Osteoporosis International

, Volume 16, Issue 4, pp 353–358 | Cite as

The need for microsimulation to evaluate osteoporosis interventions

  • David J. Vanness
  • Anna N. A. Tosteson
  • Sherine E. Gabriel
  • L. Joseph MeltonIII
Opinion Paper


Simulations play an increasingly important role in the evaluation of osteoporosis interventions. Existing evaluations have been based on “reduced-form” cohort simulations that do not reflect the complexity and heterogeneity of osteoporosis and its outcomes. Such simplified models offer parsimony and ease of use, but they also are limited in their ability to explain and extrapolate outcomes in a way that is most useful for both clinical and health policy decision makers. Alternatively, evaluations could be based on “structural” microsimulations, which explicitly model the underlying biology of osteoporosis at the individual level. The structural approach presents technical challenges, including the need to obtain more-detailed data and the requirement that underlying biological models be validated. However, evaluations based on structural microsimulation may ultimately provide substantially more useful information, resulting in improved decision making.


Cost-effectiveness Decision analysis Economics Osteoporosis Simulation 


  1. 1.
    Osteoporosis Prevention, Diagnosis and Therapy (2000) NIH Consensus Statement 27–29 March 2000 17:1–36Google Scholar
  2. 2.
    Kanis JA, Jonsson B (2002) Economic evaluation of interventions for osteoporosis. Osteoporos Int 13:765–767Google Scholar
  3. 3.
    Zethraeus N, Ben Sedrine W, Caulin F, Corcaud S, Gathon HJ, Haim M, Johnell O, Jonsson B, Kanis JA, Tsouderos Y, Reginster JY (2002) Models for assessing the cost-effectiveness of the treatment and prevention of osteoporosis. Osteoporos Int 13:841–857CrossRefPubMedGoogle Scholar
  4. 4.
    Clemen RT (1996) Making hard decisions: an introduction to decision analysis, 2nd edn. Duxbury Press, Belmont, CAGoogle Scholar
  5. 5.
    Koopmans TC (1949) Identification problems in economic model construction. Econometrica 17:125–144Google Scholar
  6. 6.
    Zethraeus N, Johannesson M, Jonsson B (1999) A computer model to analyze the cost-effectiveness of hormone replacement therapy. Int J Technol Assess Health Care 15:352–365PubMedGoogle Scholar
  7. 7.
    Tosteson ANA, Rosenthal DI, Melton LJ 3rd, Weinstein MC (1990) Cost effectiveness of screening perimenopausal white women for osteoporosis: bone densitometry and hormone replacement therapy. Ann Internal Med 113:594–603Google Scholar
  8. 8.
    Cranney A, Coyle D, Welch V, Lee KM, Tugwell P (1999) A review of economic evaluation in osteoporosis. Arthritis Care Res 12:425–434CrossRefPubMedGoogle Scholar
  9. 9.
    Heaney RP (1998) Bone mass, bone fragility, and the decision to treat. JAMA 280:2119–2120Google Scholar
  10. 10.
    Turner CH (2002) Biomechanics of bone: determinants of skeletal fragility and bone quality. Osteoporos Int 13:97–104Google Scholar
  11. 11.
    Leibson CL, Tosteson ANA, Gabriel SE, Ransom JE, Melton LJ (2002) Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study. J Am Geriatr Soc 50:1644–1650Google Scholar
  12. 12.
    Ray NF, Chan JK, Thamer M, Melton LJ 3rd (1997) Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation. J Bone Miner Res 12:24–35PubMedGoogle Scholar
  13. 13.
    Gabriel SE, Tosteson ANA, Leibson CL, Crowson CS, Pond GR, Hammond CS, Melton LJ 3rd (2002) Direct medical costs attributable to osteoporotic fractures. Osteoporos Int 13:323–330CrossRefPubMedGoogle Scholar
  14. 14.
    Brazier JE, Green C, Kanis JA (2002) A systematic review of health state utility values for osteoporosis-related conditions. Osteoporos Int 13:768–776CrossRefPubMedGoogle Scholar
  15. 15.
    Tosteson ANA, Gabriel SE, Grove MR, Moncur MM, Kneeland TS, Melton LJ 3rd (2001) Impact of hip and vertebral fractures on quality-adjusted life years. Osteoporos Int 12:1042–1049CrossRefPubMedGoogle Scholar
  16. 16.
    Hayes WC, Myers ER, Robinovitch SN, Van Den Kroonenberg A, Courtney AC, McMahon TA (1996) Etiology and prevention of age-related hip fractures. Bone 18:77S-86SGoogle Scholar
  17. 17.
    Robinovitch SN, Hsiao ET, Sandler R, Cortez J, Liu Q, Paiement GD (2000) Prevention of falls and fall-related fractures through biomechanics. Exerc Sport Sci Rev 28:74–79Google Scholar
  18. 18.
    Daley MJ, Spinks WL (2000) Exercise, mobility and aging. Sports Med 29:1–12Google Scholar
  19. 19.
    Gregg EW, Pereira MA, Caspersen CJ (2000) Physical activity, falls, and fractures among older adults: a review of the epidemiologic evidence. J Am Geriatr Soc 48:883–893PubMedGoogle Scholar
  20. 20.
    Myers ER, Wilson SE (1997) Biomechanics of osteoporosis and vertebral fracture. Spine 22:25S-31SGoogle Scholar
  21. 21.
    Grabiner MD, Pavol MJ, Owings TM (2002) Can fall-related hip fractures be prevented by characterizing the biomechanical mechanisms of failed recovery? Endocr J 17:15–20Google Scholar
  22. 22.
    Seeman E (2003) Reduced bone formation and increased bone resorption: rational targets for the treatment of osteoporosis. Osteoporos Int 14 [Suppl 3]:S2–S8Google Scholar
  23. 23.
    Riggs BL, Khosla S, Melton LJ 3rd (2002) Sex steroids and the construction and conservation of the adult skeleton. Endocr Rev 23:279–302CrossRefPubMedGoogle Scholar
  24. 24.
    Frost HM (1966) Bone dynamics in metabolic bone disease. J Bone Joint Surg 48:1192–1203Google Scholar
  25. 25.
    Banks J, Carson JS 2nd, Nelson BL, Nicol DM (2000) Discrete-event system simulation, 3rd edn. Prentice Hall, New JerseyGoogle Scholar
  26. 26.
    Parmigiani G (2002) Modeling in medical decision making: a Bayesian approach. John Wiley & Sons, New YorkGoogle Scholar
  27. 27.
    Claxton K (1999) Bayesian approaches to the value of information: implications for the regulation of new pharmaceuticals. Health Econ 8:269–274CrossRefPubMedGoogle Scholar
  28. 28.
    Riggs BL, Melton LJ 3rd (2002) Bone turnover matters: the raloxifene treatment paradox of dramatic decreases in vertebral fractures without commensurate increases in bone density. J Bone Miner Res 17:11–14PubMedGoogle Scholar
  29. 29.
    Cummings SR, Black DM, Thompson DE, Applegate WB, Barrett-Connor E, Musliner TA, Palermo L, Prineas R, Rubin SM, Scott JC, Vogt T, Wallace R, Yates AJ, LaCroix AZ (1998) Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial. JAMA 280:2077–2082CrossRefPubMedGoogle Scholar
  30. 30.
    Cummings SR, Karpf DB, Harris F, Genant HK, Ensrud K, LaCroix AZ, Black DM (2002) Improvement in spine bone density and reduction in risk of vertebral fractures during treatment with antiresorptive drugs. Am J Med 112:281–289CrossRefPubMedGoogle Scholar
  31. 31.
    Delmas PD, Ensrud KE, Adachi JD, Harper KD, Sarkar S, Gennari C, Reginster JY, Pols HA, Recker RR, Harris ST, Wu W, Genant HK, Black DM, Eastell R (2002) Mulitple outcomes of raloxifene evaluation investigators, efficacy of raloxifene on vertebral fracture risk reduction in postmenopausal women with osteoporosis: 4-year results from a randomized clinical trial. J Clin Endocrinol Metab 87:3609–3617CrossRefPubMedGoogle Scholar
  32. 32.
    McClung MR, Geusens P, Miller PD, Zippel H, Bensen WG, Roux C, Adami S, Fogelman I, Diamond T, Eastell R, Meunier PJ, Reginster JY, Hip Intervention Program Study Group (2001) Effect of risedronate on the risk of hip fracture in elderly women. N Engl J Med 344:333–340CrossRefPubMedGoogle Scholar
  33. 33.
    Black DM, Greenspan SL, Ensrud KE (2003) The effects of parathyroid hormone and alendronate alone or in combination in postmenopausal osteoporosis. N Engl J Med 349:1207–1215CrossRefPubMedGoogle Scholar
  34. 34.
    Finkelstein JS, Hayes A, Hunzelman JL, Wyland JJ, Lee H, Neer RM (2003) Effects of parathyroid hormone, alendronate, or both in men with osteoporosis. N Engl J Med 349:1216–1226CrossRefPubMedGoogle Scholar
  35. 35.
    Khosla S (2003) Parathyroid hormone plys alendronate—a combination that does not add up. N Engl J Med 349:1277–1279Google Scholar
  36. 36.
    Kanis JA, Johnell O, Oden A, De Laet C, Jonsson B, Dawson A (2002) Ten-year risk of osteoporotic fracture and the effect of risk factors on screening strategies. Bone 30:251–258CrossRefPubMedGoogle Scholar
  37. 37.
    J Mullahy (2001) Live long, live well: quantifying the health of heterogeneous populations. Health Econ 10:429–440Google Scholar
  38. 38.
    Buxton MJ, Drummond MF, Van Hout BA, Prince RL, Sheldon TA, Szucs T, Vray M (1997) Modeling in economic evaluation: an unavoidable fact of life. Health Econ 6:217–227Google Scholar
  39. 39.
    Kling A, Barao F, Nakagawa M, Tavora L, Vaz P (eds) (2001) Advanced Monte Carlo for radiation physics, particle transport simulation and applications. Springer, Heidelberg Berlin New YorkGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2005

Authors and Affiliations

  • David J. Vanness
    • 1
  • Anna N. A. Tosteson
    • 2
    • 3
  • Sherine E. Gabriel
    • 4
  • L. Joseph MeltonIII
    • 4
  1. 1.Department of Population Health SciencesUniversity of Wisconsin Medical SchoolMadisonUSA
  2. 2.Department of MedicineDartmouth Medical SchoolLebanonUSA
  3. 3.Department of Community and Family MedicineDartmouth Medical SchoolNHUSA
  4. 4.Department of Health Sciences ResearchMayo Clinic College of MedicineRochesterUSA

Personalised recommendations