamin D daily; inform people that exercise, in addition to its other benefits, should help prevent osteoporosis; and discourage people from smoking.

The cost of treating osteoporotic fractures in the United Kingdom female population

Osteoporotic fractures represent a significant burden to society. The costs of osteoporotic fractures to the UK health care system have not previously been accurately described. In this paper, we quantify the health care and social care costs of fractures occurring in women aged 50 years and over in the UK. We used a variety of data sources. For acute hospital hip fracture costs existing published estimates were used whilst for social care costs a survey of resource use among fracture patients before and after hip fracture was utilized. We undertook a case-control study using the General Practice Research Database to estimate primary care costs. From these data we estimated that the cost of a hip fracture is about 12,000 Pounds, with non-acute hospital costs representing the larger proportion. The other fractures were less expensive, at 468 Pounds, 479 Pounds and 1338 Pounds for wrist, vertebral and other fractures, respectively. For all fractures the annual cost to the UK is 727 million Pounds. Assuming each male hip fracture costs the same as a female fracture, including these would increase the total costs to 942 million Pounds.

Quality of life in the economic evaluation of osteoporosis prevention and treatment

Osteoporosis is associated with fractures that result in morbidity and mortality and a large expenditure of health care resources. Given the large number of people at risk for the development of osteoporosis and the limited health care resources, it is imperative that clinically and economically favorable approaches to osteoporosis prevention and treatment be identified and implemented. The quantitative method of cost-effectiveness evaluation is one method of identifying favorable interventions. The importance of quality of life and the concept of quality-adjusted life years as an end point for assessing the effectiveness of interventions in osteoporosis is highlighted. The quality of life data critically needed to evaluate the impact of interventions in osteoporosis on quality-adjusted life years are discussed.

Epidemiology of spinal osteoporosis

Approximately 30% of postmenopausal white women in the United States have osteoporosis, and 16% have osteoporosis of the lumbar spine in particular. Bone density of the spine is positively associated with greater height and weight, older age at menopause, a history of arthritis, more physical activity, moderate use of alcoholic beverages, diuretic treatment, and current estrogen replacement therapy, whereas later age at menarche and a maternal history of fracture are associated with lower levels of density. Low bone density leads to an increased risk of osteoporotic fractures. Fracture risk also increase with age. Vertebral fractures affect approximately 25% of postmenopausal women, although the exact figure depends on the definition used. Recent data show that vertebral fracture rates are as great in men as in women but, because women live longer, the lifetime risk of a vertebral fracture from age 50 onward is 16% in white women and only 5% in white men. Fracture rates are less in most nonwhite populations, but vertebral fractures are as common in Asian women as in those of European heritage. Other risk factors for vertebral fractures are less clear but include hypogonadism and secondary osteoporosis; obesity is protective of fractures as it is of bone loss. Compared with hip fractures, vertebral fractures are less disabling and less expensive, costing approximately $746 million in the United States in 1995. However, they have a substantial negative impact on the patient's function and quality of life. The adverse effects of osteoporotic fractures are likely to increase in the future with the growing number of elderly people.

Morbidity of osteoporosis--can estrogen use make a public health impact?

The personal morbidity and economic burden associated with osteoporosis is substantial. Estrogen has been shown to have positive effects on the prevention and treatment of this disabling disease. Information is available with regard to when to initiate estrogen therapy, how long to maintain treatment, and how best to identify those women who will benefit most from its use.

[Use of alendronate in osteoporosis--is it cost-effective?]

The objective of the analysis was to establish the cost-effectiveness of five years intervention with alendronate in women aged 65 years with a bone mineral density (BMD) of the femoral neck 2.5 SD below peak bone mass. A cost-utility analysis based on a simulation model was used. The risk of future fractures was estimated on the basis of clinical and epidemiologic data. The costs of intervention and of fracture treatment were based on market prices (measurement of BMD), the Norwegian DRG price list (in-patient hospital care), the pay scale of the Norwegian Medical Association (out-patient care, doctor's visits, laboratory tests, radiographs), public accounts (nursing home care, rehabilitation) and customary charges (transport, physiotherapy etc.). The discounted cost per Quality Adjusted Life Year (QALY) was NOK 528,000, NOK 291,000 and NOK 147,000 when BMD was respectively 1.5, 2.5 and 3.5 SD below peak bone masa at onset of intervention. Sensitivity analyses indicate that the cost per QALY is relatively sensitive to future risk of fracture, cost of intervention, discount rate, and magnitude and duration of the effects of the intervention. The results indicate that the use of alendronate competes favourably with other commonly used preventive programmes when administered to women with high risk of fragility fractures.

Estimating the cost per avoided hip fracture by osteoporosis treatment in Italy

OBJECTIVES

A cost-effectiveness analysis on osteoporosis treatment has been carried out as the basis for an estimate of the cost per avoided hip fracture (CPAHF) in Italy.

METHODS

We have assumed as correct, reported data on the efficacy of calcitonin in preventing hip fractures in European women over 50 (Mediterranean Osteoporosis Study). Health-care costs were calculated using Weinstein and Stason's equation.

RESULTS

Given the incidence of such fractures in Italy and their cost to the health service, we calculate that in order to prevent one hip fracture 1285 women need to be treated with calcitonin at a cost of over two million dollars. The introduction of an element of screening (bone mass measurement to select a high risk subpopulation) would reduce the CPAHF by 65%. Choice of a more effective treatment (as the hormone replacement therapy) would be cost-neutral.

CONCLUSIONS

Drug-related costs, selection of high risk subpopulations and drug efficacy have important implications in the estimation of optimal CPAHF.

Prediction of bone loss rate in healthy postmenopausal women

Prevention of fractures is the only way to drastically reduce osteoporosis-related health expenditures. In order to optimize the cost/benefit ratio of a strategy of prevention, it is essential to identify, as early as possible, women who will develop fractures later in their life. Therefore, and since postmenopausal bone loss is an asymptomatic process, screening procedures should detect, at the time of the menopause, women whose postmenopausal bone loss is higher than the mean, and will, a couple of years later, exhibit a low mineral content and a subsequent high risk for fractures. For 3 years we have followed a cohort of 92 healthy women who had undergone menopause less than 36 months previously. By a multivariate discriminant analysis based on the differences in lumbar bone density, assessed by dual photon absorptiometry, and in a few routine biochemical parameters (serum phosphorus, estrone, androstenedione, and urine calcium) observed during the first 6 months of the study, we have been able to correctly predict the rate of spinal bone loss, observed at the end of the 3 years, in 76% of the subjects. All of the women who presented a bone loss higher than 10% over the 3 years were correctly isolated by our discriminant functions after 6 months of follow-up. We conclude that a measurement of lumbar bone mineral density coupled with a few routine biochemical determinations, repeated twice at a 6-month interval in healthy postmenopausal women, can isolate 100% of postmenopausal "fast bone losers" with an overall specificity of 76%.

Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation

Osteoporotic fractures are a significant public health problem, resulting in substantial morbidity and mortality. Previous estimates of the economic burden of osteoporosis, however, have not fully accounted for the costs associated with treatment of nonhip fractures, minority populations, or men. Accordingly, the 1995 total direct medical expenditures for the treatment of osteoporotic fractures were estimated for all persons aged 45 years or older in the United States by age group, sex, race, type of fracture, and site of service (inpatient hospital, nursing home, and outpatient). Osteoporosis attribution probabilities were used to estimate the proportion of health service utilization and expenditures for fractures that resulted from osteoporosis. Health care expenditures attributable to osteoporotic fractures in 1995 were estimated at $13.8 billion, of which $10.3 billion (75.1%) was for the treatment of white women, $2.5 billion (18.4%) for white men, $0.7 billion (5.3%) for nonwhite women, and $0.2 billion (1.3%) for nonwhite men. Although the majority of U.S. health care expenditures for the treatment of osteoporotic fractures were for white women, one-fourth of the total was borne by other population subgroups. By site-of-service, $8.6 billion (62.4%) was spent for inpatient care, $3.9 billion (28.2%) for nursing home care, and $1.3 billion (9.4%) for outpatient services. Importantly, fractures at skeletal sites other than the hip accounted for 36.9% of the total attributed health care expenditures nationally. The contribution of nonhip fractures to the substantial morbidity and expenditures associated with osteoporosis has been underestimated by previous researchers.

Perimenopausal bone density screening--will it help prevent osteoporosis?

OBJECTIVE

To estimate the potential efficacy and cost-effectiveness of hormone replacement therapy (HRT) in the prevention of osteoporotic fractures, with and without the assistance of perimenopausal bone mineral density (BMD) screening.

METHOD

Residual lifetime fracture experience of a hypothetical cohort of 100,000. British women aged 45 years at baseline, modelled using prevailing UK mortality and fracture rates. Appropriate fracture risk gradients were used to estimate the distribution of future fragility fractures (distal forearm, proximal femur and clinically diagnosed vertebral fractures) according to quarters of baseline bone density measured at fracture specific sites. We assumed that 72% of the population could be contacted and would attend for HRT counselling, with or without bone densitometry, that 10 years of continuous HRT use would reduce fracture rates by 50%, and that compliance with HRT might vary between 10% and 50%. Universal recommendation of HRT was compared to selective treatment protocols offering HRT to those women whose BMD fell below the 25th, 50th or 75th percentile of BMD at the lumbar spine, femoral neck or distal forearm, measured either singly or in combination.

RESULTS

The proportion of future fractures averted was closely related to compliance with therapy, but for any given level of compliance, universal treatment always achieved the greatest reduction in fractures. If compliance was 10% universal HRT was also the most cost-effective strategy, but if compliance was higher or if the unit cost of HRT increased, selective strategies were often more cost-effective. The sensitivity of BMD screening in identifying women at risk of future fracture could be increased by relaxing the BMD decision threshold, or expanding the number of skeletal sites measured, or both. However increments in test sensitivity were always accompanied by reductions in specificity.

CONCLUSIONS

If BMD measurement does not influence compliance, then universal treatment with HRT is likely to prevent more fractures, at a similar or lower average cost per fracture averted, than selective therapy. However, if BMD screening leads to increased compliance, or if more expensive forms of treatment were used, then our model suggests a favourable impact of screening on the numbers and/or net cost of fractures prevented.

[Cost and effectiveness of different strategies in diagnosis of osteoporosis]

Osteoporosis represents one of the most common disorders in Germany. Because of the general aging of the population and due to several secular trends (less exercise, nutritional deficits, higher standard of living) the prevalence of osteoporosis will increase substantially. Therefore, it is important to develop preventive strategies and analyze them according to both medical and economical criteria. During the last couple of years substantial progress has been made both in the area of diagnostic approaches as well as treatment modalities. Thus, from a medical point of view important conditions for a positive assessment of the cost-benefit-ratio of diagnostic approaches in osteoporosis are now fulfilled. Currently, a strategy for selective screening of well-defined high risk groups appears to be most appropriate. These include 1. women with subnormal hormonal status provided that other risk factors are present, 2. patients with low-trauma fractures, 3. patients under prolonged steroid therapy, and 4. patients with secondary osteoporosis due to other causes. International studies have demonstrated that even more far-reaching preventive strategies can be conceived that could be both medically and economically effective. Currently, however, data for a detailed cost-benefit-analysis are lacking or based on outdated diagnostic equipment or treatment agents. New Studies on this topic are critically needed to evaluate preventive strategies, specifically for Germany.

Bone densitometry: patients with end-stage renal disease

Bone mass loss and osteoporosis are associated with various conditions, such as end-stage renal disease (ESRD), and treatments, such as prolonged steroid therapy. Bone densitometry is used to measure bone mass density to determine the degree of osteoporosis and to estimate fracture risk. Bone densitometers measure the radiation absorption by the skeleton to determine bone mass of the peripheral, axial, and total skeleton. Common techniques include single-photon absorptiometry (SPA) of the forearm and heel, dual-photon (DPA) and dual-energy x-ray absorptiometry (DXA) of the spine and hip, quantitative computed tomography (QCT) of the spine or forearm, and radiographic absorptiometry (RA) of the hand. Part I of this report addresses important technical considerations of bone densitometers, including radiation dose, site selection, and accuracy and precision, as well as cost and charges. Part II evaluates the clinical utility of bone densitometry in the management of patients with ESRD. End-stage renal disease affected more than 242,000 Americans in 1992, and each year 10,000 to 20,000 new cases are diagnosed. Although the survival rate of ESRD patients has improved, metabolic bone diseases that fall under the generic term "renal osteodystrophy" represent abnormal development of bone and major long-term complications. Issues addressed are the type and extent of bone loss associated with ESRD and whether these patients have an increased risk for fracture. The other assessments in this series address the clinical utility of bone densitometry for patients with asymptomatic primary hyperparathyroidism, steroid-dependent patients, estrogen-deficient women, and patients with vertebral abnormalities.

Osteoporosis: the need for comprehensive treatment guidelines

Osteoporosis is a debilitating disease that results in nearly 1.3 million fractures per year in the United States. The cost of treating these fractures has been estimated to be as high as $10 billion per year. These costs are expected to more than double during the next 50 years unless comprehensive programs of prevention and treatment are initiated. Both pharmacologic and nonpharmacologic interventions (eg, diet and exercise) have been shown to have a significant impact on the incidence of osteoporosis, depending on the time of their application. Unfortunately, osteoporosis is often not diagnosed until after fractures have occurred, when it may be too late for treatment to have a major impact. To be most effective, therapy should be started early, before serious bone loss has occurred. Because of its efficacy and relatively low acquisition cost, long-term hormone replacement therapy (HRT) is considered first-line pharmacologic therapy for the prevention of osteoporosis. However, for various reasons, less than 25% of US women who might benefit from HRT are receiving it. Aside from HRT, the only other products approved by the US Food and Drug Administration for the treatment of osteoporosis are salmon calcitonin and alendronate. Several other agents are under development, including sustained-release fluoride and other products in the bisphosphonate class. The development and adoption of early detection programs and treatment guidelines are crucial to help ease the economic burden of osteoporosis. These guidelines should incorporate preventive measures such as diet and exercise, risk assessment through proper screening programs, and the appropriate use of pharmaceutical products. The purpose of this paper is to discuss relevant economic issues associated with osteoporosis and discuss the need for a management algorithm that could be used to more efficiently prevent and treat this disease. We conclude that further modeling is needed to determine which programs and treatments are most cost-effective within each at-risk subgroup. As clinicians better understand the need for preventive care and the advantages of the various pharmacologic therapies, patients with osteoporosis will receive higher-quality and more efficient medical care.

The worldwide problem of osteoporosis: insights afforded by epidemiology

Osteoporosis is one of the major problems facing women and older people of both sexes. The morbid event in osteoporosis is fracture. However, the definition of osteoporosis should not require the presence of fractures but only a decrease in bone mass that is associated with an unacceptably high risk of fracture. In the USA, approximately 1.5 million fractures annually are attributable to osteoporosis: these include 700,000 vertebral fractures, 250,000 distal forearm (Colles') fractures, 250,000 hip fractures, and 300,000 fractures of other limb sites. The lifetime risk of fractures of the spine (symptomatic), hip, and distal radius is 40% for white women and 13% for white men from 50 years of age onwards. Following a hip fracture, there is a 10%-20% mortality over the subsequent 6 months, 50% of sufferers will be unable to walk without assistance, and 25% will require long-term domiciliary care. Contrary to prevailing opinion, the morbidity and suffering associated with wrist and spine fractures are also considerable. The annual cost of osteoporosis to the US healthcare system is at least $5-$10 billion with similar incidence and cost in other developed countries. These already high costs will increase further with continued aging of the population. In addition, the population explosion in underdeveloped countries will change the demography of osteoporosis; for example, the incidence of hip fracture, and, presumably, other osteoporotic fractures will increase four-fold worldwide during the next 50 years and the attendant costs will threaten the viability of the healthcare systems of many countries. Unless decisive steps for preventive intervention are taken now, a catastrophic global epidemic of osteoporosis seems inevitable.

Osteoporosis: diagnosis and management today and tomorrow

Osteoporosis is a disease in which low bone mass and microarchitectural deterioration of bone tissue lead to increased bone fragility and a consequent increase in fracture risk. The risk of developing osteoporosis can be assessed by determining the maximum density and strength achieved at maturity (peak bone mass) and the rate and duration of age-associated bone loss. The major cause of osteoporosis is estrogen withdrawal in women, most commonly associated with the menopause, but also with other causes of ovarian failure. Androgen insufficiency in men, although much less common, can also lead to osteoporosis. Measurements of bone mineral density (BMD) have been used to predict fractures, and current evidence suggests that fractures at any site can be predicted by taking measurements of BMD at any other site in the skeleton, using noninvasive techniques such as single or dual energy absorptiometry, quantitative computed tomography and ultrasound, a promising but experimental approach. Rapid bone loss at the start of the menopause is also an important contributing factor to the development of osteoporosis. Levels of biochemical markers of bone turnover in plasma and urine have been found to correlate with rapid and prolonged bone loss. Powerful new assays for estimating bone turnover have emerged and more are being developed. Various combinations of these biochemical tests may be used in conjunction with bone densitometry to predict future risk of osteoporosis and osteoporosis-related fractures. Furthermore, biochemical tests can also be useful in assessing response to therapy. Although many factors, including sex, race, heredity and lifestyle (e.g., calcium intake, minerals, nutrition and exercise), influence the risk of osteoporosis, i.e., they affect peak bone mass and subsequent bone loss, and are of little use in predicting future occurrence.

[Osteoporosis drugs prescribed on blue forms!]

The National Insurance Administration, through the system of blue prescription forms, refunds part of the cost of drugs used to treat a number of chronic diseases. To obtain a refund, the indication for prescribing the drug must be included in the list of diagnoses which entitle a refund through the system. The list is a long one, and costs are refunded for prophylactic drugs (e.g. against hypertension and hypercholesterolemia), drugs to alleviate symptoms (e.g. for certain skin diseases and heart failure) and curative measures. The qualitative criteria for a refund, over and above the diagnosis, are not precisely defined, and doctors are free to choose the drug they prefer, regardless of price. The authors discuss whether the list of diagnoses should be extended to include osteoporosis, and recommend that doctors should be able to prescribe the relevant preventive and palliative drugs on a blue form. Many think that this refund system is a good initiative.

Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report. WHO Study Group

The criteria required for an effective screening strategy for osteoporosis are largely met in Caucasian women. The disease is common and readily diagnosed by the measurement of bone mineral with single- or dual-energy absorptiometry. Such measurements have high specificity but lower sensitivity, so that the value of the technique is greater for those identified as being at higher risk. Against this background there is little evidence that osteoporosis can usefully be tackled by a public health policy to influence risk factors such as smoking, exercise and nutrition. This suggests that it is appropriate to consider targetting of treatment with agents affecting bone metabolism to susceptible individuals. Since the main benefits of the use of hormone replacement therapy (HRT) are probably on cardiovascular morbidity, the major role for selective screening is to direct non-HRT interventions. An appropriate time to consider screening and intervention is at the menopause, but screening at later ages is also worthy of consideration. Since the cost of screening is low and that of bone-active drugs is high, the selective use of screening techniques will improve the cost-benefit ratio of intervention.

Coding and reimbursement issues for dual-energy X-ray absorptiometry

Bone densitometry has a unique and invaluable place in the prevention, diagnosis, and management of osteoporosis. Dual-energy X-ray absorptiometry (DEXA) is currently considered the bone densitometric technique of choice. With this method, the patient at risk for osteoporosis can be identified so that appropriate clinical interventions to prevent fracture can be undertaken. DEXA also allows assessment of the efficacy of these interventions in preventing bone loss. As with any other technology, however, bone densitometry must be properly used in the clinical setting to achieve this benefit. Critical to the proper use of the technology is the realization that a complete assessment of fracture risk requires the measurement of both the spine and the proximal part of the femur, not either site alone, and that assessment of therapeutic efficacy might also require the measurement of both sites, not either site alone. Effective January 1, 1994, the Clinical Procedural Terminology (CPT) code for DEXA has been 76075. This code is intended for measurement of a single site and is to be reimbursed at a global rate of $60.85. Although the assignment of a CPT code for this clinically valuable technology is most welcome, the lack of a code reflecting at least two sites of study and the low rate of reimbursement for a single site suggest a misunderstanding of the actual costs of the technology and the need, on occasion, for measurements at multiple sites.

Hormone replacement therapy: II. A pharmacoeconomic appraisal of its role in the prevention of postmenopausal osteoporosis and ischaemic heart disease

The reduction in estrogen production that occurs at menopause is associated with several long term sequelae. There is an accelerated decrease in bone mineral density leading to an increased risk of osteoporotic fracture. Furthermore, changes in plasma lipid profiles and other cardiovascular parameters increase the risk of cardiovascular and cerebrovascular pathology. These effects are additional to the menopausal symptoms experienced by many women. The effectiveness of estrogen-based hormone replacement therapy (HRT) is well established in preventing bone mineral loss and also in ameliorating menopausal symptoms, with the addition of progestogen maintaining or possibly enhancing the bone-conserving effects. However, prolonged therapy appears to be necessary to conserve bone mineral density and prevent osteoporotic fracture, particularly in women aged greater than or equal to 75 years, and compliance with long term therapy is likely to be poor. Estrogen favourably alters plasma lipid profiles, improves coronary blood flow and inhibits the central distribution of body fat. Effects on haemostatic mechanisms and coronary vasomotor response to acetylcholine have also been suggested as mechanisms for the beneficial effects of estrogen on ischaemic heart disease. The effects of concomitant progestogens on plasma lipids are variable, and may depend on the type, dosage regimen and duration of therapy. Pharmacoeconomic analyses of HRT have used a variety of risk assumptions. Relative risk rates of osteoporotic fracture and mortality from myocardial infarction are assumed to reduce to 0.5 after greater than 5 years' therapy. Long term HRT is associated with a relative risk of approximately 1.3 for breast cancer, whereas the relative risk of endometrial cancer is 4.0 to 8.0 in women with intact uteri receiving prolonged unopposed estrogen therapy. HRT that includes progestogens is assumed to incur no added risk of endometrial cancer, and this treatment is generally recommended for women with intact uteri. Data concerning the effect of HRT on quality of life are limited and utility values for hip fracture of 0.95 to 0.36 have been assigned, depending on assumptions of disability. Cost-benefit, cost-effectiveness and cost-utility studies evaluating HRT in the prevention of osteoporotic fracture have differed widely in methodology, making comparison of results difficult. HRT appears to be most economically useful in the prevention of fracture if used in women who have undergone hysterectomy, in women with high risk of osteoporotic fracture or ischaemic heart disease, and/or in women with menopausal symptoms.(ABSTRACT TRUNCATED AT 400 WORDS)

Cost-effectiveness analysis of hormone replacement therapy and lifestyle intervention for hip fracture

We compared the cost-effectiveness of interventions to prevent osteoporosis using a decision analytic model for a hypothetical cohort of 100,000 healthy perimenopausal women. The interventions were: oestrogen from age 50 for life, oestrogen from age 50 for 15 years, oestrogen from age 65 years for life, and a lifestyle regime of calcium supplements and exercise. The four interventions were compared with the case of no intervention by examining the effects on medical and nursing home costs, life years gained, quality-adjusted life years (QALYs) gained and costs per QALY gained. Lifetime oestrogen therapy from age 65 years achieved the lowest cost per life year gained and the lowest cost per QALY gained. The lifestyle intervention was the most expensive intervention by all measures but was sensitive to the cost of exercise and to the effects of exercise on cardiovascular mortality. Conventionally, oestrogen therapy begins at the menopause to avoid the rapid decline in bone mass that occurs with normally decreasing oestrogen levels. These results indicate that there is evidence, both in terms of fracture prevention and cost, to justify introduction of treatment at a later age. If a lifestyle intervention regimen can reduce cardiovascular mortality as well as hip fracture, this may provide an alternative means of reducing osteoporotic hip fracture at a reasonable cost.

Assessment of the risk of osteoporosis at the menopause: therapeutic consequences

Osteoporosis prevention programs, based on risk assessment, are an important goal both for individual patients and for improved public health. I have reviewed some of the current approaches to such programs and the major questions which must be answered in order to validate these approaches. In particular, new knowledge concerning the usefulness of markers of bone turnover and of the effectiveness of antiresponsive strategies should greatly improve our ability to prevent osteoporotic fractures. Meanwhile, there is enough information to support the concept that risk assessment should be used to develop a cost-effective prevention program and to guide the approach to therapy.

Economic evaluation of osteoporosis prevention

In this paper economic evaluation of osteoporosis prevention is discussed. So far economic evaluation in this area has been limited to cost-effectiveness analysis. Four cost-effectiveness analyses of osteoporosis prevention are reviewed. It is noted that the major problem with these studies is the lack of reliable and valid data to base the cost-effectiveness analyses on, which precludes clear-cut conclusions about the cost-effectiveness of osteoporosis prevention. The studies, however, form a basis for future cost-effectiveness analyses in this field and as new data become available it should be possible to improve the accuracy and precision of the analyses. Due to the methodological problems of cost-effectiveness analysis and the decision-maker approach to economic evaluation, it is also argued that the contingent valuation (CV) method of measuring willingness to pay should be tested in this area. The CV method can be used both to value an actual treatment and the outcome of that treatment and the resulting amount can be compared with the costs (including the costs of externalities) to carry out cost-benefit analysis. It is concluded that a lot of work remains to be done in this area before economic evaluations can give a real contribution to policy, but such work may well be worthwhile due to the importance of this public health problem.

Targeted estrogen/progesterone replacement therapy for osteoporosis: calculation of health care cost savings

Osteoporosis is a crippling affliction in which bone mass decreases, making it more susceptible to fracture. In postmenopausal women it presents most often as a hip, spinal, or forearm fracture. Adult women face a 15% lifetime risk of a hip fracture, and the annual costs of hip fractures alone are estimated at $7.3 billion in the United States. Since the 1970s, estrogen/progestogen therapy has been recognized as an effective intervention that reduces the risk of fractures. Recently, the development of methods for accurately determining bone mass and thus helping to predict bone fracture risk has made this intervention attractive for use in a targeted population. This report analyzes the health care costs and calculates the cost savings of coupling bone mineral density screening at the time of menopause with long-term estrogen/progestogen therapy for those most at risk for developing fractures. The model assumes that a cohort of 100,000 American white women, aged 50, are screened for bone mineral density and that 90% of the high-risk group (density less than 0.85 g/cm3) and 70% of the mid-risk group (density between 0.85 and 1.00 g/cm3) elect to take hormone replacement therapy for 15 years. Based on calculations of the costs of screening and hormone replacement therapy, and the savings in cost of treatment and lost productivity from reduced fractures, it is estimated that the present value of savings in cost of illness for this cohort over a 40-year period is $5.1 million.(ABSTRACT TRUNCATED AT 250 WORDS)

HRT: an analysis of benefits, risks and costs

A cost-effectiveness analysis of hormone replacement therapy (HRT) was undertaken to assess the relative benefits of different treatment strategies, and to identify which factors most influence cost-effectiveness. The current lack of conclusive evidence on the effects of HRT, especially in relation to combined therapy and cardiovascular disease, necessitated the use of a large number of assumptions in our model. In terms of net health benefits, the potential reduction in cardiovascular disease would have greatest impact, and would overshadow any small increase in breast cancer risk possibly associated with long-term use. Net expenditure by the NHS will depend critically on the direct costs of treatment, rather than on any indirect costs incurred or averted as a result of side-effects. In terms of cost-effectiveness, long-term prophylactic treatment of hysterectomised women and treatment of symptomatic women with a uterus compare favourably with other accepted health care interventions.

[Post-menopausal osteoporosis in Mexico]

A review of general aspects of osteoporosis and of the post-menopausal type specially; clinical appearance and hormonal mechanisms are briefly reviewed. Special emphasis is made upon sexual hormonal events. Demographic, socio-economic and epidemiological changes in México, are analyzed; explaining their causes, present status of the problem and its possible future projection. Finally, several propositions are made in order to face the problem, as follows: 1) Promotion for more research studies as to incidence, risk factors, determination of population standards for bone mass, 2) Health education programs, and 3) Prevention and treatment programs.