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.

A cost-effectiveness analysis of hormone replacement therapy in the menopause

OBJECTIVE

To evaluate the cost-effectiveness of hormone replacement therapy in the menopause with particular reference to osteoporotic fracture and myocardial infarction.

DESIGN

The multiple-decrement form of the life table was the mathematical model used to follow women of age 50 through their lifetime under the "no hormone replacement" and "hormone replacement" assumptions. Standard demographic and health economic techniques were used to calculate the corresponding lifetime differences in direct health care costs (net costs in dollars) and health effects ("net effectiveness" in terms of life expectancy and quality, in "quality-adjusted life-years"). This was then expressed as a cost-effectiveness ratio or the cost ($) per quality-adjusted life-year (QALY) for each of the chosen hormone replacement regimens.

SETTING AND PATIENTS

All women of age 50 in New South Wales, Australia (n = 27,021).

RESULTS

The analysis showed that the lifetime net increments in direct medical care costs were largely contributed by hormone drug and consultation costs. Hormone replacement was associated with increased quality-adjusted life expectancy, a large percentage of which was attributed to a relief of menopausal symptoms. Cost-effectiveness ratios ranged from under 10,000 to over a million dollars per QALY. Factors associated with improved cost-effectiveness were prolonged treatment duration, the presence of menopausal symptoms, minimum progestogen side effects (in the case of oestrogen with progestogen regimens), oestrogen use after hysterectomy and the inclusion of cardiac benefits in addition to fracture prevention.

CONCLUSIONS

Hormone replacement therapy for symptomatic women is cost-effective when factors that enhance its efficiency are considered. Short-term treatment of asymptomatic women for prevention of osteoporotic fractures and myocardial infarction is an inefficient use of health resources. Cost-effectiveness of hormone replacement in asymptomatic women is dependent on the magnitude of cardiac benefits associated with hormone use and the treatment duration.

Cost-effectiveness of hormone replacement therapy after the menopause

The net resource costs and net health benefits of treating perimenopausal women with hormone replacement therapy were evaluated within the framework of cost-effectiveness analysis. Data from the epidemiological literature were used to estimate changes in discounted life expectancy from hip fracture, ischaemic heart disease and breast cancer that are associated with hormone replacement therapy under a variety of assumptions. Economic data were used to estimate changes in total discounted costs that result from the use of hormone replacement therapy. For women with a previous hysterectomy, 10- and 15-year courses of unopposed oestrogen were evaluated. The baseline assumptions for unopposed oestrogen were that breast cancer incidence would be increased for current users by 36% and that deaths from ischaemic heart disease would be reduced by 50% relative to non-users. Under these assumptions, oestrogen replacement therapy was found to be cost-effective, with ratios ranging from $9130 to $12,620 per additional year of life saved. For women who have not had a hysterectomy, 10- and 15-year courses of oestrogen combined with progestin were evaluated. The baseline assumptions for combined therapy were that breast cancer incidence and ischaemic heart disease deaths were unaffected. Under these assumptions, combined therapy was more costly, with ratios ranging from $86,100 to $88,500. Unless combined therapy is found to confer protection against ischaemic heart disease, the most cost-effective strategies for women with no prior hysterectomy may involve screening perimenopausal women to detect women at highest risk of hip fracture followed by selective treatment.

[Urogenital estrogen deficiency syndrome. Investigation and treatment with special reference to hormone substitution]

The risk of developing urogenital disorders increases after menopause due to decline in oestrogen production in postmenopausal women. Symptoms due to atrophy of the squamous epithelium in the vagina, urethra and bladder, recurrent urinary tract infections and abnormal function of lower urinary tract comprise the urogenital oestrogen-deficiency syndrome. The symptoms are directly related to atrophic changes in the urogenital tract. They cause reduced quality of life and persist lifelong if not treated. The present review discusses the incidence, symptoms, pathogenesis and treatment of this syndrome. Substitution therapy with oestriol is effective and has no metabolic effects or serious side effects at the recommended dosage. Oestriol should be used lifelong. The syndrome is underreported and undertreated in Norway. Therefore, an evaluation of the general health condition of elderly women, should include direct questions about these symptoms, and oestriol treatment should be offered liberally. It is effective, safe and cost-effective.

Cost effectiveness of screening perimenopausal white women for osteoporosis: bone densitometry and hormone replacement therapy

Bone mass measurement at menopause to identify and selectively prescribe hormone replacement therapy for women at high risk for fractures has seen limited clinical use. We used epidemiologic, clinical, and economic data in a decision-analytic model to compare the following clinical strategies for perimenopausal, asymptomatic, white women with intact uteri: no intervention; bone mineral density measurement followed by selective, long-term (15-year) estrogen-progestin therapy in women with low bone mass; and unselective, universal hormone replacement therapy. Life expectancy and direct medical cost per patient were estimated for each strategy. Strategies for screening and treating women with perimenopausal bone mineral density less than 0.9 g/cm2 or less than 1.0 g/cm2 would cost $11,700 or $22,100, respectively, per year of additional life gained. If the cost of screening is less than $84, then resource savings from hip fractures prevented would be more than the cost of screening and treatment. Universal treatment without screening would prevent additional fatal fractures but would expose many more women to the adverse effects of hormone replacement therapy and would cost an additional $349,000 per year of life gained compared with the screening strategies. When quality of life was considered, screening was found to be cost effective over a wide range of assumptions. The choice between universal treatment and screening depends on the risks (breast cancer), perceived side effects (menstrual bleeding), and benefits (prevention of ischemic heart disease) of estrogen-progestin therapy. We conclude that screening asymptomatic, perimenopausal white women to detect low bone mass and to target hormone replacement therapy at women who are at the greatest risk for fracture is a reasonably cost-effective use of health care resources. However, cost-effective screening guidelines cannot be explicitly established until further data addressing the association between bone mass measurements in the hip and hip fracture risk are available.

General practitioners use of hormone-replacement therapy in Yorkshire

Questionnaires were sent to 1000 general practitioners (GPs) in the Yorkshire Region to obtain information about their approach to the use of hormone-replacement therapy (HRT) in the menopause. A total of 310 GPs returned completed questionnaires. These showed widely varying views. The majority of GPs estimated that less than 10% of their perimenopausal patients had taken HRT at some time. There was confusion about the reported effects of HRT, on the risks of endometrial carcinoma and on ischaemic heart disease. Thus, while 86% correctly judged that HRT was protective against osteoporosis, 70% concluded against prevailing opinion that combined preparations increase the risk of endometrial cancer. In contrast to the bulk of evidence, nearly 50% of respondents believed that the risk of ischaemic heart disease was also increased by HRT. A number of GPs considered lack of an authoritive lead from epidemiology to be their greatest difficulty in forming an opinion on the desirability of HRT. The general approach to HRT was cautious in respect of both the frequency and the duration of the therapy. Less than a quarter of the GPs were sympathetic to the idea of prophylactic HRT and only 7% routinely discussed this possibility with menopausal patients, while the majority felt that the duration of therapy should be limited to 2 years or less. Most respondents also showed intuitive resistance to the idea of 'mass therapy' at the menopause and expressed concern at the idea of 'interfering with nature'.