Osteoporosis International

, Volume 18, Issue 11, pp 1481–1491 | Cite as

Simulation-based cost-utility analysis of population screening-based alendronate use in Switzerland

Original Article



A simulation model adopting a health system perspective showed population-based screening with DXA, followed by alendronate treatment of persons with osteoporosis, or with anamnestic fracture and osteopenia, to be cost-effective in Swiss postmenopausal women from age 70, but not in men.


We assessed the cost-effectiveness of a population-based screen-and-treat strategy for osteoporosis (DXA followed by alendronate treatment if osteoporotic, or osteopenic in the presence of fracture), compared to no intervention, from the perspective of the Swiss health care system.


A published Markov model assessed by first-order Monte Carlo simulation was refined to reflect the diagnostic process and treatment effects. Women and men entered the model at age 50. Main screening ages were 65, 75, and 85 years. Age at bone densitometry was flexible for persons fracturing before the main screening age. Realistic assumptions were made with respect to persistence with intended 5 years of alendronate treatment. The main outcome was cost per quality-adjusted life year (QALY) gained.


In women, costs per QALY were Swiss francs (CHF) 71,000, CHF 35,000, and CHF 28,000 for the main screening ages of 65, 75, and 85 years. The threshold of CHF 50,000 per QALY was reached between main screening ages 65 and 75 years. Population-based screening was not cost-effective in men.


Population-based DXA screening, followed by alendronate treatment in the presence of osteoporosis, or of fracture and osteopenia, is a cost-effective option in Swiss postmenopausal women after age 70.


Alendronate Bone densitometry Cost-utility analysis Modelling studies Osteoporosis Switzerland 


  1. 1.
    (1993) Consensus development conference: diagnosis, prophylaxis, and treatment of osteoporosis. Am J Med 94:646–650Google Scholar
  2. 2.
    Seeley DG, Browner WS, Nevitt MC et al (1991) Which fractures are associated with low appendicular bone mass in elderly women? The study of osteoporotic fractures research group. Ann Intern Med 115:837–842PubMedGoogle Scholar
  3. 3.
    Cummings SR, Melton LJ (2002) Epidemiology and outcomes of osteoporotic fractures. Lancet 359:1761–1767PubMedCrossRefGoogle Scholar
  4. 4.
    Lippuner K, Golder M, Greiner R (2005) Epidemiology and direct medical costs of osteoporotic fractures in men and women in Switzerland. Osteoporos Int 16(Suppl 2):S8–S17PubMedCrossRefGoogle Scholar
  5. 5.
    Johnell O, Kanis J (2005) Epidemiology of osteoporotic fractures. Osteoporos Int 16(Suppl 2):S3–S7PubMedCrossRefGoogle Scholar
  6. 6.
    Pasco JA, Sanders KM, Hoekstra FM et al (2005) The human cost of fracture. Osteoporos Int 16:2046–2052PubMedCrossRefGoogle Scholar
  7. 7.
    Melton LJ 3rd (2003) Adverse outcomes of osteoporotic fractures in the general population. J Bone Miner Res 18:1139–1141PubMedCrossRefGoogle Scholar
  8. 8.
    Nydegger V, Rizzoli R, Rapin CH et al (1991) Epidemiology of fractures of the proximal femur in Geneva: incidence, clinical and social aspects. Osteoporos Int 2:42–47PubMedCrossRefGoogle Scholar
  9. 9.
    Johnell O, Kanis JA, Oden A et al (2004) Mortality after osteoporotic fractures. Osteoporos Int 15:38–42PubMedCrossRefGoogle Scholar
  10. 10.
    Lips P, van Schoor NM (2005) Quality of life in patients with osteoporosis. Osteoporos Int 16:447–455PubMedCrossRefGoogle Scholar
  11. 11.
    (2001) NIH consensus development panel on osteoporosis prevention, diagnosis, and therapy. JAMA 285:785–795Google Scholar
  12. 12.
    Schwenkglenks M, Lippuner K, Hauselmann HJ et al (2005) A model of osteoporosis impact in Switzerland 2000–2020. Osteoporos Int 16:659–671PubMedCrossRefGoogle Scholar
  13. 13.
    Black DM, Cummings SR, Karpf DB 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 348:1535–1541PubMedCrossRefGoogle Scholar
  14. 14.
    Black DM, Thompson DE, Bauer DC et al (2000) Fracture risk reduction with alendronate in women with osteoporosis: the fracture intervention trial. FIT research group. J Clin Endocrinol Metab 85:4118–4124PubMedCrossRefGoogle Scholar
  15. 15.
    Cummings SR, Black DM, Thompson DE et al (1998) Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial. JAMA 280:2077–2082PubMedCrossRefGoogle Scholar
  16. 16.
    Papapoulos SE, Quandt SA, Liberman UA et al (2005) Meta-analysis of the efficacy of alendronate for the prevention of hip fractures in postmenopausal women. Osteoporos Int 16:468–474PubMedCrossRefGoogle Scholar
  17. 17.
    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 23:508–516PubMedCrossRefGoogle Scholar
  18. 18.
    Bone HG, Hosking D, Devogelaer JP et al (2004) Ten years’ experience with alendronate for osteoporosis in postmenopausal women. N Engl J Med 350:1189–1199PubMedCrossRefGoogle Scholar
  19. 19.
    Ringe JD, Faber H, Dorst A (2001) Alendronate treatment of established primary osteoporosis in men: results of a 2-year prospective study. J Clin Endocrinol Metab 86:5252–5255PubMedCrossRefGoogle Scholar
  20. 20.
    Orwoll E, Ettinger M, Weiss S et al (2000) Alendronate for the treatment of osteoporosis in men. N Engl J Med 343:604–610PubMedCrossRefGoogle Scholar
  21. 21.
    Saag KG, Emkey R, Schnitzer TJ et al (1998) Alendronate for the prevention and treatment of glucocorticoid-induced osteoporosis. Glucocorticoid-Induced Osteoporosis Intervention Study Group. N Engl J Med 339:292–299PubMedCrossRefGoogle Scholar
  22. 22.
    Borgstrom F, Johnell O, Jonsson B et al (2004) Cost effectiveness of alendronate for the treatment of male osteoporosis in Sweden. Bone 34:1064–1071PubMedCrossRefGoogle Scholar
  23. 23.
    Christensen PM, Brixen K, Gyrd-Hansen D et al (2005) Cost-effectiveness of alendronate in the prevention of osteoporotic fractures in Danish women. Basic Clin Pharmacol Toxicol 96:387–396PubMedCrossRefGoogle Scholar
  24. 24.
    Goeree R, Blackhouse G, Adachi J (2006) Cost-effectiveness of alternative treatments for women with osteoporosis in Canada. Curr Med Res Opin 22:1425–1436PubMedCrossRefGoogle Scholar
  25. 25.
    Johnell O, Jonsson B, Jonsson L et al (2003) Cost effectiveness of alendronate (fosamax) for the treatment of osteoporosis and prevention of fractures. Pharmacoeconomics 21:305–314PubMedCrossRefGoogle Scholar
  26. 26.
    Liu H, Michaud K, Nayak S et al (2006) The cost-effectiveness of therapy with teriparatide and alendronate in women with severe osteoporosis. Arch Intern Med 166:1209–1217PubMedCrossRefGoogle Scholar
  27. 27.
    Schousboe JT, Ensrud KE, Nyman JA et al (2005) Universal bone densitometry screening combined with alendronate therapy for those diagnosed with osteoporosis is highly cost-effective for elderly women. J Am Geriatr Soc 53:1697–1704PubMedGoogle Scholar
  28. 28.
    Stevenson M, Lloyd Jones M, De Nigris E et al (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)Google Scholar
  29. 29.
    Schousboe JT, Nyman JA, Kane RL et al (2005) Cost-effectiveness of alendronate therapy for osteopenic postmenopausal women. Ann Intern Med 142:734–741PubMedGoogle Scholar
  30. 30.
    Solomon DH, Kuntz KM (2000) Should postmenopausal women with rheumatoid arthritis who are starting corticosteroid treatment be screened for osteoporosis? A cost-effectiveness analysis. Arthritis Rheum 43:1967–1975PubMedCrossRefGoogle Scholar
  31. 31.
    Kanis JA (2002) Diagnosis of osteoporosis and assessment of fracture risk. Lancet 359:1929–1936PubMedCrossRefGoogle Scholar
  32. 32.
    Organisation for Economic Co-operation and Development (OECD) (2007) Purchasing Power Parities (PPP). http://www.oecd.org/department/0,2688,en_2649_34357_1_1_1_1_1,00.html
  33. 33.
    Ubel PA, Hirth RA, Chernew ME et al (2003) What is the price of life and why doesn’t it increase at the rate of inflation? Arch Intern Med 163:1637–1641PubMedCrossRefGoogle Scholar
  34. 34.
    Devlin N, Parkin D (2004) Does NICE have a cost-effectiveness threshold and what other factors influence its decisions? A binary choice analysis. Health Econ 13:437–452PubMedCrossRefGoogle Scholar
  35. 35.
    Looker AC, Johnston CC Jr, Wahner HW et al (1995) Prevalence of low femoral bone density in older U.S. women from NHANES III. J Bone Miner Res 10:796–802PubMedGoogle Scholar
  36. 36.
    Looker AC, Orwoll ES, Johnston CC Jr et al (1997) Prevalence of low femoral bone density in older U.S. adults from NHANES III. J Bone Miner Res 12:1761–1768PubMedCrossRefGoogle Scholar
  37. 37.
    Schuit SC, van der Klift M, Weel AE et al (2004) Fracture incidence and association with bone mineral density in elderly men and women: the Rotterdam Study. Bone 34:195–202PubMedCrossRefGoogle Scholar
  38. 38.
    Kanis JA, Johnell O, De Laet C et al (2004) A meta-analysis of previous fracture and subsequent fracture risk. Bone 35:375–382PubMedCrossRefGoogle Scholar
  39. 39.
    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
  40. 40.
    Chevalley T, Herman FR, Delmi M et al (2002) Evaluation of the age-adjusted incidence of hip fractures between urban and rural areas: the difference is not related to the prevalence of institutions for the elderly. Osteoporos Int 13:113–118PubMedCrossRefGoogle Scholar
  41. 41.
    Schürch MA, Rizzoli R, Mermillod B et al (1996) A prospective study on socioeconomic aspects of fracture of the proximal femur. J Bone Miner Res 11:1935–1942PubMedCrossRefGoogle Scholar
  42. 42.
    Chandler JM, Zimmerman SI, Girman CJ et al (2000) Low bone mineral density and risk of fracture in white female nursing home residents [see comments]. JAMA 284:972–977PubMedCrossRefGoogle Scholar
  43. 43.
    Sugarman JR, Connell FA, Hansen A et al (2002) Hip fracture incidence in nursing home residents and community-dwelling older people, Washington State, 1993–1995. J Am Geriatr Soc 50:1638–1643PubMedCrossRefGoogle Scholar
  44. 44.
    Cooper C, Atkinson EJ, O’Fallon WM et al (1992) Incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota, 1985–1989. J Bone Miner Res 7:221–227PubMedGoogle Scholar
  45. 45.
    Graafmans WC, Ooms ME, Bezemer PD et al (1996) Different risk profiles for hip fractures and distal forearm fractures: a prospective study. Osteoporos Int 6:427–431PubMedCrossRefGoogle Scholar
  46. 46.
    McClung MR, Geusens P, Miller PD et al (2001) Effect of risedronate on the risk of hip fracture in elderly women. Hip intervention program study group. N Engl J Med 344:333–340PubMedCrossRefGoogle Scholar
  47. 47.
    Levis S, Quandt SA, Thompson D et al (2002) Alendronate reduces the risk of multiple symptomatic fractures: results from the fracture intervention trial. J Am Geriatr Soc 50:409–415PubMedCrossRefGoogle Scholar
  48. 48.
    Tosteson AN, Jonsson B, Grima DT et al (2001) Challenges for model-based economic evaluations of postmenopausal osteoporosis interventions. Osteoporos Int 12:849–857PubMedCrossRefGoogle Scholar
  49. 49.
    Clowes JA, Peel NF, Eastell R (2004) The impact of monitoring on adherence and persistence with antiresorptive treatment for postmenopausal osteoporosis: a randomized controlled trial. J Clin Endocrinol Metab 89:1117–1123PubMedCrossRefGoogle Scholar
  50. 50.
    Kanis JA, Oden A, Johnell O et al (2003) The components of excess mortality after hip fracture. Bone 32:468–473PubMedCrossRefGoogle Scholar
  51. 51.
    Melton LJ 3rd (2000) Excess mortality following vertebral fracture. J Am Geriatr Soc 48:338–339PubMedGoogle Scholar
  52. 52.
    Pedersen K, Wittrup-Jensen K, Brooks R et al (2003) Værdisætning af sundhed-teorien om kvalitetsjusterede leveår og en dansk anvendelse. Syddansk Universitetsforlag, OdenseGoogle Scholar
  53. 53.
    Kanis JA, Johnell O, Oden A et al (2004) The risk and burden of vertebral fractures in Sweden. Osteoporos Int 15:20–26PubMedCrossRefGoogle Scholar
  54. 54.
    Tosteson AN (2001) Impact of hip and vertebral fractures on quality adjusted life years. Osteoporos Int 12:1042–1049PubMedCrossRefGoogle Scholar
  55. 55.
    Bonjour JP, Burckhardt P, Dambacher M et al (1997) Epidemiology of osteoporosis. Schweiz Med Wochenschr 127:659–667PubMedGoogle Scholar
  56. 56.
    Trombetti A, Herrmann F, Hoffmeyer P et al (2002) Survival and potential years of life lost after hip fracture in men and age-matched women. Osteoporos Int 13:731–737PubMedCrossRefGoogle Scholar
  57. 57.
    Szucs TD, Häuselmann HJ (2000) Die Wirtschaftlichkeit von Alendronat in der Behandlung der postmenopausalen Osteoporose. Gesundh Ökon Qual Manag 5:99–106Google Scholar
  58. 58.
    Hooven F, Gehlbach SH, Pekow P et al (2005) Follow-up treatment for osteoporosis after fracture. Osteoporos Int 16:296–301PubMedCrossRefGoogle Scholar
  59. 59.
    Gasser KM, Mueller C, Zwahlen M et al (2005) Osteoporosis case finding in the general practice: phalangeal radiographic absorptiometry with and without risk factors for osteoporosis to select postmenopausal women eligible for lumbar spine and hip densitometry. Osteoporos Int 16:1353–1362PubMedCrossRefGoogle Scholar
  60. 60.
    Abrahamsen B, Vestergaard P, Rud B et al (2006) Ten-year absolute risk of osteoporotic fractures according to BMD T score at menopause: the Danish osteoporosis prevention study. J Bone Miner Res 21:796–800PubMedCrossRefGoogle Scholar
  61. 61.
    Johnell O, Kanis JA, Oden A et al (2005) Predictive value of BMD for hip and other fractures. J Bone Miner Res 20:1185–1194PubMedCrossRefGoogle Scholar
  62. 62.
    Kanis JA, Johnell O, Oden A et al (2005) Ten-year probabilities of clinical vertebral fractures according to phalangeal quantitative ultrasonography. Osteoporos Int 16:1065–1070PubMedCrossRefGoogle Scholar
  63. 63.
    Kanis JA, Johnell O, Oden A et al (2001) Ten year probabilities of osteoporotic fractures according to BMD and diagnostic thresholds. Osteoporos Int 12:989–995PubMedCrossRefGoogle Scholar
  64. 64.
    Kanis JA, Johnell O, Oden A et al (2002) Ten-year risk of osteoporotic fracture and the effect of risk factors on screening strategies. Bone 30:251–258PubMedCrossRefGoogle Scholar
  65. 65.
    Eichler HG, Kong SX, Gerth WC et al (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
  66. 66.
    Swiss Federal Office of Public Health (2007) Änderungen im Handbuch betreffend die Spezialitätenliste (SL) 2007. Swiss Federal Office of Public Health, BernGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2007

Authors and Affiliations

  1. 1.European Center of Pharmaceutical MedicineUniversity of BaselBaselSwitzerland
  2. 2.Osteoporosis PoliclinicUniversity Hospital BernBernSwitzerland

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