Skip to main content

Cost-effective osteoporosis treatment thresholds: the United States perspective

Osteoporosis International volume 19, pages 437–447 (2008)Cite this article

Abstract

Summary

A United States-specific cost-effectiveness analysis, which incorporated the cost and health consequences of clinical fractures of the hip, spine, forearm, shoulder, rib, pelvis and lower leg, was undertaken to identify the 10-year hip fracture probability required for osteoporosis treatment to be cost-effective for cohorts defined by age, sex, and race/ethnicity. A 3% 10-year risk of hip fracture was generally required for osteoporosis treatment to cost less than $60,000 per QALY gained.

Introduction

Rapid growth of the elderly United States population will result in so many at risk of osteoporosis that economically efficient approaches to osteoporosis care warrant consideration.

Methods

A Markov-cohort model of annual United States age-specific incidence of clinical hip, spine, forearm, shoulder, rib, pelvis and lower leg fractures, costs (2005 US dollars), and quality-adjusted life years (QALYs) was used to assess the cost-effectiveness of osteoporosis treatment ($600/yr drug cost for 5 years with 35% fracture reduction) by gender and race/ethnicity groups. To determine the 10-year hip fracture probability at which treatment became cost-effective, average annual age-specific probabilities for all fractures were multiplied by a relative risk (RR) that was systematically varied from 0 to 10 until a cost of $60,000 per QALY gained was observed for treatment relative to no intervention.

Results

Osteoporosis treatment was cost-effective when the 10-year hip fracture probability reached approximately 3%. Although the RR at which treatment became cost-effective varied markedly between genders and by race/ethnicity, the absolute 10-year hip fracture probability at which intervention became cost-effective was similar across race/ethnicity groups, but tended to be slightly higher for men than for women.

Conclusions

Application of the WHO risk prediction algorithm to identify individuals with a 3% 10-year hip fracture probability may facilitate efficient osteoporosis treatment.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price includes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

References

  1. Kanis JA, Borgström F, De Laet C, Johansson H, Johnell O, Jönsson B, Odén A, Zethraeus N, Pfleger B, Khaltaev N (2005) Assessment of fracture risk. Osteoporos Int 16:581–589

    PubMed  Article  Google Scholar 

  2. Kanis JA, Black D, Cooper C, Dargent P, Dawson-Hughes B, De Laet C, Delmas P, Eisman J, Johnell O, Jönsson B, Melton L, Odén A, Papapoulos S, Pols H, Rizzoli R, Silman A, Tenenhouse A, International Osteoporosis F, National Osteoporosis F (2002) A new approach to the development of assessment guidelines for osteoporosis. Osteoporos Int 13:527–536

    PubMed  Article  CAS  Google Scholar 

  3. Anonymous (1998) Osteoporosis: review of the evidence for prevention, diagnosis and treatment and cost-effectiveness analysis. Introduction. Osteoporos Int 8(Suppl 4):S7–80

    Google Scholar 

  4. Department of Health and Human Services. (2004) In Bone Health and Osteoporosis A Report of the Surgeon General. Rockville, MD.

  5. Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A (2007) Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 22:465–475

    PubMed  Article  Google Scholar 

  6. Sonnenberg FA, Beck JR (1993) Markov models in medical decision making: a practical guide. Med Decis Mak 13:322–338

    Article  CAS  Google Scholar 

  7. Kanis JA, Odén A, Johnell O, Jönsson B, de Laet C, Dawson A (2001) The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporos Int 12:417–427

    PubMed  Article  CAS  Google Scholar 

  8. Kanis JA, Borgström F, Zethraeus N, Johnell O, Odén A, Jönsson B (2005) Intervention thresholds for osteoporosis in the UK. Bone 36:22–32

    PubMed  Article  Google Scholar 

  9. Kanis JA, Johnell O, Odén A, Borgström F, Johansson H, De Laet C, Jönsson B (2005) Intervention thresholds for osteoporosis in men and women: a study based on data from Sweden. Osteoporos Int 16:6–14

    PubMed  Article  Google Scholar 

  10. Haentjens P, Autier P, Collins J, Velkeniers B, Vanderschueren D, Boonen S (2003) Colles fracture, spine fracture, and subsequent risk of hip fracture in men and women. A meta-analysis. J Bone Jt Surg Am Vol 85-A:1936–1943

    Google Scholar 

  11. Kanis JA, Johnell O, De Laet C, Johansson H, Odén 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 35:375–382

    PubMed  Article  CAS  Google Scholar 

  12. 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 9:29–37

    PubMed  Article  Google Scholar 

  13. United States Census Bureau (2005) State & County QuickFacts. (Accessed at http:quickfacts.census.gov/qfd/states/27/27109.html)

  14. Cummings SR, Melton LJ (2002) Epidemiology and outcomes of osteoporotic fractures. Lancet 359:1761–1767

    PubMed  Article  Google Scholar 

  15. Cranney A, Wells G, Willan A, Griffith L, Zytaruk N, Robinson V, Black D, Adachi J, Shea B, Tugwell P, Guyatt G, Osteoporosis Methodology G, The Osteoporosis Research Advisory G (2002) Meta-analyses of therapies for postmenopausal osteoporosis. II. Meta-analysis of alendronate for the treatment of postmenopausal women. Endocr Rev 23:508–516

    PubMed  Article  CAS  Google Scholar 

  16. Borgström F, Johnell O, Kanis JA, Jönsson B, Rehnberg (2006) At what hip fracture risk is it cost-effective to treat? International Intervention thresholds for the treatment of osteoporosis. Osteoporos Int 17:1459–1471

    PubMed  Article  Google Scholar 

  17. Tosteson AN, Jönsson B, Grima DT, O’Brien BJ, Black DM, Adachi JD (2001) Challenges for model-based economic evaluations of postmenopausal osteoporosis interventions. Osteoporos Int 12:849–857

    PubMed  Article  CAS  Google Scholar 

  18. Badamgarav E, Fitzpatrick LA (2006) A new look at osteoporosis outcomes: the influence of treatment, compliance, persistence, and adherence.[comment]. Mayo Clin Proc 81:1009–1012

    PubMed  Google Scholar 

  19. Tosteson AN (2003) Characterizing preferences for health outcomes in economic evaluations. J Rheumat Suppl 68:15–18

    Google Scholar 

  20. Hanmer J, Lawrence WF, Anderson JP, Kaplan RM, Fryback DG (2006) Report of nationally representative values for the noninstitutionalized US adult population for 7 health-related quality-of-life scores. Med Decis Mak 26:391–400

    Article  Google Scholar 

  21. 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 13:323–330

    PubMed  Article  CAS  Google Scholar 

  22. Arias E, Anderson RN, Kung HC, Murphy SL, Kochanek KD (2003) Deaths: final data for 2001. Natl Vital Stat Rep 52:1–115

    PubMed  Google Scholar 

  23. Melton LJ, III (2003) Adverse outcomes of osteoporotic fractures in the general population. J Bone Miner Res 18:1139–1141

    PubMed  Article  Google Scholar 

  24. Fisher ES, Baron JA, Malenka DJ, Barrett JA, Kniffin WD, Whaley FS, Bubolz TA (1991) Hip fracture incidence and mortality in New England. Epidemiology 2:116–122

    PubMed  Article  CAS  Google Scholar 

  25. Miller CW (1978) Survival and ambulation following hip fracture. J Bone Jt Surg Am Vol 60:930–934

    CAS  Google Scholar 

  26. Cooper C, Atkinson EJ, Jacobsen SJ, O’Fallon WM, Melton LJ 3rd (1993) Population-based study of survival after osteoporotic fractures. Am J Epidemiol 137:1001–1005

    PubMed  CAS  Google Scholar 

  27. Katelaris AG, Cumming RG (1996) Health status before and mortality after hip fracture. Am J Public Health 86:557–560

    PubMed  CAS  Google Scholar 

  28. Keene GS, Parker MJ, Pryor GA (1993) Mortality and morbidity after hip fractures.[see comment]. BMJ 307:1248–1250

    PubMed  CAS  Google Scholar 

  29. Poor G, Atkinson EJ, O’Fallon WM, Melton LJ, III (1995) Determinants of reduced survival following hip fractures in men. Clin Orthop Relat Res 260–265

  30. Magaziner J, Lydick E, Hawkes W, Fox KM, Zimmerman SI, Epstein RS, Hebel JR (1997) Excess mortality attributable to hip fracture in white women aged 70 years and older. Am J Public Health 87:1630–1636

    PubMed  CAS  Article  Google Scholar 

  31. Melton LJ III, Therneau TM, Larson DR (1998) Long-term trends in hip fracture prevalence: the influence of hip fracture incidence and survival. Osteoporos Int 8:68–74

    PubMed  Article  Google Scholar 

  32. Gold M, Siegel J, Russell L, Weinstein M (1996) Cost-effectiveness in Health and Medicine. Oxford University Press, New York

    Google Scholar 

  33. Center for the Evaluation of Value and Risk in Health (2007) CEA Registry. http://www.tufts-nemc.org/cearegistry/ Institute of Clinical Research and Health Policy Studies, Tufts New England Medical Center

  34. Stone PW, Teutsch S, Chapman RH, Bell C, Goldie SJ, Neumann PJ (2000) Cost-utility analyses of clinical preventive services: published ratios, 1976–1997. Am J Prev Med 19:15–23

    PubMed  Article  CAS  Google Scholar 

  35. Dawson-Hughes B, Tosteson ANA, Melton LJ III, Baim S, Favus MJ, Khosla S, Lindsay RL (2008) Implications of absolute fracture risk assessment for osteoporosis practice guidelines in the U.S. Osteoporos Int DOI 10.1007/s00198-008-0559-5

  36. Schousboe JT, Ensrud KE, Nyman JA, Melton LJ 3rd, Kane RL (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 53:1697–1704

    PubMed  Article  Google Scholar 

  37. Schousboe JT, Taylor BC, Fink HA, Kane RL, Cummings SR, Orwoll ES, Melton LJ 3rd, Bauer DC, Ensrud KE (2007) Cost-effectiveness of bone densitometry followed by treatment of osteoporosis in older men. JAMA 298:629–637

    PubMed  Article  CAS  Google Scholar 

  38. King AB, Saag KG, Burge RT, Pisu M, Goel N (2005) Fracture Reduction Affects Medicare Economics (FRAME): impact of increased osteoporosis diagnosis and treatment. Osteoporos Int 16:1545–1557

    PubMed  Article  Google Scholar 

  39. Kraemer DF, Nelson HD, Bauer DC, Helfand M (2006) Economic comparison of diagnostic approaches for evaluating osteoporosis in older women. Osteoporos Int 17:68–76

    PubMed  Article  Google Scholar 

  40. Guyatt G, Baumann M, Pauker S, Halperin J, Maurer J, Owens DK, Tosteson AN, Carlin B, Gutterman D, Prins M, Lewis SZ, Schunemann H (2006) Addressing resource allocation issues in recommendations from clinical practice guideline panels: suggestions from an American College of Chest Physicians task force. Chest 129:182–187

    PubMed  Article  Google Scholar 

  41. Kanis JA, Johnell O, Odén A, Borgström F, Zethraeus N, De Laet C, Jönsson B (2004) The risk and burden of vertebral fractures in Sweden. Osteoporos Int 15:20–26

    PubMed  Article  CAS  Google Scholar 

Download references

Acknowledgements

The authors thank Dr. John Kanis for his insightful advice regarding this analysis. We also thank David Radley and Margaret Grove for their assistance with model development and analyses.

Conflicts of interest

None.

Funding

This study was supported by the National Osteoporosis Foundation. It was also supported in part by grants from the National Institutes of Health (AR048094 and AG12262).

Author information

Authors and Affiliations

  1. Multidisciplinary Clinical Research Center in Musculoskeletal Diseases and The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Lebanon, NH, USA

    A. N. A. Tosteson

  2. Division of Epidemiology, College of Medicine, Mayo Clinic, Rochester, MN, USA

    L. J. Melton III

  3. Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA

    B. Dawson-Hughes

  4. The Medical College of Wisconsin, Milwaukee, WI, USA

    S. Baim

  5. Department of Medicine, University of Chicago, Chicago, IL, USA

    M. J. Favus

  6. Division of Endocrinology, College of Medicine, Mayo Clinic, Rochester, MN, USA

    S. Khosla

  7. Helen Hayes Hospital, Regional Bone Center, West Haverstraw, NY, USA

    R. L. Lindsay

  8. HB7505 Clinical Research, Dartmouth Medical School, One Medical Center Drive, Lebanon, NH, 03756, USA

    A. N. A. Tosteson

Authors
  1. A. N. A. Tosteson
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. L. J. Melton III
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. B. Dawson-Hughes
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. S. Baim
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. M. J. Favus
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. S. Khosla
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. R. L. Lindsay
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to A. N. A. Tosteson.

Additional information

The authors comprise the National Osteoporosis Foundation Guide Committee.

Appendix

Appendix

Table 3 Age-specific annual fracture probability by fracture type and gender for the white population*
Full size table

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Tosteson, A.N.A., Melton, L.J., Dawson-Hughes, B. et al. Cost-effective osteoporosis treatment thresholds: the United States perspective. Osteoporos Int 19, 437–447 (2008). https://doi.org/10.1007/s00198-007-0550-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00198-007-0550-6

Keywords

  • Cost-effectiveness
  • National Osteoporosis Foundation
  • Osteoporosis
  • Practice guidelines
  • World Health Organization