Cost effectiveness of multi-therapy treatment strategies in the prevention of vertebral fractures in postmenopausal women with osteoporosis

Established Osteoporosis and Gaps in the Management: Review from a Teaching hospital

Background:

International osteoporosis foundation described severe or established osteoporosis as an osteoporotic individual with a fragility fracture. Orthopaedic surgeons frequently manage fractures, but we believe that large gaps are prevalent in the medical management of osteoporosis after fractures are fixed.

Aim:

The aim of this analysis is to assess the investigations and gaps in the management of osteoporosis in patients admitted with a fragility fracture of femur at King Fahd Hospital of the University, AlKhobar, Saudi Arabia.

Materials and Methods:

A retrospective analysis of all admission and discharge; medical and pharmacy records database of patients over ≥ 50 years with fragility fracture between January 2001 and December 2011. The outcome measures assessed were investigations such as serum calcium, phosphorous, alkaline phosphatase, parathormone, 25 hydroxy vitamin D (25OHD) levels and a dual energy X-ray absorptiometry (DEXA). Secondly once the fracture was fixed what medications were prescribed, calcium and vitamin D, antiresorptives and anabolic agents.

Results:

There were 207 patients admitted during the study period with an average age of 69.2 (12.1) years and 118 were females. In 169 (81.6%) patients, the fracture site was proximal femur. Vitamin D (25OHD) was requested in 31/207 (14.9%). DEXA scan was ordered in 49/207 (24.1%). A total of 78/207 (37.6%) patients received calcium and vitamin D3 and 94/207 (45.4%) either got calcium or vitamin D3. Bisphosphonates was used in 35, miacalcic nasal spray in 25 and anabolic agent teriparatide was prescribed in 21 patients. Post-fixation 126/207 (60.8%) patients did not receive any anti-osteoporotic medication. In untreated group, there were 87 males and 39 females.

Conclusions:

The study found that in patients, who sustained a fragility fracture, confirmation of osteoporosis by DEXA was very low and ideal treatment for severe osteoporosis was given out to few patients. More efforts are needed to fill this large gap in the correct management of osteoporosis related fractures by orthopaedic surgeons.

Does the funding source influence the results in economic evaluations? A case study in bisphosphonates for the treatment of osteoporosis

Research sponsored by the pharmaceutical industry is often assumed to be more likely to report favourable cost-effectiveness results. To determine whether there was a relationship between the source of funding and the reporting of positive results. We conducted a systematic review of the literature to identify economic evaluations of bisphosphonates for the treatment of osteoporosis. We extracted the source of funding, region of study, the journal name and impact factor, and all reported incremental cost-effectiveness ratios (ICERs). We identified which ICERs were under the thresholds of $US20 000, $US50 000 and $US100 000 per QALY. A quality score between 0 and 7 was also given to each of the studies. We used generalized estimating equations for the analysis. The systematic review yielded 532 potential abstracts; 17 of these met our final eligibility criteria. Ten studies (59%) were funded by non-industry sources. A total of 571 ICERs were analysed. There was no significant difference between the number of industry- and non-industry-funded studies reporting ICERs below the thresholds of $US20 000 and $US50 000. However, industry-sponsored studies were more likely to report ICERs below $US100 000 (odds ratio = 4.69, 95% CI 1.77, 12.43). Studies of higher methodological quality (scoring >4.5 of 7) were less likely to report ICERs below $US20 000 and $US50 000 than studies of lower methodological quality (scores <4). Methodological quality was not significantly different between studies reporting ICERs under $US100 000. In this relatively small sample of studies of bisphosphonates, the funding source (industry vs non-industry) did not seem to significantly affect the reporting of ICERs below the $US20 000 and $US50 000 thresholds. We hypothesize that methodological quality might be a more significant factor than the source of funding in differentiating which studies are likely to report favourable ICERs, with the higher-quality studies significantly less likely to report ICERs below $US20 000 and $US50 000 per QALY. Further research should explore this finding.

The impact of fewer hip fractures with risedronate versus alendronate in the first year of treatment: modeled German cost-effectiveness analysis

BACKGROUND

The Risedronate and Alendronate (REAL) cohort study provides unique comparative effectiveness data for real world bisphosphonate treatment of osteoporosis.

OBJECTIVE

The objective of this analysis was to assess the cost-effectiveness of risedronate compared to generic alendronate in Germany applying the REAL effectiveness data.

MATERIALS AND METHODS

A validated Markov model of osteoporosis was populated with REAL effectiveness data and German epidemiological, cost, and utility data. To estimate the impact of therapy on hip fractures, costs, and quality adjusted life years (QALYs), the analysis included women>or=65 years, treated with risedronate or alendronate and followed for 4 additional years. Country-specific data included population mortality, fracture costs, and annual drug costs, using a German social insurance perspective. Costs and outcomes were discounted at 3%. A differential hip fracture relative risk reduction of 43% was applied to risedronate vs. alendronate.

RESULTS

The model predicted that treatment with risedronate would result in fewer hip fractures and more QALYs at a reduced cost (savings of euro278 per treated woman) compared to treatment with generic alendronate. Sensitivity analysis assuming 2 years of treatment and equivalence of effect after 1 year show cost savings as well (euro106 per treated woman).

DISCUSSION

Whereas previous economic evaluations involving bisphosphonates have mainly relied on efficacy data from noncomparative clinical trials, this study's strength is in the use of comparative effectiveness data from one data source. The magnitude of the cost savings observed were sensitive to alternative assumptions regarding treatment duration, therapy discontinuation and cost of generic alendronate.

CONCLUSIONS

Based on "real world" data the analysis supports the first line use of risedronate for the treatment of osteoporotic women in Germany.

Closing the osteoporosis care gap: increased osteoporosis awareness among geriatrics and rehabilitation teams

Background

A care gap exists between recommendations and practice regarding the diagnosis and treatment of osteoporosis in fracture patients. The current study was designed to determine rates and predictors of in-hospital diagnosis and treatment of osteoporosis in patients admitted with fragility hip fractures, and to assess differences in these rates since the outset of the multipronged "Fracture? Think Osteoporosis" (FTOP) Program, which includes education of geriatrics and rehabilitation teams.

Methods

This is a retrospective cohort study conducted with data from two Hamilton, Ontario, university-based tertiary-care hospitals, and represents a follow-up to a previous study conducted 8 years earlier. Data pertaining to all 354 patients, age >/= 50, admitted between March 2003 and April 2004, inclusive, with a diagnosis of fragility hip fracture were evaluated. Twelve patients were excluded leaving 342 patients for analysis, with 75% female, mean age 81.

Outcomes included: Primary – In-hospital diagnosis of osteoporosis and/or initiation of anti-resorptive treatment ("new osteoporosis diagnosis/treatment"). Secondary – In-hospital mortality, BMD referrals, pre-admission osteoporosis diagnosis and treatment.

Results

At admission, 27.8% of patients had a pre-existing diagnosis of osteoporosis and/or were taking anti-resorptive treatment. Among patients with no previous osteoporosis diagnosis/treatment: 35.7% received a new diagnosis of osteoporosis, 21% were initiated on anti-resorptive treatment, and 14.3% received a BMD referral. The greatest predictor of new osteoporosis diagnosis/treatment was transfer to a rehabilitation or geriatrics unit: 79.5% of rehabilitation/geriatrics versus 18.5% of patients receiving only orthopedics care met this outcome (p < 0.001).

Conclusion

New diagnosis of osteoporosis among patients admitted with hip fracture has improved from 1.8% in the mid 1990's to 35.7%. Initiation of bisphosphonate therapy has likewise improved from 0% to 21%. Although multiple factors have likely contributed, the differential response between rehabilitation/geriatrics versus orthopedics patients suggests that education of the geriatric and rehabilitation teams, including one-on-one and group-based sessions, implemented as part of the FTOP Program, has played a role in this improvement. A significant care gap still exists for patients discharged directly from orthopedic units. The application of targeted inpatient and post-discharge initiatives, such as those that comprise the entire FTOP Program, may be of particular value in this setting.

Can calcium chemoprevention of adenoma recurrence substitute or serve as an adjunct for colonoscopic surveillance?

OBJECTIVES

The aim of this study was to examine the potential cost-effectiveness of calcium chemoprevention post-polypectomy as a substitute or adjunct for surveillance.

METHODS

We constructed a Markov model of post-polypectomy adenoma recurrence and colorectal cancer (CRC) development, calibrated to data from prospective chemoprevention trials of fiber, calcium, antioxidants, and aspirin. We modeled four scenarios for 50-year-old patients immediately after polypectomy: (i) natural history with no further intervention; (ii) elemental calcium 1,200 mg/day from age 50-80; (iii) surveillance colonoscopy from age 50-80 every 5 years, or 3 years for large adenoma; (iv) calcium + surveillance. Patients were followed up until age 100 or death.

RESULTS

Calcium was cost-effective compared to natural history ($49,900/life-year gained). However, surveillance was significantly more effective than calcium (18.729 versus 18.654 life-years/patient; 76 percent versus 14 percent reduction in CRC incidence) at an incremental cost of $15,900/life-year gained. Calcium + surveillance yielded a very small benefit (0.0003 incremental life-years/patient) compared with surveillance alone, at a substantial incremental cost of $3,090,000/life-year gained.

CONCLUSION

Post-polypectomy calcium chemoprevention is unlikely to be a reasonable substitute for surveillance. It may be cost-effective in patients unwilling or unable to undergo surveillance.

Cost-effectiveness of alendronate in the treatment of postmenopausal women in 9 European countries--an economic evaluation based on the fracture intervention trial

Treatment with alendronate (Fosamax) has been shown to significantly reduce the risk of fragility fractures. Cost-effectiveness of treatment was assessed in nine European countries in a Markov model and was generally found to be cost effective in women with a previous spine fracture.

INTRODUCTION

Treatment with alendronate (Fosamax) reduces the risk of osteoporotic fractures at the spine, hip and wrist in women with and without prevalent vertebral fracture. Cost-effectiveness estimates in one country may not be applicable elsewhere due to differences in fracture risks, costs and drug prices. The aim of this study was to assess the cost-effectiveness of treating postmenopausal women with alendronate in nine European countries, comprising Belgium, Denmark, France, Germany, Italy, Norway, Spain, Sweden, and the UK.

METHODS

A Markov model was populated with data for the nine European populations. Effect of treatment was taken from the Fracture Intervention Trial, which recruited women with low BMD alone or with a prior vertebral fracture.

RESULTS

The cost per QALY gained of treating postmenopausal women with prior vertebral fractures ranged in the base case from "cost saving" in the Scandinavian countries to <euro>15,000 in Italy. Corresponding estimates for women without prior vertebral fractures ranged from "cost saving" to <euro>40,000.

CONCLUSIONS

In relation to thresholds generally used, the analysis suggests that alendronate is very cost effective in the treatment of women with previous vertebral fracture, and in women without previous vertebral fracture, cost-effectiveness depends on the country setting, discount rates, and chosen monetary thresholds.

The burden-of-illness study on osteoporosis in the Slovenian female population

STUDY OBJECTIVE

This burden-of-illness study on osteoporosis was performed with the main goal to estimate the economic implications of osteoporosis for the Slovenian healthcare system.

METHODS

A variety of sources was used to quantify the utilization of resources in 2003, and the appropriate unit costs were assigned to the identified resources.

MAIN OUTCOME MEASURES

The study included all direct and indirect costs that arise from treatment of osteoporosis and consequent hip, spine and wrist fractures in total Slovene postmenopausal population in 2003.

RESULTS

We estimated the total burden of postmenopausal osteoporosis in Slovenia for 2003 to be over SIT 7.55 billion (approximately 31.5 million euros); among that, 45% or SIT 3.39 billion (14.2 million euros) belong to drug expenditures for osteoporosis treatment and prevention; 29% or SIT 2.2 billion (9.2 million euros) include indirect costs for osteoporosis morbidity and mortality, and 26% or SIT 1.95 billion (8.1 million euros) belong to direct costs for treatment, hospitalization, and rehabilitation of osteoporotic fractures. Total costs on osteoporotic fractures were however subject to an approximation due to the expert panel-based estimate of proportion of osteoporosis-caused fractures and the limited data on resource utilization for fracture treatment.

CONCLUSION

Osteoporosis is a costly disease with a significant burden to society and needs to be viewed as an important problem with a complex long-term impact.

The cost effectiveness of bisphosphonates for the prevention and treatment of osteoporosis: a structured review of the literature

Osteoporotic fragility fractures constitute a significant public health concern. The lifetime risk of any osteoporotic fracture is very high (40-50% in women and 13-22% in men). Fractures are associated with significant mortality and morbidity and represent a substantial economic burden to society. Bisphosphonates (alendronate, etidronate, risedronate and ibandronate) are indicated for the treatment and prevention of osteoporosis but are costly compared with other treatments, such as vitamin D and calcium. Our search identified 23 studies evaluating the cost effectiveness of bisphosphonate therapy for the treatment and prevention of fragility fractures; these studies were from five geographical areas and employed a variety of comparators and assumptions. We identified 11 studies investigating bisphosphonates in women with low bone mineral density (BMD) [T-score >2.5 standard deviations {SDs} below normal {mean} peak values for young adults] and previous fractures, five studies investigating bisphosphonates in women with low BMD and no previous fracture, one study of bisphosphonates in women with osteopenia, five studies involving screening and two studies of bisphosphonates in special populations (women initiating corticosteroid treatment and men). In women with low BMD and previous fractures, bisphosphonate therapy was most cost effective in populations aged > or =70 years and was unlikely to be cost effective in populations aged < or =50 years. There was uncertainty concerning the cost effectiveness of bisphosphonates in such populations aged 60-69 years. In women with low BMD without previous fractures, treatment with alendronate or risedronate appeared to be cost effective across countries (UK, US, Denmark), but there was some uncertainty about the cost effectiveness of etidronate in patients in the highest age groups. Identifying risk factors for fractures through means such as spine radiographs to detect vertebral deformities improves the cost effectiveness of treatment. In women with osteopenia, alendronate therapy may be cost effective in women with a T-score of -2.4SD in the US. Screening for low BMD and treatment with alendronate or etidronate appears to be cost effective in postmenopausal women in general and in women with rheumatoid arthritis initiating corticosteroid therapy. Alendronate therapy without screening was also shown to be potentially cost effective in certain at-risk male populations, as well as in women initiating corticosteroid therapy after the age of 40 years. Decision makers in the US, UK and Sweden should consider funding the use of bisphosphonates for the prevention and treatment of osteoporosis in women aged >70 years, particularly if they have other risk factors for fracture. Further studies are required to make more definitive conclusions in other countries and patient populations. Screening strategies for low BMD followed by bisphosphonate treatment should also be considered in the general female population aged >65 years in the UK and US and in patients with rheumatoid arthritis initiating corticosteroid therapy.

Effects of parathyroid hormone alone or in combination with antiresorptive therapy on bone mineral density and fracture risk--a meta-analysis

AIM

The effects of parathyroid hormone (PTH) alone or in combination with antiresorptive therapy on changes in bone mineral density (BMD) and fracture risk were studied.

MATERIALS AND METHODS

Randomised placebo controlled trials were retrieved from the PubMed, Web of Science or Embase databases.

RESULTS

PTH alone or in combination with antiresorptive drugs reduced vertebral [relative risk (RR)=0.36, 95% confidence interval (CI): 0.28-0.47, 2p<0.01] and non-vertebral (RR=0.62, 95% CI: 0.48-0.82, 2p<0.01) fracture risk and increased spine BMD by 6.6% (95% CI: 5.2-8.1%, 2p<0.01) and hip BMD non-significantly by 1.0% (95% CI: -0.1 to 2.1%, 2p=0.08) during 11-36 months of follow-up (13 trials). The gain in spine and hip BMD tended to increase with the length of the PTH treatment. No significant effect of study duration on fracture risk could be demonstrated. The major adverse events were hypercalcaemia, nausea and discomfort at the injection sites. Only limited data are currently available on fracture risk reduction with PTH plus antiresorptive therapies.

CONCLUSION

Although the number of studies on non-vertebral fractures is limited, our pooled analysis revealed that PTH alone or in combination with antiresorptive drugs would appear to be able to reduce the risk of vertebral and non-vertebral fractures and to increase spine and perhaps hip BMD. However, these analyses were based on cross-sectional data--i.e. based on indirect comparisons--and further studies with a direct comparison of study duration are necessary. No studies comparing PTH, PTH plus antiresorptive drugs and antiresorptive drug versus placebo in a factorial design are available; consequently, we were unable to draw any conclusions on the superiority of PTH plus antiresorptive drug versus antiresorptive drug or PTH alone with respect to BMD or fractures.

Considerations in developing model-based economic evaluations of glaucoma treatment

PURPOSE

To facilitate future glaucoma model development and to provide guidance for decision-makers evaluating them, we provide an overview of an innovative glaucoma model and highlight important modeling considerations.

CONSIDERATIONS

The considerations that were addressed include: disease outcome that is both relevant and meaningful to current clinical practice; diversity in treatment options and practices; incorporation of therapy discontinuation; and consideration of the variability in patient response to treatment.

MODEL SCOPE

A state-transition, Monte Carlo simulation model was developed to simulate the management and treatment of patients with glaucoma and/or ocular hypertension. The model examines strategies involving sequential use of up to 6 pharmacologic interventions. Transitions are based on the monthly probability that a patient is no longer "successfully maintained" on therapy, which can be a consequence of lack of intraocular pressure control, adverse events, lack of compliance, or lack of persistence. Outputs of the model include months on each treatment, frequency of therapy switches, days of intraocular pressure control, frequency of ophthalmologist visits, frequency of surgery, and glaucoma-related costs. The model allows the user to specify country-specific treatment strategies, survival on therapy, surgical rates, practice patterns, and costs.

CONCEPT APPLICATION

The model presented offers insights into accommodating patient and clinician variability through the use of persistence distributions. It will facilitate future glaucoma model development and provide insight for decision-makers who must evaluate model-based analyses of the economic value of glaucoma interventions.

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.

Assessing generalisability in model-based economic evaluation studies: a structured review in osteoporosis

To support decision making, many countries have now introduced some formal assessment process to evaluate whether health technologies represent good 'value for money'. These often take the form of decision models that can be used to explore elements of importance to generalisability of study results across clinical settings and jurisdictions. The objective of this review was to assess whether articles reporting decision-analytic models in the area of osteoporosis provided enough information to enable decision makers in different countries/jurisdictions to fully appreciate the variability of results according to location and be able to apply the evaluation to their own setting. Of the 18 articles included in the review, only three explicitly stated the decision-making audience. It was not possible to infer a decision-making audience in eight studies. The target population was well reported, as were resource and cost data, and clinical data used for estimates of relative risk reduction. However, baseline risk was rarely adapted to the relevant jurisdiction, and when no decision maker was explicit it was difficult to assess whether the reported cost and resource use data were in fact relevant. A few studies used sensitivity analysis to explore elements of generalisability, such as compliance rates and baseline fracture risk rates, although such analyses were generally restricted to evaluating parameter uncertainty. This review found that variability in cost effectiveness across locations is addressed to a varying extent in modelling studies in the field of osteoporosis, limiting their use for decision makers across different locations. Transparency of reporting is expected to increase as methodology develops and decision makers publish 'reference case' type guidance.

Potential cost-effective use of spine radiographs to detect vertebral deformity and select osteopenic post-menopausal women for amino-bisphosphonate therapy

Prevalent vertebral deformities are predictive of future clinical fractures independent of bone density. We used a Markov model with eight health states to estimate from the societal perspective the cost-effectiveness of using spine radiographs to identify postmenopausal women age 60 or older with one or more vertebral deformities and then treat them with anti-resorptive drug therapy to prevent fractures. We compared three strategies: 5 years of amino-bisphosphonate (alendronate) therapy for all, 5 years of alendronate therapy for only those with prevalent a radiographic vertebral deformity or no initial alendronate treatment. Lifetime direct medical and indirect costs, quality adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) were tracked. For women with one or more prevalent vertebral deformities, the costs per QALY gained ranged from 5,084 dollars (for an 80 year old with a T-score of -2.4) to 61,192 dollars (for a 60 year old with a T-score of -1.0). For women without prevalent vertebral deformity, the costs per QALY gained ranged from 41,897 dollars (for a 60 year old with a T-score of -2.4) to 166,219 dollars (for an 80 year old with a T-score of -1.0). These results were modestly sensitive to reasonable changes in fracture rates, disutility, discount rates and assumptions about the accuracy of spinal radiographs for detecting vertebral deformity. Assuming a societal willingness to pay per QALY gained of 50,000 dollars, the strategy of performing spine radiographs in post-menopausal osteopenic women with T-scores at or below -1.5 and treating those with 1 or more prevalent vertebral deformities is likely to be cost-effective. However, further research on the accuracy of vertebral deformity ascertainment from routine clinical radiographs and on the efficacy of amino-bisphosphonate drugs for reducing the risk of non-vertebral fractures in osteopenic women is needed to define more precisely the subset of osteopenic post-menopausal women in whom use of spinal radiographs is most cost-effective.

The societal value of universal childhood vaccination

Availability of new vaccines preventing infectious diseases in healthy children populations is increasing worldwide. In Canada, despite the current recommendation of the National Advisory Committee on Immunization to include recent vaccines in routine schedule, only a few provinces have incorporated some of the newer vaccines in routine vaccination programs. A review was undertaken of economic evaluations of childhood vaccination strategies performed from the societal point of view in industrialized countries, to gain perspective on their global benefits. The general trend supports most universal vaccination programs as cost-saving or cost-effective for society. Comparison of vaccination programs with other health care interventions indicates that vaccines are often one of society's best healthcare investments. Current data suggest that the Canadian society would benefit from a more complete immunization program.

Health-related quality of life and cost of ambulatory care in osteoporosis: how may such outcome measures be valuable information to health decision makers and payers?

The objective was to quantify the outcome of osteoporosis (OP) in terms of health-related quality of life (HR-QOL) and cost of ambulatory care and to look at the association between these two outcomes variables. A cross-sectional health survey of 4800 Belgian individuals over the age of 45 years was used. Individuals having reported OP were retrieved and for each of them, at least two matched individuals for age, sex, residency location, and health insurance status were identified. All individuals were assessed with the SF-36. The two major health insurance providers furnished cost value for ambulatory care. HR-QOL and cost data were compared between the OP group and control group. Beta-coefficients from linear regression were calculated to give information on the relative importance of the association between each SF-36 dimensions and cost of ambulatory care. Of 4796 individuals appropriately surveyed, 221 (4.8%) reported OP. The control group included 651 individuals. The OP group experienced impaired HR-QOL compared to their matched counterparts, all the difference in mean or median SF-36 scores being significant at the level of P < 0.001. Osteoporotic respondents averaged 816 in cost of ambulatory care whereas controls averaged 579 (P < 0.001). When looking at detailed comparisons between categories of cost, costs in the OP group far exceeded those in the control group, all the differences being significant at the level of P < 0.001 except for home health nurse (P = 0.012). In the OP group, vitality dimensions played the most important role in the determination of cost (beta = -0.28, P < 0.001), followed by physical functioning (beta = -0.26, P < 0.01), general health, and social functioning (beta = -0.23, P < 0.01). This study evidences the burden of OP in terms of HR-QOL and cost of ambulatory care. Exploring the association between HR-QOL and cost show that mental dimension such as vitality can play an important role in the determination of cost. Conclusively, they should not be neglected in future management of OP.

The impact of non-compliance on the cost-effectiveness of pharmaceuticals: a review of the literature

Non-compliance with drug therapies not only limits their effectiveness, but in some instances, is associated with grave clinical sequelae and substantial economic burden. It is important, therefore, to consider non-compliance in economic evaluations. A review of pharmacoeconomic evaluations, which have applied sensitivity analysis to non-compliance rates, was undertaken to evaluate the impact of non-compliance on the cost-effectiveness of different drug therapies. Although 22 evaluations satisfied the inclusion criteria, additional information was obtained from the authors of most studies, as the published details were inadequate. The majority of evaluations assumed altered effectiveness owing to reduced compliance in the absence of supportive clinical evidence. Because of the disparity in the nature of the outcomes, the measures of non-compliance and the time horizon of the studies evaluated, it was not possible to compare the magnitude of the impact of non-compliance among different drug-disease combinations. However, it was evident that non-compliance always results in a reduction in efficacy, but its impact on costs varied substantially. The importance of incorporating measures of compliance is highlighted, as failing to account for 'real world' compliance rates in pharmacoeconomic evaluations may lead to selection of sub-optimal treatment strategies.

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.

Accounting for noncompliance in pharmacoeconomic evaluations

Noncompliance with prescribed drug regimens is a widespread phenomenon which results in decreased efficacy and is often associated with increased medical expenditures. Despite this, economic evaluations based on decision-analytic models rarely incorporate noncompliance to allow for the differences in compliance observed between controlled clinical trials and routine clinical practice. This review examines the issues relating to the measurement of noncompliance, and the clinical and economic consequences of noncompliant drug taking behaviour. In order to fully appreciate the clinical (and therefore the economic) consequences of noncompliance, a detailed understanding of the type of noncompliance, the pharmacokinetic and pharmacodynamic properties of the drug and the pathophysiological processes of the diseases being treated is required. These are described in detail, and a classification of drug-disease combinations according to the potential economic impact of the varying forms of noncompliance is set out. Issues are raised to highlight the need for improved modelling of the impact of noncompliance, and to this end, recommendations are made for future analyses. The main points are that compliance should be defined clearly, distinguishing between the various forms of noncompliance, that the assumptions relating to the health status of noncompliers should be explicit and robust, and that sensitivity analysis should be applied appropriately to ascertain the impact of noncompliance on the cost-effectiveness of drug therapies.

A randomized controlled trial to assess alendronate-associated injury of the upper gastrointestinal tract

BACKGROUND

Aminobisphosphonates are recommended for postmenopausal osteoporosis but have been associated with injury to the upper gastrointestinal tract.

AIM

To conduct a randomized controlled trial, to assess the endoscopic damage caused by alendronate and its effect on gastric mucosal prostaglandin synthesis.

METHODS

Seventy-six healthy volunteers age 40-60 years, with normal baseline endoscopy were randomly assigned to treatment with: (A) ASA 650 mg q. d.s.; (B) alendronate 10 mg o.d.; or (C) placebo o.d. for 14 days. Mucosal injury scores on day 14 of treatment were reported by a blinded endoscopist. Gastric biopsies were analysed for prostaglandin E2 (PGE2) concentration by radioimmunoassay.

RESULTS

Oesophageal injury did not differ among treatment groups. Gastric ulcers developed in five out of 26 subjects given ASA, two out of 25 given alendronate, and none of 25 given placebo. The mucosal damage scores for the alendronate group exceeded those for the placebo group in the gastric body but not at other sites. Injury scores for ASA exceeded those for placebo in the duodenum, antrum, body, and fundus. The mean change in log10[PGE2] (ng/mg protein) was - 0.07 for placebo, - 0.80 for ASA, and + 0.62 for alendronate (differences not significant).

CONCLUSIONS

Alendronate is associated with injury and ulceration of the gastric mucosa. This effect was not associated with any significant change in gastric mucosal PGE2 levels.

Position of the American Dietetic Association: nutrition, aging, and the continuum of care

Scientific evidence increasingly supports that good nutrition is essential to the health, self-sufficiency, and quality of life of older adults. With the population of the United States living longer than ever before, the older adult population will be more diverse and heterogeneous in the 21st century. The oldest-old and minority populations will grow more quickly than the young-old and non-Hispanic white populations, respectively. For the current 34 million adults 65 years of age and older living in the United States, there are about 12 million caregivers who provide formal or informal care. A broad array of culturally appropriate food and nutrition services, physical activities, and health and supportive care customized to accommodate the variations within this expanding population of older adults is needed. With changes and lack of coordination in health care and social-support systems, dietetics professionals need to be proactive and collaborate with aging-services and other health care professionals to improve policies, interventions, and programs that service older adults throughout the continuum of care to ensure nutritional well-being and quality of life. The American Dietetic Association supports both the provision of comprehensive food and nutrition services and the continuation and expansion of research to identify the most effective food and nutrition interventions for older adults over the continuum of care.