We developed a Markov microsimulation model among hypothetical cohorts of community-dwelling US white women without prior major osteoporotic fractures over a lifetime horizon. At ages 75 and 80, adding 1 year of exercise to 5 years of oral bisphosphonate therapy is cost-effective at a conventionally accepted threshold compared with bisphosphonates alone.
The purpose of this study was to examine the cost-effectiveness of the combined strategy of oral bisphosphonate therapy for 5 years and falls prevention exercise for 1 year compared with either strategy in isolation.
We calculated incremental cost-effectiveness ratios [ICERs] (2014 US dollars per quality-adjusted life year [QALY]), using a Markov microsimulation model among hypothetical cohorts of community-dwelling US white women with different starting ages (65, 70, 75, and 80) without prior history of hip, vertebral, or wrist fractures over a lifetime horizon from the societal perspective.
At ages 65, 70, 75, and 80, the combined strategy had ICERs of $202,020, $118,460, $46,870, and $17,640 per QALY, respectively, compared with oral bisphosphonate therapy alone. The combined strategy provided better health at lower cost than falls prevention exercise alone at ages 70, 75, and 80. In deterministic sensitivity analyses, results were particularly sensitive to the change in the opportunity cost of participants’ time spent exercising. In probabilistic sensitivity analyses, the probabilities of the combined strategy being cost-effective compared with the next best alternative increased with age, ranging from 35 % at age 65 to 48 % at age 80 at a willingness-to-pay of $100,000 per QALY.
Among community-dwelling US white women ages 75 and 80, adding 1 year of exercise to 5 years of oral bisphosphonate therapy is cost-effective at a willingness-to-pay of $100,000 per QALY, compared with oral bisphosphonate therapy only. This analysis will help clinicians and policymakers make better decisions about treatment options to reduce fracture risk.
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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 Off J Am Soc Bone Miner Res 22:465–475
Wells GA, Cranney A, Peterson J, Boucher M, Shea B, Robinson V, Coyle D, Tugwell P (2008) Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev CD001155
Crandall CJ, Newberry SJ, Diamant A et al (2012) Treatment to prevent fractures in men and women with low bone density or osteoporosis: update of a 2007 report. Agency for Healthcare Research and Quality (US), Rockville
Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE (2012) Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 9, CD007146
Hiligsmann M, Evers SM, Ben Sedrine W, Kanis JA, Ramaekers B, Reginster JY, Silverman S, Wyers CE, Boonen A (2015) A systematic review of cost-effectiveness analyses of drugs for postmenopausal osteoporosis. Pharmacoeconomics 33:205–224
Tosteson AN, Melton LJ 3rd, Dawson-Hughes B, Baim S, Favus MJ, Khosla S, Lindsay RL (2008) Cost-effective osteoporosis treatment thresholds: the United States perspective. Osteoporos Int 19:437–447
Pham AN, Datta SK, Weber TJ, Walter LC, Colon-Emeric CS (2011) Cost-effectiveness of oral bisphosphonates for osteoporosis at different ages and levels of life expectancy. J Am Geriatr Soc 59:1642–1649
Davis JC, Robertson MC, Ashe MC, Liu-Ambrose T, Khan KM, Marra CA (2010) Does a home-based strength and balance programme in people aged > or =80 years provide the best value for money to prevent falls? A systematic review of economic evaluations of falls prevention interventions. Br J Sports Med 44:80–89
Carande-Kulis V, Stevens JA, Florence CS, Beattie BL, Arias I (2015) A cost-benefit analysis of three older adult fall prevention interventions. J Saf Res 52:65–70
Robertson MC, Devlin N, Gardner MM, Campbell AJ (2001) Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: randomised controlled trial. BMJ 322:697–701
Robertson MC, Campbell AJ, Gardner MM, Devlin N (2002) Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data. J Am Geriatr Soc 50:905–911
Centers for Disease Control and Prevention Exercise-based Interventions: the Otago Exercise Programme. http://www.cdc.gov/HomeandRecreationalSafety/Falls/compendium/1.2_otago.html Accessed 1 Sept 2016
Cooper C, Atkinson EJ, O’Fallon WM, Melton LJ 3rd (1992) Incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota, 1985–1989. J Bone Miner Res Off J Am Soc Bone Miner Res 7:221–227
Sherrington C, Tiedemann A, Fairhall N, Close JC, Lord SR (2011) Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. N S W Public Health Bull 22:78–83
Schousboe JT, Gourlay M, Fink HA, Taylor BC, Orwoll ES, Barrett-Connor E, Melton LJ 3rd, Cummings SR, Ensrud KE (2013) Cost-effectiveness of bone densitometry among Caucasian women and men without a prior fracture according to age and body weight. Osteoporos Int 24:163–177
Ito K, Leslie WD (2015) Cost-effectiveness of fracture prevention in rural women with limited access to dual-energy X-ray absorptiometry. Osteoporos Int 26:2111–2119
Nayak S, Roberts MS, Greenspan SL (2011) Cost-effectiveness of different screening strategies for osteoporosis in postmenopausal women. Ann Intern Med 155:751–761
Wright NC, Looker AC, Saag KG, Curtis JR, Delzell ES, Randall S, Dawson-Hughes B (2014) The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res Off J Am Soc Bone Miner Res 29:2520–2526
Si L, Winzenberg TM, Palmer AJ (2014) A systematic review of models used in cost-effectiveness analyses of preventing osteoporotic fractures. Osteoporos Int 25:51–60
Karlsson L, Lundkvist J, Psachoulia E, Intorcia M, Strom O (2015) Persistence with denosumab and persistence with oral bisphosphonates for the treatment of postmenopausal osteoporosis: a retrospective, observational study, and a meta-analysis. Osteoporos Int 26:2401–2411
Yun H, Curtis JR, Saag K, Kilgore M, Muntner P, Smith W, Matthews R, Wright N, Morrisey MA, Delzell E (2013) Generic alendronate use among Medicare beneficiaries: are Part D data complete? Pharmacoepidemiol Drug Saf 22:55–63
Ettinger B, Black DM, Dawson-Hughes B, Pressman AR, Melton LJ 3rd (2010) Updated fracture incidence rates for the US version of FRAX. Osteoporos Int 21:25–33
Melton L 3rd, Crowson C, O’Fallon W (1999) Fracture incidence in Olmsted County, Minnesota: comparison of urban with rural rates and changes in urban rates over time. Osteoporos Int 9:29
Kanis JA, Johnell O, Oden A, Jonsson B, De Laet C, Dawson A (2000) Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 27:585–590
Marshall D, Johnell O, Wedel H (1996) Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 312:1254–1259
Johnell O, Kanis JA, Oden A et al (2005) Predictive value of BMD for hip and other fractures. J Bone Miner Res Off J Am Soc Bone Miner Res 20:1185–1194
Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA 3rd, 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 Off J Am Soc Bone Miner Res 15:721–739
Arias E (2014) United States life tables, 2010. Natl Vital Stat Rep 63:1–63
Haentjens P, Magaziner J, Colon-Emeric CS, Vanderschueren D, Milisen K, Velkeniers B, Boonen S (2010) Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med 152:380–390
Kanis JA, Oden A, Johnell O, De Laet C, Jonsson B, Oglesby AK (2003) The components of excess mortality after hip fracture. Bone 32:468–473
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
Si L, Winzenberg TM, de Graaff B, Palmer AJ (2014) A systematic review and meta-analysis of utility-based quality of life for osteoporosis-related conditions. Osteoporos Int 25:1987–1997
Si L, Winzenberg TM, Jiang Q, Palmer AJ (2015) Screening for and treatment of osteoporosis: construction and validation of a state-transition microsimulation cost-effectiveness model. Osteoporos Int 26:1477–1489
Hiligsmann M, Ethgen O, Richy F, Reginster JY (2008) Utility values associated with osteoporotic fracture: a systematic review of the literature. Calcif Tissue Int 82:288–292
Walmart Pharmacy $4 Prescriptions. http://www.walmart.com/cp/PI-4-Prescriptions/1078664 Accessed 1 Sept 2016
Red Book (2010) Pharmacy’s fundamental reference. Thomson Reuters (Healthcare) Inc, Montvale, NJ
Bureau of Labor Statistics (2015) Labor Force Statistics from the Current Population Survey. http://www.bls.gov/cps/cpsaat03.htm Accessed 1 Sept 2016
Bureau of Labor Statistics (2008) Old workers. http://www.bls.gov/spotlight/2008/older_workers/ Accessed 1 Sept 2016
Centers for Medicare & Medicaid Services Physician Fee Schedule. http://www.cms.gov/apps/physician-fee-schedule/ Accessed 1 Sept 2016
Kilgore ML, Morrisey MA, Becker DJ et al (2009) Health care expenditures associated with skeletal fractures among Medicare beneficiaries, 1999–2005. J Bone Miner Res Off J Am Soc Bone Miner Res 24:2050–2055
U.S. Department of Health and Human Services Costs of Care. http://longtermcare.gov/costs-how-to-pay/costs-of-care/ Accessed 1 Sept 2016
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 50:1644–1650
Bureau of Labor Statistics Consumer Price Index. http://www.bls.gov/cpi/ Accessed 1 Sept 2016
Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB (1996) Recommendations of the panel on cost-effectiveness in health and medicine. JAMA 276:1253–1258
Ensrud KE, Schousboe JT (2011) Clinical practice. Vertebral fractures. N Engl J Med 364:1634–1642
Conflict of Interest
The authors (Takahiro Mori, Carolyn J. Crandall, and David A. Ganz) declare that they have no conflict of interest. Takahiro Mori was supported by the Veterans Affairs Special Fellowship in Advanced Geriatrics. The Department of Veterans Affairs had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
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a Results of Deterministic Sensitivity Analyses, Age 65 (PNG 105 kb)
d Results of Deterministic Sensitivity Analyses, Age 80 (PNG 101 kb)
The figures present the incremental cost-effectiveness ratios of the combined strategy compared with bisphosphonates alone, when varying the indicated model parameters across their ranges. The vertical hashed line represents $100,000 per QALY. Please refer to Table 1 for the ranges of each parameter. Other osteoporotic fractures included humerus, distal forearm other than wrist, pelvis, tibia/fibula, or femur other than hip
a Results of Probabilistic Sensitivity Analyses, Age 65 (PNG 109 kb)
The cost-effectiveness acceptability curves represent probabilities of being cost-effective compared with the next best alternative at different levels of willingness-to-pay per QALY gained
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Mori, T., Crandall, C.J. & Ganz, D.A. Cost-effectiveness of combined oral bisphosphonate therapy and falls prevention exercise for fracture prevention in the USA. Osteoporos Int 28, 585–595 (2017). https://doi.org/10.1007/s00198-016-3772-7
- Cost-effectiveness analysis
- Falls prevention exercise
- Fracture prevention
- Oral bisphosphonate therapy