Using economics to prioritize research: a case study of randomized trials for the prevention of hip fractures due to osteoporosis

[Direct medical costs of hospital treatment of fractures of the upper extremity of the femur]

Fractures of the upper extremity of the femur are serious because of their morbidity and social and/or economic consequences. They have been the subject of several studies of world literature concerning their hospital treatment, evolution and prevention. The increase in the incidence of this pathology seems unavoidable due to population ageing and to the lengthening life expectancy; it is posing a real long-term public health problem whose importance will be further increased by the need to control health care costs. The results of this study show that the average age of onset of fracture of the proximal extremity of the femur is 68,13 ± 16.9 years, with a male predominance and a sex ratio of 1.14. In our study pertrochanterian fractures represented 69.4% of cases. Direct medical costs of the hospital treatment of fractures of the upper extremity of the femur at the Hassan II University Hospital were £387 714,38 in 222 cases, with an average cost of £1757,4 , including costs for patient's stay in hospital, which represented the majority of expenses ( 77% of total costs). It is desirable to raise staff awareness of the costs of consumables in order to reduce treatment costs and to adopt cost-oriented behaviour. Length of stay should be limited to the maximum extent because it only allows to reduce staff and accommodation costs.

Gaussian Process Modeling in Conjunction with Individual Patient Simulation Modeling: A Case Study Describing the Calculation of Cost-Effectiveness Ratios for the Treatment of Established Osteoporosis

Individual patient-level models can simulate more complex disease processes than cohort-based approaches. However, large numbers of patients need to be simulated to reduce 1storder uncertainty, increasing the computational time required and often resulting in the inability to perform extensive sensitivity analyses. A solution, employing Gaussian process techniques, is presented using a case study, evaluating the cost-effectiveness of a sample of treatments for established osteoporosis. The Gaussian process model accurately formulated a statistical relationship between the inputs to the individual patient model and its outputs. This model reducedthe time required for future runs from 150 min to virtually-instantaneous, allowing probabilistic sensitivity analyses-to be undertaken. This reduction in computational time was achieved with minimal loss in accuracy. The authors believe that this case study demonstrates the value of this technique in handling 1st- and 2nd-order uncertainty in the context of health economic modeling, particularly when more widely used techniques are computationally expensive or are unable to accurately model patient histories.

Setting priorities for research: a practical application of 'payback' and expected value of information

BACKGROUND

Setting priorities for research using economic in addition to scientific criteria can ensure that resources are spent efficiently and equitably.

OBJECTIVE

This study applies two priority setting methods 'payback' and expected value of information (EVI) to two research areas (osteoporosis and pressure ulcers) and where appropriate to four clinical trials: the Record Trial, the Vitamin D and Calcium Trial and the Hip Protector Trial (osteoporosis), and the Pressure Trial (wound care).

METHODS

Two decision-analytic models were developed. For 'payback', the PATHS model was used to estimate the expected net benefits of conducting the four clinical trials. An EVI framework was applied to estimate the cost-effectiveness of conducting further research in the two disease areas investigated.

RESULTS

The application of 'payback' suggests that the Record Trial and the Vitamin D and Calcium Trial would be cost-effective. The Hip Protector and the Pressure Ulcer Trial are cost-effective under certain assumptions concerning the likelihood of obtaining positive, negative or inconclusive results. The EVI method suggests that research would be potentially cost-effective in these areas in the populations considered.

CONCLUSION

EVI provides strategic information for setting priorities for research between disease areas and study populations. 'Payback' provides information on the cost-effectiveness of specific research designs. However, further work in this area, particularly concerning the issue of implementation of research, is required.

Using a modified nominal group technique to elicit director of nursing input for an osteoporosis intervention

BACKGROUND

Barriers prevent osteoporosis care in nursing homes. Successful interventions designed to circumvent these barriers benefit from target recipient input during development.

OBJECTIVE

To elicit suggestions for an osteoporosis quality improvement intervention designed for use by nursing home health care professionals.

DESIGN

Modified nominal group technique.

SETTING

Convenience sample of Alabama nursing home directors.

PARTICIPANTS

Fifteen Alabama nursing home directors of nursing were recruited by mailing. Sixty percent of respondents participated (n = 9).

MEASUREMENTS

In the first phase conducted via teleconference, an experienced moderator used a preformulated question and elicited 41 suggestions to improve osteoporosis care in nursing homes. Substantively similar suggestions were combined and idiosyncratic suggestions were discarded resulting in the retention of 20 suggestions. In the second phase conducted by mail, the same participants rated the 20 suggestions based on perceived practicality and helpfulness. Elements were grouped into tertiles based on the ranking of the mean ratings of the 2 attributes and then cross-tabulated.

RESULTS

All director of nursing (n = 9) participants completed both phases. The most practical, most helpful suggestions were information on fall prevention program implementation, osteoporosis treatment protocols, and osteoporosis medication information.

CONCLUSIONS

A modified nominal group technique provided useful information from nursing home directors of nursing for an osteoporosis intervention. The technique proved efficient and facile to perform.

Vitamin D insufficiency in older female community-dwelling acute hospital admissions and the response to supplementation

OBJECTIVES

A significant proportion of the older population may exhibit vitamin D insufficiency. We sought to establish the proportion of 25-hydroxyvitamin D (25OHD) insufficient individuals in an older female cohort presenting for acute medical admission and how they responded to supplementation.

DESIGN

A prospective cohort study.

SETTING

Hospital admissions followed up as a population-based study.

SUBJECTS

A total of 114 consecutive female acute medical admissions aged over 65 years from November 2003 to January 2004 were enrolled. All admissions with hypercalcaemia, metabolic bone disease (other than osteoporosis/osteomalacia) and creatinine > 150 micromol/l were excluded.

INTERVENTIONS

iPTH, calcium and 25OHD levels were measured in each patient. Of the total, 22 were already receiving calcium and vitamin D supplementation at enrolment. The remaining 92 were commenced on 800 IU of vitamin D and 1 g calcium, and levels were reassessed after supplementation for 3 months.

RESULTS

25-Hydroxyvitamin D insufficiency, as defined by a 25OHD concentration of < 50 nmol/l, was present in 86 (75.4%) patients at initial assessment (mean 35.8 nmol/l, s.d. 23.3). Secondary hyperparathyroidism was present in only 36.7% of those with 25OHD deficiency at baseline. Of the total, 51 (44.7%) patients presented for follow-up. 25-Hydroxyvitamin D concentration increased in this group from 42.1 nmol/l (s.d. 26.6) to 59.5 nmol/l (s.d. 27.4) after supplementation, P < 0.001, but 18(35.3%) still remained deficient. There was no significant change in iPTH or calcium following supplementation. Assessment of compliance revealed 6 (11.7%) admitted to partial or non-compliance.

CONCLUSIONS

Insufficiency of 25OHD was very common in this cohort. Despite calcium and vitamin D supplementation, 25OHD concentrations failed to reach normality in a significant proportion. Maintaining vitamin D and calcium intake at the level of current recommended doses may not be sufficient to ensure adequate 25OHD stores.

Economic evaluations of interventions for the prevention and treatment of osteoporosis: a structured review of the literature

Economic evaluations are increasingly being used by decision-makers to estimate the cost-effectiveness of interventions. The objective of this study was to conduct a structured review of economic evaluations of interventions to prevent and treat osteoporosis. Articles were identified independently by two reviewers through searches on MEDLINE, the bibliographies of reviews and identified economic models, and expert opinion, using predefined inclusion and exclusion criteria. Data on country, type and level of interventions, type of fractures, interventions, study population and the authors' stated conclusions were extracted. Forty-two relevant studies were identified. The majority of studies (71%) were conducted in Sweden, the UK and the US. The main interventions investigated were hormone replacement therapy (27%), bisphosphonates (17%) and combinations of vitamin D and calcium (16%). In 38% of studies, hip fracture was the sole fracture outcome. Eighty-eight percent (88%) of studies investigated female populations only. A relatively large number of economic evaluations were identified in the field of osteoporosis. Major changes have recently occurred in the treatment of this disease, following the publication of the results of the Women's Health Initiative trial. Methodological developments in economic evaluations, such as the use of probabilistic sensitivity analysis and cost-effectiveness acceptability curves, have also taken place. Such changes are reflected in the studies that were reviewed. The development of economic models should be an iterative process that incorporates new information, whether clinical or methodological, as it becomes available.

Setting priorities for research

Setting priorities for research should be conducted in order to make the most efficient use of scarce resources. Yet the uptake in practice of such methods by researchers and commissioners of research alike has been slow, in part because the methodologies available to do so have not been widely disseminated. This paper argues that an appropriate priority-setting methodology should meet the objectives of the health system, that is to provide the most health benefits to the population that it serves within the budget constraint and while respecting equity considerations. A condition for these criteria to be met is to construct and operationalise an appropriate definition of the value of research. Five different ways that have been used in practice to value research and set priorities were reviewed. Shortcomings in the ways research is valued make it unlikely that the application of subjective methods, burden of disease methods, and clinical variations and payback methods meet the objectives of the health system. Using the fifth method, value of information, priority-setting can meet the objectives of the health system because it expresses the value of research using the same overall cost-effectiveness framework that is employed for decisions on service provision. However, this method still requires further work to evaluate how research outcomes can then be communicated to clinical practitioners and how practitioners can be encouraged to implement them.

A preventative health education programme for osteoporosis

BACKGROUND

Osteoporosis is a preventable disease that is usually not managed until the disease becomes evident, although it places huge economic and social burdens on societies worldwide. It is predicted that this burden will grow if left unchecked. Despite this, evidence suggests that osteoporosis prevention activity is given a low priority, and services often only provide biomedically-based programmes, in which resources are predominantly allocated to screening and pharmacological treatments. Referral to these services mostly occurs when a client is already known to have osteoporosis or to be at risk, rather than as an early preventative intervention.

AIM

This paper reports an action research project with one hospital osteoporosis service. The aim of the project was to assess the current service, identify areas where change was needed, and evaluate the implementation of such changes.

METHOD

Participatory action research was used, with group meetings and reflective journals to collect data for analysis. The process involved assessment of a preventative osteoporosis service, and determination of clinical issues and problems, and it aided decisions on an appropriate course of organizational reform and evaluated any change processes as they occurred. It also encouraged participants to reflect on and evaluate their experiences of using a participatory framework.

CONCLUSION

A change programme was implemented that focused on preventative health education activity in a range of clinical settings. Over the two and a half years of the project, the osteoporosis service expanded its programme to include a wide range of preventative activities, running alongside other organizational reforms.

Cost-effectiveness of fracture prevention treatments in the elderly

Objectives:The cost-effectiveness of fracture prevention treatments (vitamin D and calcium and hip protectors) in male and female populations older than seventy years of age in the United-Kingdom was investigated.

Methods:A Markov model was developed to follow up, over lifetime, a hypothetical cohort of males and females at high-risk and general risk of fracture. Patients could sustain hip, wrist, vertebral, and/or other fractures. Fracture rates were obtained from population surveys in the United Kingdom. Effectiveness and quality of life data were identified from the clinical literature. Costs were those incurred by the UK National Health Service, and were obtained from several published sources. Uncertainty was explored through probabilistic sensitivity analysis.

Results:In the general-risk female (male) population, the incremental cost per Quality Adjusted Life Year (QALY) was $11,722 ($47,426) for hip protectors. In the male high-risk population, the incremental cost per QALY was $17,017 for hip protectors. In the female high-risk population, hip protectors were cost-saving. Vitamin D and calcium alone was dominated by hip protectors in all four subgroups.

Conclusions:Current information available on interventions to prevent fractures in the elderly in the United Kingdom, suggests that, at the decision-maker's ceiling ratio of $20,000 per QALY, hip protectors are cost-effective in the general female population and high-risk male population, and cost-saving in the high-risk female population, despite the low compliance rate with the treatment.

Creative way to improve practice: the research journal club

Research highlights interventions that improve patient care; however, this evidence does not consistently show up in practice. To decrease adverse events and increase patient and referral satisfaction, home care agencies must find ways to keep their clinical staff up to date. This article describes how one agency created a journal club that has met with success.

Effect of four monthly oral vitamin D3 (cholecalciferol) supplementation on fractures and mortality in men and women living in the community: randomised double blind controlled trial

OBJECTIVE

To determine the effect of four monthly vitamin D supplementation on the rate of fractures in men and women aged 65 years and over living in the community.

DESIGN

Randomised double blind controlled trial of 100 000 IU oral vitamin D3 (cholecalciferol) supplementation or matching placebo every four months over five years.

SETTING AND PARTICIPANTS

2686 people (2037 men and 649 women) aged 65-85 years living in the general community, recruited from the British doctors register and a general practice register in Suffolk.

MAIN OUTCOME MEASURES

Fracture incidence and total mortality by cause.

RESULTS

After five years 268 men and women had incident fractures, of whom 147 had fractures in common osteoporotic sites (hip, wrist or forearm, or vertebrae). Relative risks in the vitamin D group compared with the placebo group were 0.78 (95% confidence interval 0.61 to 0.99, P=0.04) for any first fracture and 0.67 (0.48 to 0.93, P=0.02) for first hip, wrist or forearm, or vertebral fracture. 471 participants died. The relative risk for total mortality in the vitamin D group compared with the placebo group was 0.88 (0.74 to 1.06, P=0.18). Findings were consistent in men and women and in doctors and the general practice population.

CONCLUSION

Four monthly supplementation with 100 000 IU oral vitamin D may prevent fractures without adverse effects in men and women living in the general community.

Setting priorities for the evaluation of health interventions: when theory does not meet practice

Priority setting is a key component of the process of evaluating health interventions. This has traditionally been an informal process led by power and influence, but a number of explicit criteria and systematic models have been developed since the late 1980s. This paper presents a review and appraisal of these conceptual models and examines how they have influenced the practice of priority setting in the United States and Europe. The main conclusion is that a significant gap exists between theory and practice. Most models have been developed for the purpose of maximising health gains through an efficient allocation of resources. However, they present at least three important limitations that need to be removed if formal models are to play a more substantial role in decision making: they tend to prioritize interventions for evaluation, rather than evaluations themselves; they fail to address priority setting in a research portfolio perspective; and they fail to adopt an incremental perspective. Existing prioritization models are not suitable for supporting cost-containment or distributional objectives.

Hip fracture prevention: cost-effective strategies

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

The effectiveness of bone density measurement and associated treatments for prevention of fractures. An international collaborative review

This review assesses the evidence regarding the effectiveness of bone density measurement (BDM) screening and related interventions--hormone replacement therapy (HRT) and intranasal salmon calcitonin (SCT[N])--in menopausal women to prevent fractures in later life. Data sources included systematic reviews of evidence and relevant primary studies identified through literature searches on MEDLINE and EMBASE. Study selection included trials of BDM screening programs, prospective studies examining the predictive value of BDM, randomized controlled trials, cohort studies, and case-control studies of HRT and SCT (N). The evidence was evaluated using a classification system incorporating study design and quality. Outcomes were measured in terms of relative risk of fracture for a 1 SD decrease in bone mineral density below the age-adjusted mean, relative risks or odds ratios for fractures associated with treatments, and proportion of hip fractures potentially prevented by BDM screening linked to treatments. Fair evidence from prospective cohort studies suggests that BDM can predict the risk of fractures, but not with high accuracy. Fair evidence from low-quality randomized controlled trials and observational studies suggests that HRT and SCT(N) are efficacious in preventing fractures. Good evidence supports the efficacy of these treatments in preserving bone mass, but there is fair evidence that the effect wears off after cessation of therapy. There is little evidence on the impact of screening menopausal women with BDM in association with HRT or SCT(N) treatment. Estimates based on combining existing evidence regarding the predictive value of BDM and efficacy of HRT suggests that 1-7% of hip fractures might be prevented.

The efficiency of specialist outreach clinics in general practice: is further evaluation needed?

OBJECTIVES

To assess the need for further evaluation of general practice-based outreach clinics in two specialties using data from a UK pilot study to model their cost-effectiveness.

METHODS

A pilot study was undertaken comparing one outreach and one outpatient clinic held by three dermatology specialists and three orthopaedic specialists. Information was collected on waiting times, costs to patients, casemix and resource use.

RESULTS

Only dermatology outreach clinic patients experienced significantly shorter waiting times for first appointments than their hospital counterparts. Outreach clinic patients incurred lower costs in attending appointments in either specialty but the differences were not statistically significant. Evidence of a difference in casemix between patients attending outreach and outpatient clinics meant that treatment costs incurred in both types of clinic could not be compared. Outreach clinics in both specialties were significantly more costly in terms of staff, staff travel and associated opportunity costs compared with outpatient clinics. Sensitivity analysis showed that outreach and outpatient clinics had the same marginal cost if the number of patients per outreach clinic increased greatly or attendance fell considerably at outpatient clinics.

CONCLUSIONS

This study has found no evidence that outreach clinics in these two specialties are cost-effective in terms of costs and benefits. A more definitive conclusion could only be made if studies estimated other costs and benefits not accounted for in this study. Further research is required to see whether outreach clinics in other specialties or clinics with different configurations to those studied are efficient.