Original Article

Cost-effectiveness Strategies to Treat Osteoporosis in Elderly Women

Authors: Alfred K. Pfister, MD, Christine A. Welch, MS, Melissa D. Lester, DO, Mary K. Emmett, PHD, Paul D. Saville, MD, Shea A. Duerring


Background: Comparing the cost-effectiveness of various antiosteoporotic drugs has not been defined.

Methods: We determined the cost-effectiveness of calcitonin, raloxifene, bisphosphates and PTH in a base-case cohort of women aged 65 or older with osteoporosis.

After bone densitometry, women were stratified into groups of treatment or no treatment. Our outcome goal was a value of $100,000 or less per quality-adjusted life years (QALY). A sensitivity analysis varied nonvertebral fracture reduction and compliance between the two most effective strategies to test various cost per QALY thresholds.

Results: Bisphosphonates displayed the most favorable incremental cost saving and prevented more fractures in our base-case analysis. In a sensitivity analysis, virtually all values of bisphosphonates were under $100,000 per QALY and parathyroid hormone (PTH) was between $100,000 and $200,000 per QALY.

Conclusions: Only bisphosphonates are cost-effective for fracture prevention in osteoporotic women aged 65 or older and this economic advantage is also maintained in subsets who have a lower relative risk of future fracture.

Key Points

* The best incremental cost per QALY and fracture reduction occurred with the bisphosphonate strategy in our base-case analysis.

* At comparable levels of compliance and efficacy of nonvertebral fracture reduction, PTH prevented more fractures but was not cost-effective.

* In a sensitivity analysis, more cost saving occurred by improved effectiveness of nonvertebral fracture prevention than improved compliance.

* Cost analysis studies of osteoporosis should be structured on fracture reduction not only at the vertebral spine, but also at nonvertebral sites. Also, FDA-approved drug doses and reasonable compliance rates should be factored into these evaluations.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Melton LJIII. Epidemiology of fractures. In: Riggs BL, Melton LJ eds. Osteoporosis: Etiology, Diagnosis and Management.New York, Philadelphia, Lipincott-Raven Publishers, 2nd ed, 1995, pp 225–247.
2. Zuckerman JD. Hip Fracture. N Eng J Med 1995;25:1519–1525.
3. Cooper C, Campion G, Melton LJ III. Hip Fractures in the Elderly: A Worldwide projection.Osteoporos Int 1992;2:285–289.
4. Wolinsky FD, Fitzgerald JF, Stump TE. The effect of hip fracture on mortality, hospitalization, and function status: A prospective study. Am J Public Health 1997;87:398–403.
5. Center JR, Nguyen TV, Schneider D, et al. Mortality after all major types of osteoporotic fracture in men and women: An observational study. Lancet 1999;353:878–882.
6. Crischilles EA, Butler CD, Davis CS, et al. A model of lifetime osteoporosis impact. Arch Int Med1991;151:2026–2032.
7. Chrischilles E, Shireman T, Wallace R. Costs and health effects of osteoporotic fractures. Bone1994;14:377–386.
8. Cauley JA, Thompson DE, Ensrud KC, et al. Risk of mortality following clinical fractures. Osteoporos Int 2000;11:556–561.
9. Zimmerman SI, Fox SM, Magazine J. Psychosocial aspects of osteoporosis. Phys Med Rehab Clin N Am 1995;6:441–453.
10. Ross PD. Clinical consequences of vertebral fractures. Amer J Med 1993;30S–43S.
11. Nevitt MC, Ettinger B, Black DM, et al. The association of radiographically detected vertebral fractures with back pain and function: A prospective study. Ann Int Med 1998;128:793–800.
12. Iacovino J. Mortality outcomes after osteoporotic fractures in men and women. Am Acad Insur Med2001;33:316–320.
13. Melton LJ III. Adverse outcomes of osteoporotic fractures in the general population. J Bone Miner Res 2003;18:1139–1141.
14. Ray NF, Chan JK, Thamer M, et al. Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: Report from the National Osteoporosis Foundation. J Bone Miner Res1995;12:24–35.
15. Tinetti ME. Preventing falls in elderly persons. N Eng J Med 2003;348:42–49.
16. Kannus P, Parkkari J, Niemi S, et al. Prevention of hip fracture in elderly people with use of a hip protector. N Eng J Med 2000;343:1506–1513.
17. McClung MR, Geusens P, Miller PD, et al. Effect of risedronate on the risk of hip fracture in elderly women. N Eng J Med 2001;334:333–340.
18. Black DM, Cummings SR, Karpf DB, et al. Randomized trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet 1996;348:535–541.
19. Guyatt GH, Cranney A, Griffith L, et al. Summary of meta-analysis of therapies for postmenopausal osteoporosis and the relationship of bone mineral density and fractures. Endocrinol Metab Clin North Am 2002;31:659–679.
20. Chesnut CH, Silverman S, Andriano K, et al. A randomized trial of nasal spray salmon calcitonin in postmenopausal women with established osteoporosis: the prevent recurrence of osteoporotic fractures study. Amer J Med 2000;109:267–276.
21. Neer RM, Arnaud CD, Zanchetta JR, et al. Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Eng J Med 2001;344:1434–1441.
22. Ettinger B, Black DM, Mitlack BH, et al. Reduction of vertebral fracture risk in postmenopausal women treated with raloxifene. JAMA 1999;282:637–645.
23. America's Bone Health: The State of Osteoporosis and Low Bone Mass in our Nation. National Osteoporosis Foundation, Washington, DC; 2002.
24. Nelson HD, Helfand M, Woolf SH, et al. Screening for postmenopausal osteoporosis: A review of the evidence for the U. S. Preventive Services Task Force. Ann Int Med 2002;137:529–541.
25. Pfister AK, McJunkin J, Santrock DA. Hip fracture outcomes and their prevention in Kanawha County, West Virginia. WV Med J 1999;95:170–174.
26. US Centennial Life Tables, 1989-1991. West Virginia Department of Health and Human Resources, Bureau for Public Health, Office of Epidemiology and Health Promotion.
27. Bureau of Economic Analysis. Available at: http://www.newyorkfed.org/research/directors_charts/i-reg_40.pdf. Accessed September 29, 2004.
28. Incidence and Costs to Medicare of Fractures Among Medicare Beneficiaries Aged 65 ≥ Years—United States, July 1991–June 1992. MMWR Morb Mort Wkly Rep 1996;45:878–883.
29. Melton LJ, Crowson CS, O'Fallon WM. Fracture incidence in Olmstead County, Minnesota: comparison of urban with rural rates and changes in urban rates over time. Osteoporos Int 1999;9:29–37.
30. Van Der Klift M, De Laet CEDH, McCloskey EV, et al. The incidence of vertebral fractures in men and women. The Rotterdam Study. J Bone Miner Res 2002;17:1051–1056.
31. Black DM, Arden NK, Palermo L, et al. Prevalent vertebral deformities predict hip fractures and new vertebral deformities but not wrist fractures. Study of Osteoporotic Fractures Research Group. J Bone Miner Res 1999;14:821–828.
32. Ross PD, Davis JW, Epstein RS, et al. Pre-existing fractures and bone mass predict vertebral fracture incidence in women. Ann Int Med 1991;114:919–923.
33. Cooper C, Atkinson EJ, O'Fallon WM, et al. Incidence of clinically diagnosed vertebral fractures: A population-based study in Rochester, Minnesota, 1985-1989. J Bone Miner Res 1992;7:221–227.
34. Tosteson ANA, Grove MR, Hammond CS, et al. Early discontinuation of treatment for osteoporosis.Amer J Med 2003;115:209–216.
35. Kayser J, Ettinger B, Pressman A. Postmenopausal hormone support:discontinuation of raloxifene versus estrogen. Menopause 2001;8:328–332.
36. Cole RP, Palushock S, Haboubi A. Osteoporosis management: Physicians recommendations and women's compliance following osteoporosis testing. Womens Health 1999;29:101–115.
37. Cairo JJ, Ishak KJ, Huybrechts KF, et al. Compliance patterns with osteoporosis medications.Osteoporos Int 2003;13 (Suppl 3):S16–S16.
38. Papaionnou A, Ioannidis G, Adachi JD, et al. Adherence to bisphosphonate and hormone replacement therapy in a tertiary care setting of patients in the CANDOO database. Osteoporos Int2003;14:808–813.
39. Brainsky D, Glick H, Lydick E, et al. The economic cost of hip fractures in community-dwelling residents: A prospective study. J Am Geriatr Soc 1997;45:281–287.
40. Hip fractures in people age 50 and over. Available at: http://www.wws.princeton.edu/cgt-bin/byteserv.prl/ota/ns20/alpha_f.html. Accessed September 27, 2004.
41. Johnell O, Jonsson B, Jonsson L, et al. Cost effectiveness of alendronate (Fosamax) for the treatment of osteoporosis and prevention of fractures. Pharmacoeconomics 2003;21:305–314.
42. Stone KL, Seeley DG, Lui L, et al. BMD at multiple sites and risk of fracture of multiple types: Long-term results from the Study of Osteoporotic Fractures. J Bone Miner Res 2003;18:1947–1954.
43. Kanis JA, Johnell O, De Laet C, et al. International variations in hip fracture probabilities: Implications for risk assessment. J Bone Miner Res 2002;17:1237–1244.
44. Black DM, Steinbuch M, Palermo L, et al. An assessment tool for predicting fracture risk in postmenopausal women. Osteoporos Int 2001;12:519–528.
45. Cummings SR, Nevitt MV, Browner WS, et al. Risk factors for hip fracture in white women. N Eng J Med 1995;332:767–773.
46. Barrett-Conner E, Siris ES, Wehren LE, et al. Osteoporosis and fracture risk in women of different ethnic groups. J Bone Miner Res 2005;20:185–194.
47. Cauley JA, Lui L-Y, Ensrud KE, et al. Bone mineral density and the risk of incident nonspinal fractures in black and white women. JAMA 2005;293:2102–2108.
48. Ubel PA, Hirth RA, Chernew ME, et al. What is the price of life and why doesn't it increase with inflation? Arch Int Med 2003;163:1637–1641.
49. Jonsson B, Christiansen C, Johnell O, et al. Cost effectiveness of fracture prevention in established osteoporosis. Scand J Rheumatol. 1996;103 (Suppl 103):30–38.
50. Kanis JA, Dawson A, Oden A, et al. Cost effectiveness of preventing hip fracture in the general female population. Osteoporos Int 2001;12:356–361.
51. Kanis JA, Borgstrom F, Johnell O, et al. Cost-effectiveness of risedronate for the treatment of osteoporosis and prevention of fractures in postmenopausal women. Osteoporos Int 2004;15:862–871.
52. Brecht JG, Kruse HP, Felsenberg D, et al. Pharmacoeconomic analysis of osteoporosis treatment with risedronate. Int J Clin Pharmacol Res 2003;23:93–105.
53. Lundkvist J, Johnell O, Cooper C, et al. Economic evaluation of parathyroid hormone (PTH) in the treatment of osteoporosis in postmenopausal women. Osteoporos Int. 2005; July 19 [Epub ahead of print].
54. Melton LJ, Gabriel SE, Crowson CS, et al. Cost-equivalence of different osteoporotic fractures.Osteoporos Int 2003;14:383–388.
55. Reid IR, Brown JP, Burckhardt P, et al. Intravenous zoledronic acid in postmenopausal women with low bone mineral density. N Eng J Med 2002;346:653–661.
56. Cummings SR, Duong T, Kenyon E, et al. Multiple outcomes of raloxifene evaluation (MORE) trial. Serum estradiol and the risk of breast cancer during treatment with raloxifene. JAMA 2002;287:216–22.
57. Jiang Y, Zhao JJ, Mitlak BH, et al. Recombinant human parathyroid hormone (1-34) [teripeptide] improves both cortical and cancellous bone structure. J Bone Miner Res 2003;18:1932–1941.
58. Sorenson OH, Crawford GM, Mudler H, et al. Long-term efficacy of risedronate: a 5-year placebo controlled clinical experience. Bone 2003;32:120–126.
59. Bone HG, Hosking D, Devogelaer J, et al. Ten years' experience with alendronate for osteoporosis in postmenopausal women. N Eng J Med 2004;350:1189–1199.
60. Kanis JA, Johnell O, Oden A, et al. The risk and burden of vertebral fractures in Sweden.Osteoporos Int 2003;15:20–26.
61. Richy F, Ethgen O, Bruyere O, et al. Primary prevention of osteoporosis: mass screening scenario or prescreening with questionnaire? An economic perspective. J Bone Miner Res 2004;19:1255–1260.