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.

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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.