Osteoporosis International

, Volume 24, Issue 1, pp 355–367 | Cite as

Balloon kyphoplasty compared to vertebroplasty and nonsurgical management in patients hospitalised with acute osteoporotic vertebral compression fracture: a UK cost-effectiveness analysis

  • A. Svedbom
  • L. Alvares
  • C. Cooper
  • D. Marsh
  • O. Ström
Original Article

Abstract

Summary

The purpose of the study was to estimate the cost-effectiveness of balloon kyphoplasty compared to nonsurgical management and vertebroplasty for the treatment of hospitalised osteoporotic vertebral compression fractures in the UK. A cost-effectiveness model was constructed and used for analysis. Balloon kyphoplasty may be cost-effective compared to relevant alternatives.

Introduction

The objective of this study was to estimate the cost-effectiveness of balloon kyphoplasty (BKP) for the treatment of patients hospitalised with acute osteoporotic vertebral compression fracture (OVCF) compared to percutaneous vertebroplasty (PVP) and nonsurgical management (NSM) in the UK.

Methods

A Markov simulation model was developed to evaluate treatment with BKP, NSM and PVP in patients with symptomatic OVCF. Data on health-related quality of life (HRQoL) with acute OVCF were derived from the FREE and VERTOS II randomised clinical trials (RCTs) and normalised to the NSM arm in the FREE trial. Estimated differences in mortality among the treatments and costs for NSM were obtained from the literature whereas procedure costs for BKP and PVP were obtained from three National Health Service hospitals. It was assumed that BKP and PVP reduced hospital length of stay by 6 days compared to NSM.

Results

The incremental cost-effectiveness ratio was estimated at Great Britain Pound Sterling (GBP) 2,706 per quality-adjusted life year (QALY) and GBP 15,982 per QALY compared to NSM and PVP, respectively. Sensitivity analysis showed that the cost-effectiveness of BKP vs. NSM was robust when mortality and HRQoL benefits with BKP were varied. The cost-effectiveness of BKP compared to PVP was particularly sensitive to changes in the mortality benefit.

Conclusion

BKP may be a cost-effective strategy for the treatment of patients hospitalised with acute OVCF in the UK compared to NSM and PVP. Additional RCT data on the benefits of BKP and PVP compared to simulated sham surgery and further data on the mortality benefits with BKP compared to NSM and PVP would reduce uncertainty.

Keywords

HTA Markov Osteoporosis QALY Spinal fracture United Kingdom 

References

  1. 1.
    (2002) Incidence of vertebral fracture in europe: results from the European prospective osteoporosis study (EPOS). J Bone Miner Res 17: 716–24Google Scholar
  2. 2.
    Strom O, Borgstrom F, Kanis JA, Compston J, Cooper C, McKloskey EV, Jonsson B (2011) Osteoporosis: burden, health care provision and opportunities in the EU. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos 6:59–155Google Scholar
  3. 3.
    Cooper C, Atkinson EJ, O’Fallon WM, Melton LJ III (1992) Incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota, 1985-1989. J Bone Miner Res 7:221–27PubMedCrossRefGoogle Scholar
  4. 4.
    Gehlbach SH, Bigelow C, Heimisdottir M, May S, Walker M, Kirkwood JR (2000) Recognition of vertebral fracture in a clinical setting. Osteoporos Int 11:577–82PubMedCrossRefGoogle Scholar
  5. 5.
    Hallberg I, Rosenqvist AM, Kartous L, Lofman O, Wahlstrom O, Toss G (2004) Health-related quality of life after osteoporotic fractures. Osteoporos Int 15:834–41PubMedCrossRefGoogle Scholar
  6. 6.
    Kado DM, Huang MH, Nguyen CB, Barrett-Connor E, Greendale GA (2007) Hyperkyphotic posture and risk of injurious falls in older persons: the Rancho Bernardo study. J Gerontol A Biol Sci Med Sci 62:652–57PubMedCrossRefGoogle Scholar
  7. 7.
    Silverman SL, Minshall ME, Shen W, Harper KD, Xie S (2001) The relationship of health-related quality of life to prevalent and incident vertebral fractures in postmenopausal women with osteoporosis: results from the multiple outcomes of raloxifene evaluation study. Arthritis Rheum 44:2611–19PubMedCrossRefGoogle Scholar
  8. 8.
    Lindsay R, Silverman SL, Cooper C, Hanley DA, Barton I, Broy SB, Licata A, Benhamou L, Geusens P, Flowers K, Stracke H, Seeman E (2001) Risk of new vertebral fracture in the year following a fracture. JAMA 285:320–323PubMedCrossRefGoogle Scholar
  9. 9.
    Lindsay R, Burge RT, Strauss DM (2005) One year outcomes and costs following a vertebral fracture. Osteoporos Int 16:78–85PubMedCrossRefGoogle Scholar
  10. 10.
    Nevitt MC, Ettinger B, Black DM, Stone K, Jamal SA, Ensrud K, Segal M, Genant HK, Cummings SR (1998) The association of radiographically detected vertebral fractures with back pain and function: a prospective study. Ann Intern Med 128:793–800PubMedGoogle Scholar
  11. 11.
    Sinaki M, Brey RH, Hughes CA, Larson DR, Kaufman KR (2005) Balance disorder and increased risk of falls in osteoporosis and kyphosis: significance of kyphotic posture and muscle strength. Osteoporos Int 16:1004–10PubMedCrossRefGoogle Scholar
  12. 12.
    Culham EG, Jimenez HA, King CE (1994) Thoracic kyphosis, rib mobility, and lung volumes in normal women and women with osteoporosis. Spine (Phila Pa 1976) 19:1250–1255Google Scholar
  13. 13.
    Leech JA, Dulberg C, Kellie S, Pattee L, Gay J (1990) Relationship of lung function to severity of osteoporosis in women. Am Rev Respir Dis 141:68–71PubMedGoogle Scholar
  14. 14.
    Schlaich C, Minne HW, Bruckner T, Wagner G, Gebest HJ, Grunze M, Ziegler R, Leidig-Bruckner G (1998) Reduced pulmonary function in patients with spinal osteoporotic fractures. Osteoporos Int 8:261–67PubMedCrossRefGoogle Scholar
  15. 15.
    Miyakoshi N, Kasukawa Y, Sasaki H, Kamo K, Shimada Y (2009) Impact of spinal kyphosis on gastroesophageal reflux disease symptoms in patients with osteoporosis. Osteoporos Int 20:1193–98PubMedCrossRefGoogle Scholar
  16. 16.
    Kado DM, Browner WS, Palermo L, Nevitt MC, Genant HK, Cummings SR (1999) Vertebral fractures and mortality in older women: a prospective study. Study of osteoporotic fractures research group. Arch Intern Med 159:1215–20PubMedCrossRefGoogle Scholar
  17. 17.
    Kado DM, Lui LY, Ensrud KE, Fink HA, Karlamangla AS, Cummings SR (2009) Hyperkyphosis predicts mortality independent of vertebral osteoporosis in older women. Ann Intern Med 150:681–87PubMedGoogle Scholar
  18. 18.
    Borgstrom F, Zethraeus N, Johnell O, Lidgren L, Ponzer S, Svensson O, Abdon P, Ornstein E, Lunsjo K, Thorngren KG, Sernbo I, Rehnberg C, Jonsson B (2006) Costs and quality of life associated with osteoporosis-related fractures in Sweden. Osteoporos Int 17:637–50PubMedCrossRefGoogle Scholar
  19. 19.
    Finnern HW, Sykes DP (2003) The hospital cost of vertebral fractures in the EU: estimates using national datasets. Osteoporos Int 14:429–36PubMedCrossRefGoogle Scholar
  20. 20.
    Gehlbach SH, Burge RT, Puleo E, Klar J (2003) Hospital care of osteoporosis-related vertebral fractures. Osteoporos Int 14:53–60PubMedCrossRefGoogle Scholar
  21. 21.
    Jensen ME, McGraw JK, Cardella JF, Hirsch JA (2007) Position statement on percutaneous vertebral augmentation: a consensus statement developed by the American society of interventional and therapeutic neuroradiology, society of interventional radiology, American association of neurological surgeons/congress of neurological surgeons, and American society of spine radiology. J Vasc Interv Radiol 18:325–30PubMedCrossRefGoogle Scholar
  22. 22.
    Taylor RS, Fritzell P, Taylor RJ (2007) Balloon kyphoplasty in the management of vertebral compression fractures: an updated systematic review and meta-analysis. Eur Spine J 16:1085–100PubMedCrossRefGoogle Scholar
  23. 23.
    Boonen S, Wahl DA, Nauroy L, Brandi ML, Bouxsein ML, Goldhahn J, Lewiecki EM, Lyritis GP, Marsh D, Obrant K, Silverman S, Siris E, Akesson K (2011) Balloon kyphoplasty and vertebroplasty in the management of vertebral compression fractures. Osteoporos Int 22:2915–34PubMedCrossRefGoogle Scholar
  24. 24.
    Liu JT, Liao WJ, Tan WC, Lee JK, Liu CH, Chen YH, Lin TB (2010) Balloon kyphoplasty versus vertebroplasty for treatment of osteoporotic vertebral compression fracture: a prospective, comparative, and randomized clinical study. Osteoporos Int 21:359–64PubMedCrossRefGoogle Scholar
  25. 25.
    Eck JC, Nachtigall D, Humphreys SC, Hodges SD (2008) Comparison of vertebroplasty and balloon kyphoplasty for treatment of vertebral compression fractures: a meta-analysis of the literature. Spine J 8:488–97PubMedCrossRefGoogle Scholar
  26. 26.
    Felder-Puig R, Piso B, Guba B, Gartlehner G (2009) Kyphoplasty and vertebroplasty for the management of osteoporotic vertebral compression fractures: a systematic review. Orthopade 38:606–15PubMedCrossRefGoogle Scholar
  27. 27.
    Edidin AA, Ong KL, Lau E, Kurtz SM (2011) Mortality risk for operated and non-operated vertebral fracture patients in the medicare population. J Bone Miner Res 26:1617–1626PubMedCrossRefGoogle Scholar
  28. 28.
    Boonen S, Van MJ, Bastian L, Cummings SR, Ranstam J, Tillman JB, Eastell R, Talmadge K, Wardlaw D (2011) Balloon kyphoplasty for the treatment of acute vertebral compression fractures: 2-year results from a randomized trial. J Bone Miner Res 26:1627–1637PubMedCrossRefGoogle Scholar
  29. 29.
    Wardlaw D, Cummings SR, Van MJ, Bastian L, Tillman JB, Ranstam J, Eastell R, Shabe P, Talmadge K, Boonen S (2009) Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomised controlled trial. Lancet 373:1016–24PubMedCrossRefGoogle Scholar
  30. 30.
    Klazen CA, Lohle PN, de Vries J, Jansen FH, Tielbeek AV, Blonk MC, Venmans A, van Rooij WJ, Schoemaker MC, Juttmann JR, Lo TH, Verhaar HJ, Van der Graaf Y, Everdingen KJ, Muller AF, Elgersma OE, Halkema DR, Fransen H, Janssens X, Buskens E, Mali WP (2010) Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trial. Lancet 376:1085–92PubMedCrossRefGoogle Scholar
  31. 31.
    Buchbinder R, Osborne RH, Ebeling PR, Wark JD, Mitchell P, Wriedt C, Graves S, Staples MP, Murphy B (2009) A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med 361:557–68PubMedCrossRefGoogle Scholar
  32. 32.
    Kallmes DF, Comstock BA, Heagerty PJ, Turner JA, Wilson DJ, Diamond TH, Edwards R, Gray LA, Stout L, Owen S, Hollingworth W, Ghdoke B, Annesley-Williams DJ, Ralston SH, Jarvik JG (2009) A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med 361:569–79Google Scholar
  33. 33.
    Gangi A, Clark WA (2010) Have recent vertebroplasty trials changed the indications for vertebroplasty? Cardiovasc Intervent Radiol 33:677–80PubMedCrossRefGoogle Scholar
  34. 34.
    Baerlocher MO, Munk PL, Liu DM, Tomlinson G, Badii M, Kee ST, Loh CT, Hardy BW, Murphy KJ (2010) Clinical utility of vertebroplasty: need for better evidence. Radiology 255:669–74PubMedCrossRefGoogle Scholar
  35. 35.
    Clark W, Goh AC (2010) Vertebroplasty for acute osteoporotic spinal fractures—best evidence? J Vasc Interv Radiol 21:1330–1333PubMedCrossRefGoogle Scholar
  36. 36.
    Kallmes DF, Jarvik JG, Osborne RH, Comstock BA, Staples MP, Heagerty PJ, Turner JA, Buchbinder R (2010) Clinical utility of vertebroplasty: elevating the evidence. Radiology 255:675–80PubMedCrossRefGoogle Scholar
  37. 37.
    Firanescu C, Lohle PN, de Vries J, Klazen CA, Juttmann JR, Clark W, van Rooij WJ (2011) A randomised sham controlled trial of vertebroplasty for painful acute osteoporotic vertebral fractures (VERTOS IV). Trials 12:93PubMedCrossRefGoogle Scholar
  38. 38.
    Clark WA, Burnes JP, Lyon SM (2011) Vertebroplasty for acute osteoporotic fractures—position statement from the Interventional Radiology Society of Australasia. J Med Imaging Radiat Oncol 55:1–3PubMedCrossRefGoogle Scholar
  39. 39.
    Staples MP, Kallmes DF, Comstock BA, Jarvik JG, Osborne RH, Heagerty PJ, Buchbinder R (2011) Effectiveness of vertebroplasty using individual patient data from two randomised placebo controlled trials: meta-analysis. BMJ 343:d3952PubMedCrossRefGoogle Scholar
  40. 40.
    Strom O, Leonard C, Marsh D, Cooper C (2009) Cost-effectiveness of balloon kyphoplasty in patients with symptomatic vertebral compression fractures in a UK setting. Osteoporos IntGoogle Scholar
  41. 41.
    NICE (2008) Guide to the methods of technology appraisal. Technology Appraisal GuideGoogle Scholar
  42. 42.
    OECD (2011) Consumer prices—annual inflationGoogle Scholar
  43. 43.
    Ara R, Tumur I, Pandor A, Duenas A, Williams R, Wilkinson A, Paisley S, Chilcott J (2008) Ezetimibe for the treatment of hypercholesterolaemia: a systematic review and economic evaluation. Health Technol Assess 12(iii):xi–iii, 212Google Scholar
  44. 44.
    Kind P, Dolan P, Gudex C, Williams A (1998) Variations in population health status: results from a United Kingdom national questionnaire survey. BMJ 316:736–41PubMedCrossRefGoogle Scholar
  45. 45.
    Puffer S, Torgerson DJ, Sykes D, Brown P, Cooper C (2004) Health care costs of women with symptomatic vertebral fractures. Bone 35:383–86PubMedCrossRefGoogle Scholar
  46. 46.
    Stevenson M, Davis S (2006) Analyses of the cost-effectiveness of pooled alendronate and risedronate, compared with strontium ranelate, raloxifene, etidronate and teriparatide. The University of Sheffield, SheffieldGoogle Scholar
  47. 47.
    Stevenson MD, Davis SE, Kanis JA (2006) The hospitalisation costs and out-patient costs of fragility fractures. Women-s Health Med 3:145–89CrossRefGoogle Scholar
  48. 48.
    Curtis L (2008) Unit costs of health and social care. Personal Social Services Research Unit, CanterburyGoogle Scholar
  49. 49.
    Singer BR, McLauchlan GJ, Robinson CM, Christie J (1998) Epidemiology of fractures in 15,000 adults: the influence of age and gender. J Bone Joint Surg Br 80:243–48PubMedCrossRefGoogle Scholar
  50. 50.
    Kanis JA, Johnell O, Oden A, Sembo I, Redlund-Johnell I, Dawson A, De Laet C, Jonsson B (2000) Long-term risk of osteoporotic fracture in Malmo. Osteoporos Int 11:669–74PubMedCrossRefGoogle Scholar
  51. 51.
    Borgstrom F, Strom O, Kleman M, McCloskey E, Johansson H, Oden A, Kanis JA (2011) Cost-effectiveness of bazedoxifene incorporating the FRAX(R) algorithm in a European perspective. Osteoporos Int 22:955–65PubMedCrossRefGoogle Scholar
  52. 52.
    Borgstrom F, Jonsson B, Strom O, Kanis JA (2006) An economic evaluation of strontium ranelate in the treatment of osteoporosis in a Swedish setting: based on the results of the SOTI and TROPOS trials. Osteoporos Int 17:1781–93PubMedCrossRefGoogle Scholar
  53. 53.
    Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston CC Jr, Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8:468–89PubMedCrossRefGoogle Scholar
  54. 54.
    Marshall D, Johnell O, Wedel H (1996) Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 312:1254–59PubMedCrossRefGoogle Scholar
  55. 55.
    Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA III, Berger M (2000) Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 15:721–39PubMedCrossRefGoogle Scholar
  56. 56.
    NHS (2011) Prescription Services. Drug tariffGoogle Scholar
  57. 57.
    Atalay B, Caner H, Gokce C, Altinors N (2005) Kyphoplasty: 2 years of experience in a neurosurgery department. Surg Neurol 64(Suppl 2):S72–S76PubMedCrossRefGoogle Scholar
  58. 58.
    Dudeney S, Lieberman IH, Reinhardt MK, Hussein M (2002) Kyphoplasty in the treatment of osteolytic vertebral compression fractures as a result of multiple myeloma. J Clin Oncol 20:2382–87PubMedCrossRefGoogle Scholar
  59. 59.
    Ledlie JT, Renfro MB (2006) Kyphoplasty treatment of vertebral fractures: 2-year outcomes show sustained benefits. Spine (Phila Pa 1976 ) 31:57–64CrossRefGoogle Scholar
  60. 60.
    Lieberman IH, Dudeney S, Reinhardt MK, Bell G (2001) Initial outcome and efficacy of “kyphoplasty” in the treatment of painful osteoporotic vertebral compression fractures. Spine (Phila Pa 1976) 26:1631–38CrossRefGoogle Scholar
  61. 61.
    Rollinghoff M, Zarghooni K, Schluter-Brust K, Sobottke R, Schlegel U, Eysel P, Delank KS (2010) Indications and contraindications for vertebroplasty and kyphoplasty. Arch Orthop Trauma Surg 130:765–774PubMedCrossRefGoogle Scholar
  62. 62.
    Strom O, Bianchi ML, Dimai HP, Lekander I, Svedbom A, F T, Borgstron T (2011) Characteristics of patients with vertebral fractures stratified by treatment type (non-surgical management, balloon kyphoplasty and vertebroplasty)—results from the Austrian, French and Italian ICUROS substudies. Osteoporos Int 22:204–205Google Scholar
  63. 63.
    Wilson DJ, Owen S, Corkill RA (2011) Facet joint injections as a means of reducing the need for vertebroplasty in insufficiency fractures of the spine. Eur Radiol 21:1772–78PubMedCrossRefGoogle Scholar
  64. 64.
    Wilson DJ (2011) Vertebroplasty for vertebral fracture. BMJ 343:d3470PubMedCrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2012

Authors and Affiliations

  • A. Svedbom
    • 1
  • L. Alvares
    • 2
  • C. Cooper
    • 3
    • 4
  • D. Marsh
    • 5
  • O. Ström
    • 6
  1. 1.OptumInsightStockholmSweden
  2. 2.Spine and BiologicsMedtronic InternationalTolochenazSwitzerland
  3. 3.MRC Lifecourse Epidemiology UnitUniversity of SouthamptonSouthamptonUK
  4. 4.Institute of Musculoskeletal SciencesUniversity of OxfordOxfordUK
  5. 5.Royal National Orthopaedic HospitalStanmoreUK
  6. 6.Department of Learning, Informatics, Management and Ethics, Medical Management CenterKarolinska InstitutetStockholmSweden

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