Abstract
Summary
This is a cost-effectiveness analysis of training rural providers to identify and treat osteoporosis. Results showed a slight cost savings, increase in life years, increase in treatment rates, and decrease in fracture incidence. However, the results were sensitive to small differences in effectiveness, being cost-effective in 70 % of simulations during probabilistic sensitivity analysis.
Introduction
We evaluated the cost-effectiveness of training rural providers to identify and treat veterans at risk for fragility fractures relative to referring these patients to an urban medical center for specialist care. The model evaluated the impact of training on patient life years, quality-adjusted life years (QALYs), treatment rates, fracture incidence, and costs from the perspective of the Department of Veterans Affairs.
Methods
We constructed a Markov microsimulation model to compare costs and outcomes of a hypothetical cohort of veterans seen by rural providers. Parameter estimates were derived from previously published studies, and we conducted one-way and probabilistic sensitivity analyses on the parameter inputs.
Results
Base-case analysis showed that training resulted in no additional costs and an extra 0.083 life years (0.054 QALYs). Our model projected that as a result of training, more patients with osteoporosis would receive treatment (81.3 vs. 12.2 %), and all patients would have a lower incidence of fractures per 1,000 patient years (hip, 1.628 vs. 1.913; clinical vertebral, 0.566 vs. 1.037) when seen by a trained provider compared to an untrained provider. Results remained consistent in one-way sensitivity analysis and in probabilistic sensitivity analyses, training rural providers was cost-effective (less than $50,000/QALY) in 70 % of the simulations.
Conclusions
Training rural providers to identify and treat veterans at risk for fragility fractures has a potential to be cost-effective, but the results are sensitive to small differences in effectiveness. It appears that provider education alone is not enough to make a significant difference in fragility fracture rates among veterans.
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References
Gennari L, Bilezikian JP (2007) Osteoporosis in men. Endocrinol Metab Clin N Am 36:399–419
National Osteoporosis Foundation (2010) Clinician’s Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation
Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR (2009) Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA 301:513–521
Fransen M, Woodward M, Norton R, Robinson E, Butler M, Campbell AJ (2002) Excess mortality or institutionalization after hip fracture: men are at greater risk than women. J Am Geriatr Soc 50:685–690
Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A (2007) Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 22:465–475
Kane T (2006) Who are the recruits? The demographic characteristics of U.S. Military Enlistment, 2003–2005. Center for Data Analysis Report #06-09. Heritage Foundation, Washington, DC
Weeks WB, Wallace AE, Wang S, Lee A, Kazis LE (2006) Rural-urban disparities in health-related quality of life within disease categories of veterans. J Rural Health 22:204–211
Wallace AE, Lee R, Mackenzie TA, West AN, Wright S, Booth BM, Hawthorne K, Weeks WB (2010) A longitudinal analysis of rural and urban veterans’ health-related quality of life. J Rural Health 26:156–163
Health Services Research and Development DoVA (2012) Community-Based Outpatient Clinics (CBOC). http://www.researchvagov/resources/pubs/cboccfm
Nelson RE, Hicken B, West A, Rupper R (2012) The effect of increased travel reimbursement rates on health care utilization in the VA. J Rural Health 28:192–201
Nelson RE, Battistone MJ, Ashworth WD, Barker AM, Grotzke M, Huhtala TA, Lafleur J, Tashjian RZ, Cannon GW (2013) Cost effectiveness of training rural providers to perform joint injections. Arthritis Care Res (Hoboken) 66(4):559--66. doi:10.1002/acr.22179
LaFleur J, Nelson R, Adler R, Nebeker J, Nelson S, Smith J, Malone D (2012) Cost-effectiveness analysis of different strategies for fragility fracture prevention in United States male veterans. ISPOR 17th Annual International Meeting. Value in Health, Washington, D.C., p A8
Nelson S, Malone D, LaFleur J (2014) Calculating the baseline incidence in patients without risk factors: a strategy for economic evaluation. Manuscript submitted for publication
Sawka AM, Papaioannou A, Adachi JD, Gafni A, Hanley DA, Thabane L (2005) Does alendronate reduce the risk of fracture in men? A meta-analysis incorporating prior knowledge of anti-fracture efficacy in women. BMC Musculoskelet Disord 6:39
Bone HG, Hosking D, Devogelaer JP et al (2004) Ten years’ experience with alendronate for osteoporosis in postmenopausal women. N Engl J Med 350:1189–1199
Mellstrom DD, Sorensen OH, Goemaere S, Roux C, Johnson TD, Chines AA (2004) Seven years of treatment with risedronate in women with postmenopausal osteoporosis. Calcif Tissue Int 75:462–468
LaFleur J, Pickard S, Nebeker J (2008) Recognition and treatment of male osteoporosis is low in at least one VISN. HSR&D National Meeting, Baltimore
Arias E (2011) United States Life Tables, 2007. Natl Vital Stat Rep. Division of Vital Statistics, Centers for Disease Control, Washington, D.C., p 61
Ito K, Hollenberg JP, Charlson ME (2009) Using the osteoporosis self-assessment tool for referring older men for bone densitometry: a decision analysis. J Am Geriatr Soc 57:218–224
Melton LJ 3rd (2000) Excess mortality following vertebral fracture. J Am Geriatr Soc 48:338–339
Browner WS, Pressman AR, Nevitt MC, Cummings SR (1996) Mortality following fractures in older women. The study of osteoporotic fractures. Arch Intern Med 156:1521–1525
Ettinger B, Black DM, Dawson-Hughes B, Pressman AR, Melton LJ 3rd (2010) Updated fracture incidence rates for the US version of FRAX. Osteoporos Int 21:25–33
Schousboe JT, Taylor BC, Fink HA, Kane RL, Cummings SR, Orwoll ES, Melton LJ 3rd, Bauer DC, Ensrud KE (2007) Cost-effectiveness of bone densitometry followed by treatment of osteoporosis in older men. JAMA 298:629–637
Brunkhorst FM, Engel C, Ragaller M et al (2008) Practice and perception—a nationwide survey of therapy habits in sepsis. Crit Care Med 36:2719–2725
Stone PW, Pogorzelska-Maziarz M, Herzig CT, Weiner LM, Furuya EY, Dick A, Larson E (2014) State of infection prevention in US hospitals enrolled in the National Health and Safety Network. Am J Infect Control 42:94–99
Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR (1999) Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 282:1458–1465
Acknowledgments
This project has been supported by the Office of Specialty Care Transformation which is a part of the T-21 New Models of Care Initiative, VA Central Office, Washington DC, and supported with resources and the use of facilities at the George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah. Dr. Nelson is supported by the VA Advanced Fellowship Program in Medical Informatics of the Office of Academic Affiliations, Department of Veterans Affairs.
Conflict of interest
The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
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Nelson, S.D., Nelson, R.E., Cannon, G.W. et al. Cost-effectiveness of training rural providers to identify and treat patients at risk for fragility fractures. Osteoporos Int 25, 2701–2707 (2014). https://doi.org/10.1007/s00198-014-2815-1
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DOI: https://doi.org/10.1007/s00198-014-2815-1