Osteoporosis International

, Volume 6, Issue 4, pp 265–275

Prevention of osteoporosis: Cost-effectiveness of different pharmaceutical treatments

  • A. Ankjaer-Jensen
  • O. Johnell
Original Article

Abstract

The cost-effectiveness of different pharmaceutical programmes to prevent osteoporosis has been compared. The following pharmaceutical treatments were analysed and compared: calcium supplementation, etidronate and calcitonin. As a benchmark for comparison, oestrogen replacement therapy, in the form of both pills and plaster, was also included in the analysis. The cost-effectiveness of different strategies for particular age groups was analysed. Finally, the cost-effectiveness of population-based prevention programmes was compared with the cost-effectiveness of programmes based on screening followed by treatment of women with low bone mineral density (BMD). A cost-effectiveness analysis (CEA) was carried out. The cost/effectiveness ratio computed was net costs per hip fracture avoided. The evaluation was based on a simulation model in which 1000 women were followed from the age of 50 years. The model was based on Danish epidemiological data and Danish health care cost figures. Assumptions concerning the health effect of the pharmaceutical methods of prevention were based on results from existing studies. As different results have been reported, ‘optimistic’ and ‘pessimistic’ alternatives were simulated in the model. The analysis revealed large differences in the cost-effectiveness of different pharmaceutical methods; however, the cost-effectiveness is highly sensitive to the treatment effect assumed. Treatment will be more cost-effective the higher the fracture risk of the group treated, so cost-effectiveness will therefore increase the later in life the intervention takes place, and if only women screened for low BMD are treated. However, the overall effect from a general screening programme will be low and highly sensitive to compliance. As compliance with pharmaceutical treatment seems to be low, and as the effectiveness — and thereby the cost-effectiveness — is encumbered with much uncertainty, prevention of osteoporosis through screening for low BMD should not be recommended at present.

Keywords

Cost-effectiveness Fracture Osteoporosis Pharmaceutical Prevention 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Cooper C, Campion G, Melton LJ. Hip fractures in the elderly: a world-wide projection. Osteoporosis Int 1992;2:285–9.Google Scholar
  2. 2.
    Daly E, Roche M, Barlow D, Gray A, McPherson K, Vessey M. HRT: an analysis of benefits, risks and costs. Br Med Bull 1992;48:368–400.Google Scholar
  3. 3.
    Cheung AP, Wren BG. A cost-effectiveness analysis of hormone replacement therapy in the menopause. Med J Aust 1992;156:312–6.Google Scholar
  4. 4.
    Weinstein MC. Oestrogen use in postmenopausal women: costs, risks, and benefits. N Engl J Med 1980;303:308–16.Google Scholar
  5. 5.
    Weinstein MC, Tosteson ANA. Cost-effectiveness of hormone replacement. Ann NY Acad Sci 1990;592:162–72.Google Scholar
  6. 6.
    Reid IR. Benefits, risks and costs of calcium supplementation in postmenopausal women. PharmacoEconomics 1994;5:1–4.Google Scholar
  7. 7.
    Johnell O. Prevention of fractures in elderly: a review. Acta Orthop Scand 1995;66:90–8.Google Scholar
  8. 8.
    Ribot C, Tremollieres F, Pouilles JM, et al. Risk factors or hip fracture. MEDOS study: results of the Toulouse Centre. Bone 1993;14:S77–80.Google Scholar
  9. 9.
    Aloia JF, Cohn SH, Vaswani A, Yeh JK, Yuen K, Ellis K. Risk factors for post-menopausal osteoporosis. Am J Med 1985;78:95–100.Google Scholar
  10. 10.
    Torrance GW. Measurement of health state utilities for economic appraisal: a review. J Health Econ 1986;5:1–30.Google Scholar
  11. 11.
    Drummond MF, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programmes. 2nd ed. Oxford: Oxford University Press, 1989.Google Scholar
  12. 12.
    Mooney G. Economics, medicine and health care. Brighton: Wheatsheaf Books, 1986.Google Scholar
  13. 13.
    Weinstein MC. Principles of cost-effective resource allocation in health care organizations. Int J Tech Ass Health Care 1990;6:93–103.Google Scholar
  14. 14.
    Cairns J. Discounting and health benefits: another perspective. Health Econ 1992;1:76–9.Google Scholar
  15. 15.
    Parsonage M, Neuburger H. Discounting and health benefits. Health Econ 1992;1:71–6.Google Scholar
  16. 16.
    Winner SJ, Morgan CA, Evans JG. Perimenopausal risk of falling and incidence of distal forearm fracture. BMJ 1989;298:1486–8.Google Scholar
  17. 17.
    Melton LJ, Kan SH, Frye MA, Wahner HW, O'Fallon WM, Riggs BL. Epidemiology of vertebral fractures in women. Am J Epidemiol 1989;129:1000–11.Google Scholar
  18. 18.
    Cooper C, Atkinson EJ, O'Fallon WM, Melton LJ. Incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota, 1985–1989. J Bone Miner Res 1992;7:221–7.Google Scholar
  19. 19.
    WHO. Assessment of fracture risk and its application to screening for post-menopausal osteoporosis (WHO technical report series 843). Geneva: WHO, 1994.Google Scholar
  20. 20.
    Overgaard K, Hansen MA, Birk Jensen S, Christiansen C. Effects of salcatonin given intranasally on bone mass and fracture rates in established osteoporosis: a dose-response study. BMJ 1992;305:556–61.Google Scholar
  21. 21.
    Kanis JA, Johnell O, Gullberg B, et al. Evidence for efficacy of drugs affecting bone metabolism in preventing hip fracture. BMJ 1992;305:1124–8.Google Scholar
  22. 22.
    Watts NB. Intermittent cyclical etidronate treatment of postmenopausal osteoporosis. N Engl J Med 1990;323:73–9.Google Scholar
  23. 23.
    Grady D, Rubin SM, Petitti DB, et al. Hormone therapy to prevent disease and prolong life in postmenopausal women. Ann Intern Med 1992;117:1016–37.Google Scholar
  24. 24.
    Delva MD. Hormone replacement therapy: risks, benefits, and costs. Can Fam Physician 1993;39:2149–54.Google Scholar
  25. 25.
    Whittington R, Faulds D. Hormone replacement therapy. II. A pharmacoeconomic appraisal of its role in the prevention of postmenopausal osteoporosis and ischaemic heart disease. PharmacoEconomics 1994;5:513–54.Google Scholar
  26. 26.
    Belchetz PE. Hormonal treatment of postmenopausal women. N Engl J Med 1994;330:1062–1071.Google Scholar
  27. 27.
    Jacobs HS, Loeffler FE. Postmenopausal hormone replacement therapy. BMJ 1992;305:1403–8.Google Scholar
  28. 28.
    Felson DT, Zhang Y, Hannan MT, Kiel DP, Wilson PWF, Anderson JJ. The effect of postmenopausal oestrogen therapy on bone density in elderly women. N Engl J Med 1993;329:1141–6.Google Scholar
  29. 29.
    Barrett-Connor E, Buch TL. Oestrogen and coronary heart disease in women. JAMA 1991;265:1861–7.Google Scholar
  30. 30.
    Stamper MJ, Willett WC, Colditz GA, Rosner B, Speizer FE, Hennekens CH. A prospective study of postmenopausal oestrogen therapy and coronary heart disease. Engl J Med 1985;313:1044–9.Google Scholar
  31. 31.
    Stamper MJ, Colditz GA, Willett WC, et al. Postmenopausal oestrogen therapy and cardiovascular disease: ten-year follow-up from the Nurses' Health Study. N Engl J Med 1991;325:756–62.Google Scholar
  32. 32.
    Ewertz M. Influence of non-contraceptive exogenous and endogenous sex hormones on breast cancer risk in Denmark. Int J Cancer 1988;42:832–8.Google Scholar
  33. 33.
    Bergkvist L, Adami H-O, Persson I, Hoover R, Schairer C. The risk of breast cancer after oestrogen and oestrogen-progestin replacement. N Engl J Med 1989;321:293–7.Google Scholar
  34. 34.
    Steinberg KK, Thacker SB, Smith SJ, et al. A meta-analysis of the effect of oestrogen replacement therapy on the risk of breast cancer. JAMA 1991;265:1985–90.Google Scholar
  35. 35.
    Chapuy MC, Arlott ME, Duboeuf F, et al. Vitamin D3 and calcium to prevent hip fractures in elderly women. N Engl J Med 1992;327:1627–42.Google Scholar
  36. 36.
    Ankjaer-Jensen A, Thune Jacobsen E, Smidt Thomsen I. Rehabilitering af aeldre med hoftebrud: Omkostninger og effekt (DSI-rapport 94.08). Copenhagen: Dansk Sygehus Institut, 1994.Google Scholar
  37. 37.
    Nevitt MC, Johnell O, Black DM, Ensrud K, Genant HK, Cummings SR. Bone mineral density predicts non-spine fractures in very elderly women. Osteoporosis Int 1994;4:325–31.Google Scholar
  38. 38.
    Storm T, Thamsborg G, Steinische T, Genant HK, Sorensen OH. Effect of intermittent cyclical etidronate therapy on bone mass and fracture rate in postmenopausal osteoporosis. N Engl J Med 1990;322:1265–71.Google Scholar
  39. 39.
    Harris ST, Watts NB, Jackson RD, Genant HK, Wasnich RD, Ross P, Miller PD, Licita AA, Chesnut CH III. Four year study of intermittent cyclic etidronate treatment of postmenopausal osteoporosis: three years of blinded therapy followed by one year of open therapy. Am J Med 1993;95:557–67.Google Scholar
  40. 40.
    Jönsson B, Christiansen C, Johnell O, Hedbrandt J. The cost-effectiveness of fracture prevention in established osteoporosis. Osteoporosis Int 1995;5:136–42.Google Scholar
  41. 41.
    Tosteson AN, Rosenthal DI, Melton J, Weinstein MC. Cost effectiveness of screening perimenopausal white women for osteoporosis: bone densitometry and hormone replacement therapy. Ann Intern Med 1990;113:594–603.Google Scholar
  42. 42.
    Sernbo I, Johnell O. Consequences of a hip fracture: a prospective study over 1 year. Osteoporosis Int 1993;3:148–53.Google Scholar
  43. 43.
    Office of Technology Assessment (OTA). Hip fracture outcomes in people age fifty and over. Washington, DC: OTA, 1994.Google Scholar

Copyright information

© European Foundation for Osteoporosis 1996

Authors and Affiliations

  • A. Ankjaer-Jensen
    • 2
  • O. Johnell
    • 1
  1. 1.Department of OrthopaedicsMalmö General HospitalMalmöSweden
  2. 2.Danish Hospital InstituteCopenhagenDenmark

Personalised recommendations