Osteoporosis International

, Volume 17, Issue 1, pp 68–76 | Cite as

Economic comparison of diagnostic approaches for evaluating osteoporosis in older women

  • Dale F. Kraemer
  • Heidi D. Nelson
  • Douglas C. Bauer
  • Mark Helfand
Original Article

Abstract

Of the technologies available, dual-energy X-ray absorptiometry of the hip or femoral neck (DXA-FN) is the best predictor of hip fractures. Diagnostic approaches utilizing measures of peripheral sites with office-based technology, such as calcaneal quantitative ultrasound (QUS), may reduce costs although clinical and economic outcomes have not been evaluated. The objective was to compare three approaches for diagnosing osteoporosis in older women. The design was a decision-analytic model using diagnostic measures and clinical and economic outcomes from the Study of Osteoporotic Fractures, a prospective cohort of older white women that measured BMD and QUS and assessed fracture outcomes. The setting and patients were a hypothetical cohort of older white women presenting for diagnosis of osteoporosis. For the diagnostic and treatment alternatives, three diagnostic approaches—DXA-FN alone, QUS alone and a sequential approach (first QUS, then DXA-FN for those with low values for QUS)—were compared to no diagnosis. The outcome measures were the number of women identified for treatment, number of hip fractures prevented following diagnosis and subsequent treatment, number of women needed to treat to prevent one hip fracture and total direct medical costs. The sequential approach identified fewer women to treat, prevented more hip fractures and incurred lower total costs than using DXA alone. Diagnosis with QUS alone identified more women to treat and incurred higher total costs than DXA alone under most conditions. Compared to other approaches for diagnosing osteoporosis, sequential use of QUS followed by DXA resulted in fewer women treated and lower total costs.

Keywords

Bone mineral density Costs Densitometry Osteoporosis Postmenopausal women 

References

  1. 1.
    The WHO Study Group (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. World Health Organization, GenevaGoogle Scholar
  2. 2.
    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 12:24–35PubMedCrossRefADSMATHGoogle Scholar
  3. 3.
    Hoerger TJ, Downs KE, Lakshmanan MC, Lindrooth RC, Plouffe L Jr, Wendling B, West SL, Ohsfeldt RL (1999) Heath care use among U.S. women aged 45 and older: total costs and costs for selected postmenopausal health risks. J Womens Health Gend Based Med 8:1077–1089PubMedGoogle Scholar
  4. 4.
    Melton LJ 3rd (1995) How many women have osteoporosis now? J Bone Miner Res 10:175–177PubMedADSCrossRefGoogle Scholar
  5. 5.
    National Osteoporosis Foundation (1998) Osteoporosis: review of the evidence for prevention, diagnosis, and treatment and cost-effectiveness analysis. Executive summary. Osteoporos Int [Suppl]:S3–6Google Scholar
  6. 6.
    Nelson HD, Morris CD, Kraemer DF, Mahon S, Carney N, Nygren PM, Helfand M (2001) Osteoporosis in postmenopausal women: diagnosis and monitoring. Rockville, MD: Agency for Healthcare Research and Quality. Evidence Report/Technology Assessment no. 28 (prepared by the Oregon Health and Science University Evidence-based Practice Center under contract no. 290–97–0018). AHRQ publication no. 01-E032Google Scholar
  7. 7.
    Nelson HD, Helfand M (2002) Screening for postmenopausal osteoporosis. Systematic Evidence Review (Prepared by the Oregon Health & Science University Evidence-based Practice Center under Contract No. 290-97-0018). Rockville, MD: Agency for Heathcare Research and Quality. September 2002. (Available only on the AHRQ web site at: www.ahrq.gov/clinic/serfiles.htm)
  8. 8.
    US Preventive Services Task Force (2002) Screening for osteoporosis in postmenopausal women: recommendations and rationale. Ann Intern Med 137:526–528PubMedGoogle Scholar
  9. 9.
    Nelson HD, Helfand M, Woolf SH, Allan JD (2002) Screening for postmenopausal osteoporosis: a review of the evidence for the US Preventive Services Task Force. Ann Intern Med 137:529–541PubMedGoogle Scholar
  10. 10.
    Siris ES, Miller PD, Barrett-Conner E, Faulkner KG, Wehren LE, Abbott TA, Berger ML, Santora AC, Sherwood LM (2001) Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment. JAMA. 286:2815–2822Google Scholar
  11. 11.
    Bauer DC, Gluer CC, Cauley JA, Vogt TM, Ensrud KE, Genant HK, Black DM (1997) Broadband ultrasound attenuation predicts fractures strongly and independently of densitometry in older women. A prospective study. Study of Osteoporotic Fractures Research Group. Arch Intern Med 157:629–634PubMedCrossRefADSGoogle Scholar
  12. 12.
    Dargent-Molina P, Piault S, Breart G (2003) A comparison of different screening strategies to identify elderly women at high risk of hip fracture: results from the EPIDOS prospective study. Osteoporos Int 14:969–977PubMedCrossRefGoogle Scholar
  13. 13.
    Cummings SR, Nevitt MC, Browner WS, Stone K, Fox KM, Ensrud KE, Cauley J, Black D, Vogt TM (1995) Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med 332:767–773PubMedCrossRefGoogle Scholar
  14. 14.
    U.S. Congressional Office of Technology Assessment (1994) Hip fracture outcomes in people age 50 and over. Background paper. US Government Printing Office OTA-BP-H-120, Washington, DCGoogle Scholar
  15. 15.
    Microsoft Excel97 (ca. 1996) Microsoft Corporation, Redmond, WAGoogle Scholar
  16. 16.
    SAS Institute Inc (ca. 1998) SAS Institute Inc, Cary, NCGoogle Scholar
  17. 17.
    Health Care Financing Administration (accessed January 2000) National physician fee schedule payment amount file. Available at: http://www.hcfa.gov/stats/carrpuf.htmGoogle Scholar
  18. 18.
    U.S. Bureau of Labor Statistics. Available at: http://www.bls.gov/top20.html/#CPI; http://146.142.4.4.24/cgi-bin/surveymost?cuGoogle Scholar
  19. 19.
    U.S. National Center for Health Statistics. United States life tables. Available at: http://www.cdc.gov/nchs/datawh/statab/unpubd/mortabs/lewk3.htmGoogle Scholar
  20. 20.
    Hans D, Dargent-Molina P, Schott AM, Sebert JL, Cormier C, Kotzki PO, Delmas PD, Pouilles JM, Breart G, Meunier PJ (1996) Ultrasonographic heel measurements to predict hip fracture in elderly women: the EPIDOS prospective study. Lancet 348:511–514CrossRefPubMedGoogle Scholar
  21. 21.
    Masud T, Langley S, Wiltshire P, Doyle DV, Spector TD (1993) Effect of spinal osteophytosis on bone mineral density measurements in vertetral osteoporosis. BMJ 307:172–173PubMedCrossRefGoogle Scholar
  22. 22.
    Jones G, Nguyen T, Sambrook P, Kelly PJ, Eisman JA (1994) Progressive loss of bone in the femoral neck in elderly people: longitudinal findings from Dubbo osteoporosis epidemiology study. BMJ 309:691–695PubMedGoogle Scholar
  23. 23.
    Hodson J, Marsh J (2003) Quantitative ultrasound and risk factor enquiry as predictors of postmenopausal osteoporosis: comparative study in primary care. BMJ 326:1250–1251PubMedCrossRefGoogle Scholar
  24. 24.
    Orwoll ES, Bauer DC, Vogt TM, Fox KM (1996) Axial bone mass in older women: Study of Osteoporotic Fractures Research Group. Ann Intern Med 124:187–196PubMedGoogle Scholar
  25. 25.
    Bauer DC, Browner WS, Cauley JA, Orwoll ES, Scott JC, Black DM, Tao JL, Cummings SR (1993) Factors associated with appendicular bone mass in older women. The Study of Osteoporotic Fractures Research Group. Ann Intern Med 118:657–655PubMedGoogle Scholar
  26. 26.
    Slemenda CW, Hui SL, Longcope C, Wellman H, Johnston CC Jr (1990) Predictors of bone mass in perimenopausal women: A prospective study of clinical data using photon absorptiometry. Ann Intern Med 112:96–101PubMedGoogle Scholar
  27. 27.
    Langton CM, Ballard PA, Langton DK, Purdie DW (1997) Maximising the cost effectiveness of BMD referral for DXA using ultrasound as a selective population pre-screen (1997). Technol Health Care 5:235–241PubMedGoogle Scholar
  28. 28.
    Kanis JA (2002) Diagnosis of osteoporosis and assessment of fracture risk. Lancet 359:1929–1936PubMedCrossRefGoogle Scholar
  29. 29.
    Young H, Howey S, Purdie DW (1993) Broadband ultrasound attenuation compared with dual-energy X-ray absorptiometry in screening for postmenopausal low bone density. Osteoporos Int 3:160–164PubMedCrossRefGoogle Scholar
  30. 30.
    Faulkner KG, McClung MR, Coleman LJ, Kingston-Sandahl E (1994) Quantitative ultrasound of the heel: correlation with densitometric measurements at different skeletal sites. Osteoporos Int 4:42–47PubMedCrossRefGoogle Scholar
  31. 31.
    Herd RJ, Blake GM, Miller CG, Parker JC, Fogelman I (1994) The ultrasonic assessment of osteopenia as defined by dual X-ray absorptiometry. Br J Radiol 67:631–635PubMedCrossRefGoogle Scholar
  32. 32.
    Benitez CL, Schneider DL, Barrett-Connor E, Sartoris DJ (2000) Hand ultrasound for osteoporosis screening in postmenopausal women. Osteoporos Int 11:203–210PubMedCrossRefGoogle Scholar
  33. 33.
    Fordham JN, Chinn DJ, Kumar N (2000) Identification of women with reduced bone density at the lumbar spine and femoral neck using BMD at the os calcis. Osteoporos Int 11:797–802CrossRefPubMedGoogle Scholar
  34. 34.
    Gold MR, Siegel JE, Russell LB, Weinstein MC (eds) (1996) Cost-effectiveness in health and medicine. Oxford University Press, New YorkGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2005

Authors and Affiliations

  • Dale F. Kraemer
    • 1
    • 3
  • Heidi D. Nelson
    • 1
    • 2
  • Douglas C. Bauer
    • 4
  • Mark Helfand
    • 1
    • 2
    • 5
  1. 1.Department of Medical Informatics and Clinical Epidemiology and Evidence-based Practice CenterOregon Health and Science UniversityPortlandUSA
  2. 2.Department of MedicineOregon Health and Science UniversityPortlandUSA
  3. 3.Department of Pharmacy PracticeOregon State UniversityPortlandUSA
  4. 4.Division of General Internal Medicine and Department of Epidemiology and BiostatisticsUniversity of California at San FranciscoSan FranciscoUSA
  5. 5.Medical ServiceVeterans Affairs Medical CenterPortlandUSA

Personalised recommendations