Health-related quality of life of Colles' fracture patients

Use of the visual analogue scale for health state valuation: a scoping review

OBJECTIVES

The visual analogue scale (VAS) has been used in the context of health and healthcare for various purposes, for example, to measure pain and to provide a single-index measure of health-related quality of life (HRQoL). This scoping review aims to describe how the VAS has been used for health state valuation in the published literature.

METHODS

The search was carried out in Medline, Web of Science and PsycInfo. The findings of the included articles were tabulated and presented descriptively using frequencies and proportions.

RESULTS

The database search yielded 4856 unique articles, out of these, 308 were included. In 83% of the articles, the main purpose for using a VAS was to value health states. The two most common perspectives when valuing health states with a VAS were hypothetical (44%) and own health (34%). Some (n = 14) articles used the VAS in the context of economic evaluations, including calculating quality-adjusted life years (QALYs). A large variation in the design of the VAS was found, including the description of the lower and upper anchors. Advantages and disadvantages with using a VAS were mentioned in 14% of the included articles.

CONCLUSION

The VAS has been a common method for valuing health states, both as a stand-alone method and in combination with other valuation methods. Despite its widespread use, the design of the VAS has been inconsistent which makes comparison of results across studies challenging. Further research on the role of using the VAS in economic evaluations is warranted.

Quality of life after fragility fracture in the Russian Federation: results from the Russian arm of the International Cost and Utility Related to Osteoporotic Fractures Study (ICUROS)

Changes in health-related quality of life (QoL) due to hip, humeral, ankle, spine, and distal forearm fracture were measured in Russian adults age 50 years or more over the first 18 months after fracture. The accumulated mean QoL loss after hip fracture was 0.5 and significantly greater than after fracture of the distal forearm (0.13), spine (0.21), proximal humerus (0.26), and ankle (0.27).

INTRODUCTION

Data on QoL following osteoporotic fractures in Russia are scarce. The present study evaluated the impact of hip, vertebral, proximal humerus, distal forearm, and ankle fracture up to 18 months after fracture from the Russian arm of the International Costs and Utilities Related to Osteoporotic Fractures Study.

METHODS

Individuals age ≥ 50 years with low-energy-induced humeral, hip, clinical vertebral, ankle, or distal forearm fracture were enrolled. After a recall of pre-fracture status, HRQoL was prospectively collected over 18 months of follow-up using EQ-5D-3L. Multivariate regression analysis was used to identify determinants of QALYs loss.

RESULTS

At 2 weeks, patients with hip fracture (n = 223) reported the lowest mean health state utility value (HSUV) compared with other fracture sites. Thereafter, utility values increased but remained significantly lower than before fracture. For spine (n = 183), humerus (n = 166), and ankle fractures (n = 214), there was a similar pattern of disutility with a nadir within 2 weeks and a progressive recovery thereafter. The accumulated mean QoL loss after hip fracture was 0.5 and significantly greater than after fracture of the distal forearm (0.13), spine (0.21), proximal humerus (0.26), and ankle (0.27). Substantial impairment in self-care and usual activities immediately after fracture were important predictors of recovery across at all fracture sites.

CONCLUSIONS

Fractures of the hip, vertebral, distal forearm, ankle, and proximal humerus incur substantial loss of QoL in Russia. The utility values derived from this study can be used in future economic evaluations.

Patient-reported functional outcomes and health-related quality of life following fractures of the talus

INTRODUCTION

The primary aim of this study was to investigate patient-reported outcomes following talar fractures. Secondary aims were to investigate health-related quality of life and to determine whether it is influenced by functional outcome.

MATERIALS AND METHODS

This retrospective study identified 56 talar fractures over eight years. Patients were contacted by post and the Olerud and Molander score (OMS), Manchester-Oxford Foot and Ankle scores (MOXFQ) and Euroqol-5D-3L collected.

RESULTS

The mean age was 35.2 years (range 13-78 years). There were four cases (7.1%) of avascular necrosis and one (1.8%) non-union occurred. Data from patient-reported outcome measures were available for 42 patients (75.0%) with a median follow-up of 67.1 months (range 23.2-111.8 months). Mean OMS was 60.0 (standard deviation ± 29.51) and median MOXFQ was 30.33 (interquartile range 47.13). Median Euroqol-5D-3L index was 0.74 (interquartile range 0.213) and median Euroqol-5D-3L visual analogue score was 80 (interquartile range 21). Older age, open fractures, multiple injuries and subsequent avascular necrosis were associated with worse patient-reported outcomes (P < 0.05), with older age, avascular necrosis and open fractures found to be independent predictors of poor OMS, and avascular necrosis and open fractures independently predicting MOXFQ score on regression analysis (P < 0.05). Poor self-reported function, measured by OMS and MOXFQ, correlated with worse health-related quality of life as measured by the Euroqol-5D-3L index (OMS: r = 0.764, P < 0.001; MOXFQ: r = 0.824, P < 0.001) and visual analogue score (OMS: r = 0.450, P = 0.003; MOXFQ: r=0.559, P < 0.001).

CONCLUSIONS

Older age, avascular necrosis and open fractures predict poorer functional outcomes following talar fractures. Patients with worse limb-specific functional outcomes are more likely to have a worse perception of health-related quality of life.

The Impact of Chronic Discogenic Low Back Pain: Costs and Patients' Burden

Introduction

Chronic discogenic low back pain (CDP) is frequently diagnosed in patients referred to specialized pain clinics for their back pain. The aim of this study is to assess the impact of CDP both on the individual patient and on society.

Materials and Methods

Using the baseline records of 80 patients in a randomized trial assessing the effectiveness of a new intervention for CDP, healthcare and societal costs related to back pain are calculated. Furthermore, the impact of the condition on perceived pain, disability, health-related quality of life, Quality of life Adjusted Life Years (QALY), and QALY loss is assessed.

Results

Using the friction costs approach, we found that the annual costs for society are €7,911.95 per CDP patient, 51% healthcare and 49% societal costs. When using the human capital approach, total costs were €18,940.58, 22% healthcare and 78% societal costs. Healthcare costs were mainly related to pain treatment. Mean pain severity was 6.5 (0-10), and 46% suffered from severe pain (≥7/10). Mean physical limitations rate was 43.7; 13.5% of the patients were very limited to disabled. QALY loss compared to a healthy population was 64%.

Discussion

This study shows that in patients with CDP referred to a pain clinic, costs for society are high and the most used healthcare resources are pain therapies. Patients suffer severe pain, are physically limited, and experience a serious loss in quality of life.

Cost-effectiveness of osteoporosis screening strategies for hip fracture prevention in older Chinese people: a decision tree modeling study in the Mr. OS and Ms. OS cohort in Hong Kong

Despite the high costs of hip fracture, many governments provide limited support for osteoporosis screening. We demonstrated that osteoporosis screening by dual-energy X-ray absorptiometry (DXA) with or without pre-screening by Fracture Risk Assessment Tool (FRAX) or calcaneal ultrasound are more cost-effective than no screening in Chinese people aged 65 or over in Hong Kong.

INTRODUCTION

To examine the cost-effective potential osteoporosis screening strategies for hip fracture prevention in Hong Kong.

METHODS

Decision tree models were constructed to evaluate the cost per quality-adjusted life years (QALYs) of the different osteoporosis screening strategies followed by subsequent 5-year treatment with alendronate compared to no screening (but treat if a hip fracture occurs). The multiple osteoporosis screening strategies were composed of alternative tests and initiation age groups were evaluated with a 10-year horizon, and treatment were assigned if central dual-energy X-ray absorptiometry (DXA) T-score (at either the hip or spine) is - 2.5 or less. Strategies included DXA for all people and pre-screening with the Fracture Risk Assessment Tool (FRAX) at specific thresholds or by calcaneal quantitative ultrasonography (QUS) before taking DXA examination. All the model inputs were based on the Mr. OS and Ms. OS Hong Kong cohort; data are obtained from the Social Welfare Department or the published literature.

RESULTS

All of the screening strategies, including the universal screening with DXA and the pre-screening with FRAX or QUS before DXA, were consistently more cost-effective than no screening for people aged 65 years old or over. One-way sensitivity analysis with a more optimistic assumption on treatment adherence or inclusion of other major osteoporotic fractures did not change the results materially. Probabilistic sensitivity analyses showed a dominant role of pre-screening with FRAX followed by subsequent osteoporosis drug treatment in people aged 70 years old or over in Hong Kong.

CONCLUSIONS

Osteoporosis screening strategies based on DXA with or without pre-screening are more cost-effective compared to no screening for Chinese people aged 65 or over in Hong Kong.

A systematic review and economic evaluation of bisphosphonates for the prevention of fragility fractures

BACKGROUND

Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture.

OBJECTIVES

To evaluate the clinical effectiveness and safety of bisphosphonates [alendronic acid (Fosamax^® and Fosamax^® Once Weekly, Merck Sharp & Dohme Ltd), risedronic acid (Actonel^® and Actonel Once a Week^®, Warner Chilcott UK Ltd), ibandronic acid (Bonviva^®, Roche Products Ltd) and zoledronic acid (Aclasta^®, Novartis Pharmaceuticals UK Ltd)] for the prevention of fragility fracture and to assess their cost-effectiveness at varying levels of fracture risk.

DATA SOURCES

For the clinical effectiveness review, six electronic databases and two trial registries were searched: MEDLINE, EMBASE, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Web of Science and BIOSIS Previews, Clinicaltrials.gov and World Health Organization International Clinical Trials Registry Platform. Searches were limited by date from 2008 until September 2014.

REVIEW METHODS

A systematic review and network meta-analysis (NMA) of effectiveness studies were conducted. A review of published economic analyses was undertaken and a de novo health economic model was constructed. Discrete event simulation was used to estimate lifetime costs and quality-adjusted life-years (QALYs) for each bisphosphonate treatment strategy and a strategy of no treatment for a simulated cohort of patients with heterogeneous characteristics. The model was populated with effectiveness evidence from the systematic review and NMA. All other parameters were estimated from published sources. A NHS and Personal Social Services perspective was taken, and costs and benefits were discounted at 3.5% per annum. Fracture risk was estimated from patient characteristics using the QFracture^® (QFracture-2012 open source revision 38, Clinrisk Ltd, Leeds, UK) and FRAX^® (web version 3.9, University of Sheffield, Sheffield, UK) tools. The relationship between fracture risk and incremental net benefit (INB) was estimated using non-parametric regression. Probabilistic sensitivity analysis (PSA) and scenario analyses were used to assess uncertainty.

RESULTS

Forty-six randomised controlled trials (RCTs) were included in the clinical effectiveness systematic review, with 27 RCTs providing data for the fracture NMA and 35 RCTs providing data for the femoral neck bone mineral density (BMD) NMA. All treatments had beneficial effects on fractures versus placebo, with hazard ratios varying from 0.41 to 0.92 depending on treatment and fracture type. The effects on vertebral fractures and percentage change in BMD were statistically significant for all treatments. There was no evidence of a difference in effect on fractures between bisphosphonates. A statistically significant difference in the incidence of influenza-like symptoms was identified from the RCTs for zoledronic acid compared with placebo. Reviews of observational studies suggest that upper gastrointestinal symptoms are frequently reported in the first month of oral bisphosphonate treatment, but pooled analyses of placebo-controlled trials found no statistically significant difference. A strategy of no treatment was estimated to have the maximum INB for patients with a 10-year QFracture risk under 1.5%, whereas oral bisphosphonates provided maximum INB at higher levels of risk. However, the PSA suggested that there is considerable uncertainty regarding whether or not no treatment is the optimal strategy until the QFracture score is around 5.5%. In the model using FRAX, the mean INBs were positive for all oral bisphosphonate treatments across all risk categories. Intravenous bisphosphonates were estimated to have lower INBs than oral bisphosphonates across all levels of fracture risk when estimated using either QFracture or FRAX.

LIMITATIONS

We assumed that all treatment strategies are viable alternatives across the whole population.

CONCLUSIONS

Bisphosphonates are effective in preventing fragility fractures. However, the benefit-to-risk ratio in the lowest-risk patients may be debatable given the low absolute QALY gains and the potential for adverse events. We plan to extend the analysis to include non-bisphosphonate therapies.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013006883.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The influence of late displacement in distal radius fractures on function, grip strength, range of motion and quality of life

Late displacement of distal radius fractures, still in acceptable radiological position after 1-2 weeks, occurs in approximately one-third of cases. The aim of this study was to investigate the influence of late displacement on the functional outcome and quality of life at 1 year in non-operatively treated distal radius fractures. One hundred and seventy five unilateral conservatively treated distal radius fractures with minimal displacement after 10-14 days were finally evaluated in the study. Follow-up included radiographs at 3 months and clinical examination 1 year after the fracture. Final radiographic parameters, grip strength, range of motion, QuickDASH, EQ-5D and pain visual analogue scale were evaluated with multivariate analysis. Late displacement occurred in 28% of the cases and was associated with loss of grip strength and range of motion. No significant differences were seen in the outcome questionnaires.

LEVEL OF EVIDENCE

II.

Osteoporotic fractures may impair life as much as the complications of diabetes

RATIONALE, AIMS, AND OBJECTIVES

To compare the effect of osteoporotic fractures and complications of diabetes mellitus on quality of life (QoL).

METHOD

A cross-sectional study was performed in 840 patients with osteoporosis and in 943 patients with diabetes in Hungary to estimate the effect of osteoporotic fractures and microvascular and macrovascular complications of diabetes on QoL using the EQ-5D questionnaire. Ordinary least-squares regression was performed for the analysis to control for age and gender.

RESULTS

The effects of certain of osteoporotic fractures and diabetes complications were similar in size measured by the EQ-5D. Patients with hip fractures and compressions of the vertebrae suffered more than 0.2 drop in their QoL, which is comparable in size to the most severe complications of diabetes, such as vision loss and amputations.

CONCLUSIONS

The use of mortality and premature mortality as the traditional measures of disease burden in public health policy making means that diseases which strongly affect QoL but less survival might not get the necessary priority. This is especially the case in low-income and middle-income countries where studies on QoL are scarce. Our comparative analysis, which showed that osteoporotic fractures reduce QoL as much as major complications of diabetes, highlights the need for comprehensive disease burden assessment, including losses in functionality and QoL, to support decision making.

Influence of Cortical Comminution and Intra-articular Involvement in Distal Radius Fractures on Clinical Outcome: A Prospective Multicenter Study

Aim  The purpose of this prospective multicenter study was to test the predictive value of cortical comminution and intra-articular involvement on function and quality of life in distal radius fractures (DRFs) using the Buttazzoni's classification system. Patients and Methods  We studied 406 patients between skeletal maturity and 74 years of age with DRF. Fractures with acceptable radiographic alignment were immobilized with a cast. Fractures with nonacceptable radiographic alignment underwent closed reduction and 4 to 6 weeks cast immobilization. Radiographs were obtained after reduction and at 10 to 14 days. Redisplaced fractures were offered surgical treatment. One-year follow-up included grip strength, range of motion (ROM), quickDASH, EQ-5D (including visual analog scale [VAS] for health status), and VAS pain. Results  We found no statistically significant differences in QuickDASH, EQ-5D questionnaire, EQ-5D health status VAS, and VAS pain among the Buttazzoni classes. However, initial displacement was associated with worse quickDASH score, worse EQ-5D score, reduced grip strength, and reduced ROM. Dorsal comminution was associated with worse quickDASH score, reduced flexion, and reduced pronation-supination ability. Volar comminution predicted loss of extension, while intra-articular involvement was associated with reduced flexion-extension arc and worse EQ-5D score. There was a significant difference in ROM between noncomminuted and comminuted fracture classes. Conclusion  Initial fracture position, type of comminution, and intra-articular involvement influenced the clinical outcome in DRF.

Cross cultural adaptation of the English version of the IOF-QLQ to Polish, to assess the health-related quality-of-life of patients after a distal radius fracture

BACKGROUND

A distal radius fracture (DRF) is a common injury that can cause significant pain and lead to a prolonged decrease in physical, emotional, and social functioning. In modern randomized clinical trials, assessing outcomes after a DRF, health-related quality-of-life (HRQoL) is a "must-be" endpoint. Additionally, HRQoL assessments are essential in the clinical decision-making process. The aim of this study to cross-culturally adapt the International Osteoporosis Foundation Quality of Life Questionnaire (IOF QLQ) for patients with a DRF to Polish.

METHODS

A standard forward-backward translation procedure and pilot-testing were used to prepare the Polish version of the IOF QLQ for use in this case-control study. Patients were eligible if they were between 18-80 years and were within 1-3 days after a non-comminuted DRF. The study group was gender and aged matched with healthy controls. All DRF patients filled out the Polish version of the IOF QLQ, the SF-36 and a demographic questionnaire. Assessment points were set as soon as possible after the fracture, 7 days, 6 weeks, 3, 6, 12, and 18 months after the fracture. Standard validity and reliability analyses were performed.

RESULTS

Ninety-seven patients (73 women - 75.3%) with a mean age of 62.4 ± 7.1 years agreed to take part in the study. The control group consisted of 81 patients (60 women - 74.1%) with a mean age 63.9 ± 8.2 years. No significant differences were found between the mean age of patients and controls (p = 0.19). Cronbach's alpha coefficients showed positive internal consistency (0.79-0.89). The interclass correlations for the IOF QLQ domains and the overall score ranged from 0.85 to 0.92. Satisfactory convergent and discriminant validity of the IOF QLQ was seen.

CONCLUSIONS

The Polish version of the IOF QLQ for patients with a DRF is a reliable and valid tool for measuring HRQoL. It can be fully recommended for use in clinical settings in the Polish population. When combined with the SF-36 the IOF QLQ allows to obtain a comprehensive HRQoL assessment in patients with a DRF.

Economic evaluation of a group-based exercise program for falls prevention among the older community-dwelling population

Background

Falls among older people are of growing concern globally. Implementing cost-effective strategies for their prevention is of utmost importance given the ageing population and associated potential for increased costs of fall-related injury over the next decades. The purpose of this study was to undertake a cost-utility analysis and secondary cost-effectiveness analysis from a healthcare system perspective, of a group-based exercise program compared to routine care for falls prevention in an older community-dwelling population.

Methods

A decision analysis using a decision tree model was based on the results of a previously published randomised controlled trial with a community-dwelling population aged over 70. Measures of falls, fall-related injuries and resource use were directly obtained from trial data and supplemented by literature-based utility measures. A sub-group analysis was performed of women only. Cost estimates are reported in 2010 British Pound Sterling (GBP).

Results

The ICER of GBP£51,483 per QALY for the base case analysis was well above the accepted cost-effectiveness threshold of GBP£20,000 to £30,000 per QALY, but in a sensitivity analysis with minimised program implementation the incremental cost reached GBP£25,678 per QALY. The ICER value at 95% confidence in the base case analysis was GBP£99,664 per QALY and GBP£50,549 per QALY in the lower cost analysis. Males had a 44% lower injury rate if they fell, compared to females resulting in a more favourable ICER for the women only analysis. For women only the ICER was GBP£22,986 per QALY in the base case and was below the cost-effectiveness threshold for all other variations of program implementation. The ICER value at 95% confidence was GBP£48,212 in the women only base case analysis and GBP£23,645 in the lower cost analysis. The base case incremental cost per fall averted was GBP£652 (GBP£616 for women only). A threshold analysis indicates that this exercise program cannot realistically break even.

Conclusions

The results suggest that this exercise program is cost-effective for women only. There is no evidence to support its cost-effectiveness in a group of mixed gender unless the costs of program implementation are minimal. Conservative assumptions may have underestimated the true cost-effectiveness of the program.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-015-0028-x) contains supplementary material, which is available to authorized users.

Health-related quality of life after upper extremity injuries and predictors for suboptimal outcome

PURPOSE

The purpose of this study was to examine the impact of upper extremity injuries (UEIs) on health-related quality of life (HRQoL) in adult patients compared with victims of other types of injuries and with the general population, in order to establish recovery patterns of different types of UEIs and determine predictors for suboptimal outcome in the long term.

METHODS

Data were obtained from the Dutch Injury Surveillance System, from the National Hospital Discharge Registry, and from a patient follow-up survey. A total of 608 patients (aged ≥18 years) with an UEI were included. The main outcome measure was HRQoL measured at 2.5, 5, 9 and 24 months after UEI according to the EuroQol-5D (EQ-5D). The predictors for the suboptimal outcome were examined by multivariate linear regression analyses.

RESULTS

For non-hospitalized UEI patients, a substantial loss in HRQoL was observed after 2.5 months which improved to the level of the general population norms by 24 months. For hospitalized UEI patients, HRQoL improved from 2.5 to 24 months but remained far below population norms. The more proximal UEI had a lower HRQoL and a slower recovery of HRQoL than distal injuries. At all time points, the proportion of UEI patients with limitations on the health domains self-care, usual activities and complaints of pain and/or discomfort was higher than in the group of all injuries. Female gender, higher age, low educational level, co-morbidity, shoulder or upper arm injury, multiple injuries and hospitalization are independent predictors for long-term loss in HRQoL.

CONCLUSIONS

The impact of UEI exceeds the health consequences of the group with all injuries, for both non-hospitalized and hospitalized patients. The presence of UEI substantially reduces HRQoL in the short and long term, mainly due to limitations on the health domains self-care, usual activities and complaints of pain and/or discomfort.

CLINICAL RELEVANCE

The impact of UEIs on HRQoL exceeds the health consequences of the group with all injuries. Proximal UEIs had a lower HRQoL and slower recovery than distal injuries. The predictors for the outcome on specific UEIs need to be further investigated in clinical studies, to understand how these differences affect patient-reported outcome measures. These data provide additional insight into treatment outcome and are needed to improve quality of care.

Pain conditions ranked by healthcare costs for members of a national health plan

Healthcare resource utilization (HCRU) and associated costs specific to pain are a growing concern, as increasing dollar amounts are spent on pain-related conditions. Understanding which pain conditions drive the highest utilization and cost burden to the healthcare system would enable providers and payers to better target conditions to manage pain adequately and efficiently. The current study focused on 36 noncancer chronic and 14 noncancer acute pain conditions and measured the HCRU and costs per member over 365 days. These conditions were ranked by per-member costs and total adjusted healthcare costs to determine the most expensive conditions to a national health plan. The top 5 conditions for the commercial line of business were back pain, osteoarthritis (OA), childbirth, injuries, and non-hip, non-spine fractures (adjusted annual total costs for the commercial members were $119 million, $98 million, $69 million, $61 million, and $48 million, respectively). The top 5 conditions for Medicare members were OA, back pain, hip fractures, injuries, and non-hip, non-spine fractures (adjusted annual costs for the Medicare members were $327 million, $218 million, $117 million, $82 million, and $67 million, respectively). The conditions ranked highest for both per-member and total healthcare costs were hip fractures, childbirth, and non-hip, non-spine fractures. Among these, hip fractures in the Medicare member population had the highest mean cost per member (adjusted per-member cost was $21,058). Further examination specific to how pain is managed in these high-cost conditions will enable providers and payers to develop strategies to improve patient outcomes through appropriate pain management.

Comparing 15D and SF-6D performance in fragility wrist and hip fracture patients in a two-year follow-up case-control study

OBJECTIVES

To examine and compare the two utility and health-related quality-of-life (HRQOL) measures 15D and (SF-6D) in fragility wrist and hip fracture patients and controls, study the responsiveness of 15D and SF-6D, and examine the impact of these fractures on changes in 15D and SF-6D scores over 2 years.

METHODS

A total of 152 wrist fracture patients and 164 controls and 61 hip fracture patients and 61 controls with 15D and SF-6D scores were studied.

RESULTS

The mean 15D score decreased significantly in wrist fracture patients between baseline and 2-year follow-up (P=0.003). A wrist fracture was a significant predictor of a decrease in 15D scores 2 years after fracture (B=-0.016; P=0.049), along with low body mass index (B=-0.002; P=0.009). In hip fracture patients, both 15D and SF-6D scores decreased significantly (P<0.001). A hip fracture was a significant predictor of a decrease in 15D (B=-0.060; P=0.001) and SF-6D (B=-0.096; P=0.001) scores.

CONCLUSIONS

Our data suggest that a fragility wrist fracture has a long-term negative effect on HRQOL, but not as strong as for fragility hip fractures. 15D seems to be more responsive than SF-6D when assessing HRQOL in patients with fragility fractures.

Burden of non-hip, non-vertebral fractures on quality of life in postmenopausal women: the Global Longitudinal study of Osteoporosis in Women (GLOW)

Among 50,461 postmenopausal women, 1,822 fractures occurred (57% minor non-hip, non-vertebral [NHNV], 26% major NHNV, 10% spine, 7% hip) over 1 year. Spine fractures had the greatest detrimental effect on EQ-5D, followed by major NHNV and hip fractures. Decreases in physical function and health status were greatest for spine or hip fractures.

INTRODUCTION

There is growing evidence that NHNV fractures result in substantial morbidity and healthcare costs. The aim of this prospective study was to assess the effect of these NHNV fractures on quality of life.

METHODS

We analyzed the 1-year incidences of hip, spine, major NHNV (pelvis/leg, shoulder/arm) and minor NHNV (wrist/hand, ankle/foot, rib/clavicle) fractures among women from the Global Longitudinal study of Osteoporosis in Women (GLOW). Health-related quality of life (HRQL) was analyzed using the EuroQol EQ-5D tool and the SF-36 health survey.

RESULTS

Among 50,461 women analyzed, there were 1,822 fractures (57% minor NHNV, 26% major NHNV, 10% spine, 7% hip) over 1 year. Spine fractures had the greatest detrimental effect on EQ-5D summary scores, followed by major NHNV and hip fractures. The number of women with mobility problems increased most for those with major NHNV and spine fractures (both +8%); spine fractures were associated with the largest increases in problems with self care (+11%), activities (+14%), and pain/discomfort (+12%). Decreases in physical function and health status were greatest for those with spine or hip fractures. Multivariable modeling found that EQ-5D reduction was greatest for spine fractures, followed by hip and major/minor NHNV. Statistically significant reductions in SF-36 physical function were found for spine fractures, and were borderline significant for major NHNV fractures.

CONCLUSION

This prospective study shows that NHNV fractures have a detrimental effect on HRQL. Efforts to optimize the care of osteoporosis patients should include the prevention of NHNV fractures.

Vitamin K supplementation for the primary prevention of osteoporotic fractures: is it cost-effective and is future research warranted?

Lifetime supplementation with vitamin K, vitamin D(3), and calcium is likely to reduce fractures and increase survival in postmenopausal women. It would be a cost-effective intervention at commonly used thresholds, but high uncertainty around the cost-effectiveness estimates persists. Further research on the effect of vitamin K on fractures is warranted.

INTRODUCTION

Vitamin K might have a role in the primary prevention of fractures, but uncertainties about its effectiveness and cost-effectiveness persist.

METHODS

We developed a state-transition probabilistic microsimulation model to quantify the cost-effectiveness of various interventions to prevent fractures in 50-year-old postmenopausal women without osteoporosis. We compared no supplementation, vitamin D(3) (800 IU/day) with calcium (1,200 mg/day), and vitamin K(2) (45 mg/day) with vitamin D(3) and calcium (at the same doses). An additional analysis explored replacing vitamin K(2) with vitamin K(1) (5 mg/day).

RESULTS

Adding vitamin K(2) to vitamin D(3) with calcium reduced the lifetime probability of at least one fracture by 25%, increased discounted survival by 0.7 quality-adjusted life-years (QALYs) (95% credible interval (CrI) 0.2; 1.3) and discounted costs by $8,956, yielding an incremental cost-effectiveness ratio (ICER) of $12,268/QALY. At a $50,000/QALY threshold, the probability of cost-effectiveness was 95% and the population expected value of perfect information (EVPI) was $28.9 billion. Adding vitamin K(1) to vitamin D and calcium reduced the lifetime probability of at least one fracture by 20%, increased discounted survival by 0.4 QALYs (95% CrI -1.9; 1.4) and discounted costs by $4,014, yielding an ICER of $9,557/QALY. At a $50,000/QALY threshold, the probability of cost-effectiveness was 80% while the EVPI was $414.9 billion. The efficacy of vitamin K was the most important parameter in sensitivity analyses.

CONCLUSIONS

Lifetime supplementation with vitamin K, vitamin D(3), and calcium is likely to reduce fractures and increase survival in postmenopausal women. Given high uncertainty around the cost-effectiveness estimates, further research on the efficacy of vitamin K on fractures is warranted.

Impact of generic alendronate cost on the cost-effectiveness of osteoporosis screening and treatment

Introduction

Since alendronate became available in generic form in the Unites States in 2008, its price has been decreasing. The objective of this study was to investigate the impact of alendronate cost on the cost-effectiveness of osteoporosis screening and treatment in postmenopausal women.

Methods

Microsimulation cost-effectiveness model of osteoporosis screening and treatment for U.S. women age 65 and older. We assumed screening initiation at age 65 with central dual-energy x-ray absorptiometry (DXA), and alendronate treatment for individuals with osteoporosis; with a comparator of “no screening” and treatment only after fracture occurrence. We evaluated annual alendronate costs of $20 through $800; outcome measures included fractures; nursing home admission; medication adverse events; death; costs; quality-adjusted life-years (QALYs); and incremental cost-effectiveness ratios (ICERs) in 2010 U.S. dollars per QALY gained. A lifetime time horizon was used, and direct costs were included. Base-case and sensitivity analyses were performed.

Results

Base-case analysis results showed that at annual alendronate costs of $200 or less, osteoporosis screening followed by treatment was cost-saving, resulting in lower total costs than no screening as well as more QALYs (10.6 additional quality-adjusted life-days). When assuming alendronate costs of $400 through $800, screening and treatment resulted in greater lifetime costs than no screening but was highly cost-effective, with ICERs ranging from $714 per QALY gained through $13,902 per QALY gained. Probabilistic sensitivity analyses revealed that the cost-effectiveness of osteoporosis screening followed by alendronate treatment was robust to joint input parameter estimate variation at a willingness-to-pay threshold of $50,000/QALY at all alendronate costs evaluated.

Conclusions

Osteoporosis screening followed by alendronate treatment is effective and highly cost-effective for postmenopausal women across a range of alendronate costs, and may be cost-saving at annual alendronate costs of $200 or less.

Cost-effectiveness of different screening strategies for osteoporosis in postmenopausal women

BACKGROUND

The best strategies to screen postmenopausal women for osteoporosis are not clear.

OBJECTIVE

To identify the cost-effectiveness of various screening strategies.

DESIGN

Individual-level state-transition cost-effectiveness model.

DATA SOURCES

Published literature.

TARGET POPULATION

U.S. women aged 55 years or older.

TIME HORIZON

Lifetime.

PERSPECTIVE

Payer.

INTERVENTION

Screening strategies composed of alternative tests (central dual-energy x-ray absorptiometry [DXA], calcaneal quantitative ultrasonography [QUS], and the Simple Calculated Osteoporosis Risk Estimation [SCORE] tool) initiation ages, treatment thresholds, and rescreening intervals. Oral bisphosphonate treatment was assumed, with a base-case adherence rate of 50% and a 5-year on/off treatment pattern.

OUTCOME MEASURES

Incremental cost-effectiveness ratios (2010 U.S. dollars per quality-adjusted life-year [QALY] gained).

RESULTS OF BASE-CASE ANALYSIS

At all evaluated ages, screening was superior to not screening. In general, quality-adjusted life-days gained with screening tended to increase with age. At all initiation ages, the best strategy with an incremental cost-effectiveness ratio (ICER) of less than $50,000 per QALY was DXA screening with a T-score threshold of -2.5 or less for treatment and with follow-up screening every 5 years. Across screening initiation ages, the best strategy with an ICER less than $50,000 per QALY was initiation of screening at age 55 years by using DXA -2.5 with rescreening every 5 years. The best strategy with an ICER less than $100,000 per QALY was initiation of screening at age 55 years by using DXA with a T-score threshold of -2.0 or less for treatment and then rescreening every 10 years. No other strategy that involved treatment of women with osteopenia had an ICER less than $100,000 per QALY. Many other strategies, including strategies with SCORE or QUS prescreening, were also cost-effective, and in general the differences in effectiveness and costs between evaluated strategies was small.

RESULTS OF SENSITIVITY ANALYSIS

Probabilistic sensitivity analysis did not reveal a consistently superior strategy.

LIMITATIONS

Data were primarily from white women. Screening initiation at ages younger than 55 years were not examined. Only osteoporotic fractures of the hip, vertebrae, and wrist were modeled.

CONCLUSION

Many strategies for postmenopausal osteoporosis screening are effective and cost-effective, including strategies involving screening initiation at age 55 years. No strategy substantially outperforms another.

PRIMARY FUNDING SOURCE

National Center for Research Resources.

Nondisplaced proximal humeral fractures: high incidence among outpatient-treated osteoporotic fractures and severe impact on upper extremity function and patient subjective health perception

BACKGROUND

Although most proximal humeral fractures are attributed to osteoporosis, they are usually not considered individually in osteoporotic studies because of their lower incidence. The purpose of this study was to evaluate the incidence of nondisplaced proximal humeral fractures in comparison with other outpatient-treated osteoporotic fractures, as well as to assess their functional impact and effects on patient-perceived quality of life.

MATERIALS AND METHODS

In this multicenter, cross-sectional, prospective study, all osteoporotic fractures in postmenopausal women aged 50 years or older treated nonoperatively in 358 trauma centers were recorded during a 3-month period. Fractures were considered osteoporotic if caused by a low-energy trauma. Pathologic fractures were excluded. The incidence of proximal humeral fractures in relation to other osteoporotic fractures was calculated. Patients were interviewed by telephone 6 months after the fracture with the Disabilities of the Arm, Shoulder and Hand and EuroQoL 5D questionnaires.

RESULTS

This study comprised 5,147 women (mean age, 72.6 ± 7.5 years) with 5,268 fractures. Of these, 912 (17.5%) had had proximal humeral fractures. The mean Disabilities of the Arm, Shoulder and Hand score was 26.6 ± 25.7. Of the women, 67.3% had pain or discomfort and disclosed significant reductions in functional capacity, especially with regard to self-care (44.5%), daily life activities (56.5%), and anxiety or depression (32.7%).

CONCLUSION

Nondisplaced proximal humeral fractures are among the most common fractures associated with osteoporosis, and they can be a major cause of functional disability and reduction in subjective patient-perceived health.

Impact of prevalent fractures on quality of life: baseline results from the global longitudinal study of osteoporosis in women

OBJECTIVE

To examine several dimensions of health-related quality of life (HRQL) in postmenopausal women who report previous fractures, and to provide perspective by comparing these findings with those in other chronic conditions (diabetes, arthritis, lung disease).

PATIENTS AND METHODS

Fractures are a major cause of morbidity among older women. Few studies have examined HRQL in women who have had prior fractures and the effect of prior fracture location on HRQL. In this observational study of 57,141 postmenopausal women aged 55 years and older (enrollment from December 2007 to March 2009) from 17 study sites in 10 countries, HRQL was measured using the European Quality of Life 5 Dimensions Index (EQ-5D) and the health status, physical function, and vitality questions of the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36).

RESULTS

Reductions in EQ-5D health-utility scores and SF-36-measured health status, physical function, and vitality were seen in association with 9 of 10 fracture locations. Spine, hip, and upper leg fractures resulted in the greatest reductions in quality of life (EQ-5D scores, 0.62, 0.64, and 0.61, respectively, vs 0.79 without prior fracture). Women with fractures at any of these 3 locations, as well as women with a history of multiple fractures (EQ-5D scores, 0.74 for 1 prior fracture, 0.68 for 2, and 0.58 for >/=3), had reductions in HRQL that were similar to or worse than those in women with other chronic diseases (0.67 for diabetes, 0.69 for arthritis, and 0.71 for lung disease).

CONCLUSION

Previous fractures at a variety of bone locations, particularly spine, hip, and upper leg, or involving more than 1 location are associated with significant reductions in quality of life.

Quality of life in glaucoma and three other chronic diseases: a systematic literature review

Chronic diseases have a long-term negative impact on quality of life (QOL). Decreased QOL is associated with increased financial burden on healthcare systems and society. However, few publications have investigated the impact of glaucoma on patients' QOL in comparison with other chronic diseases observed in patients with similar demographic characteristics. To this end, a systematic literature search to assess QOL in glaucoma and three other chronic diseases (osteoporosis, type 2 diabetes mellitus and dementia) was performed. A total of 146 publications were identified that reported QOL using six commonly used generic QOL instruments: 36-, 12- and 20-item Short-Form Health Surveys (SF-36, -12 and -20), EuroQoL (EQ-5D), Sickness Impact Profile (SIP) and the Health Utilities Index-Mark III (HUI-III). The publication breakdown was as follows: glaucoma (10%), osteoporosis (26%), diabetes (52%) and dementia (12%); one publication assessed QOL in glaucoma, diabetes and dementia. QOL was affected to a similar or slightly lesser degree by glaucoma than by osteoporosis, diabetes or dementia. Among the publications reporting SF-36, -12 and -20 evaluations, physical component scores were generally lower than mental component scores across all diseases. QOL was affected more in patients with glaucoma than in demographically matched non-glaucomatous controls according to SF-20 assessment. EQ-5D and SIP results showed that QOL decreased as the severity of glaucoma increased. Patients with glaucoma had the lowest scores on the SIP instrument, indicating better QOL than patients with osteoporosis or diabetes (no data were available on dementia). The HUI-III instrument identified poorer QOL in patients with dementia than other diseases, probably due to cognitive deficits. However, for some of the instruments, data were scarce, and interpretation of the results should be conservative. Although there are limited published QOL studies in glaucoma, its impact on QOL appears to be broadly similar to that of other serious chronic diseases. Development of a QOL instrument that measures vision-specific and general health aspects would better document the impact of glaucoma on QOL and would facilitate comparisons with other chronic disease states.

Validation of the IOF quality of life questionnaire for patients with wrist fracture

INTRODUCTION

Wrist fracture causes pain and decreased physical, social and emotional function. The International Osteoporosis Foundation has developed a specific questionnaire to assess quality of life in patients with wrist fracture. This questionnaire, including 12 questions, was validated in a multicentre study and compared with an osteoporosis-specific questionnaire (Qualeffo-41) and a generic questionnaire (EQ-5D).

METHODS

The study included 105 patients with a recent wrist fracture and 74 sex- and age-matched control subjects. The questionnaire was administered as soon as possible after the fracture, at 6 weeks, 3 months, 6 months and 1 year after the fracture. Test-retest reproducibility, internal consistency and sensitivity to change were assessed.

RESULTS AND DISCUSSION

The results showed adequate repeatability and internal consistency of the International Osteoporosis Foundation (IOF) wrist fracture questionnaire. The discriminatory capacity between patients and control subjects was very high, with significant odds ratios for each question and domain. The IOF-wrist fracture questionnaire domain scores showed significant improvement after 3 and 6 months and some improvement from 6 months up to 1 year. The sensitivity to change was much higher for the IOF-wrist fracture total score than for Qualeffo-41 and EQ-5D.

CONCLUSION

In conclusion, the IOF-wrist fracture questionnaire appears to be a reliable and responsive quality of life questionnaire.

Does farm worker health vary between localised and globalised food supply systems?

Significant environmental benefits are claimed for local food systems, but these biophysical indicators are increasingly recognised as inadequate descriptors of supply chain ethics. Social factors such as health are also important indicators of good practice, and are recognised by the organic and local food movements as important to the development of rounded sustainable agricultural practices. This study compared the self-reported health status of farm workers in the United Kingdom, Spain, Kenya and Uganda who were supplying distant markets with fresh vegetables. Workers on Kenyan export horticulture farms reported significantly higher levels of physical health than did Kenyan non-export farm workers and workers in the other study countries. Mean health levels for farm workers in the United Kingdom were significantly lower than relevant population norms, indicating widespread levels of poor health amongst these workers. These results suggest that globalised supply chains can provide social benefits to workers, while local food systems do not always provide desirable social outcomes. The causal mechanisms of these observations probably relate more to the social conditions of workers than directly to income.

An updated systematic review of Health State Utility Values for osteoporosis related conditions

INTRODUCTION

An important component of cost effectiveness models in the field of osteoporosis is the set of Health State Utility Values (HSUVs) used for key fracture outcomes. This paper presents a review of HSUVs for key osteoporotic states (hip, wrist, shoulder, clinical, and morphometric vertebral fractures, established osteoporosis, and interaction of several fractures). It provides an update to the systematic review conducted by Brazier et al. (Osteoporos Int 13(10):768-776, 2002).

MATERIALS AND METHODS

A systematic search was undertaken of the main literature databases for HSUVs for established osteoporosis, vertebral, hip, wrist, and shoulder fractures were identified. Studies meeting the inclusion criteria were reviewed in terms of the patient population, the method of describing health (if not obtained directly from patients), the method of valuing health states and the source of values.

RESULTS

Estimates of Health State Utility Values were found across the osteoporosis conditions from 27 studies. A wide range of empirical estimates were found, partly due to differences in valuation technique (VAS, SG, TTO), descriptive system and differences in respondents (population or patient), the perspective of the task (own health or a scenario), sample size, and study quality.

CONCLUSION

The paper provides a set of multipliers representing the loss in HSUVs for use as a "reference case" in cost-effectiveness models.

Sequential change in quality of life for patients with incident clinical fractures: a prospective study

Health-related quality of life in elderly women with sustained incident fractures was assessed prospectively for 1 year, using the EuroQol standard. Loss of QOL was more severe in patients after hip or vertebral fractures than those with wrist fracture. QOL was not completely restored in patients suffering from hip fracture.

INTRODUCTION

Osteoporosis-related fractures decrease mobility, social interaction, and emotional well-being. All of these characteristics determine health-related quality of life (HR-QOL). In this study, we assessed HR-QOL in elderly women following incident clinical fractures.

METHODS

Thirty-seven patients with hip fractures (mean age 76.1 years), 35 with vertebral fractures (mean age 72.6 years), and 50 with wrist fractures (mean age 68.6 years) were enrolled. HR-QOL was prospectively measured using EuroQol (EQ-5D) before the fracture, 2 weeks, 3 months, 6 months, and 1 year after the fracture.

RESULTS

During the observation period, reduction of EQ-5D values was greatest in the hip fracture group. In the wrist fracture group, EQ-5D values at 6 months after the fracture showed recovery; however, in the hip and vertebral fracture groups, recovery was significantly lower than before the fracture. One year after the fracture, EQ-5D values were not significantly different from prefracture values in the vertebral and wrist fracture groups, but remained significantly lower in the hip fracture group.

CONCLUSIONS

Loss of QOL was more severe in patients after hip or vertebral fractures than in patients with wrist fracture. HR-QOL was not completely restored in patients suffering from hip fracture.

Utility values associated with osteoporotic fracture: a systematic review of the literature

We reviewed studies that have estimated the impact of osteoporotic fracture on quality-adjusted life years (QALY) and to determine reference values for countries that would like to carry out cost-utility analyses but that do not have their own values. The computerized medical literature databases Medline and EMBASE were searched from January 1990 to December 2006. The search was carried out in two steps. The first step was to identify studies that related to quality of life in osteoporosis. As part of the second step, only the studies that translated quality of life into a utility value (one single value for health status ranging 0-1) and calculated a utility loss over a period of at least 1 year were selected. From the 152 studies identified in the first analysis, only 16 were retained after the second step. Ten studies investigated utility values for hip fractures, 11 for vertebral fractures, five for distal forearm fractures, and four for other osteoporotic fractures and fracture interactions. Utility values differed substantially between studies, partly due to the valuation technique used, the severity of fractures, and the sample size. This review suggests that there is no meaningful average value across different studies, different samples, different countries, or different instruments. Although we tried to determine the best available values, these values do not preclude the need for country-specific studies. Finally, we also make recommendations regarding the design and methodology for such studies.

Cost effectiveness and cost utility of risedronate for osteoporosis treatment and fracture prevention in women: a Swiss perspective

OBJECTIVES

To assess the incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR) of risedronate compared to no intervention in postmenopausal osteoporotic women in a Swiss perspective.

METHODS

A previously validated Markov model was populated with epidemiological and cost data specific to Switzerland and published utility values, and run on a population of 1,000 women of 70 years with established osteoporosis and previous vertebral fracture, treated over 5 years with risedronate 35 mg weekly or no intervention (base case), and five cohorts (according to age at therapy start) with eight risk factor distributions and three lengths of residual effects.

RESULTS

In the base case population, the ICER of averting a hip fracture and the ICUR per quality-adjusted life year gained were both dominant. In the presence of a previous vertebral fracture, the ICUR was below euro45,000 (pound30,000) in all the scenarios. For all osteoporotic women>or=70 years of age with at least one risk factor, the ICUR was below euro45,000 or the intervention may even be cost saving. Age at the start of therapy and the fracture risk profile had a significant impact on results.

CONCLUSION

Assuming a 2-year residual effect, that ICUR of risedronate in women with postmenopausal osteoporosis is below accepted thresholds from the age of 65 and even cost saving above the age of 70 with at least one risk factor.

Beyond hip: importance of other nonspinal fractures

It is widely accepted that hip and spine fractures are associated with substantial morbidity, but there is growing awareness that other fractures are under-recognized. The incidence of nonspinal, nonhip fractures is higher than for hip fractures because they occur at an earlier age. Furthermore, the incidence of nonspinal, nonhip fractures exceeds that of hip fractures in men and women >80 years old. Nonspinal, nonhip fractures are associated with considerable morbidity. On average, women with humeral, ankle, distal forearm, and foot fractures experience substantial numbers of limited activity days, and nonspinal, nonhip fractures account for almost a third of health care expenditures attributable to osteoporotic fractures. Nonspinal, nonhip fractures are associated with low bone mineral density, thus it may be possible to identify those at risk. Because these fractures also are indicative of increased risk at other sites, those susceptible might benefit from assessments including these other fracture types. It is the clinician's responsibility to attend to and recognize that nonspinal, nonhip fractures are usually associated with osteoporosis and should be treated.

A meta-analysis demonstrates no significant differences between patient and population preferences

BACKGROUND AND OBJECTIVES

To summarize and quantify mean differences between directly elicited patient and population health state evaluations (= preferences) and to identify factors explaining these differences.

MATERIALS AND METHODS

Two meta-analyses of observational studies comparing directly elicited patient and population preferences for two stratified health state classifications: actual/hypothetical and hypothetical/hypothetical health states.

RESULTS

Thirty-three articles comparing directly elicited patient and population preferences were included, yielding 78 independent preference estimates. These preference estimates served as input for the two stratified health state classifications. Data on health state assessments, elicitation methods, assessment method, and population characteristics was extracted by one reviewer, and checked by two other reviewers. These parameters were used to explain sources of heterogeneity. Overall, patients' actual health state preferences were not significantly higher than populations hypothetical health state preferences (summary mean difference [SMD] = -0.01, 95% confidence interval [CI] = -0.01, 0.03). Nor did preferences for hypothetical health states differ between patients and population (SMD -0.00, 95% CI = -0.02, 0.02). Most parameters substantially influenced the SMD, although the magnitude and direction differed for the two strata used (all P-values <.05).

CONCLUSIONS

The actual/hypothetical and hypothetical/hypothetical meta-analyses demonstrated no significant differences between patient and population preferences, suggesting that both can be used to allocate scarce resources.

Impact of recent fracture on health-related quality of life in postmenopausal women

The effect of fractures other than hip and spine on HRQoL in younger and older women has not been extensively studied. In a cohort of 86,128 postmenopausal women, we found the impact of recent osteoporosis-related fractures on HRQoL to be similar between women < 65 compared with those > or = 65 years of age. The impact of spine, hip, or rib fractures was greater than that of wrist fractures in both age groups.

INTRODUCTION

Health-related quality of life (HRQoL) after vertebral and hip fractures has been well studied. Less is known about HRQoL after fractures at other sites. We studied the effect of recent clinical fractures on HRQoL, using Short Form-12 (SF-12).

MATERIALS AND METHODS

This study included 86,128 postmenopausal participants in the National Osteoporosis Risk Assessment (NORA) who responded to two follow-up surveys during a 2-year interval. At each survey, they completed the SF-12 HRQoL questionnaire and reported new fractures of the hip, spine, wrist, and rib. The effect of recent fracture on HRQoL was assessed by comparing Physical Component Score (PCS) and Mental Component Score (MCS) means for women with and without new fractures at the second survey. Analyses were by fracture type and by age group (50-64 and 65-99) and were adjusted for PCS and MCS at the first survey.

RESULTS

New fractures (320 hip, 445 vertebral, 657 rib, 835 wrist) occurring during the interval between the first and second follow-up surveys were reported by 2257 women. The PCS was poorer in both older and younger women who had fractured the hip, spine, or rib (p < or = 0.001). Wrist fractures had an impact on PCS in women < or = 65 years of age (p < 0.001), but not older women (p > 0.10). These differences in PCS by fracture status were similar to those reported for other chronic diseases such as asthma, chronic obstructive pulmonary disease (COPD), and osteoarthritis. MCS was less consistently changed by fracture status, but younger and older women with vertebral fracture (p < 0.004), older women with hip fracture (p < 0.004), and younger women with rib fracture (p < 0.004) had poorer MCS compared with those who did not fracture within their age cohort.

CONCLUSIONS

Recent osteoporosis-related fractures have significant impact on HRQoL as measured by SF-12. The impact of recent fracture on HRQoL was similar for older and younger postmenopausal women. Fracture prevention and postfracture interventions that target the subsequent symptoms are needed for postmenopausal women of any age.

Costs and quality of life associated with osteoporosis-related fractures in Sweden

This prospective observational data collection study assessed the cost and quality of life related to hip, vertebral and wrist fracture 1 year after the fracture, based on a patient sample consisting of 635 male and female patients surviving a year after fracture. Data regarding resource use and quality of life related to fractures was collected by questionnaires at baseline, 4 months and 12 months. Information was collected by the use of patients' records, register sources and by asking the patient. Quality of life was estimated with the EQ-5D questionnaire. Costs were estimated from a societal perspective, including direct and indirect costs. The mean fracture-related cost the year after a hip, vertebral and wrist fracture were estimated, in euros (<euro>), at <euro>14,221, <euro>12,544 and <euro>2,147, respectively [converted from Swedish krona (SEK) at an exchange rate of 9.1268 SEK/<euro>]. The mean reduction in quality of life was estimated at 0.17, 0.26 and 0.06 for hip, vertebral and wrist fracture, respectively. Based on the results, the yearly burden of osteoporosis in Sweden could be estimated at <euro>0.5 billion (SEK 4.6 billion). The patient sample for vertebral fracture was fairly small and included a high proportion of fractures leading to hospitalization, but they indicate a higher cost and loss of quality of life related to vertebral fracture than previously perceived.

How many people develop fractures with what outcome?

Osteoporosis is an important clinical and public health problem because of its association with fractures. Osteoporotic fractures result in significant morbidity, mortality and health and social care costs. Hip fracture is the major adverse health consequence associated with the disease, although other fractures are also linked with significant adverse outcomes. Because of current demographic trends, the number of men and women with osteoporosis and osteoporotic fractures is set to increase dramatically over the next 50 years unless effective preventive measures are adopted. Over and above this demographic trend there is evidence that the age-specific rates of fractures have increased during the last century. This chapter reviews the epidemiology of osteoporotic fractures, including their occurrence, descriptive epidemiology and impact.

Quality of life in post-menopausal osteoporosis

Background

To evaluate the impact of osteoporosis on the patients' quality of life, particularly in the absence of fractures.

Methods

100 post-menopausal women (age 50-85) - 62 with uncomplicated primary osteoporosis and 38 with primary osteoporosis complicated by vertebral fractures; all already treated - were studied using two validated questionnaires: Qualeffo-41 for quality of life in osteoporosis, and Zung for depression. Data were compared to those of 35 controls of comparable age, affected by a different chronic disease (hypothyroidism).

Results

Family history of osteoporosis and T-score of spine were similar in the two subgroups of osteoporotic women. Body mass index, age at menopause and education level were similar in the two subgroups of osteoporotic women and in the control group.

The patients affected by osteoporosis perceived it as a disease affecting their personal life with undesirable consequences: chronic pain (66% of women with fractures and 40% of women without fractures), impaired physical ability, reduced social activity, poor well-being (21% of women without fractures) and depressed mood (42% of women irrespective of fractures). Overall, 41% of the women showed a reduced quality of life. On the contrary, in the control group only 11% reported a reduced quality of life.

Conclusion

The quality of life of osteoporotic patients should be investigated even before fractures, in order to develop appropriate counselling, support and care interventions to help patients develop efficient strategies for accepting the disease and coping with it.

Cost-effectiveness of alendronate in the prevention of osteoporotic fractures in Danish women

Pharmacological interventions for osteoporosis may reduce morbidity and mortality, but they incur additional health care costs. The aim was to quantify the additional costs and health benefits of prescribing alendronate 10 mg and calcium/vitamin D daily for 71-year-old women with a fracture risk twice that of the population average in stead of calcium/vitamin D alone. A state transition model based primarily on Scandinavian data was developed. Women were followed from age of 71 years until 100. Alendronate was assumed to reduce the fracture risk by 50%. Health benefits from the interventions were expressed in terms of life years, quality adjusted life years, and fractures avoided. Societal costs were estimated using literature estimates and Danish tariffs. All costs were measured in 2002 Danish Kroner (DKK). Future costs and benefits were discounted at 5% per year. The incremental cost per QALY gained was DKK125,000 while the cost per life year gained was DKK 374,000. The use of alendronate was cost-saving when 1) the treatment was extended to five years, 2) the risk of fracture was four times the population average, 3) the effect of alendronate was assumed to persist for three years after discontinuation of treatment, 4) a greater proportion had severe sequelae after a hip fracture, or 5) the start of therapy was delayed until age of 77 years. In conclusion, the use of alendronate compares well with other well established therapies in terms of cost-effectiveness in older women with high risk of fracture.

Quality of life in patients with osteoporosis

Complaints regarding, and morbidity of, osteoporosis are caused by fractures which are associated with pain and decrease of physical function, social function, and well-being. These are aspects of quality of life. Health-related quality of life covers physical, mental, and social well-being. Quality of life may be measured for evaluation of treatment effects in clinical trials, for the assessment of the burden of the disease of osteoporosis, and for estimates of the cost-effectiveness of different treatment scenarios in health care policy. Quality of life has been measured in patients with osteoporosis with generic questionnaires such as SF-36 and EQ-5D, which can be used in many diseases, or with one of the six available osteoporotic-specific questionnaires, e.g., Qualeffo-41 or OPAQ. Every questionnaire has to be validated to assess psychometric properties and discrimination power between patients with osteoporosis and control subjects. The value attached to specific health states (utility) can be assessed with some generic instruments or by systematic questioning of the patient, e.g., the time-trade-off method. This results in one value for health status ranging from 0 (death) to 1 (perfect health). Utility values can be used to calculate loss of quality-adjusted life years (QALY). Most data have been obtained in patients with prevalent vertebral fractures. Scores of specific and generic questionnaires showed significant loss of quality of life with prevalent vertebral fractures. In addition, studies with Qualeffo-41 and OPAQ showed a deteriorating quality of life with increasing number of vertebral fractures. Lumbar fractures had more impact on quality of life than thoracic fractures. Incident vertebral fractures were also associated with a decrease of quality of life especially in the physical function domain. This applied to clinical incident vertebral fractures as well as to subclinical fractures to a lesser degree. Loss of quality of life following hip fracture has been documented with generic and osteoporosis-specific questionnaires. A considerable loss was observed in the 1st year with some improvement in the 2nd year, but not to baseline values. Quality of life depended on comorbidity, mobility, activities of daily life (ADL)-independence, and fracture complaints. Utility loss has been observed following hip fracture, especially disabling hip fracture, hip and vertebral fracture combined, or multiple vertebral fractures. Utility following osteoporotic fractures has been valued by patients, the healthy elderly, and panels of experts. The healthy elderly gave the worse quality-of-life scores (lower utility) to various hip fractures than patients with hip fractures themselves. In conclusion, suitable instruments exist for measuring quality of life in patients with osteoporotic fractures. These instruments are useful for clinical trials and for assessment of the burden of disease.

Health-related quality of life after osteoporotic fractures

OBJECTIVE

To estimate the impact of osteoporosis fractures on health-related quality of life (HRQOL) in postmenopausal women.

METHODS

To compare the impact on HRQOL of different osteoporotic fractures, 600 consecutive women 55-75 years old with a new fracture (inclusion fracture) were invited by mail. After exclusions by preset criteria (high-energy fractures, ongoing osteoporosis treatment, or unwillingness to participate), 303 women were included, 171 (56%) of whom had a forearm, 37 (12%) proximal humerus, 40 (13%) hip, and 55 (18%) vertebral fracture, respectively, and all were investigated and treated according to the current local consensus program for osteoporosis. In addition, HRQOL was evaluated by the SF-36 questionnaire and compared with local, age-matched reference material. Examinations were performed 82 days (median) after the fracture and 2 years later.

RESULTS

HRQOL was significantly reduced at baseline regarding all SF-36 domains after vertebral fractures and most after hip fractures, but only regarding some domains after forearm and humerus fracture. After 2 years, improvements had occurred after all types of fractures, and after forearm or humerus fracture, HRQOL was completely normalized in all domains. However, 2 years after hip fracture, HRQOL was still below normal regarding physical function, role-physical and social function, while after vertebral fracture, scores were still significantly lower for all domains, physical as well as mental. Patients with one or more previous fractures before the inclusion fracture had lower HRQOL at baseline and after 2 years, compared with those with no previous fracture. Patients with osteoporosis (T-score <-2.5 in hip or spine) had lower HRQOL than those with normal BMD.

CONCLUSION

Vertebral and hip fractures have a considerably greater and more prolonged impact on HRQOL than forearm and humerus fractures. The number of fractures was inversely correlated to HRQOL. These differences should be taken into account when making priorities in health care programs.

Use of the EQ-5D among patients suffering from dementia

BACKGROUND AND OBJECTIVE

This study was designed to determine the acceptability, feasibility, reliability, and validity of the French version of EQ-5D measuring HRQol in subjects with dementia.

METHODS

EQ-5D was administered to 142 subjects. The feasibility and acceptability were determined by the refusal rate, the type of administration, and the percentage and distribution of missing data. Test-retest reliability was studied by kappa coefficients and validity by agreement between subjects' and proxies' assessments.

RESULTS

The response rate was satisfactory. The instrument discriminated well among the subjects. Test-retest reliability was average. The validity was poor if we consider the agreement between patients' and caregivers' reports, but other criteria of validity produced better results. Subjects' responses on each dimension were related with their global judgment of health in the expected direction. Significant relations were found between the Katz index of ADL and self-rated difficulties only for expected dimensions. Relations with age and with gender were in line with expectations.

CONCLUSION

Results led to consider that patients' responses are not entirely devoid of judgment. It seems that dementia patients are capable of expressing their health-related quality of life through a brief instrument as the EQ-5D.

The Impact of Fragility Fracture on Health-Related Quality of Life

Both general and specific health status instruments can be utilised in evaluating health-related quality of life (HR-QOL) deficits resulting from osteoporotic fractures. Osteoporotic hip, vertebral and wrist fractures significantly decrease HR-QOL in most HR-QOL domains investigated. The presence of multiple vertebral fractures leads to larger decrements in HR-QOL. More research needs to be completed with these HR-QOL tools to better assess the true burden of osteoporotic fractures, particularly in the case of hip fractures, as the burden is surely being underestimated without recognition of HR-QOL. Only when the burden of fragility fractures is understood, inclusive of HR-QOL, will the value of proven antifracture prevention and treatment therapies be appreciated. Information collected by HR-QOL instruments may provide new insight as to how to improve quality of life for patients with fractures and how to properly allocate healthcare spending.

The risk and burden of vertebral fractures in Sweden

The aim of this study was to determine the risk and burden of vertebral fractures judged as those coming to clinical attention and as morphometric fractures. Incidence and utility loss were computed from data from Malmo, Sweden. Clinical fractures accounted for 23% of all vertebral deformities in women and for 42% in men. The average 10-year fracture probability for morphometric fractures increased with age in men from 2.9% at the age of 50 years (7.2% in women) to 8.4 at the age of 85 years (26.7% in women). As expected, probabilities increased with decreasing T-score for hip BMD. Cumulative utility loss from a clinical vertebral fracture was substantial and was 50-62% of that due to a hip fracture depending on age. When incidence of fractures in the population was weighted by disutility, all spine fractures accounted for more morbidity than hip fracture up to the age of 75 years. We conclude that vertebral fractures have a major personal and societal impact that needs to be recognised in algorithms for assessment of risk and in health economic strategies for osteoporosis.

Clinical and economic issues in the treatment of advanced breast cancer with bisphosphonates

An ideal palliative therapy for bone metastases would successfully reduce skeletal complications in several thousands of breast cancer patients. Second- and third-generation bisphosphonates are effective in reducing the overall skeletal complication rate and the time to first skeletal complication. Nevertheless, not enough evidence supports their benefit on quality of life. Furthermore, bisphosphonates are expensive (up to 775 US dollars per month, 2002 value) and cost-effectiveness evaluations have been limited to pamidronate (pamidronic acid). In economic evaluations of pamidronate, resulting incremental dollar per quality-adjusted life year gained ranged from cost savings to 108,000 US dollars per quality-adjusted life year. The data were quite sensitive to quality-of-life estimates and country-specific cost values. Because of the wide range of the cost-effectiveness ratio, it is uncertain whether the universal prescription of bisphosphonates in this setting represents an efficient use of healthcare resources. Probably, country- and drug-specific policies might increase the efficiency of this treatment. Further outcomes research is required to assess these agents more fully.

The association between osteoporotic fractures and health-related quality of life as measured by the Health Utilities Index in the Canadian Multicentre Osteoporosis Study (CaMos)

Osteoporotic fractures can be a major cause of morbidity. It is important to determine the impact of fractures on health-related quality of life (HRQL). A total of 3,394 women and 1,122 men 50 years of age and older, who were recruited for the Canadian Multicentre Osteoporosis Study (CaMos), participated in this cross-sectional study. Minimal trauma fractures of the hip, pelvis, spine, lower body (included upper and lower leg, knee, ankle, and foot), upper body (included arm, elbow, sternum, shoulder, and clavicle), wrist and hand (included forearm, hand, and finger), and ribs were studied. Participants with subclinical vertebral deformities were also examined. The Health Utilities Index Mark II and III Systems were used to assess HRQL. Past osteoporotic fractures varied in prevalence from 1.2% (pelvis) to 27.8% (lower body) in women and 0.3% (pelvis) to 29.3% (wrist) in men. Multivariate linear regression analyses [parameter estimates and corresponding 95% confidence intervals (CI)] indicated that minimal trauma fractures were negatively associated with HRQL and that this relationship depends on fracture type and gender. The multi-attribute scores for the Mark II system were negatively related to hip (-0.05; 95% CI: -0.09, -0.01), lower body (-0.02; 95% CI: -0.03, -0.000), and subclinical vertebral fractures (-0.02; 95% CI: -0.03, -0.00) for women. The multi-attribute scores for the Mark III system were negatively related to hip (-0.09; 95% CI: -0.14, -0.03) and rib fractures (-0.06; 95% CI: -0.11, -0.00) for women, and rib fractures (-0.06; 95% CI: -0.12, -0.00) for men. In conclusion, this study demonstrates a negative association between osteoporotic fractures and quality of life in both women and men.

Adverse outcomes of osteoporotic fractures in the general population

Osteoporotic fractures exact a terrible toll on the population with respect to morbidity and cost, and to a lesser extent mortality, which will increase dramatically with the growing elderly population. Attention has focused on the 12-20% excess deaths after hip fracture, but most are caused by underlying medical conditions unrelated to osteoporosis. More important is fracture-related morbidity. An estimated 10% of patients are disabled by hip fracture, and 19% require institutionalization, accounting for almost 140,000 nursing home admissions annually in this country. Distal forearm and vertebral fractures less commonly result in nursing home placement, but about 10% of postmenopausal women have vertebral deformities that cause chronic pain, and a substantial minority have poor function after forearm fracture. These fractures interfere greatly with the activities of daily living, and all of them can have a substantial negative impact on quality of life. Annual expenditures for osteoporotic fracture care in the United States (dollar 17.5 million in 2002 dollars) are dominated by hip fracture treatment, but vertebral fractures, distal forearm fractures, and importantly, the other fractures related to osteoporosis contribute one-third of the total. Although all fracture patients are at increased risk of future fractures, few of them are currently treated for osteoporosis, and only a subset (i.e., those with vertebral fractures) are considered candidates for many clinical trials. Eligibility criteria should be expanded and fracture end-points generalized to acknowledge the overall burden of osteoporotic fractures.

Cost effectiveness of alendronate (fosamax) for the treatment of osteoporosis and prevention of fractures

BACKGROUND

The Fracture Intervention Trial (FIT) demonstrated that the bisphosphonate alendronate reduces the risk of hip, spine and wrist fracture in osteoporotic women by approximately one half.

OBJECTIVE

To use data from FIT to conduct a cost-effectiveness analysis of alendronate.

DESIGN

A Markov model was developed for a cohort of Swedish women, comparable in relative fracture risk to the women enrolled in the FIT vertebral fracture arm (i.e. age 71 years with low bone mass plus at least one prior spine fracture). The women in the model (with low bone mass and a previous spine fracture) were exposed to alendronate therapy and transitioned over time from a 'well' health state to health states of 'hip fracture', 'spine fracture', 'wrist fracture' or 'death'. All costs were calculated in 2000 Swedish kronors (SEK).

TIME HORIZON

In the Markov model our base-case treatment duration was 5 years followed by a 5-year period where the benefit declined linearly to 0.

RESULTS

We found that treating 71-year-old osteoporotic women with a prior spine fracture with alendronate resulted in a cost per quality-adjusted life-year (QALY) gained of SEK76000, which is well below the threshold for cost effectiveness of SEK300000. For women aged 65 years, the cost-effectiveness ratio increased to SEK173000 and for women aged 77 years, the cost-effectiveness ratio decreased to SEK52000.

CONCLUSIONS

Treating older osteoporotic women with alendronate was more cost effective than treating younger women with osteoporosis, and treating osteoporotic women with prior spine fracture was more cost effective than treating osteoporotic women without prior spine fracture. However, the costs per QALY gained for all populations studied were below generally accepted thresholds for cost effectiveness.

Quality-of-life assessment in osteoporosis: health-status and preference-based measures

Health-status and preference-based approaches to assessing health-related quality of life (HR-QOL) in osteoporosis are reviewed. Osteoporosis-targeted health-status instruments [i.e. Osteoporosis Quality-of-Life Questionnaire (OQLQ), Osteoporosis Assessment Questionnaire (OPAQ), Quality-of-Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO), Osteoporosis-Targeted Quality-of-Life Questionnaire (OPTQoL), Osteoporosis Functional Disability Questionnaire (OFDQ), Quality-of-Life Questionnaire in Osteoporosis (QUALIOST)], which have been utilised to document the adverse impact of osteoporosis on HR-QOL in diverse clinical and epidemiological studies, are described first. Preference-based approaches to osteoporosis health-outcome measurement are then considered in both clinical and health policy settings. In the clinical setting, direct preference assessments [i.e. visual analogue scale (VAS), time tradeoff (TTO), standard gamble (SG)] using either experienced or described health outcomes have consistently shown significantly lower values for osteoporosis-related health states relative to usual or ideal health. In the health-policy context, preference-classification systems [i.e. EuroQoL (EQ-5D), Health Utilities Index (HUI)] for valuing health in economic studies are reviewed. At present, there is little evidence to guide the choice of one system over another for assessing the cost effectiveness of osteoporosis interventions; however, use of a consistent set of health-state values is essential. Further research is needed to characterise associations between osteoporosis-targeted health-status instruments and preference-based health-outcome measures. In addition, the longitudinal impact of osteoporosis and related fractures on HR-QOL must be documented.

Preference-based health outcome measures in low back pain

Preference-based health outcome measures were considered in two settings. In the clinical context, utility assessment using the VAS, TTO or SG was described. It is recognized that formal utility assessment is generally not needed in day-to-day clinical practice. When the need to explicitly value alternative health outcomes arises, the VAS is recommended because of its ease of implementation. In the health policy context, preference classification systems are recommended for valuing health when a cost-effectiveness analysis of alternative health care interventions is planned. At present, there is little evidence to base choice of one system over another for assessing the cost-effectiveness of low back pain interventions.