Osteoporosis International

, Volume 16, Issue 12, pp 1883–1893 | Cite as

Potential cost-effective use of spine radiographs to detect vertebral deformity and select osteopenic post-menopausal women for amino-bisphosphonate therapy

  • John T. Schousboe
  • Kristine E. Ensrud
  • John A. Nyman
  • Robert L. Kane
  • L. Joseph MeltonIII
Original Article

Abstract

Prevalent vertebral deformities are predictive of future clinical fractures independent of bone density. We used a Markov model with eight health states to estimate from the societal perspective the cost-effectiveness of using spine radiographs to identify postmenopausal women age 60 or older with one or more vertebral deformities and then treat them with anti-resorptive drug therapy to prevent fractures. We compared three strategies: 5 years of amino-bisphosphonate (alendronate) therapy for all, 5 years of alendronate therapy for only those with prevalent a radiographic vertebral deformity or no initial alendronate treatment. Lifetime direct medical and indirect costs, quality adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) were tracked. For women with one or more prevalent vertebral deformities, the costs per QALY gained ranged from $5,084 (for an 80 year old with a T-score of −2.4) to $61,192 (for a 60 year old with a T-score of −1.0). For women without prevalent vertebral deformity, the costs per QALY gained ranged from $41,897 (for a 60 year old with a T-score of −2.4) to $166,219 (for an 80 year old with a T-score of −1.0). These results were modestly sensitive to reasonable changes in fracture rates, disutility, discount rates and assumptions about the accuracy of spinal radiographs for detecting vertebral deformity. Assuming a societal willingness to pay per QALY gained of $50,000, the strategy of performing spine radiographs in post-menopausal osteopenic women with T-scores at or below –1.5 and treating those with 1 or more prevalent vertebral deformities is likely to be cost-effective. However, further research on the accuracy of vertebral deformity ascertainment from routine clinical radiographs and on the efficacy of amino-bisphosphonate drugs for reducing the risk of non-vertebral fractures in osteopenic women is needed to define more precisely the subset of osteopenic post-menopausal women in whom use of spinal radiographs is most cost-effective.

Keywords

Amino-bisphosphonate therapy Cost-effectiveness Fracture Spine radiography 

Notes

Acknowledgements

Dr. Schousboe received research grant support from Hologic, Inc., and Dr. Ensrud received research grant support from Pfizer, Inc., and from Eli Lilly and Co.

References

  1. 1.
    Melton LJI (2003) Adverse outcomes of osteoporotic fractures in the general population. J Bone Miner Res 18:1139–1141PubMedGoogle Scholar
  2. 2.
    National Osteoporosis Foundation (2005) Physician guide to prevention and treatment of osteoporosis. http://www.nof.org/physguide/index.htm (accessed 15 January 2005)Google Scholar
  3. 3.
    Hodgson SF, Watts NB, Force AT (2001) American Association of Clinical Endocrinologists 2001 medical guidelines for clinical practice for the prevention and management of postmenopausal osteoporosis. Endocr Pract :293–312Google Scholar
  4. 4.
    Brown JP, Josse RG (2002) Clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ 167 [Suppl 10]:S1–34Google Scholar
  5. 5.
    Johnell O, Kanis JA, Oden A, et al (2004) Mortality after osteoporotic fractures. Osteoporos Int 15:38–42CrossRefPubMedGoogle Scholar
  6. 6.
    Meunier PJ, Delmas PD, Eastell R, et al (1999) Diagnosis and management of osteoporosis in postmenopausal women: clinical guidelines. International Committee for Osteoporosis Clinical Guidelines. Clin Ther 21:1025–1044CrossRefPubMedGoogle Scholar
  7. 7.
    Kanis JA, Melton LJ III, Christiansen C, Johnston CC, Khaltaev N (1994) The diagnosis of osteoporosis. J Bone Miner Res 9:1137–1141PubMedGoogle Scholar
  8. 8.
    Johnell O, Jonsson B, Jonsson L, Black D (2003) Cost effectiveness of alendronate (fosamax) for the treatment of osteoporosis and prevention of fractures. Pharmacoeconomics 21:305–314PubMedGoogle Scholar
  9. 9.
    Iglesias CP, Torgerson DJ, Bearne A, Bose U (2002) The cost utility of bisphosphonate treatment in established osteoporosis. QJM 95:305–311CrossRefPubMedGoogle Scholar
  10. 10.
    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
  11. 11.
    Siris ES, Chen YT, Abbott TA, et al (2004) Bone mineral density thresholds for pharmacological intervention to prevent fractures. Arch Intern Med 164:1108–1112Google Scholar
  12. 12.
    Wainwright SA, Phipps KR, Stone JV, et al (2001) A large proportion of fractures in postmenopausal women occur with baseline bone mineral density T-score >-2.5 (abstract). J Bone Miner Res 16 [Suppl 1]:S155Google Scholar
  13. 13.
    Eddy DM, Johnston CC Jr, Cummings SR, et al (1998) Osteoporosis: review of the evidence for prevention, diagnosis, and treatment and cost-effectiveness analysis. Osteoporos Int 8 [Suppl 4]:S3–S88Google Scholar
  14. 14.
    Black DM, Steinbuch M, Palermo L, et al (2001) An assessment tool for predicting fractures in post-menopausal women. Osteoporos Int 12:519–528CrossRefPubMedGoogle Scholar
  15. 15.
    Siris ES, Miller PD, Barrett-Connor E, et al (2001) Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment. JAMA 286:2815–2822CrossRefPubMedGoogle Scholar
  16. 16.
    Black DM, Arden NK, Palermo L, Pearson J, Cummings SR (1999) Prevalent vertebral deformities predict hip fractures and new vertebral deformities but not wrist fractures. Study of Osteoporotic Fractures Research Group. J Bone Miner Res 14:821–828PubMedGoogle Scholar
  17. 17.
    Ziegler R, Scheidt-Nave C, Leidig-Bruckner G (1996) What is a vertebral fracture? Bone 18 [Suppl 3]:169S–177SGoogle Scholar
  18. 18.
    O’Neill TW, Silman AJ (1997) Definition and diagnosis of vertebral fracture. J Rheumatol 24:1208–1211PubMedGoogle Scholar
  19. 19.
    Melton LJ III, Lane AW, Cooper C, Eastell R, O’Fallon WM, Riggs BL (1993) Prevalence and incidence of vertebral deformities. Osteoporos Int 3:113–119CrossRefPubMedGoogle Scholar
  20. 20.
    Nevitt MC, Ettinger B, Black DM, et al (1998) The association of radiographically detected vertebral fractures with back pain and function: a prospective study. Ann Intern Med 128:793–800PubMedGoogle Scholar
  21. 21.
    Melton LJ III, Crowson CS, O’Fallon WM (1999) Fracture incidence in Olmsted County, Minnesota: comparison of urban with rural rates and changes in urban rates over time. Osteoporos Int 9:29–37Google Scholar
  22. 22.
    Melton LJ III (1996) History of the Rochester Epidemiology Project. Mayo Clin Proc 71:266–274PubMedGoogle Scholar
  23. 23.
    De Laet CE, van Hout BA, Burger H, Hofman A, Pols HA (1997) Bone density and risk of hip fracture in men and women: cross sectional analysis. BMJ 315:221–225PubMedGoogle Scholar
  24. 24.
    De Laet CE, Van Hout BA, Burger H, Weel AE, Hofman A, Pols HA (1998) Hip fracture prediction in elderly men and women: validation in the Rotterdam study. J Bone Miner Res 13:1587–1593PubMedGoogle Scholar
  25. 25.
    Looker AC, Wahner HW, Dunn WL, et al (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8:468–489Google Scholar
  26. 26.
    Marshall D, Johnell O, Wedel H (1996) Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 312:1254–1259PubMedGoogle Scholar
  27. 27.
    Melton LJ III, Ilstrup DM, Beckenbaugh RD, Riggs BL (1982) Hip fracture recurrence. A population-based study. Clin Orthop 167:131–138PubMedGoogle Scholar
  28. 28.
    Cuddihy MT, Gabriel SE, Crowson CS, O’Fallon WM, Melton LJ III (1999) Forearm fractures as predictors of subsequent osteoporotic fractures. Osteoporos Int 9:469–475PubMedGoogle Scholar
  29. 29.
    Cranney A, Wells G, Willan A, et al (2002) Meta-analyses of therapies for postmenopausal osteoporosis. II. Meta-analysis of alendronate for the treatment of postmenopausal women. Endocr Rev 23:508–516CrossRefPubMedGoogle Scholar
  30. 30.
    Tosteson AN, Jonsson B, Grima DT, O’Brien BJ, Black DM, Adachi JD (2001) Challenges for model-based economic evaluations of postmenopausal osteoporosis interventions. Osteoporos Int 12:849–857CrossRefPubMedGoogle Scholar
  31. 31.
    United States Life Tables 1999 (2002) National vital statistics report 50:17–18Google Scholar
  32. 32.
    Kanis JA, Oden A, Johnell O, De Laet C, Jonsson B, Oglesby AK (2003) The components of excess mortality after hip fracture. Bone 32:468–473CrossRefPubMedGoogle Scholar
  33. 33.
    Kanis JA, Oden A, Johnell O, De Laet C, Jonsson B (2004) Excess mortality after hospitalisation for vertebral fracture. Osteoporos Int15:108–112CrossRefGoogle Scholar
  34. 34.
    (2001) Drug topics 2001 red book 2001. Medical Economics Co, Montvale, New JerseyGoogle Scholar
  35. 35.
    Gabriel SE, Tosteson AN, Leibson CL, et al (2002) Direct medical costs attributable to osteoporotic fractures. Osteoporos Int 13:323–330CrossRefPubMedGoogle Scholar
  36. 36.
    Centers for Medicare and Medicaid Services (2003) http://cms.hhs.gov/providers/pufdownload/rvudown.asp (accessed 12 August 2003)Google Scholar
  37. 37.
    Leibson CL, Tosteson AN, 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 50:1644–1650PubMedGoogle Scholar
  38. 38.
    Agency for Health Care Research and Quality. Medical Expenditure Panel Survey (2003) http://www.meps.ahrq.gov/ (accessed 12 August 2003)Google Scholar
  39. 39.
    Meerding WJ, Looman CW, Essink-Bot ML, Toet H, Mulder S, van Beeck EF (2004) Distribution and determinants of health and work status in a comprehensive population of injury patients. J Trauma 56:150–161PubMedGoogle Scholar
  40. 40.
    Bureau of Labor Statistics, US Census Bureau (2002) CPS annual demographic survey. http://ferret.bls.census.gov/macro/032002/perinc/new05_000.htm (accessed 28 May 2004)Google Scholar
  41. 41.
    US Census Bureau. Workforce participation rates. http://factfinder.census.gov/home/saff/main.html?_lang=en (accessed 28 May 2004)Google Scholar
  42. 42.
    Oleksik A, Lips P, Dawson A, et al (2000) Health-related quality of life in postmenopausal women with low BMD with or without prevalent vertebral fractures. J Bone Miner Res 15:1384–1392PubMedGoogle Scholar
  43. 43.
    Huang C, Ross PD, Wasnich RD (1996) Vertebral fracture and other predictors of physical impairment and health care utilization. Arch Intern Med 156:2469–2475CrossRefPubMedGoogle Scholar
  44. 44.
    Huang C, Ross PD, Wasnich RD (1996) Vertebral fractures and other predictors of back pain among older women. J Bone Miner Res 11:1026–1032PubMedGoogle Scholar
  45. 45.
    Tosteson AN, Gabriel SE, Grove MR, Moncur MM, Kneeland TS, Melton LJ III (2001) Impact of hip and vertebral fractures on quality-adjusted life years. Osteoporos Int 12:1042–1049CrossRefPubMedGoogle Scholar
  46. 46.
    Melton LJ, Chrischilles EA, Cooper C, Lane AW, Riggs BL (1992) Perspective: how many women have osteoporosis? J Bone Miner Res 7:1005–1010PubMedGoogle Scholar
  47. 47.
    Raftery J (2001) NICE: faster access to modern treatments? Analysis of guidance on health technologies. BMJ 323:1300–1303CrossRefPubMedGoogle Scholar
  48. 48.
    George B, Harris A, Mitchell A (2001) Cost-effectiveness analysis and the consistency of decision making: evidence from pharmaceutical reimbursement in Australia (1991 to 1996). Pharmacoeconomic 19:1103–1109Google Scholar
  49. 49.
    Ross PD, Davis JW, Epstein RS, Wasnich RD (1991) Pre-existing fractures and bone mass predict vertebral fracture incidence in women. Ann Intern Med 114:919–923PubMedGoogle Scholar
  50. 50.
    Abdel-Hamid Osman A, Bassiouni H, Koutri R, Nijs J, Geusens P, Dequeker J (1994) Aging of the thoracic spine: distinction between wedging in osteoarthritis and fracture in osteoporosis—a cross-sectional and longitudinal study. Bone 15:437–442CrossRefGoogle Scholar
  51. 51.
    Hirth R, Chernow M, Miller E, Fendrick A, Weissert W (2000) Willingness to pay for a quality-adjusted life year: in search of a standard. Med Decis Making 20:332–342PubMedGoogle Scholar
  52. 52.
    Ubel PA, Hirth RA, Chernew ME, Fendrick AM (2003) What is the price of life and why doesn’t it increase at the rate of inflation? Arch Intern Med 163:1637–1641CrossRefPubMedGoogle Scholar
  53. 53.
    Black DM, Palermo L, Nevitt MC, et al (1995) Comparison of methods for defining prevalent vertebral deformities: the Study of Osteoporotic Fractures. J Bone Miner Res 10:890–902PubMedGoogle Scholar
  54. 54.
    Ross PD, Genant HK, Davis JW, Miller PD, Wasnich RD (1993) Predicting vertebral fracture incidence from prevalent fractures and bone density among non-black, osteoporotic women. Osteoporos Int 3:120–126CrossRefPubMedGoogle Scholar
  55. 55.
    Fechtenbaum J, Bugnard F, Kolta S, et al (2004) Vertebral fracture: a difficult diagnosis? The Act’os study (abstract). J Bone Miner Res 19 [Suppl 1]:S233Google Scholar
  56. 56.
    Greenspan S, von Stetten E, Emond S, Jones L, Parker R (2001) Instant vertebral assessment. J Clin Densitometry 4:373–380CrossRefGoogle Scholar
  57. 57.
    Schousboe J, DeBold C, Bowles C, Glickstein S, Rubino R (2002) Prevalence of vertebral compression fracture deformity by X-ray absorptiometry of lateral thoracic and lumbar spines in a population referred for bone densitometry. J Clin Densitometry 5:239–246CrossRefGoogle Scholar
  58. 58.
    Rea JA, Chen MB, Li J et al (2000) Morphometric X-ray absorptiometry and morphometric radiography of the spine: a comparison of prevalent vertebral deformity identification. J Bone Miner Res 15:564–574PubMedGoogle Scholar
  59. 59.
    Ismail AA, Cockerill W, Cooper C, et al (2001) Prevalent vertebral deformity predicts incident hip though not distal forearm fracture: results from the European Prospective Osteoporosis Study. Osteoporos Int 12:85–90CrossRefPubMedGoogle Scholar
  60. 60.
    Rosner AJ, Grima DT, Torrance GW, et al (1998) Cost effectiveness of multi-therapy treatment strategies in the prevention of vertebral fractures in postmenopausal women with osteoporosis. Pharmacoeconomics 14:559–573PubMedGoogle Scholar
  61. 61.
    Le Pen C, Maurel F, Breart G, et al (2000) The long-term effectiveness of preventive strategies for osteoporosis in postmenopausal women: A modeling approach. Osteoporos Int 11:524–532CrossRefPubMedGoogle Scholar
  62. 62.
    Cummings SR, Black DM, Nevitt MC, et al (1993) Bone density at various sites for prediction of hip fractures. The Study of Osteoporotic Fractures Research Group. Lancet 341:72–75CrossRefPubMedGoogle Scholar
  63. 63.
    Jones G, White C, Nguyen T, Sambrook PN, Kelly PJ, Eisman JA (1996) Prevalent vertebral deformities: relationship to bone mineral density and spinal osteophytosis in elderly men and women. Osteoporos Int 6:233–239CrossRefPubMedGoogle Scholar
  64. 64.
    Leidig-Bruckner G, Limberg B, Felsenberg D, et al (2000) Sex difference in the validity of vertebral deformities as an index of prevalent vertebral osteoporotic fractures: a population survey of older men and women. Osteoporos Int 11:102–119PubMedGoogle Scholar
  65. 65.
    Burstrom K, Johannesson M, Diderichsen F (2001) Swedish population health-related quality of life results using the EQ-5D. Qual Life Res 10:621–635CrossRefPubMedGoogle Scholar
  66. 66.
    Kind P, Dolan P, Gudex C, Williams A (1998) Variations in population health status: results from a United Kingdom national questionnaire survey. BMJ 316:736–741PubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2005

Authors and Affiliations

  • John T. Schousboe
    • 1
    • 2
  • Kristine E. Ensrud
    • 3
    • 4
  • John A. Nyman
    • 2
  • Robert L. Kane
    • 2
    • 5
  • L. Joseph MeltonIII
    • 6
  1. 1.Park Nicollet Health ServicesMinneapolisUSA
  2. 2.Division of Health Services Research and Policy, School of Public HealthUniversity of MinnesotaMinneapolisUSA
  3. 3.Department of MedicineVeterans Administration Medical CenterMinneapolisUSA
  4. 4.Division of Epidemiology, School of Public HealthUniversity of MinnesotaMinneapolisUSA
  5. 5.Clinical Outcomes Research CenterUniversity of MinnesotaMinneapolisUSA
  6. 6.Division of Epidemiology, Department of Health Sciences ResearchMayo ClinicRochesterUSA

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