Osteoporosis International

, Volume 17, Issue 1, pp 29–40

Economic evaluations of interventions for the prevention and treatment of osteoporosis: a structured review of the literature

  • Rachael L. Fleurence
  • Cynthia P. Iglesias
  • David J. Torgerson


Economic evaluations are increasingly being used by decision-makers to estimate the cost-effectiveness of interventions. The objective of this study was to conduct a structured review of economic evaluations of interventions to prevent and treat osteoporosis. Articles were identified independently by two reviewers through searches on MEDLINE, the bibliographies of reviews and identified economic models, and expert opinion, using predefined inclusion and exclusion criteria. Data on country, type and level of interventions, type of fractures, interventions, study population and the authors’ stated conclusions were extracted. Forty-two relevant studies were identified. The majority of studies (71%) were conducted in Sweden, the UK and the US. The main interventions investigated were hormone replacement therapy (27%), bisphosphonates (17%) and combinations of vitamin D and calcium (16%). In 38% of studies, hip fracture was the sole fracture outcome. Eighty-eight percent (88%) of studies investigated female populations only. A relatively large number of economic evaluations were identified in the field of osteoporosis. Major changes have recently occurred in the treatment of this disease, following the publication of the results of the Women’s Health Initiative trial. Methodological developments in economic evaluations, such as the use of probabilistic sensitivity analysis and cost-effectiveness acceptability curves, have also taken place. Such changes are reflected in the studies that were reviewed. The development of economic models should be an iterative process that incorporates new information, whether clinical or methodological, as it becomes available.


Cost-effectiveness Economics Fractures Model Osteoporosis Review 


  1. 1.
    Taylor RS, Drummond MF, Salkeld G, Sullivan SD (2004) Inclusion of cost effectiveness in licensing requirements of new drugs: the fourth hurdle. BMJ 329: 972–975CrossRefPubMedGoogle Scholar
  2. 2.
    Fleurence RL, Iglesias CP, Torgerson DJ (2003) Cost-effectiveness of nutritional supplements for the treatment of osteoporosis. In: Bonjour JP, New S (eds) Nutritional aspects of bone health. Royal Society of Chemistry, London, pp 693–708Google Scholar
  3. 3.
    Fleurence RL, Iglesias CP, Torgerson DJ (2005) Economic aspects of osteoporosis treatment. In Cooper C, Lindsay R (eds) The prevention and treatment of osteoporosis in the high-risk patient. Martin Dunitz, London, pp 81–102Google Scholar
  4. 4.
    Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, et al (2002) Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA 288:321–333CrossRefPubMedGoogle Scholar
  5. 5.
    Wassertheil-Smoller S, Hendrix SL, Limacher M, Heiss G, et al (2003) Effect of estrogen plus progestin on stroke in postmenopausal women: the Women’s Health Initiative: a randomized trial. JAMA 289:2673–2684CrossRefPubMedGoogle Scholar
  6. 6.
    Anderson GL, Limacher M, Assaf AR, Bassford T, et al (2004) Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women’s Health Initiative randomized controlled trial. JAMA 291:1701–1712CrossRefPubMedGoogle Scholar
  7. 7.
    Birks YF, Porthouse J, Addie C, Loughney K, et al (2004) Randomized controlled trial of hip protectors among women living in the community. Osteoporos Int 15:701–706PubMedCrossRefGoogle Scholar
  8. 8.
    Trivedi DP, Doll R, Khaw KT (2003) Effect of four monthly oral vitamin D3 (cholecalciferol) supplementation on fractures and mortality in men and women living in the community: randomised double blind controlled trial. BMJ 326:469CrossRefPubMedGoogle Scholar
  9. 9.
    Porthouse J, Cockayne S, King C, Saxon L, et al (2005) Randomised controlled trial of calcium and supplementation with cholecalciferol (vitamin D3) for prevention of fractures in primary care. BMJ (in press)Google Scholar
  10. 10.
    The RECORD Trial Group (2005). Oral vitamin D3 and calcium for secondary prevention of low-trauma fractures in elderly people (Randomised Evaluation of Calcium Or vitamin D, RECORD): a randomised placebo-controlled trial. Lancet (in press)Google Scholar
  11. 11.
    Zethraeus N, Ben Sedrine W, Caulin F, Corcaud S, et al (2002) Models for assessing the cost-effectiveness of the treatment and prevention of osteoporosis. Osteoporos Int 13:841–857CrossRefPubMedGoogle Scholar
  12. 12.
    Coyle D, Cranney A, Lee KM, Welch V, et al (2000) Cost-effectiveness research in osteoporosis. Drug Dev Res 49:135–140CrossRefGoogle Scholar
  13. 13.
    Johannesson M, Jonsson B (1993) Economic evaluation of osteoporosis prevention. Health Policy 24:103–124CrossRefPubMedGoogle Scholar
  14. 14.
    Sculpher M, Torgerson D, Goeree R, O’Brien BJ (1999) A critical structured review of economic evaluations of interventions for the prevention and treatment of osteoporosis. CHE Discussion Paper 169, University of York, YorkGoogle Scholar
  15. 15.
    Torgerson DJ, Reid DM (1997) The economics of osteoporosis and its prevention. A review. Pharmacoeconomics 11:126–138PubMedCrossRefGoogle Scholar
  16. 16.
    Whittington R, Faulds D (1994) Hormone replacement therapy: II. A pharmacoeconomic appraisal of its role in the prevention of postmenopausal osteoporosis and ischaemic heart disease. Pharmacoeconomics 5:513–554PubMedGoogle Scholar
  17. 17.
    Cheung AP, Wren BG (1992) A cost-effectiveness analysis of hormone replacement therapy in the menopause. Med J Aust 156:312–316PubMedMathSciNetGoogle Scholar
  18. 18.
    Tosteson AN, Rosenthal DI, Melton III LJ, Weinstein MC (1990) Cost effectiveness of screening perimenopausal white women for osteoporosis: bone densitometry and hormone replacement therapy. Ann Intern Med 113:594–603PubMedGoogle Scholar
  19. 19.
    Tosteson AN, Weinstein MC (1991) Cost-effectiveness of hormone replacement therapy after the menopause. Bailliere’s Clin Obstetr Gynaecol 5:943–959Google Scholar
  20. 20.
    Weinstein MC (1980) Estrogen use in postmenopausal women—costs, risks, and benefits. N Engl J Med 303:308–316PubMedCrossRefGoogle Scholar
  21. 21.
    Weinstein MC, Schiff I (1983) Cost-effectiveness of hormone replacement therapy in the menopause. Obstet Gynecol Surv 38:445–455PubMedGoogle Scholar
  22. 22.
    Weinstein MC, Tosteson AN (1990) Cost-effectiveness of hormone replacement. Ann N Y Acad Sci 592:162–172PubMedADSGoogle Scholar
  23. 23.
    Jonsson B, Kanis J, Dawson A, Oden A, et al (1999) Effect and offset of effect of treatments for hip fracture on health outcomes. Osteoporos Int 10:193–199CrossRefPubMedGoogle Scholar
  24. 24.
    Kanis JA, Dawson A, Oden A, Johnell O, et al (2001) Cost-effectiveness of preventing hip fracture in the general female population. Osteoporos Int 12:356–361CrossRefPubMedGoogle Scholar
  25. 25.
    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
  26. 26.
    Fleurence RL, Torgerson DJ, Reid DM (2002) Cost-effectiveness of hormone replacement therapy for fracture prevention in young postmenopausal women: an economic analysis based on a prospective cohort study. Osteoporos Int 13:637–643CrossRefPubMedGoogle Scholar
  27. 27.
    Buxton MJ, Drummond MF, Van Hout BA, Prince RL, et al (1997) Modelling in economic evaluation: an unavoidable fact of life. Health Econ 6:217–227CrossRefPubMedGoogle Scholar
  28. 28.
    Sculpher M, Fenwick E, Claxton K (2000) Assessing quality in decision analytic cost-effectiveness models. A suggested framework and example of application. Pharmacoeconomics 17:461–477PubMedCrossRefGoogle Scholar
  29. 29.
    Tosteson AN, Jonsson B, Grima DT, O’Brien BJ, et al (2001) Challenges for model-based economic evaluations of postmenopausal osteoporosis interventions. Osteoporos Int 12:849–857CrossRefPubMedGoogle Scholar
  30. 30.
    Borgstrom F, Johnell O, Jonsson B, Zethraeus N, et al (2004) Cost effectiveness of alendronate for the treatment of male osteoporosis in Sweden. Bone 34:1064–1071CrossRefPubMedGoogle Scholar
  31. 31.
    Fleurence RL (2004) The cost-effectiveness of fracture prevention treatments in the elderly. Int J Technol Assess Health Care 20:184–191CrossRefPubMedGoogle Scholar
  32. 32.
    Iglesias CP, Torgerson DJ, Bearne A, Bose U (2002) The cost utility of bisphosphonate treatment in established osteoporosis. QJM 95:305–311CrossRefPubMedGoogle Scholar
  33. 33.
    Kanis JA, Borgstrom F, Johnell O, Jonsson B (2004) Cost-effectiveness of risedronate for the treatment of osteoporosis and prevention of fractures in postmenopausal women. Osteoporos Int 15:862–871CrossRefPubMedGoogle Scholar
  34. 34.
    Kanis JA, Borgstrom F, Johnell O, Oden A, Sykes D, Jonsson B (2005) Cost-effectiveness of raloxifene in the UK: an economic evaluation based on the MORE study. Osteoporos Int 16:15–25CrossRefPubMedGoogle Scholar
  35. 35.
    Torgerson DJ, Bell-Syer SE (2001) Hormone replacement therapy and prevention of nonvertebral fractures: a meta-analysis of randomized trials. JAMA 285:2891–2897CrossRefPubMedGoogle Scholar
  36. 36.
    Manson JE, Hsia J, Johnson KC, Rossouw JE, et al (2003) Estrogen plus progestin and the risk of coronary heart disease. N Engl J Med 349:523–534CrossRefPubMedGoogle Scholar
  37. 37.
    Majumdar SR, Almasi EA, Stafford RS (2004) Promotion and prescribing of hormone therapy after report of harm by the Women’s Health Initiative. JAMA 292:1983–1988CrossRefPubMedGoogle Scholar
  38. 38.
    Grady D (2003) Postmenopausal hormones—therapy for symptoms only. N Engl J Med 348:1835–1837CrossRefPubMedGoogle Scholar
  39. 39.
    Black DM, Cummings SR, Karpf DB, Cauley JA, et al (1996) Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet 348:1535–1541CrossRefPubMedGoogle Scholar
  40. 40.
    Cummings SR, Eckert S, Krueger KA, Grady D, et al (1999) The effect of raloxifene on risk of breast cancer in postmenopausal women: results from the MORE randomized trial. Multiple Outcomes of Raloxifene Evaluation. JAMA 281:2189–2197CrossRefPubMedGoogle Scholar
  41. 41.
    Ettinger B, Black DM, Mitlak BH, Knickerbocker RK, et al (1999) Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial. Multiple Outcomes of Raloxifene Evaluation (MORE) Investigators. JAMA 282:637–645CrossRefPubMedGoogle Scholar
  42. 42.
    Levis S, Quandt SA, Thompson D, Scott J, et al (2002) Alendronate reduces the risk of multiple symptomatic fractures: results from the fracture intervention trial. J Am Geriatr Soc 50:409–415CrossRefPubMedGoogle Scholar
  43. 43.
    Reginster J, Minne HW, Sorensen OH, Hooper M, et al (2000) Randomized trial of the effects of risedronate on vertebral fractures in women with established postmenopausal osteoporosis. Vertebral Efficacy with Risedronate Therapy (VERT) Study Group. Osteoporos Int 11:83–91CrossRefPubMedGoogle Scholar
  44. 44.
    Johnell O, Kanis J, Gullberg G (2001) Mortality, morbidity, and assessment of fracture risk in male osteoporosis. Calcif Tissue Int 69:182–184CrossRefPubMedGoogle Scholar
  45. 45.
    Segui-Gomez M, Keuffel E, Frick KD (2002) Cost and effectiveness of hip protectors among the elderly. Int J Technol Assess Health Care 18:55–66PubMedGoogle Scholar
  46. 46.
    Kanis JA (2002) Diagnosis of osteoporosis and assessment of fracture risk. Lancet 359:1929–1936PubMedCrossRefGoogle Scholar
  47. 47.
    Stevenson MD, Oakley J, Chilcott JB (2004) Gaussian process modeling in conjunction with individual patient simulation modeling: a case study describing the calculation of cost-effectiveness ratios for the treatment of established osteoporosis. Med Decis Making 24:89–100CrossRefPubMedGoogle Scholar
  48. 48.
    Ankjaer-Jensen A, Johnell O (1996) Prevention of osteoporosis: cost-effectiveness of different pharmaceutical treatments. Osteoporos Int 6:265–275CrossRefPubMedGoogle Scholar
  49. 49.
    Armstrong K, Chen TM, Albert D, Randall TC, et al (2001) Cost-effectiveness of raloxifene and hormone replacement therapy in postmenopausal women: impact of breast cancer risk. Obstet Gynecol 98:996–1003CrossRefPubMedGoogle Scholar
  50. 50.
    Brecht JG, Kruse HP, Felsenberg D, Mohrke W, et al (2003) Pharmacoeconomic analysis of osteoporosis treatment with risedronate. Int J Clin Pharmacol Res 23:93–105PubMedGoogle Scholar
  51. 51.
    Brecht JG, Kruse HP, Mohrke W, Oestreich A, et al (2004) Health-economic comparison of three recommended drugs for the treatment of osteoporosis. Int J Clin Pharmacol Res 24:1–10PubMedGoogle Scholar
  52. 52.
    Colon-Emeric CS, Datta SK, Matchar DB (2003) An economic analysis of external hip protector use in ambulatory nursing facility residents. Age Ageing 32:47–52CrossRefPubMedGoogle Scholar
  53. 53.
    Coyle D, Cranney A, Lee KM (2001) Cost effectiveness of nasal calcitonin in postmenopausal women: use of Cochrane Collaboration methods for meta-analysis within economic evaluation. Pharmacoeconomics 19:565–575PubMedCrossRefGoogle Scholar
  54. 54.
    Daly E, Roche M, Barlow D, Gray A, et al (1992) HRT: an analysis of benefits, risks and costs. Br Med Bull 48:368–400PubMedGoogle Scholar
  55. 55.
    Daly E, Vessey MP, Barlow D, Gray A, et al (1996) Hormone replacement therapy in a risk-benefit perspective. Maturitas 23:247–259CrossRefPubMedGoogle Scholar
  56. 56.
    Francis RM, Anderson FH, Torgerson DJ (1995) A comparison of the effectiveness and cost of treatment for vertebral fractures in women. Br J Rheumatol 34:1167–1171PubMedGoogle Scholar
  57. 57.
    Garton MJ, Cooper C, Reid D (1997) Perimenopausal bone density screening—will it help prevent osteoporosis? Maturitas 26:35–43CrossRefPubMedGoogle Scholar
  58. 58.
    Geelhoed E, Harris A, Prince R (1994) Cost-effectiveness analysis of hormone replacement therapy and lifestyle intervention for hip fracture. Aust J Public Health 18:153–160PubMedCrossRefGoogle Scholar
  59. 59.
    Hart WM, Rubio-Terres C, Burrell A, Aristegui I, et al (2002) Pharmacoeconomic analysis of the treatment of postmenopausal osteoporosis with risedronate or alendronate. Revista Espanola de Enfermedades Metabolicas Oseas 11:97–104Google Scholar
  60. 60.
    Johnell O, Jonsson B, Jonsson L, Black D (2003) Cost effectiveness of alendronate (fosamax) for the treatment of osteoporosis and prevention of fractures. Pharmacoeconomics 21:305–314PubMedCrossRefGoogle Scholar
  61. 61.
    Jonsson B (1998) Targeting high-risk populations. Osteoporos Int 8 [Suppl 1]:S13–S16Google Scholar
  62. 62.
    Jonsson B, Christiansen C, Johnell O, Hedbrandt J (1995) Cost-effectiveness of fracture prevention in established osteoporosis. Osteoporos Int 5:136–142CrossRefPubMedGoogle Scholar
  63. 63.
    Kanis JA, Brazier JE, Stevenson M, Calvert NW, et al (2002) Treatment of established osteoporosis: a systematic review and cost-utility analysis. Health Technol Assess 6:1–146PubMedGoogle Scholar
  64. 64.
    Nagata-Kobayashi S, Shimbo T, Fukui T (2002) Cost-effectiveness analysis of screening for osteoporosis in postmenopausal Japanese women. J Bone Miner Metab 20:350–357CrossRefPubMedGoogle Scholar
  65. 65.
    Rodriguez EC, Fidalgo Garcia ML, Rubio CS (1999) A cost-effectiveness analysis of alendronate compared to placebo in the prevention of hip fracture. Aten Primaria 24:390–396PubMedGoogle Scholar
  66. 66.
    Rosner AJ, Grima DT, Torrance GW, Bradley C, et al (1998) Cost effectiveness of multi-therapy treatment strategies in the prevention of vertebral fractures in postmenopausal women with osteoporosis. Pharmacoeconomics 14:559–573PubMedCrossRefGoogle Scholar
  67. 67.
    Singh S, Sun H, Anis AH (2004) Cost-effectiveness of hip protectors in the prevention of osteoporosis related hip fractures in elderly nursing home residents. J Rheumatol 31:1607–1613PubMedGoogle Scholar
  68. 68.
    Torgerson D, Kanis JA (1995) Cost-effectiveness of preventing hip fractures in the elderly population using vitamin D and calcium. QJM 88:135–139PubMedGoogle Scholar
  69. 69.
    Torgerson D, Donaldson C, Reid D (1996) Using economics to prioritize research: a case study of randomized trials for the prevention of hip fractures due to osteoporosis. J Health Serv Res Policy 1:141–146PubMedGoogle Scholar
  70. 70.
    Visentin P, Ciravegna R, Fabris F (1997) Estimating the cost per avoided hip fracture by osteoporosis treatment in Italy. Maturitas 26:185–192CrossRefPubMedGoogle Scholar
  71. 71.
    Waldegger L, Cranney A, Man-Son-Hing M, Coyle D (2003) Cost-effectiveness of hip protectors in institutional dwelling elderly. Osteoporos Int 14:243–250PubMedGoogle Scholar
  72. 72.
    Willis M, Odegaard K, Persson U, Mellstrom D, et al (2001) A cost-effectiveness model of tibolone as treatment for the prevention of osteoporosis fractures in postmenopausal women in Sweden. Clin Drug Invest 21:115–127CrossRefGoogle Scholar
  73. 73.
    Willis M (2002) The health economics of calcium and vitamin D3 for the prevention of osteoporotic hip fractures in Sweden. Int J Technol Assess Health Care 18:791–807CrossRefPubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2005

Authors and Affiliations

  • Rachael L. Fleurence
    • 1
    • 3
  • Cynthia P. Iglesias
    • 2
  • David J. Torgerson
    • 2
  1. 1.The MEDTAP Institute at UBCBethesdaUSA
  2. 2.Department of Health SciencesUniversity of YorkYorkUK
  3. 3.BethesdaUSA

Personalised recommendations