Osteoporosis International

, Volume 17, Issue 10, pp 1459–1471 | Cite as

At what hip fracture risk is it cost-effective to treat?

International intervention thresholds for the treatment of osteoporosis
  • F. Borgström
  • O. Johnell
  • J. A. Kanis
  • B. Jönsson
  • C. Rehnberg
Original Article

Abstract

Introduction

Intervention thresholds (ITs), the 10-year hip fracture risk at which treatment can be considered to be cost-effective, have previously been estimated for Sweden and the UK.

Objective

The aim of this study was to provide a Markov cohort model platform for a multinational estimation of thresholds at which intervention becomes cost-effective and to investigate and determine the main factors behind differences in these thresholds between countries.

Results and discussion

Intervention thresholds were estimated for Australia, Germany, Japan, Sweden, Spain, the UK and USA using a societal perspective. The model was populated with as much relevant country-specific data as possible. Intervention was assumed to be given for 5 years and to decrease the risk of all osteoporotic fractures by 35%. The societal willingness to pay (WTP) for a quality-adjusted life-year (QALY) gained was set to the gross domestic product (GDP) per capita multiplied by two. In the base case analysis, the 10-year hip fracture probability at which intervention became cost-effective varied across ages and countries. For women starting therapy at an age of 70 years, the IT varied from a hip fracture probability of 5.6% in Japan to 14.7% in Spain. The main factors explaining differences in the IT between countries were the WTP for a QALY gained, fracture-related costs and intervention costs.

Conclusion

The ITs presented in this paper are appropriate for use in treatment guidelines that consider health economic aspects, and they can be used in combination with fracture risk prediction algorithms to improve the selection of patients who are suitable for osteoporotic intervention.

Keywords

Cost-effectiveness Hip fracture Intervention threshold Osteoporosis 

References

  1. 1.
    Johannesson M (2001) At what coronary risk level is it cost-effective to initiate cholesterol lowering drug treatment in primary prevention? Eur Heart J 22:919–925PubMedCrossRefGoogle Scholar
  2. 2.
    Kanis JA, Johnell O, Oden A, De Laet C, Oglesby A, Jonsson B (2002) Intervention thresholds for osteoporosis. Bone 31:26–31PubMedCrossRefGoogle Scholar
  3. 3.
    Kanis JA, Johnell O, Oden A, Borgstrom F, Johansson H, De Laet C, Jonsson B (2005) Intervention thresholds for osteoporosis in men and women: a study based on data from Sweden. Osteoporos Int 16:6–14PubMedCrossRefGoogle Scholar
  4. 4.
    Kanis JA, Borgstrom F, Zethraeus N, Johnell O, Oden A, Jonsson B (2005) Intervention thresholds for osteoporosis in the UK. Bone 36:22–32PubMedCrossRefGoogle Scholar
  5. 5.
    Kanis JA, Oden A, Johnell O, Jonsson B, de Laet C, Dawson A (2001) The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporos Int 12:417–427PubMedCrossRefGoogle Scholar
  6. 6.
    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 16:15–25PubMedCrossRefGoogle Scholar
  7. 7.
    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 15:862–871PubMedCrossRefGoogle Scholar
  8. 8.
    Jonsson L, Borgstrom F, Zethraeus N (2003) Cost-effectiveness of alendronate treatment of osteoporosis in Denmark. An economic evaluation based on the Fracture Intervention Trial. Ugeskr Laeger 165:4112–4116PubMedGoogle Scholar
  9. 9.
    Borgstrom F, Zethraeus N (2003) Economic assessment based on a clinical study of risedronate. Fracture prevention in elderly women with osteoporosis is cost-effective. Lakartidningen 100:36–40PubMedGoogle Scholar
  10. 10.
    Borgstrom F, Johnell O, Kanis JA, Oden A, Sykes D, Jonsson B (2004) Cost effectiveness of raloxifene in the treatment of osteoporosis in Sweden: an economic evaluation based on the MORE study. Pharmacoeconomics 22:1153–1165PubMedCrossRefGoogle Scholar
  11. 11.
    Borgstrom F, Johnell O, Jonsson B, Zethraeus N, Sen SS (2004) Cost effectiveness of alendronate for the treatment of male osteoporosis in Sweden. Bone 34:1064–1071PubMedCrossRefGoogle Scholar
  12. 12.
    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
  13. 13.
    Melton LJ 3rd, Gabriel SE, Crowson CS, Tosteson AN, Johnell O, Kanis JA (2003) Cost-equivalence of different osteoporotic fractures. Osteoporos Int 14:383–388PubMedCrossRefGoogle Scholar
  14. 14.
    Borgström F, Kanis JA, Johnell O, Jönsson B (2006) Are costs of fracture proportional to their morbidity?. Osteoporos Int ECCEO abstract 17[Suppl 2]:47Google Scholar
  15. 15.
    Borgström F, Kanis JA, Johnell O, Jönsson B (2006) Costing fractures for use in health economics modelling. Osteoporos Int ECCEO abstract 17[Suppl 2]: 97Google Scholar
  16. 16.
    ISPOR (2005) ISPOR pharmacoeconomic guidelines. http://www.ispor.org/PEguidelines/index.asp
  17. 17.
    Kanis JA, Brazier JE, Stevenson M, Calvert NW, Lloyd Jones M (2002) Treatment of established osteoporosis: a systematic review and cost-utility analysis. Health Technol Assess 6:1–146PubMedGoogle Scholar
  18. 18.
    Jonsson B, Kanis J, Dawson A, Oden A, Johnell O (1999) Effect and offset of effect of treatments for hip fracture on health outcomes. Osteoporos Int 10:193–199PubMedCrossRefGoogle Scholar
  19. 19.
    Jonsson B, Christiansen C, Johnell O, Hedbrandt J (1995) Cost-effectiveness of fracture prevention in established osteoporosis. Osteoporos Int 5:136–142PubMedCrossRefGoogle Scholar
  20. 20.
    Stevenson M, Lloyd Jones M, De Nigris E, Brewer N, Davis S, Oakley J (2005) A systematic review and economic evaluation of alendronate, etidronate, risedronate, raloxifene and teriparatide for the prevention and treatment of postmenopausal osteoporosis. Health Technol Assess 9(22):1–160PubMedGoogle Scholar
  21. 21.
    Kanis JA, Johnell O, Oden A, Borgstrom F, Zethraeus N, De Laet C, Jonsson B (2004) The risk and burden of vertebral fractures in Sweden. Osteoporos Int 15:20–26PubMedCrossRefGoogle Scholar
  22. 22.
    Eichler HG, Kong SX, Gerth WC, Mavros P, Jonsson B (2004) Use of cost-effectiveness analysis in health-care resource allocation decision-making: how are cost-effectiveness thresholds expected to emerge? Value Health 7:518–528PubMedCrossRefGoogle Scholar
  23. 23.
    Commission on Macroeconomics and Health (2001) Report on macroeconomics and health: investing in health for economic development. WHO, GenevaGoogle Scholar
  24. 24.
    Murray CJ, Lauer JA, Hutubessy RC, Niessen L, Tomijima N, Rodgers A, Lawes CM, Evans DB (2003) Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk. Lancet 361:717–725PubMedCrossRefGoogle Scholar
  25. 25.
    Murray CJ, Lopez AD (1997) Global mortality, disability, and the contribution of risk factors: global burden of disease study. Lancet 349:1436–1442PubMedCrossRefGoogle Scholar
  26. 26.
    Tengs TO, Wallace A (2000) One thousand health-related quality-of-life estimates. Med Care 38:583–637PubMedCrossRefGoogle Scholar
  27. 27.
    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 11:669–674PubMedCrossRefGoogle Scholar
  28. 28.
    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 80:243–248PubMedCrossRefGoogle Scholar
  29. 29.
    Elffors I, Allander E, Kanis JA, Gullberg B, Johnell O, Dequeker J, Dilsen G, Gennari C, Lopes Vaz AA, Lyritis G et al. (1994) The variable incidence of hip fracture in southern Europe: the MEDOS Study. Osteoporos Int 4:253–263PubMedCrossRefGoogle Scholar
  30. 30.
    Euopean Commission – Employment and Social Affairs (1998) Report on Osteoporosis in the European Community - Action for Prevention. European Commission – Employment & Social Affairs, BrusselsGoogle Scholar
  31. 31.
    Nagata-Kobayashi S, Shimbo T, Fukui T (2002) Cost-effectiveness analysis of screening for osteoporosis in postmenopausal Japanese women. J Bone Miner Metab 20:350–357PubMedCrossRefGoogle Scholar
  32. 32.
    Melton LJ 3rd, 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 9:29–37PubMedCrossRefGoogle Scholar
  33. 33.
    Sanders KM, Seeman E, Ugoni AM, Pasco JA, Martin TJ, Skoric B, Nicholson GC, Kotowicz MA (1999) Age- and gender-specific rate of fractures in Australia: a population-based study. Osteoporos Int 10:240–247PubMedCrossRefGoogle Scholar
  34. 34.
    Government Actuary´s Department. Interim Life Tables. http://www.gad.gov.uk/policy_and_stats/life_tables.htm. Access date: 2004-10-15
  35. 35.
    Instituto Nacional del Estadistica (2002) Tablas de Mortalidad de la Población de España 1998–1999. MadridGoogle Scholar
  36. 36.
    Statistical Yearbook of Sweden (2004). Statistics Sweden, StockholmGoogle Scholar
  37. 37.
    Human Mortality Database. University of California, Berkeley (USA) and Max Planck Institute for Demographic Research (Germany)Google Scholar
  38. 38.
    Kanis JA, Oden A, Johnell O, De Laet C, Jonsson B, Oglesby AK (2003) The components of excess mortality after hip fracture. Bone 32:468–473PubMedCrossRefGoogle Scholar
  39. 39.
    Oden A, Dawson A, Dere W, Johnell O, Jonsson B, Kanis JA (1998) Lifetime risk of hip fractures is underestimated. Osteoporos Int 8:599–603PubMedCrossRefGoogle Scholar
  40. 40.
    Parker MJ, Anand JK (1991) What is the true mortality of hip fractures? Public Health 105:443–446PubMedCrossRefGoogle Scholar
  41. 41.
    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 (2005) Costs and quality of life associated with osteoporosis-related fractures in Sweden. Osteoporos Int 1–14Google Scholar
  42. 42.
    Jonsson B, Christiansen C, Johnell O, Hedbrandt J, Karlsson G (1996) Cost-effectiveness of fracture prevention in established osteoporosis. Scand J Rheumatol Suppl 103:30–38; discussion, pp 39–40PubMedCrossRefGoogle Scholar
  43. 43.
    Brecht JG, Kruse HP, Felsenberg D, Mohrke W, Oestreich A, Huppertz E (2003) Pharmacoeconomic analysis of osteoporosis treatment with risedronate. Int J Clin Pharmacol Res 23:93–105PubMedGoogle Scholar
  44. 44.
    Hart WM, Rubio-Terres C, Burrell A, Aristegui I, Escobar-Jimenez Y (2002) Análisis farmacoeconómico del tratamiento de la osteoporosis postmenopáusica con risedronato o alendronato. Rev Esp Enferm Metab Óseas 11:97–104Google Scholar
  45. 45.
    Zethraeus N, Stromberg L, Jonsson B, Svensson O, Ohlen G (1997) The cost of a hip fracture. Estimates for 1,709 patients in Sweden. Acta Orthop Scand 68:13–17PubMedCrossRefGoogle Scholar
  46. 46.
    Dolan P, Torgerson DJ (1998) The cost of treating osteoporotic fractures in the United Kingdom female population. Osteoporos Int 8:611–617PubMedCrossRefGoogle Scholar
  47. 47.
    Kanis JA (2002) Epidemiology and costs of fractures in the UK: background document for male osteoporosis model. Personal communicationGoogle Scholar
  48. 48.
    Gabriel SE, Tosteson AN, Leibson CL, Crowson CS, Pond GR, Hammond CS, Melton LJ 3rd (2002) Direct medical costs attributable to osteoporotic fractures. Osteoporos Int 13:323–330PubMedCrossRefGoogle Scholar
  49. 49.
    OECD Health Data (2005)Google Scholar
  50. 50.
    Meltzer D (1997) Accounting for future costs in medical cost-effectiveness analysis. J Health Econ 16:33–64PubMedCrossRefGoogle Scholar
  51. 51.
    Ekman M, Zethraeus N, Jonsson B (2001) Cost effectiveness of bisoprolol in the treatment of chronic congestive heart failure in Sweden: analysis using data from the Cardiac Insufficiency Bisoprolol Study II trial. Pharmacoeconomics 19:901–916PubMedCrossRefGoogle Scholar
  52. 52.
    Meltzer D, Egleston B, Stoffel D, Dasbach E (2000) Effect of future costs on cost-effectiveness of medical interventions among young adults: the example of intensive therapy for type 1 diabetes mellitus. Med Care 38:679–685PubMedCrossRefGoogle Scholar
  53. 53.
    Kanis JA, Johnell O, De Laet C, Jonsson B, Oden A, Ogelsby AK (2002) International variations in hip fracture probabilities: implications for risk assessment. J Bone Miner Res 17:1237–1244PubMedCrossRefGoogle Scholar
  54. 54.
    Kanis JA, Borgstrom F, De Laet C, Johansson H, Johnell O, Jonsson B, Oden A, Zethraeus N, Pfleger B, Khaltaev N (2005) Assessment of fracture risk. Osteoporos Int 16:581–589PubMedCrossRefGoogle Scholar
  55. 55.
    Kanis JA, Johansson H, Johnell O, Oden A, De Laet C, Eisman JA, Pols H, Tenenhouse A (2005) Alcohol intake as a risk factor for fracture. Osteoporos Int 16:737–742PubMedCrossRefGoogle Scholar
  56. 56.
    Johnell O, Kanis JA, Oden A, Johansson H, De Laet C, Delmas P, Eisman JA, Fujiwara S, Kroger H, Mellstrom D, Meunier PJ, Melton LJ 3rd, O’Neill T, Pols H, Reeve J, Silman A, Tenenhouse A (2005) Predictive value of BMD for hip and other fractures. J Bone Miner Res 20:1185–1194PubMedCrossRefGoogle Scholar
  57. 57.
    Kanis JA, Johnell O, De Laet C, Johansson H, Oden A, Delmas P, Eisman J, Fujiwara S, Garnero P, Kroger H, McCloskey EV, Mellstrom D, Melton LJ, Pols H, Reeve J, Silman A, Tenenhouse A (2004) A meta-analysis of previous fracture and subsequent fracture risk. Bone 35:375–382PubMedCrossRefGoogle Scholar
  58. 58.
    Kanis JA, Johansson H, Oden A, Johnell O, De Laet C, Eisman JA, McCloskey EV, Mellstrom D, Melton LJ 3rd, Pols HA, Reeve J, Silman AJ, Tenenhouse A (2004) A family history of fracture and fracture risk: a meta-analysis. Bone 35:1029–1037PubMedCrossRefGoogle Scholar
  59. 59.
    De Laet C, Oden A, Johansson H, Johnell O, Jonsson B, Kanis JA (2005) The impact of the use of multiple risk indicators for fracture on case-finding strategies: a mathematical approach. Osteoporos Int 16:313–318PubMedCrossRefGoogle Scholar
  60. 60.
    World Bank (2003) World development indicators. The World Bank, Washington, D.C.Google Scholar
  61. 61.
    Bacon WE, Maggi S, Looker A, Harris T, Nair CR, Giaconi J, Honkanen R, Ho SC, Peffers KA, Torring O, Gass R, Gonzalez N (1996) International comparison of hip fracture rates in 1988–89. Osteoporos Int 6:69–75PubMedCrossRefGoogle Scholar
  62. 62.
    Johnell O, Gullberg B, Allander E, Kanis JA (1992) The apparent incidence of hip fracture in Europe: a study of national register sources. MEDOS Study Group. Osteoporos Int 2:298–302PubMedCrossRefGoogle Scholar
  63. 63.
    Zethraeus N, Borgstrom F, Jonsson B, Kanis J (2005) Reassessment of the cost-effectiveness of hormone replacement therapy in Sweden: results based on the Women’s Health Initiative randomized controlled trial. Int J Technol Assess Health Care 21:433–441PubMedCrossRefGoogle Scholar
  64. 64.
    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
  65. 65.
    Cummings SR, Eckert S, Krueger KA, Grady D, Powles TJ, Cauley JA, Norton L, Nickelsen T, Bjarnason NH, Morrow M, Lippman ME, Black D, Glusman JE, Costa A, Jordan VC (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 281:2189–2197PubMedCrossRefGoogle Scholar
  66. 66.
    Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, Jackson RD, Beresford SA, Howard BV, Johnson KC, Kotchen JM, Ockene J (2002) Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA 288:321–333PubMedCrossRefGoogle Scholar
  67. 67.
    Hillner BE, Hollenberg JP, Pauker SG (1986) Postmenopausal estrogens in prevention of osteoporosis. Benefit virtually without risk if cardiovascular effects are considered. Am J Med 80:1115–1127PubMedCrossRefGoogle Scholar
  68. 68.
    Beral V (2003) Breast cancer and hormone-replacement therapy in the Million Women Study. Lancet 362:419–427PubMedCrossRefGoogle Scholar
  69. 69.
    Bagger YZ, Tanko LB, Alexandersen P, Hansen HB, Mollgaard A, Ravn P, Qvist P, Kanis JA, Christiansen C (2004) Two to three years of hormone replacement treatment in healthy women have long-term preventive effects on bone mass and osteoporotic fractures: the PERF study. Bone 34:728–735PubMedCrossRefGoogle Scholar
  70. 70.
    Neer RM, Arnaud CD, Zanchetta JR, Prince R, Gaich GA, Reginster JY, Hodsman AB, Eriksen EF, Ish-Shalom S, Genant HK, Wang O, Mitlak BH (2001) Effect of parathyroid hormone (1–34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med 344:1434–1441PubMedCrossRefGoogle Scholar
  71. 71.
    Randell A, Sambrook PN, Nguyen TV, Lapsley H, Jones G, Kelly PJ, Eisman JA (1995) Direct clinical and welfare costs of osteoporotic fractures in elderly men and women. Osteoporos Int 5:427–432PubMedCrossRefGoogle Scholar
  72. 72.
    Report on Government Services 2000 (2000) Canberra, AustraliaGoogle Scholar
  73. 73.
    Stadsledningskontorets redovisningsstab. Stockholms stads budgetavräkning. http://www.stockholm.se Access date: 2004–08–22
  74. 74.
    Netten A, Rees T, Harrison G; Unit Costs of health and Social Care (2002) Personal Social Services Research Unit, University of KentGoogle Scholar
  75. 75.
    MetLife Mature Market Institute (2003)Google Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2006

Authors and Affiliations

  • F. Borgström
    • 1
    • 2
  • O. Johnell
    • 3
  • J. A. Kanis
    • 4
  • B. Jönsson
    • 5
  • C. Rehnberg
    • 1
  1. 1.Medical Management CentreKarolinska InstitutetStockholmSweden
  2. 2.Stockholm Health EconomicsStockholmSweden
  3. 3.Department of OrthopaedicsMalmö General HospitalMalmöSweden
  4. 4.Centre for Metabolic Bone Diseases (WHO Collaborating Centre)University of Sheffield Medical SchoolSheffieldUK
  5. 5.Stockholm School of EconomicsStockholmSweden

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