Cost-effectiveness modeling research of pharmacologic therapy to prevent osteoporosis-related fractures

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.

The role of previous falls in major osteoporotic fracture prediction in conjunction with FRAX in older Chinese men and women: the Mr. OS and Ms. OS cohort study in Hong Kong

Falls are a major concern in terms of fracture risk. Although awareness rising for the absence of falls in the FRAX algorithm, our study only identified the independent predictive role of previous recurrent falls and their better conjunction use with FRAX for major osteoporotic fracture prediction in older Chinese men.

INTRODUCTION

Although the association of falls with fracture has been widely explored, the impact of previous falls is not included in the FRAX algorithm currently. Our aim was to examine the FRAX-independent associations between falls in the previous year and subsequent fracture risk, as well as the conjunctive use of falls and the FRAX score for major osteoporotic fracture (MOF) prediction in older Chinese people.

METHODS

Four thousand community older men and women aged 65 years or older were followed up for 9.9 ± 2.7 and 8.8 ± 1.5 years, respectively. The associations between falls in the previous 1 year and MOF risk by follow-up years were evaluated using the Fine and Gray model. New prediction scores were calculated by incorporating the falls and FRAX scores using the Fine and Gray model, or developed by adjusting the FRAX scores by 30% increased risk for each fall in the previous year. The predictive powers for MOF risk between the new scores and FRAX scores were evaluated by the area under the curve (AUC) and category-based net reclassification improvement index (NRI).

RESULTS

During the follow-up period, 139 (7.0%) men and 236 (11.8%) women had at least one incident MOF. One previous fall significantly predicted the first year incident MOF in men [hazard ratio (HR) (95%CI), 3.47 (1.02, 11.80)]. Previous recurrent falls significantly predicted a 10-year incident MOF in men [HR (95%CI), 2.42 (1.30, 4.51)]. In men, the fall-adjusting FRAX scores showed significant improvement on total net reclassification of fracture (3-6%). No improved predictive accuracy shown in women.

CONCLUSION

Falls in the previous year are likely to provide some predictive power to FRAX for MOF risk assessment in older Chinese men, but not women.

The cost effectiveness of teriparatide as a first-line treatment for glucocorticoid-induced and postmenopausal osteoporosis patients in Sweden

Background

This paper presents the model and results to evaluate the use of teriparatide as a first-line treatment of severe postmenopausal osteoporosis (PMO) and Glucocorticoid-induced osteoporosis (GIOP). The study’s objective was to determine if teriparatide is cost effective against oral bisphosphonates for two large and high risk cohorts.

Methods

A computer simulation model was created to model treatment, osteoporosis related fractures, and the remaining life of PMO and GIOP patients. Natural mortality and additional mortality from osteoporosis related fractures were included in the model. Costs for treatment with both teriparatide and oral bisphosphonates were included. Drug efficacy was modeled as a reduction to the relative fracture risk for subsequent osteoporosis related fractures. Patient health utilities associated with age, gender, and osteoporosis related fractures were included in the model. Patient costs and utilities were summarized and incremental cost-effectiveness ratios (ICERs) for teriparatide versus oral bisphosphonates and teriparatide versus no treatment were estimated.

For each of the PMO and GIOP populations, two cohorts differentiated by fracture history were simulated. The first contained patients with both a historical vertebral fracture and an incident vertebral fracture. The second contained patients with only an incident vertebral fracture. The PMO cohorts simulated had an initial Bone Mineral Density (BMD) T-Score of −3.0. The GIOP cohorts simulated had an initial BMD T-Score of −2.5.

Results

The ICERs for teriparatide versus bisphosphonate use for the one and two fracture PMO cohorts were €36,995 per QALY and €19,371 per QALY. The ICERs for teriparatide versus bisphosphonate use for the one and two fracture GIOP cohorts were €20,826 per QALY and €15,155 per QALY, respectively.

Conclusions

The selection of teriparatide versus oral bisphosphonates as a first-line treatment for the high risk PMO and GIOP cohorts evaluated is justified at a cost per QALY threshold of €50,000.

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 strategies for selecting and treating individuals at increased risk of osteoporosis or osteopenia: a systematic review

OBJECTIVES

To compare cost-effectiveness modeling analyses of strategies to prevent osteoporotic and osteopenic fractures either based on fixed thresholds using bone mineral density or based on variable thresholds including bone mineral density and clinical risk factors.

METHODS

A systematic review was performed by using the MEDLINE database and reference lists from previous reviews. On the basis of predefined inclusion/exclusion criteria, we identified relevant studies published since January 2006. Articles included for the review were assessed for their methodological quality and results.

RESULTS

The literature search resulted in 24 analyses, 14 of them using a fixed-threshold approach and 10 using a variable-threshold approach. On average, 70% of the criteria for methodological quality were fulfilled, but almost half of the analyses did not include medication adherence in the base case. The results of variable-threshold strategies were more homogeneous and showed more favorable incremental cost-effectiveness ratios compared with those based on a fixed threshold with bone mineral density. For analyses with fixed thresholds, incremental cost-effectiveness ratios varied from €80,000 per quality-adjusted life-year in women aged 55 years to cost saving in women aged 80 years. For analyses with variable thresholds, the range was €47,000 to cost savings.

CONCLUSIONS

Risk assessment using variable thresholds appears to be more cost-effective than selecting high-risk individuals by fixed thresholds. Although the overall quality of the studies was fairly good, future economic analyses should further improve their methods, particularly in terms of including more fracture types, incorporating medication adherence, and including or discussing unrelated costs during added life-years.

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.

The economics of improving medication adherence in osteoporosis: validation and application of a simulation model

CONTEXT

Adherence to osteoporosis treatment is low. Although new therapies and behavioral interventions may improve medication adherence, questions are likely to arise regarding their cost-effectiveness.

OBJECTIVE

Our objectives were to develop and validate a model to simulate the clinical outcomes and costs arising from various osteoporosis medication adherence patterns among women initiating bisphosphonate treatment and to estimate the cost-effectiveness of a hypothetical intervention to improve medication adherence.

DESIGN

We constructed a computer simulation using estimates of fracture rates, bisphosphonate treatment effects, costs, and utilities for health states drawn from the published literature. Probabilities of transitioning on and off treatment were estimated from administrative claims data.

SETTING AND PATIENTS

Patients were women initiating bisphosphonate therapy from the general community.

INTERVENTION

We evaluated a hypothetical behavioral intervention to improve medication adherence.

MAIN OUTCOME MEASURES

Changes in 10-yr fracture rates and incremental cost-effectiveness ratios were evaluated.

RESULTS

A hypothetical intervention with a one-time cost of $250 and reducing bisphosphonate discontinuation by 30% had an incremental cost-effectiveness ratio (ICER) of $29,571 per quality-adjusted life year in 65-yr-old women initiating bisphosphonates. Although the ICER depended on patient age, intervention effectiveness, and intervention cost, the ICERs were less than $50,000 per quality-adjusted life year for the majority of intervention cost and effectiveness scenarios evaluated. Results were sensitive to bisphosphonate cost and effectiveness and assumptions about the rate at which intervention and treatment effects decline over time.

CONCLUSIONS

Our results suggests that behavioral interventions to improve osteoporosis medication adherence will likely have favorable ICERs if their efficacy can be sustained.

Cost-effectiveness of using clinical risk factors with and without DXA for osteoporosis screening in postmenopausal women

BACKGROUND

According to several guidelines, the assessment of postmenopausal fracture risk should be based on clinical risk factors (CRFs) and bone density. Because measurement of bone density by dual x-ray absorptiometry (DXA) is quite expensive, there has been increasing interest to estimate fracture risk by CRFs.

OBJECTIVE

The aim of this study was to determine the cost-effectiveness of osteoporosis screening of CRFs with and without DXA compared with no screening in postmenopausal women in Germany.

METHODS

A cost-utility analysis and a budget-impact analysis were performed from the perspective of the statutory health insurance. A Markov model simulated costs and benefits discounted at 3% over lifetime.

RESULTS

Cost-effectiveness of CRFs compared with no screening is euro4607, euro21,181, and euro10,171 per quality-adjusted life-year (QALY) for 60-, 70-, and 80-year-old women, respectively. Cost-effectiveness of DXA plus CRFs compared with CRFs alone is euro20,235 for 60-year-old women. In women above the age of 70, DXA plus CRFs dominates CRFs alone. DXA plus CRFs results in annual costs of euro175 million, or 0.4% of the statutory health insurance's annual budget.

CONCLUSION

Funders should be careful in adopting a strategy based on CRFs alone instead of DXA plus CRFs. Only if DXA is not available, assessing CRFs only is an acceptable option in predicting a woman's risk of fracture.

Cost effectiveness of ultrasound and bone densitometry for osteoporosis screening in post-menopausal women

BACKGROUND

According to a new German guideline, decisions about bisphosphonate treatment for post-menopausal women should be based on 10-year fracture risk, and bone density should be measured by dual x-ray absorptiometry (DXA). Recently, there has been growing interest in quantitative ultrasound (QUS) as a less expensive screening alternative.

OBJECTIVE

To determine the cost effectiveness of osteoporosis screening with QUS as a pre-test for DXA and treatment with alendronate compared with (i) immediate access to DXA and (ii) no screening in women of the general population aged 50-90 years in Germany.

METHODS

A cost-utility analysis and a budget impact analysis were performed from the perspective of the statutory health insurance (SHI). A Markov model with a 1-year cycle length was used to simulate costs and benefits (QALYs), discounted at 3% per annum, over a lifetime. The number of women correctly diagnosed by QUS and DXA as being above a 10-year risk of > or =30% was estimated for different age groups (50-60, 60-70, 70-80 and 80-90 years, respectively). The robustness of the results was tested by a probabilistic Monte Carlo simulation.

RESULTS

Compared with no screening, the cost effectiveness of QUS plus DXA was found to be Euro 3529, Euro 9983, Euro 4382 and Euro 1987 per QALY for 50-, 60-, 70- and 80-year-old women, respectively (year 2006 values). This screening strategy results in annual costs of Euro 96 million or 0.07% of the SHI's annual budget. The cost effectiveness of DXA alone compared with DXA plus QUS is Euro 5331, Euro 60, 804, Euro 14, 943 and Euro 3654 per QALY for 50-, 60-, 70- and 80-year-old women, respectively. DXA alone results in a higher number of QALYs in all age groups. The results were robust in the sensitivity analysis.

CONCLUSION

Compared with no screening, the cost effectiveness of QUS and DXA in sequence is very favourable in all age groups. However, direct access to DXA is also a cost-effective option, as it increases the number of QALYs at an acceptable cost compared with pre-testing by QUS (except for women aged 60-70 years). Therefore, QUS as a pre-test for DXA can be clearly recommended only in women aged 60-70 years. For the other age groups, the cost effectiveness of QUS as a pre-test depends on the global budget constraint and the accessibility of DXA.

Cost effectiveness of screen-and-treat strategies for low bone mineral density: how do we screen, who do we screen and who do we treat?

Bone densitometry is currently widely recommended for, and considered central to, identifying post-menopausal women and older men at high risk of fracture and establishing an indication for pharmacological fracture-prevention therapy. The purpose of this article is to comprehensively review cost-effectiveness modelling studies published to date of bone mass measurement technologies (primarily dual energy x-ray absorptiometry [DXA]) designed to identify those individuals at sufficiently high risk of fracture to warrant pharmacological fracture-prevention therapy.Based on older paradigms of the pharmacological treatment of those with a bone density value below a specific threshold, bone densitometry appears to be cost effective for post-menopausal women aged > or =65 years, regardless of the presence or absence of other clinical risk factors. For younger post-menopausal women, bone densitometry is likely to be cost effective only for those with specific clinical risk factors, such as prior fracture or low bodyweight. For older men, bone densitometry may be cost effective for those who have had a prior fracture and/or are aged > or =80 years, but the subset of men for whom bone densitometry is likely to be cost effective may vary from country to country depending on societal willingness to pay for health benefits, fracture rates in the population and the costs of bone densitometry and drug treatment. The cost effectiveness of other technologies such as heel ultrasound, peripheral DXA and quantitative CT remains uncertain.However, in the context of the new WHO paradigm of directing treatment based on absolute fracture risk rather than bone density, a new generation of cost-effectiveness modelling studies will be required to define the most cost-effective way bone densitometry can be used to identify those who are likely to benefit sufficiently from pharmacological fracture-prevention therapies.