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

Combination of Red Clover and Hops Extract Improved Menopause Symptoms in an Ovariectomized Rat Model

Red clover and hops are already known for their alternative menopausal therapies; however, their combination has not yet been studied. This study aimed to evaluate the efficacy of the combination of red clover and hops extract (RHEC) for treating menopausal symptoms for the first time. A high-performance liquid chromatography (HPLC) method for RHEC was developed and validated for the analysis of biochanin A in red clover extract and xanthohumol in hops extract. An in vivo study was conducted using an ovariectomized rat model treated with RHEC (125, 250, and 500 mg/kg, p.o.) for a 12-week test period. Changes in body weight, tail skin temperature (TST), serum lipid profile, bone metabolism, antioxidants, and markers of vasorelaxation and uterus endometrium were evaluated. RHEC significantly inhibited body weight gain and decreased fat weight. Changes in TST associated with flashes were significantly inhibited in the RHEC groups. Other markers related to menopausal symptoms, such as blood lipid profile (total cholesterol and low-density-lipoprotein cholesterol), bone metabolism (serum alkaline phosphatase, osteocalcin, and c-terminal telopeptide type 1), antioxidants (superoxide dismutase and malondialdehyde), and vasorelaxants (endothelin-1 and nitric oxide), were significantly improved after the administration of RHEC. We also confirmed the safety of RHEC through histopathological observation of the endometrium. Our findings demonstrate that RHEC appears to have high potential for comprehensively improving various symptoms of menopause.

One year outcomes and costs following a vertebral fracture

Vertebral fractures are believed to be important predictors for future vertebral and other fractures, leading to at least a 4- to 5-fold increase in the risk of subsequent fractures. However, little is known about their associated near-term costs. The purpose of this study was to quantify the subsequent fracture and cost outcomes emanating from patients with an incident vertebral fracture. A probabilistic decision analysis model was developed to estimate the expected cost of all subsequent fractures. We ran Kaplan-Meier time-to-event models on placebo patients in risedronate's pivotal phase III clinical trial data to determine the cumulative incidence or probabilities of all fractures within one year of an incident vertebral fracture. Unit costs for health care payers in the USA and Sweden for vertebral, hip, other, and forearm/wrist fractures were multiplied by fracture probabilities to generate the expected costs of new fractures within one year of incident vertebral fractures. Our analysis found that that 26.1% of vertebral fracture patients with a mean age of 74 years refractured within 1 year (vertebral 17.4%; hip 3.6%; "other" 3.5%; forearm/wrist 1.6%). The calculated medical costs for those patients who refracture within 1 year was $5906 and 3670 euros for the USA and Sweden, respectively, while the weighted average cost across all patients (refracture and non-fracture) within a year of their incident fracture was $1541 (USA) and 958 euros (Sweden). These results suggest that therapies with proven, rapid efficacy may offer important economic value to healthcare payers, providers and patients.

Methodology for estimating current and future burden of osteoporosis in state populations: application to Florida in 2000 through 2025

OBJECTIVES

The aging population is expected to increase the burden of osteoporosis on the US health-care system. We developed a methodology for estimating current and future costs of osteoporosis in state populations and applied it to Florida.

METHODS

We used Florida hospital, population and mortality data, along with national data on outpatient and long-term care, to estimate the cost of osteoporotic fractures in the year 2000. For men and for "other" fractures in women, costs were based on the incidence of hospital admissions for fractures. For hip, spine, and wrist fractures in women, we integrated hospital and nonhospital fracture incidence in a Markov model of osteoporosis. Consecutive cohorts were run by race for each age, 50 to 99 years, to estimate the number and cost of incident fractures. Ongoing costs of prevalent fractures in women were estimated using postfracture health states for each individual age cohort. Total costs and fractures for the years 2001 through 2025 were projected by multiplying the base-year cost and fracture distribution by age-, sex-, and race-specific population growth rates.

RESULTS

In Florida, 86,428 osteoporotic fractures were estimated to occur in the year 2000 at a cost of 1,238,445,114 dollars. By 2025, the estimated number of incident fractures would increase to 151,622, at a cost of 2,135,130,564 dollars.

CONCLUSIONS

This disease-modeling approach generates detailed information on the current and future cost burden of osteoporosis for an individual state population. Predictions based on this methodology may enable health-policy decisions that are tailored to local needs.

Estimating hip fracture morbidity, mortality and costs

OBJECTIVES

To estimate lifetime morbidity, mortality, and costs from hip fracture incorporating the effect of deficits in activities of daily living.

DESIGN

Markov computer cohort simulation considering short- and long-term outcomes attributable to hip fractures. Data estimates were based on published literature, and costs were based primarily on Medicare reimbursement rates.

SETTING

Postacute hospital facility.

PARTICIPANTS

Eighty-year-old community dwellers with hip fractures.

MEASUREMENTS

Life expectancy, nursing facility days, and costs.

RESULTS

Hip fracture reduced life expectancy by 1.8 years or 25% compared with an age- and sex-matched general population. About 17% of remaining life was spent in a nursing facility. The lifetime attributable cost of hip fracture was $81,300, of which nearly half (44%) related to nursing facility expenses. The development of deficits in ADLs after hip fracture resulted in substantial morbidity, mortality, and costs.

CONCLUSION

Hip fractures result in significant mortality, morbidity, and costs. The estimated lifetime cost for all hip fractures in the United States in 1997 likely exceeded $20 billion. These results emphasize the importance of current and future interventions to decrease the incidence of hip fracture.

Inpatient hospital and post-acute care for vertebral fractures in women

OBJECTIVE

Approximately 700,000 vertebral fractures occur annually in the United States. Available estimates on hospital costs and length of stay for vertebral fractures do not reflect current practice patterns, nor has post-acute care utilization been reported in sufficient detail. This paper provides new estimates on acute care charges, length-of-stay (LOS), and distribution patterns of post-acute care for osteoporotic vertebral fractures in women aged 50 years and older in the United States.

METHODS

The Nationwide Inpatient Sample (NIS) database (1997) was used to identify admissions with a primary diagnosis of vertebral fracture. Decision rules based on clinical criteria were developed to identify vertebral fracture cases considered to be osteoporosis-related. Charges, LOS and discharge disposition were analyzed according to patient demographics and hospital characteristics.

RESULTS

In 1997, there were 53,066 hospital admissions for osteoporotic vertebral fractures in women. Mean charges and LOS were US 9,532 dollars and 6.2 days, respectively, while US totals were US 506 million dollars and 329,000 days. More than 40% were discharged to long-term care (LTC); another 24.3% required other follow-up care. Charges and LOS were inversely related to age. Female patients aged 75 or more were more than five times as likely to be discharged to LTC compared to women between the ages of 50 and 64. Charges and LOS were in general, significantly higher for patients in the Northeast, urban areas, teaching hospitals and in larger hospitals, and for patients transferred from other acute care hospitals.

CONCLUSIONS

Vertebral fractures are more expensive and resource-intensive than previously reported. Furthermore, total costs may be much greater when the components of post-acute care are fully captured.

Hip fracture prevention: cost-effective strategies

The available literature on cost benefit, cost effectiveness and cost utility of different drug and non-drug regimens in preventing hip fractures was reviewed. The cost of a hip fracture and of the different treatment regimens varied considerably from one country to another. In primary prevention, potential savings only exceeded costs in women over the age of 70 years treated with hormonal replacement therapy (HRT). In the case of HRT, treating those with low bone mineral density levels (secondary prevention) seems to be more cost effective than general treatment (primary prevention). There are few studies that have compared several different preventive regimens. Cost effectiveness is directly related to the cost of the regimen used because there is no significant difference in their effectiveness. That is, a high cost regimen such as bisphosphonates would be less cost effective than a low cost regimen such as HRT, judged from existing literature. High risk groups can be identified (nursing home residents) and treated with low cost interventions (calcium plus vitamin D or hip protectors). Considerable differences in the estimates used for the efficacy of different regimens in studies exist. Further studies comparing several hip fracture preventive regimens are required in order to establish the most cost-effective strategy.

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.

The economic cost of hip fractures in community-dwelling older adults: a prospective study

OBJECTIVES

To evaluate the incremental cost in the year after hip fracture.

DESIGN

Prospective cohort study.

SETTING

Baltimore, Maryland.

PARTICIPANTS

759 community dwelling older patients who sustained a hip fracture and participated in the Baltimore Hip Fracture Study.

MEASUREMENTS

Resource use for direct medical care, formal nonmedical care, and informal care in the 6 months before and the year after fracture was estimated from interviews with patients or proxy respondents. Costs in 1993 dollars were estimated by multiplying resources times national unit cost estimates.

RESULTS

The annualized costs in the year before the fracture ranged between $18,523 and $20,928. The costs in the year after the fracture equaled $37,250. The incremental costs in the year after the fracture, compared with the costs in the year before the fracture, ranged between $16,322 and $18,727. The largest cost differences were attributable to hospitalizations, nursing home stays, and rehabilitation services.

CONCLUSIONS

Because we compared the costs after a fracture with costs before, our estimates of the incremental cost of a hip fracture are lower than others in the literature. These results, obtained from interviews with patients enrolled in a cohort study, or their proxies, provide the best data available to date on the economic cost of hip fractures among community-dwelling older persons.

Direct clinical and welfare costs of osteoporotic fractures in elderly men and women

Osteoporosis is an increasing health care problem in all aging populations, but overall direct costs associated with the total fracture burden of osteoporosis remain uncertain. We have examined direct costs associated with 151 osteoporotic fractures occurring between 1989 and 1992 in a large cohort of elderly men and women followed prospectively as part of the Dubbo Osteoporosis Epidemiology Study. The median cost of hospital treated fractures was $A10,511 per fracture and for fractures treated on an outpatient basis $A455 in 1992 Australian dollars. Femoral neck fractures were the most expensive fractures ($15,984 median cost). There was no significant difference in costs between men and women for either hospital- or outpatient-treated fractures. Rehabilitation hospital costs comprised the largest proportion of costs (49%) for hospital-treated fractures. Community services comprised the major cost (40%) of outpatient-treated fractures. Univariate predictors of costs were quadriceps strength and bone density, although multivariate analysis showed quadriceps strength to be the best overall predictor of costs. The predicted annual treatment costs in Australia for atraumatic fractures occurring in subjects > or = 60 years was $A779 million or approximately $A44 million per million of population per annum. Estimated total osteoporotic fracture-related costs for the Australian population were much higher than previously reported. The majority of direct costs (95%) were incurred by hospitalized patients and related to hospital and rehabilitation costs. Extrapolation of these data suggests that the direct costs for hip fracture alone will increase approximately twofold in most Western countries by 2025. Improving the cost-effectiveness of treating osteoporotic fractures should involve reduced hospitalization and/or greater efficiency in community rehabilitation services. The costs of various approaches to osteoporosis prevention must be placed into the context of these direct costs and prevention should target men as well as women.