Impact of hormone therapy on Medicare spending in the Women's Health Initiative randomized clinical trials

BACKGROUND

Randomized trials can compare economic as well as clinical outcomes, but economic data are difficult to collect. Linking clinical trial data with Medicare claims could provide novel information on health care utilization and cost.

METHODS

We linked data from Medicare claims of women ≥65 years old who had Medicare fee-for-service coverage with their clinical data from the Women's Health Initiative trials of conjugated equine estrogens plus medroxyprogesterone acetate (CEE+MPA) versus placebo and of CEE-alone versus placebo. The primary outcome was total Medicare spending during the intervention phase of the trial, and the secondary outcomes were spending on diseases hypothesized a priori to be sensitive to the effects of hormone therapy.

RESULTS

In the CEE+MPA trial, 4,557 participants ≥65 years old were included. Women randomly assigned to CEE+MPA had 4% higher mean Medicare spending overall ($45,690 vs $43,920, P = .08) but 0.5% lower spending for hormone-sensitive diseases ($3,526 vs $3,547, P = .07), with 73% higher spending for coronary heart disease (P = .045) and 122% higher spending for pulmonary embolism (P = .026). In the CEE-alone trial, 3,107 participants were included. Total spending among women randomly assigned to CEE was 3.3% higher ($75,411 vs $72,997, P = .16), and 1.7% higher spending for hormone-sensitive diseases ($5,213 vs $5,127, P = .57), but with 39% lower spending for hip fracture (p<0.03).

CONCLUSIONS

Menopausal hormone therapy increased spending for some diseases, but decreased spending for others. These offsetting effects led to modest (3%-4%), nonsignificant increases in overall spending among women aged 65 years and older.

Hormone replacement therapy and the association with coronary heart disease and overall mortality: clinical application of the timing hypothesis

Conclusions from randomized controlled trial (RCT) data over the past 10 years has spanned from presumed harm to consistency with observational data that hormone replacement therapy (HRT) decreases the risk for coronary heart disease (CHD) as well as overall mortality in women who are recently postmenopausal. Multiple clinical studies including randomized trials and observational studies converge with animal experimentation to show a consistency that HRT decreases CHD risk and overall mortality in primary prevention when HRT is started at the time of or soon after menopause. The totality of data supports the "timing" hypothesis that posits that HRT effects are dependent on when HRT is started in relation to age and/or time-since-menopause. The totality of data shows that HRT decreases CHD and overall morality when started in women who are less than 60 years old and/or less than 10 years postmenopausal, providing a "window-of-opportunity". Further evidence shows that women who start HRT when in their 50s and continued for 5-30 years that there is an increase of 1.5 quality-adjusted life-years (QALYs). Additionally, HRT is highly cost-effective at $2438 per QALY gained. The totality of data converges to show a consistency between randomized trials and observational studies that when started in women at or near menopause and continued long-term, HRT decreases CHD and overall mortality compared with women who do not use HRT. This article is part of a Special Issue entitled 'Menopause'.

A multicentric study regarding the use of hormone therapy during female mid-age (REDLINC VI)

BACKGROUND

Menopausal hormone therapy (HT) has shown benefits for women; however, associated drawbacks (i.e. risks, costs, fears) have currently determined its low use.

OBJECTIVE

To determine the prevalence of current HT use among mid-aged women and describe the characteristics of those who have never used, have abandoned or are currently using HT. In addition, reasons for not using HT were analyzed.

METHOD

This was a cross-sectional study that analyzed a total of 6731 otherwise healthy women (45-59 years old) of 15 cities in 11 Latin American countries. Participants were requested to fill out the Menopause Rating Scale (MRS) and a questionnaire containing sociodemographic data and items regarding the menopause and HT use.

RESULTS

The prevalence of current HT use was 12.5%. Oral HT (43.7%) was the most frequently used type of HT, followed by transdermal types (17.7%). The main factors related to the current use of HT included: positive perceptions regarding HT (odds ratio (OR) 11.53, 95% confidence interval (CI) 9.41-14.13), being postmenopausal (OR 3.47, 95% CI 2.75-4.36) and having a better socioeconomic level. A total of 48.8% of surveyed women had used HT in the past, but abandoned it due to symptom improvement or being unconcerned; fear of cancer or any other secondary effects were also reported but in less than 10%. Among women who had never used HT, 28% reported the lack of medical prescription as the main reason, followed by the absence of symptoms (27.8%). Among those reporting lack of prescription as the main reason for not using HT, 30.6% currently had severe menopausal symptoms (total MRS score > 16); 19.5% of women were using alternative 'natural' therapies, with 35.1% of them displaying severe menopausal symptoms as compared to a 22.5% observed among current HT users.

CONCLUSION

The use of HT has not regained the rates observed a decade ago. Positive perceptions regarding HT were related to a higher use. Lack of medical prescription was the main reason for not using HT among non-users, many of whom were currently displaying severe menopausal symptoms.

Burden of illness of hypertension among women using menopausal hormone therapy: a US perspective

OBJECTIVE

To estimate the burden of illness (BOI) of hypertension in a cohort of women receiving menopausal hormone therapy (HT).

METHODS

Patients with at least one prescription for menopausal HT were selected from the PharMetrics database during the period July 1, 2003, to June 30, 2005. Hormone therapy patients were divided into those with and without hypertension. The nonhypertensive cohort was propensity score-matched to the hypertensive cohort, controlling for patient demographics, overall comorbidities, and type of HT use. The BOI of hypertension in the menopausal HT cohort was defined as the difference in average annual total healthcare expenditures per person between the cohorts.

RESULTS

The prevalence of menopausal HT use was 9.75% among potentially eligible patients in this commercially insured sample. Hypertension was the most common comorbidity in the menopausal HT cohort, with a prevalence of 34%. Hormone therapy patients with hypertension (n = 106,729) had significantly higher average annual healthcare expenditures compared to matched HT patients without hypertension ($8908 vs. $5960 per person per year; difference of $2948; p < 0.001).

CONCLUSIONS

Hypertension is the most common comorbidity among menopausal HT users in the United States. The annual BOI of hypertension is both substantial and significant when compared to matched patients without hypertension, averaging $2948 per patient per year.

Undertreatment of menopausal symptoms and novel options for comprehensive management

OBJECTIVE

There is currently a gap in treatment options for menopausal symptoms and a need for comprehensive therapies that are safe and effective for postmenopausal women. This review discusses challenges in the management of menopausal symptoms and the effect of the Women's Health Initiative (WHI) study findings on current treatment patterns. It also examines present and future therapies.

RESEARCH DESIGN AND METHODS

A literature search was conducted using Medline, the Cochrane Database, and the National Heart Lung and Blood Institute WHI website with the following search terms: primary care, menopause, vasomotor symptoms, hormone therapy, osteoporosis, and vaginal atrophy. Searches were limited to articles published between 1995 and 2009.

RESULTS

Comprehensive therapies that target several aspects of menopause, such as vasomotor symptoms and chronic disease prevention, are currently hormone based. These hormone-based approaches are considered more effective than currently available nonhormonal therapies for the relief of menopausal symptoms. However, hormone therapy is not recommended for women at high risk for venous thromboembolic events, cardiovascular disease, and/or breast cancer. A need exists for novel therapies that mitigate menopausal symptoms, provide protection from osteoporosis, and encourage patient compliance without promoting cancer, heart disease, or stroke. Emerging modalities and strategies, such as the tissue selective estrogen complex (TSEC), Org 50081, MF101, and desvenlafaxine, may provide improved options for postmenopausal women.

CONCLUSIONS

Several new menopausal therapies that may help to address the ongoing unmet need for safe and effective therapies for postmenopausal women are currently in development. In particular, the TSEC, which provides the benefits of both a selective estrogen receptor modulator and conjugated estrogens with an improved tolerability profile, may offer advantages over currently available treatment options. Limitations of this review include the narrow search criteria and limited search period.

Osteoporosis guidelines

The Position Statement from the International Menopause Society (IMS) in 2004 recommends the use of hormone therapy for the 'avoidance of bone-wasting and fractures'. It also states that 'prevention, not treatment, is the most feasible goal'. In updating the Statement, this paper considers the relevance of Osteoporosis Guidelines. Relevant documents will be of two broad types. These may be consensus statements/position statements that summarize the 'state of the art' for practitioners, based on the work of expert groups, or they may be formal Guidelines generated through formal 'evidence-based' methodology. The former approach is generally used by Societies and can be generated through relatively efficient consensus processes. The latter approach will normally involve extensive work and cost, necessarily becomes very detailed, involving systematic review and technology appraisal and can lead to highly specific recommendations on intervention thresholds. For the revision of the general IMS Position Statement, the specific IMS Paper on Postmenopausal Osteoporosis (2005) must be a key reference document. This provides a description of the international consensus on the management of osteoporosis up to late 2004 and which remains relevant today. Additionally, other consensus statements and systematic guidelines need to be considered. Across these documents providing guidance, the substantial influence of the International Osteoporosis Foundation/National Osteoporosis Foundation Position Paper, defining a 'New approach to the development of assessment guidelines for osteoporosis', can be seen. This flagged the importance of a shift from guidance, tying the diagnostic threshold to the intervention threshold, and instead advised linking the intervention threshold to estimated fracture risk probability. This moves the intervention decision away from a simple bone density threshold to a more complex, but more realistic, threshold estimate, taking into account a range of important clinical risk factors and bone mineral density. This thinking is reflected in the IMS Paper on Postmenopausal Osteoporosis (2005).

Cost effectiveness of hormone therapy in women at high risks of fracture in Sweden, the US and the UK--results based on the Women's Health Initiative randomised controlled trial

OBJECTIVE

The purpose of the study was to assess the cost effectiveness of hormone therapy (HT) for postmenopausal women without menopausal symptoms at an increased risk of fracture in Sweden, the UK and the US.

METHODS

Using a state-transition model, the cost effectiveness of 50 year old women was assessed based on a societal perspective and the medical evidence found in the Women Health Initiative (WHI) trials. The model had a lifetime horizon divided into cycle lengths of 1 year and comprised the following disease states: hip fracture, vertebral fracture, wrist fracture, breast cancer, colorectal cancer, coronary heart disease, stroke and venous thromboembolic events. An intervention was modelled by its impact on the disease risks during and after the cessation of treatment. The model required data on clinical effects, risks, mortality rates, quality of life weights and costs valid for Sweden, the UK and the US. The main outcome of the model was cost per QALY gained of HT compared to no treatment.

RESULTS

The results indicated that HT compared to no treatment was cost-effective for most sub-groups of hysterectomised women, whereas for women with an intact uterus without a previous fracture, HT was commonly dominated by no treatment. Fracture risks were the single most important determinant of the cost effectiveness results.

CONCLUSIONS

HT is cost-effective in women with a hysterectomy irrespective of prior fracture status. In women with an intact uterus, opposed HT was cost-effective in those with a prior vertebral fracture, but cost-ineffective in women without a prior vertebral fracture. Even though HT is found cost-effective for a selection of osteoporotic women, it is unlikely to be considered for first-line therapy for osteoporosis because bisphosphonates have shown a similar reduction in fracture risks but without an increased risk of adverse events.

Economic impact of Tibolone compared with Continuous-Combined Hormone Replacement Therapy in the management of climacteric symptoms in postmenopausal women

BACKGROUND

Deciding whether to treat postmenopausal women suffering from climacteric symptoms with Continuous Combined Hormone Replacement Therapy (CCHRT) has become increasingly difficult after the release of the Women's Health Initiative results. As a result, development of alternatives to CCHRT is required. Tibolone, which is a synthetic steroid that has estrogenic, progestogenic and androgenic properties, is reported to be a promising alternative. It has been used in Europe, in the same indication as CCHRT, for approximately 20 years but is not yet available in Canada.

OBJECTIVE

We carried out a cost-utility analysis comparing a 3-year-treatment course with Tibolone 2.5mg and conjugated equine estrogens (CEE)/medroxyprogesterone acetate (MPA) (0.625 mg/2.5 mg) in the management of postmenopausal women with climacteric symptoms.

METHODS

A Markov model, considering persistence, vaginal bleeding and climacteric symptoms, was elaborated to compare the different options in terms of cost and Quality Adjusted Life Years (QALYs), according to a public third-party payer perspective.

RESULTS

Compared with CEE/MPA, Tibolone led to an increase in cost (dollars 485 for Tibolone versus dollars 232 for CEE/MPA) and a slight increase in QALYs (2.08 for Tibolone versus 2.05 for CEE/MPA). Consequently, the incremental cost per QALY gained ratio was dollars 9198.

CONCLUSION

According to the results, Tibolone seems to be a cost-effective alternative to CEE/MPA. However, those results should be interpreted with caution insofar as the difference in terms of QALY is clinically difficult to value and taking into account the limited data on Tibolone's long-term innocuity.

Climacteric symptoms and hormones

Climacteric symptoms are so closely associated with the menopause to be practically considered its hallmark. However, symptoms can already appear before the onset of menopause. The frequency, extent and intensity of symptoms are dependent on social factors, body composition, race and geographical region. In about 20-25% of menopausal women they do not occur at all. These symptoms are most prominent in women who are suddenly deprived of their endogenous estrogen secretion, for instance by bilateral ovariectomy, particularly in younger women. Climacteric symptoms can to be subdivided into five categories: menstrual bleeding disorders; vegetative symptoms; psychosomatic symptoms; somatotrophic changes; and metabolic changes. For prevention and treatment of the various symptoms, estrogen/progestogen replacement therapy (HRT) or estrogen replacement therapy (ERT) in individualized dosages and various forms of applications are the most cost-effective modalities in order to control menopausal symptoms and restore organic function, or prevent all of this and improve women's quality of life. Recent publications indicate that gene polymorphisms may be associated with severe and persistent climacteric symptoms. This is also true for current and ever cigarette smokers.

A cost-utility analysis of low-dose hormone replacement therapy in postmenopausal women with an intact uterus

OBJECTIVE

The objective of this study was to evaluate the cost utility of one year's treatment with a low-dose conjugated estrogen/medroxyprogesterone acetate (CE/MPA low dose) preparation (Premique Low Dose [Wyeth Pharmaceuticals, Maidenhead, UK]), compared with a higher-dose preparation (Premique; CE/MPA [Wyeth Pharmaceuticals, Maidenhead, UK]), in postmenopausal women with an intact uterus. The evaluation captured the resource implications associated with the difference in treatment discontinuation and adverse event driven consultations in patients receiving either the low- or higher-dose preparation. This economic evaluation was conducted from the perspective of the NHS.

RESEARCH DESIGN AND METHODS

A health economic model was developed to calculate the incremental cost per quality-adjusted life year (QALY) gained from treatment with a lower-dose CE/MPA combination, compared with a higher-dose CE/MPA preparation. Cohorts of 100 patients were assumed to receive either CE/MPA low dose or CE/MPA for one year. A probabilistic sensitivity analysis was used to explore whether the base case model was robust to the assumptions employed. Neither costs nor consequences were discounted because of the one year timeframe.

RESULTS

In the base case, CE/MPA low dose dominates, i.e. it showed a greater health gain at a reduced cost, in both mild and severe symptom populations. These results were repeated in the sensitivity analysis, with the cost-effectiveness planes for both mild and severe symptom populations showing a greater utility at a reduced cost.

CONCLUSIONS

CE/MPA low dose has been demonstrated to be a cost-effective treatment of estrogen-deficiency symptoms in postmenopausal women with an intact uterus. It has great potential for increasing the number of patients benefiting from relief of menopausal symptoms while also reducing the resource utilisation associated with managing the adverse effects associated with higher-dose HRT.

Psychosocial and socioeconomic burden of vasomotor symptoms in menopause: a comprehensive review

Many women experience vasomotor symptoms at or around the time of menopause. Hot flushes and night sweats are considered primary menopausal symptoms that may also be associated with sleep and mood disturbances, as well as decreased cognitive function. All of these symptoms may lead to social impairment and work-related difficulties that significantly decrease overall quality of life. Hot flushes have shown a great deal of variability in their frequency and severity in women. In some women, hot flushes persist for several months; in others, they may last for more than 10 years. Traditionally vasomotor symptoms were reported to begin 5 to 10 years prior to the cessation of the final menstrual cycle, corresponding with the initial decline in circulating gonadal hormones; however, night sweats in particular most often begin in perimenopause. The pathogenesis of hot flushes has not yet been fully elucidated, but the circuitry involving estrogen and neurotransmitters, norepinephrine and serotonin specifically, are hypothesized to play a major role in the altered homeostatic thermoregulatory mechanisms underlying these events.

Menopause-associated vasomotor symptoms are associated with significant direct and indirect costs. Overall costs of traditional pharmacotherapy or complementary and alternative medicine modalities, including over-the-counter treatments and dietary supplements, for managing menopause-related vasomotor symptoms are substantial and include initial and follow-up physician visits and telephone calls. Additional costs include laboratory testing, management of adverse events, loss of productivity at work, and personal and miscellaneous costs. Pharmacoeconomic analyses, including those that consider risks identified by the Women's Health Initiative, generally support the cost-effectiveness of hormonal therapy for menopause-associated vasomotor symptoms, which have been the mainstay for the management of these symptoms for more than 50 years. However, because many women now want to avoid hormone therapy, there is a need for additional targeted therapies, validated by results from controlled clinical trials that are safe, efficacious, cost-effective, and well tolerated by symptomatic menopausal women.

Compliance with drug therapies for the treatment and prevention of osteoporosis

OBJECTIVES

This study used paid claims data from real-world treatment settings to investigate the impact of hormone replacement therapy (HRT), bisphosphonate and raloxifene on patients with a recorded diagnosis of osteoporosis.

METHODS

Data from a large health insurer were used to identify 58,109 osteoporosis patients who initiated drug therapy for osteoporosis. Multivariate statistical models were developed for duration of therapy, compliance at 1 year, time to discontinuation or a change in therapy, health care costs and risk of fracture over 1 year.

RESULTS

One-year compliance rates were below 25% for all osteoporosis therapies. The mean unadjusted duration of continuous therapy was 221 days for raloxifene, 245 days for bisphosphonate, 262 for estrogen-only and 292 days for estrogen plus progestin. Raloxifene patients were consistently less compliant than estrogen-only patients after adjusting for differences in patient characteristics. Estrogen plus progestin patients were generally more compliant while bisphosphonate did not differentiate from estrogen-only. Compliance reduced the risk of hip fracture (o.r. = 0.382, P < 0.01) and vertebral fracture (o.r. = 0.601, P < 0.05). Compliant patients used fewer physicians services (-US dollars 56, P < 0.0001), hospital outpatient services (-US dollars 38, P < 0.05) and hospital care (-US dollars 155, P < 0.01). Bisphosphonate patients were twice as likely as estrogen-only patients to experience vertebral, Colles and other fractures and experienced higher health care costs (+US dollars 420, P < 0.01). The effectiveness of both raloxifene and bisphosphonate medications relative to estrogen-only improved significantly with the age of the patient.

CONCLUSIONS

Compliance with drug therapies for osteoporosis over 1 year is poor leaving patients at risk for fractures and higher health care costs.

Promotion and prescribing of hormone therapy after report of harm by the Women's Health Initiative

CONTEXT

Little is known about how the pharmaceutical industry responds to evidence of harm associated with its products, such as the publication in July 2002 of the Women's Health Initiative Estrogen Plus Progestin Trial (WHI E+P) report demonstrating that standard-dose Prempro produced significant harm and lacked net benefits.

OBJECTIVE

To examine pharmaceutical industry response to the WHI E+P results by analyzing promotional expenditures for hormone therapy before and after July 2002.

DESIGN AND SETTING

Nationally representative and prospectively collected longitudinal data (January 2001 through December 2003) on prescribing and promotion of hormone therapies were obtained from IMS Health and Consumer Media Reports.

MAIN OUTCOME MEASURES

Trends in quarterly prescriptions for hormone therapy and expenditures on 5 modes of drug promotion: samples, office-based detailing, hospital-based promotion, journal advertisements, and direct-to-consumer advertising.

RESULTS

Prior to the WHI E+P report, prescribing rates and promotional spending for hormone therapy were stable. In the quarter before the WHI E+P report (April-June 2002), 22.4 million prescriptions for hormone therapy were dispensed and 71 million dollars was spent on promotion (in annual terms, 350 dollars per year per US physician). Within 9 months of the report's publication (quarter 1 of 2003), there was a 32% decrease in hormone therapy prescriptions, and a nadir had been reached for promotional spending (37% decrease compared with pre-WHI E+P levels). Spending decreased for all promotional activities and most hormone therapies. Overall, the greatest declines were for samples (36% decrease as of quarter 1 of 2003) and direct-to-consumer advertising (100% decrease). The greatest declines in promotion occurred for standard-dose Prempro (61% decrease as of quarter 1 of 2003), the agent implicated by the WHI E+P report. More recently, promotional efforts have increased, particularly for lower-dose Prempro, a resurgence associated with modestly increased prescriptions for this newer agent.

CONCLUSIONS

Concordant with its widespread use, hormone therapy was among the most heavily promoted medications prior to the WHI E+P report. Following reporting of the evidence of harm from this trial, there was a substantial decline in promotional spending for hormone therapy, particularly for the agents most directly implicated in the trial. Interrelated with the impact of the trial results themselves and the ensuing media coverage, reduced promotion may have contributed to a substantial decline in hormone therapy prescriptions.

Medical care costs associated with postmenopausal estrogen plus progestogen therapy

OBJECTIVE

To investigate the medical management costs of estrogen plus progestogen hormone therapy (HT) among postmenopausal women taking HT primarily as a preventive treatment for osteoporosis.

DESIGN

Retrospective longitudinal comparative analysis of HT users and demographically matched nonusers using administrative databases on physician services, hospital stays and prescription medications.

SETTING

Saskatchewan, Canada.

PATIENTS

a total of 5762 women aged 55 years or more who took HT sometime between 1990 and 1997 and 5762 demographically matched controls who did not take HT from 1990 to 1997.

MAIN OUTCOME MEASURES

total medical care expenditures and apparent costs of managing adverse events associated with HT.

RESULTS

Excluding drug acquisition costs for HT and costs of care for osteoporosis, women in their first year of postmenopausal HT had total medical care costs about $400 greater than women who had never used HT (1997 Canadian dollars). This total medical care cost differential falls to about $90 to $120 per annum after the first year of therapy. If osteoporosis-related medical care costs are not excluded, the cost differential is about $390 during the first year of therapy and $80 to $110 per annum after the first year of therapy. These excess costs primarily are the result of excess rates of resource utilization for uterine- and breast-related diagnostic and treatment procedures.

CONCLUSION

Medical management costs for HT may be substantial during the first year of therapy, and some medical management costs may persist over several years. These short-term management costs, combined with recent data about the long-term safety of HT as a preventive therapy, reinforce the importance of considering therapeutic alternatives to HT.

A cost-effectiveness evaluation of two continuous-combined hormone therapies for the management of moderate-to-severe vasomotor symptoms

OBJECTIVES

After the release of the results of the Women's Health Initiative, an emerging consensus suggests that continuous-combined hormone therapy (CCHT) should be limited to short-term management of moderate-to-severe vasomotor symptoms. This, in turn, raises the important question of the economic value, if any, of short-term CCHT for this indication. We conducted a cost-effectiveness analysis comparing a 1-year treatment course with 1 mg of norethindrone acetate/5 microg of ethinyl estradiol (1/5 NA/EE) or 0.625 mg/day of conjugated estrogens plus 2.5 mg of medroxyprogesterone (0.625/2.5 CEE/MPA) compared with no therapy for the management of moderate-to-severe vasomotor symptoms.

DESIGN

A literature-based Markov model was developed to compare these three options' cost and quality-of-life (QOL) benefits. The impact of therapy on vasomotor symptoms and breakthrough bleeding/spotting on the direct costs of care and QOL were considered.

RESULTS

Compared with no therapy, CCHTs resulted in net increases in quality-adjusted life-years (QALYs) gained (0.110 for 1/5 NA/NE v 0.104 for 0.625/2.5 CEE/MPA). Net costs (v no therapy) were $167 lower for 1/5 NA/NE compared with 0.625/2.5 CEE/MPA. Cost per QALY gained (compared with no therapy) were $6,200 and $8,200, respectively. Cost-effectiveness was most favorable for individuals with more severe symptoms who were less bothered by breakthrough bleeding/spotting.

CONCLUSIONS

A short-term course of CCHT for the sole purpose of managing moderate-to-severe vasomotor symptoms is cost-effective. However, 1/5 NA/NE seemed to be more cost-effective than 0.625/2.5 CEE/MPA. These findings can be used to further refine the role of CCHT and to improve formulary decisions.

The drug industry and medical practice--the case of menopausal hormone therapy in Estonia

After the dissolution of the Soviet Union, Estonia quickly adopted a market economy. In medicine this has included the uptake of western-style health care and drug promotion aimed at practising physicians. Using post-menopausal hormone therapy (HT) as an example, we studied the consequences of this natural experiment on prescribing and on physicians' opinions of HT and drug promotion. Data were obtained from a cross-sectional questionnaire survey sent to gynaecologists and family practitioners (FPs) in 2000 compared to an earlier Finnish survey, and from drug sales figures (based on defined daily doses), local medical journals and observations. The survey focussed on physicians' opinions of HT, HT information and HT education, and was sent to a random sample of 500 physicians, of whom 68% responded. The sales of HT drugs in the 1990s in Estonia were much lower than in Finland, but rapidly rose during that decade. Physicians considered drug advertising to be a factor contributing to the increased HT use. Most gynaecologists but fewer FPs reported that they had had enough continuing education on menopause and HT. For 39% of the gynaecologists and 20% of the FPs, (part of) the costs to attend their last education activity was paid by a drug firm. Respondents who wished for further education considered drug firms to be potential organisers. Gynaecologists had had more communication on HT with the drug industry, and their attitudes towards HT were more positive than those of FPs. Fears about cancer in the 1980s were not found in 2000. The study suggests that the drug industry contributed to the change in physicians' views of HT.

An economic analysis of hormone replacement therapy for the prevention of fracture in young postmenopausal women

Osteoporosis is a major public health problem that will become increasingly important as our population ages. It leads to fractures that deeply affect the patients' quality of life. Osteoporosis is recognised as a leading factor in healthcare cost worldwide. For years, experts have recommended hormone replacement therapy (HRT), consisting of oestrogen with or without progestin, as the first-line therapy to prevent bone loss in postmenopausal women. Recently published randomised, controlled trials and well-designed meta-analyses confirm that HRT has both advantages and disadvantages. The advantages include prevention of osteoporotic fractures and colorectal cancer. The disadvantages are the resulting adverse effects such as coronary artery disease, stroke, thromboembolic events, breast cancer and cholecystitis. In the light of these findings, medical associations recommend against the routine use of oestrogen and progestin for the prevention of chronic conditions in postmenopausal women. HRT, administered for the prevention of fractures in all young postmenopausal women, would have an additional cost/year of life gained that is too expensive. However, this strategy seems to be cost-effective when young postmenopausal women at high risk for fractures are selected. Even if this strategy seems attractive, the adverse effects of HRT are not acceptable. This situation implies that other treatments must be found to prevent or treat osteoporosis. Among them, calcium and vitamin D were shown to be cost-saving in osteoporosis and even costs-effective in osteopoenia in young postmenopausal women.

The cost of treating osteoporosis in a managed health care organization

OBJECTIVE

To measure the differences in direct health care costs and resource utilization among female enrollees in a health maintenance organization who were aged 45 through 65 years and had either osteoporosis or an osteoporosis-related fracture.

METHODS

One year of medical and pharmacy claims (October 1, 1998, to September 30, 1999) from a mixed-model health plan located in the Midwest were evaluated. Diagnoses were determined from medical claims with ICD-9 codes specific to either osteoporosis or osteoporosis-related fracture. Aggregate costs specific to osteoporosis were compared to all costs incurred by the members regardless of the disease states.

RESULTS

We identified 600 women who had consumed a total of $4.6 million in health care resources and $411,684 in direct costs specifically related to osteoporosis. The highest total average disease-specific costs were found for women with a fracture ($939 per patient per year [PPPY]) compared to those with osteoporosis only ($645 PPPY). Outpatient costs accounted for the highest percentage of mean total annual costs of care, representing up to 38% of the total health care resources consumed. Average medical costs for women with a fracture were highest for the 60 to 64 years age category, the oldest age category in the study population ($17,403 PPPY, P=.0379). Estrogen was the most utilized drug for treatment of osteoporosis, accounting for 41% of the total osteoporosis-specific prescription utilization.

CONCLUSION

The costs of care for members with osteoporosis-related fractures were, on average, higher than for women with osteoporosis only. The component costs included outpatient services, inpatient services, and prescription costs. Women not receiving drug therapy for management of osteoporosis incurred slightly higher total health care costs than women who did not receive drug therapy for osteoporosis.

A comparison of therapy continuation rates of different hormone replacement agents: a 9-month retrospective, longitudinal analysis of pharmacy claims among new users

OBJECTIVE

To estimate the rate of therapy continuation among women using six different hormone replacement therapies (HRTs).

DESIGN

A retrospective, longitudinal analysis of pharmacy claims data was conducted for 7,120 women who were new users of six HRT regimens. Continuation rates of therapies were examined at the end of the 9-month period. In addition, the odds ratio of continuation for each product was determined using a logistic model, which controlled for the potential influence of a patient's age and a provider's age, gender, specialty, and geographical location.

RESULTS

Treatment continuation rates at the end of the 9-month period were significantly higher among patients prescribed oral 1 mg norethindrone acetate/5 microgram ethinyl estradiol (EE) (femhrt, Pfizer Inc, New York, NY, USA) compared with other HRT regimens. Patients prescribed 1 mg norethindrone acetate/5 microgram EE were 52% more likely to continue therapy compared with patients prescribed 0.625 mg conjugated equine estrogens/2.5 mg or 5 mg medroxyprogesterone acetate (Prempro, Wyeth, Madison, NJ, USA). Significantly higher rates of therapy continuation were seen in women aged 55 years or older, those who did not switch HRT during the analysis, those who received care in the central and northeast regions of the United States, and those who were seen by obstetricians/gynecologists (v primary care physicians) or female (v male) providers.

CONCLUSIONS

The higher rates of treatment continuation seen with newer continuous combined HRTs, such as 1 mg norethindrone acetate/5 microgram EE, may lead to improved long-term compliance and, therefore, better protection against osteoporosis in postmenopausal women.

A cost effectiveness analysis of calcium and vitamin D supplementation, etidronate, and alendronate in the prevention of vertebral fractures in women treated with glucocorticoids

OBJECTIVE

To assess the relative costs and benefits of calcium and vitamin D supplements, cyclic etidronate, or alendronate in the prevention of vertebral fractures for women and with normal bone density and osteopenia who are about to initiate moderate dose glucocorticoid treatment.

METHODS

Using a decision analysis model, we evaluated the following patients: 4 hypothetical cohorts: 30-yr-old women with normal lumbar spine (LS) bone mineral density (BMD) (t score = 0), 50-yr-old women with borderline osteopenia (t score = -1), 60-yr-old women with moderate osteopenia (t score = -1.5), and 70-yr-old women with severe osteopenia (t score = -2) treated with a mean prednisone dose of 10 mg/day for one year. The main outcomes included the development of vertebral fractures 10 years after glucocorticoid treatment and at age 80 (life-time risk) and direct and indirect costs.

RESULTS

At 10 years, calcium and vitamin D supplements decreased fracture rates by 30-50% at a minimal cost (US$800 or less per vertebral fracture avoided) or at a cost saving compared to no treatment for women with osteopenia (t score -1 to -2). Etidronate and alendronate are most cost effective in women with borderline osteoporosis (t scores of -1.5 and -2) in the 10 year analysis. In the life-time analysis, calcium and vitamin D treatment yielded a cost savings compared to no treatment for all groups with osteopenia. Etidronate decreased fracture rates further in all groups at a cost of less than $2,000 per fracture prevented. Alendronate reduced the fracture risk further at cost of $3,000-7,000 per fracture avoided.

CONCLUSION

Calcium and vitamin D supplements and low cost bisphosphonate regimens such as cyclic etidronate decrease the life-time vertebral fracture risk at acceptable costs and should be considered when initiating glucocorticoid treatment for women who do not have osteoporosis.

Cost-effectiveness of hormone replacement therapy for fracture prevention in young postmenopausal women: an economic analysis based on a prospective cohort study

A recent systematic review of randomized controlled trials has shown that hormone replacement therapy (HRT) prevents fractures when taken soon after the menopause. HRT for treatment of menopausal symptoms is relatively cost-effective, but whether its use for prevention of perimenopausal fractures is economically efficient is unknown. We undertook a 6-year follow-up of 3645 perimenopausal women who had a bone mineral density (BMD) measurement with recommendation to use HRT if low BMD was present. Data were collected on incident fractures and costs. After an average of 6.2 years of follow-up HRT use significantly reduced incident fractures by 52% (95% CI: 67% to 18%). However, costs were increased by an average of pounds sterling 275 (95% CI: pounds sterling 228 to pounds sterling 330) for the group as a whole; for hysterectomized women costs were increased less (pounds sterling 138), but this was still significantly greater than for non-HRT users (95% CI: pounds sterling 6 to pounds sterling 275). The cost per averted fracture was about pounds sterling 11 000 (95% CI: pounds sterling 8625 to pounds sterling 13 872) for the whole group and for hysterectomized women the corresponding figure was substantially less (pounds sterling 1784; 95% CI: pounds sterling 59 to pounds sterling 3532). HRT given to women at or shortly after the menopause is therefore associated with a halving of fracture incidence. Such a policy for hysterectomized women without menopausal symptoms may be cost-effective as such women are at elevated risk of fracture and need cheaper, unopposed, estrogens.

[Pharmaco-economic evaluation of drug therapy osteoporosis. A literature review]

INTRODUCTION

Interventions against osteoporosis may reduce the incidence of fractures in patients and costs to society, but they also incur additional expenditure and thus call for economic evaluation. The aim of this paper was to evaluate existing literature by applying cost-effectiveness (CEA) and cost-utility analyses (CUA) to pharmacological treatment of osteoporosis.

MATERIAL AND METHODS

MEDLINE and the reference lists of relevant papers were searched to identify original papers on the subject. Studies were included if they were peer reviewed, written in English or a Scandinavian language, and reported CEA or CUA for a specified pharmacological intervention.

RESULTS

Of the 37 identified studies, 16 met the inclusion criteria (ten CUA and six CEA), and 21 studies were excluded. Of the studies examined, 13 studies concerned hormone replacement therapy (HRT), four bisphosphonate, four calcitonin, and four calcium supplementation and/or vitamin D treatment. All were based on simulations of the long-term effects of the intervention with respect to cost and effect. However, the studies varied widely in patient selection and assumptions about duration and effectiveness of intervention, assessment of quality of life, and mortality following hip fracture.

DISCUSSION

The published studies rely on limited empirical data as regards the effect of treatment, costs, and adverse effects. Several, however, indicate that some interventions may be cost-effective in high-risk groups.

Economics of lower urinary tract symptoms (LUTS) in older people

Urinary incontinence is an area of clinical and social importance to older people and providers of care. This article provides an update on the 'symptom' of urinary incontinence and reviews the concept of lower urinary tract symptoms (LUTS). The challenges facing health services researchers working in this field are also discussed in terms of trying to quantify the size and extent of the underlying problem. Economic issues and work undertaken to evaluate the cost of LUTS are appraised and the common nonsurgical treatments for LUTS are described together with associated conditions and their cost implications. The cost to individuals and society of LUTS is generally underestimated and the importance of reducing its severity (if cure is not achievable) makes clinical and economic sense.

[Equine estrogens vs. esterified estrogens in the climacteric and menopause. The controversy arrives in Mexico]

It exists controversies about if the effects and benefits of the esterified estrogens could be similar to those informed for equines, because its chemical composition and bioavailability are different. Esterified estrogens has not delta 8,9 dehydroestrone, and its absorption and level of maximum plasmatic concentrations are reached very fast. In United States of America and another countries, esterified estrogens has been marketed and using for treatment of climacteric syndrome and prevention of postmenopausal osteoporosis, based on the pharmacopoiea of that country, but the Food and Drug administration (FDA) has not yet authorized up today, a generic version of conjugated estrogens. In Instituto Mexicano del Seguro Social (IMSS) and another institutions of health sector in Mexico, starting in year 2000, it has been used esterified estrogens for medical treatment of climacteric and menopausal conditions. For this reason, in this paper we revised the most recent information about pharmacology, chemical composition, clinical use and costs of the conjugated estrogens with the purpose to guide the decisions to purchase this kind of drugs in Mexican heath institutions.

Urogenital atrophy: prevention and treatment

Fifteen percent of premenopausal women, 10-40% of postmenopausal women, and 10-25% of women receiving systemic hormone therapy experience urogenital atrophy. The most common symptoms are dryness, burning, pruritus, irritation, and dyspareunia. Estrogen loss, drugs, and chemical sensitivities are causes. Estrogen or hormone replacement therapy (ERT-HRT) is the treatment of choice in postmenopausal women. Dosages prescribed for menopause symptoms or to prevent osteoporosis (and, potentially, other conditions) can restore the vagina to premenopausal physiology and relieve symptoms. Concomitant progestins are necessary for women with an intact uterus to minimize or eliminate estrogen-induced endometrial cancer. Low-dosage oral and vaginal ERT can relieve urogenital atrophy but might not produce systemic effects. Progestins are not necessary with vaginal rings and vaginal tablets. If ERT is given only to treat urogenital atrophy, estrogen creams 1 or 2 times/week may prevent recurrence after symptoms are resolved. Progestins are not required for occasional estrogen cream use. Vaginal moisturizers provide longer relief by changing the fluid content of endothelium and lowering vaginal pH. Vaginal lubricants provide short-term relief. Women with contraindications to ERT-HRT could use lubricants for intercourse-related dryness or moisturizers for more continuous relief. The lay press promotes agrimony, black cohosh, chaste tree, dong quai, witch hazel, and phytoestrogens for vaginal dryness and dyspareunia; however, no evidence exists to support these specific claims. Pharmacists should be actively involved in identifying, preventing, and treating urogenital atrophy.

Physicians' perceptions of menopause and prescribing practices in Morocco

OBJECTIVE

To investigate the prescribing practices of Moroccan physicians around menopause.

METHODS

A survey was carried out on a representative sample of physicians in the capital city Rabat. The sample included general practitioners, gynecologists, cardiologists and rheumatologists, practicing in both public and private facilities. The instrument consisted of close- and open-ended questions about the socio-demographic characteristics of physicians, their patient population, their prescribing practices, and their perceptions of menopause and the different medical approaches to managing the symptoms and risks associated with it.

RESULTS

Most of the physicians interviewed are positively inclined towards the notion of prevention and in favor of hormonal treatment, and approximately half report that they have prescribed hormone therapy. Gynecologists and male physicians prescribe hormones more frequently, as well as physicians who are at private facilities. These findings are discussed in relation to the physicians' perceptions of the menopause transition.

CONCLUSION

There are considerable variations in prescribing practices and perceptions of menopause among Moroccan physicians.

Recruitment of participants for the Estrogen Replacement and Atherosclerosis (ERA) trial. a comparison of costs, yields, and participant characteristics from community- and hospital-based recruitment strategies

This paper documents recruitment for the Estrogen Replacement and Atherosclerosis trial, a multicenter, placebo-controlled, double-blind angiographic trial of the effects of opposed and unopposed estrogen on coronary atherosclerosis in postmenopausal women (average scheduled duration of follow-up 3.2 years). We compare costs, yields, and participant characteristics between community-based and hospital-based recruitment strategies. We further compare community-based enriched sources (i.e., those that allowed self-selection or targeted women with known health characteristics) and nonenriched sources. Data gathered on potential participants include method of contact, clinical site, eligibility, completion of screening visits, and randomization rates. Demographic data on participants include age, race, education, marital status, and income. Self-reported health status, smoking status, lipid level, ejection fraction as well as history of chest pain, hypertension, and diabetes were recorded at baseline. Recruitment costs were estimated from employee salaries and costs of screening tests and procedures. Yields were compared by clinical site and by method of contact. Enriched sources of recruitment yielded higher percentages of enrolled participants than nonenriched sources. Both types of source resulted in demographically similar participants. Costs of community-based recruitment were less than hospital-based recruitment; however, screening costs were higher. Overall, screening and recruitment averaged $2508 per randomized participant. Control Clin Trials 2001;22:13-25

Evaluation of a formulary switch from conjugated to esterified estrogens in a managed care setting

BACKGROUND

Formulary switches between agents in the same therapeutic class have become commonplace in the managed care setting as a strategy to reduce costs.

OBJECTIVES

We evaluated the impact of a formulary switch from conjugated to esterified estrogen tablets at the Fallon Community Health Plan, a mixed-model health maintenance organization.

DESIGN

A retrospective study was conducted with the use of the automated database of the health plan.

SUBJECTS

Study subjects were members of the health plan during the period from May 1, 1995, to December 31, 1997, who were dispensed > or =1 estrogen replacement product. From this population, a cohort of users of conjugated estrogens during the period from May 1, 1995, to October 31, 1995, was selected.

MEASURES

The cumulative incidence of switching from conjugated to esterified estrogen tablets and subsequent discontinuations of esterified estrogens was evaluated. The frequencies of ambulatory encounters during the 6 months before and after a switch or discontinuation were compared.

RESULTS

During the period after promotion of the formulary switch, 2,149 of 2,984 patients (72%) originally dispensed conjugated estrogen tablets switched to esterified estrogen tablets. Among those patients switching to esterified estrogens, an excess of 20 office visits per 100 patients was noted in the postswitch period (P = 0.005). The risk of switching back to conjugated estrogen tablets was 15% by 2 years.

CONCLUSIONS

The findings of this study suggest that plan efforts were successful in switching most users of conjugated estrogens to esterified estrogens. The switch was associated with an increase in utilization of health care services.

Should postmenopausal women with rheumatoid arthritis who are starting corticosteroid treatment be screened for osteoporosis? A cost-effectiveness analysis

OBJECTIVE

To evaluate the cost-effectiveness of different strategies for preventing corticosteroid-induced osteoporosis.

METHODS

Simulated cohorts of postmenopausal women with rheumatoid arthritis (RA) starting corticosteroid treatment were examined. A Markov decision analysis model was developed to compare different management strategies, including watchful waiting, screen and treat, and empirical treatment. Treatment thresholds for the screen and treat strategy were varied from bone mineral density (BMD) T scores <-1.0 to BMD T scores <-4.0.

RESULTS

Compared with a watchful waiting approach, the incremental cost-effectiveness ratio for a strategy of screen and treat with alendronate at a BMD T score of <-1.0 was $92,600 per quality-adjusted life year (QALY) gained. This result was sensitive to the cost and efficacy of osteoporosis therapy and, importantly, to the treatment threshold. At a treatment threshold of a BMD T score <-2.5, the incremental cost-effectiveness ratio of screening and treating was $76,100 per QALY. None of these results differed substantially for women taking estrogen replacement therapy.

CONCLUSION

The incremental cost-effectiveness ratio of a strategy of screening and treating postmenopausal female RA patients with BMD T scores of < -1.0, compared with watchful waiting, was greater than that of other well-accepted medical interventions. The cost-effectiveness ratios were more acceptable when a T score treatment threshold of <-2.5 was used. These conclusions are limited by the lack of data on fracture and treatment efficacy in corticosteroid-treated patients.

Use of unopposed estrogen in women with uteri: prevalence, clinical implications, and economic consequence

OBJECTIVE

Hormone replacement therapy with estrogen/progestin is the treatment of choice for relieving postmenopausal vasomotor symptoms and preventing urogenital atrophy and osteoporosis in women with intact uteri. However, despite the known increased incidence of endometrial hyperplasia when unopposed estrogen is used in such women, this progestin regimen has not been universally adopted.

DESIGN

This study was conducted in a managed care organization to determine the extent of the use of unopposed estrogen in women with intact uteri. Pharmacy claims data for all women 55 years or older with claims for estrogen only from September 1, 1996, to December 31, 1996, were reviewed. A total of 5,209 records were identified, from which 480 were randomly selected. A survey of the members' physicians was then carried out to determine hysterectomy status and was confirmed by chart audit.

RESULTS

Thirty-three (11%) of the members identified had not undergone hysterectomy. Follow-up physician contact revealed that five women did not have a uterus. Use of estrogen without opposing progestin was documented in a substantial percentage of files reviewed. It is of concern that with the documentation of the risks of endometrial hyperplasia and carcinoma in the intact uterus, unopposed therapy still occurs. In addition to the clinical costs, there are economic consequences to this practice. An economic model of unopposed estrogen use was created. A management cost of $1,504 for 3 years was estimated.

CONCLUSIONS

Further educational efforts are needed to ensure the use of opposed estrogen in the woman with an intact uterus.

Evaluation of hormone replacement therapy use by the sales figures

Despite the efficiency of hormone replacement therapy (HRT) to prevent climacteric manifestations and possibly the long-term deleterious influences of menopause, the prevalence of HRT is relatively low, and quite variable, depending on the population studied. Presently, there is no information regarding HRT in Switzerland and in the region of Geneva, which have particularly aged populations, with a life expectancy among the longest in the Western world. In this study, the number of women treated per year in 1993 and 1996, as well as the prevalence of HRT were estimated, based on the total amount of hormone preparations sold for HRT. In Switzerland, for a female population older than 45 years of about 1.45 million, the number of women on HRT was approximately 166,000 in 1993 and 202,000 in 1996. For Geneva, the female population was more than 86,000, and the number of treated women was about 14,000 and 21,000 in 1993 and 1996, respectively. Depending on the age class considered as susceptible of receiving HRT, the prevalence of this therapy may vary between 15 and 20% for Switzerland, and between 21 and 27% for Geneva in 1993. It was estimated between 17 and 24%, and 31 and 41% in 1996. These values are quite comparable to those reported for other countries with a similar socioeconomic level and obtained using different methods of evaluation.

[Menopause, the down side of medicalization]

Over the past 30 years, women have been the target of intense advertising focused on hormone replacement therapy. The author takes a critical look at the distorting nature of this approach, which has succeeded in convincing many Western women that menopause is an illness, and hormone replacement therapy a panacea. Through studies she has consulted, and discussions on the economic situation associated with age and poverty among the elderly, the author underlines that menopause is a lucrative industry. She advances several relevant issues for discussion.

Hormone replacement therapy and Alzheimer's disease: an update on the issues

Alzheimer's disease (AD) is a significant personal, family, social, and public health problem. Currently there is no way to prevent or cure AD. The latest opinions on the possibility of hormone replacement therapy (HRT)/estrogen replacement therapy (ERT) as a means to prevent and treat AD are reviewed. Although prevention and treatment of AD cannot yet be added to the list of HRT/ERT's benefits, research in the area is promising. The potential benefits and problems of HRT for the woman with or at risk for AD are examined. The potential benefits include improved interest and compliance with HRT, improved quality of life, and cost savings. The problems include difficulties in monitoring and managing clients with AD, assuring compliance with the therapeutic regimen, and deciding when to withdraw therapy. Clinical trials have not yet been able to determine the appropriate dosages, to standardize or predict the magnitude of the therapeutic effect, or to determine the safety of ERT/HRT as a long-term therapy, particularly when continued in the elderly years. Implications for practitioners are addressed.

A computer model to analyze the cost-effectiveness of hormone replacement therapy

This paper gives a detailed presentation of a computer model for evaluating the cost-effectiveness (CE) of hormone replacement therapy (HRT), describing the model's design, structure, and data requirements. The model needs data specified for costs, quality of life, risks, and mortality rates. As an illustration, the CE of HRT in Sweden is calculated. Two treatment strategies are evaluated for asymptomatic women: estrogen-only therapy and estrogen combined with a progestin. The model produces similar results compared with earlier studies. The CE ratios improve with the size of the risk reduction and generally with age. Further, estrogen-only therapy is associated with a lower cost per gained effectiveness unit compared with combined therapy. Uncertainty surrounding the long-term effects of HRT means that the CE estimates should be interpreted carefully. The model permits the inclusion of indirect costs and costs in added life-years, allowing the analysis to be made from a societal perspective, which is an improvement relative to previous studies.

Raloxifene: a selective estrogen receptor modulator

Raloxifene is a selective estrogen receptor modulator that produces both estrogen-agonistic effects on bone and lipid metabolism and estrogen-antagonistic effects on uterine endometrium and breast tissue. Because of its tissue selectivity, raloxifene may have fewer side effects than are typically observed with estrogen therapy. The most common adverse effects of raloxifene are hot flushes and leg cramps. The drug is also associated with an increased risk of thromboembolic events. The beneficial estrogenic activities of raloxifene include a lowering of total and low-density lipoprotein cholesterol levels and an augmentation of bone mineral density. Raloxifene has been labeled by the U.S. Food and Drug Administration for the prevention of osteoporosis. However, its effects on fracture risk and its ability to protect against cardiovascular disease have yet to be determined. Studies are also being conducted to determine its impact on breast and endometrial cancer reduction.

[Costs of different intervention strategies to prevent hip fractures]

The cost of primary prevention and the number of hip fractures prevented was compared in different scenarios. Primary prevention with hormonal replacement therapy (HRT) in women over the age of 50 years, secondary prevention with HRT in women over 50 years with low bone mineral on screening, use of external hip protectors in nursing home residents, use of calcium and vitamin D in nursing home residents and tertiary prevention with bisphosphonates (alendronate) or external hip protectors in subjects with a previous hip fracture were evaluated. External hip protectors or calcium plus vitamin D were cheap in nursing home residents. The economic cost of bisphosphonate treatment was high even in tertiary prevention in the high risk group with previous hip fracture. It was doubtful whether potential savings in prevention would out-weigh the cost in younger individuals even in high-risk groups.