Skip to main content

Advertisement

SpringerLink
Log in

Cost-effectiveness of combined oral bisphosphonate therapy and falls prevention exercise for fracture prevention in the USA

  • Original Article
  • Published:
Osteoporosis International Aims and scope Submit manuscript

Abstract

Summary

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.

Introduction

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.

Methods

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.

Results

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.

Conclusions

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

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

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. 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

    Article  Google Scholar 

  2. 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

  3. 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

    Google Scholar 

  4. 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

    Google Scholar 

  5. 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

    Article  PubMed  Google Scholar 

  6. 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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. 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

    Article  PubMed  Google Scholar 

  8. 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

    Article  CAS  PubMed  Google Scholar 

  9. 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

    Article  Google Scholar 

  10. 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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. 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

    Article  PubMed  Google Scholar 

  12. 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

  13. 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

    Article  CAS  Google Scholar 

  14. 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

    Article  PubMed  Google Scholar 

  15. 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

    Article  CAS  PubMed  Google Scholar 

  16. 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

    Article  CAS  PubMed  Google Scholar 

  17. Nayak S, Roberts MS, Greenspan SL (2011) Cost-effectiveness of different screening strategies for osteoporosis in postmenopausal women. Ann Intern Med 155:751–761

    Article  PubMed  PubMed Central  Google Scholar 

  18. 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

    Article  Google Scholar 

  19. 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

    Article  CAS  Google Scholar 

  20. 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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. 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

    Article  PubMed  Google Scholar 

  22. 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

    Article  CAS  PubMed  Google Scholar 

  23. 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

    Article  PubMed  Google Scholar 

  24. 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

    Article  CAS  PubMed  Google Scholar 

  25. 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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. 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

    Article  Google Scholar 

  27. 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

    Article  CAS  Google Scholar 

  28. Arias E (2014) United States life tables, 2010. Natl Vital Stat Rep 63:1–63

    PubMed  Google Scholar 

  29. 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

    Article  PubMed  PubMed Central  Google Scholar 

  30. 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

    Article  CAS  PubMed  Google Scholar 

  31. 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 

  32. 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

    Article  CAS  PubMed  Google Scholar 

  33. 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

    Article  CAS  PubMed  Google Scholar 

  34. 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

    Article  CAS  PubMed  Google Scholar 

  35. Walmart Pharmacy $4 Prescriptions. http://www.walmart.com/cp/PI-4-Prescriptions/1078664 Accessed 1 Sept 2016

  36. Red Book (2010) Pharmacy’s fundamental reference. Thomson Reuters (Healthcare) Inc, Montvale, NJ

    Google Scholar 

  37. Bureau of Labor Statistics (2015) Labor Force Statistics from the Current Population Survey. http://www.bls.gov/cps/cpsaat03.htm Accessed 1 Sept 2016

  38. Bureau of Labor Statistics (2008) Old workers. http://www.bls.gov/spotlight/2008/older_workers/ Accessed 1 Sept 2016

  39. Centers for Medicare & Medicaid Services Physician Fee Schedule. http://www.cms.gov/apps/physician-fee-schedule/ Accessed 1 Sept 2016

  40. 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

    Article  Google Scholar 

  41. 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

  42. 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

    Article  PubMed  Google Scholar 

  43. Bureau of Labor Statistics Consumer Price Index. http://www.bls.gov/cpi/ Accessed 1 Sept 2016

  44. 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

    Article  CAS  PubMed  Google Scholar 

  45. Ensrud KE, Schousboe JT (2011) Clinical practice. Vertebral fractures. N Engl J Med 364:1634–1642

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of General Internal Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa City, Chiba, 296-8602, Japan

    T. Mori

  2. Department of Primary Care and Medical Education, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba City, Ibaraki, Japan

    T. Mori

  3. Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba City, Ibaraki, Japan

    T. Mori

  4. Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA

    C. J. Crandall

  5. Geriatric Research, Education and Clinical Center and HSR&D Center for Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA

    D. A. Ganz

  6. Division of Geriatrics, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA

    D. A. Ganz

  7. Health Unit, RAND Corporation, Santa Monica, CA, USA

    D. A. Ganz

Authors
  1. T. Mori
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. C. J. Crandall
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. D. A. Ganz
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to T. Mori.

Ethics declarations

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.

Electronic supplementary material

Below is the link to the electronic supplementary material.

ESM 1

(DOCX 264 kb)

ESM 2

(DOCX 9.5 kb)

Supplemental Figure 1

a Results of Deterministic Sensitivity Analyses, Age 65 (PNG 105 kb)

b. Results of Deterministic Sensitivity Analyses, Age 70 (PNG 101 kb)

c Results of Deterministic Sensitivity Analyses, Age 75 (PNG 102 kb)

198_2016_3772_MOESM6_ESM.png

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

Supplemental Figure 2

a Results of Probabilistic Sensitivity Analyses, Age 65 (PNG 109 kb)

b Results of Probabilistic Sensitivity Analyses, Age 70 (PNG 111 kb)

c Results of Probabilistic Sensitivity Analyses, Age 75 (PNG 112 kb)

d Results of Probabilistic Sensitivity Analyses, Age 80 (PNG 111 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

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

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

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00198-016-3772-7

Keywords

Search

Navigation