Cost-effectiveness of osteoporosis screening strategies for hip fracture prevention in older Chinese people: a decision tree modeling study in the Mr. OS and Ms. OS cohort in Hong Kong

  • Y. Su
  • F.T.T. Lai
  • B.H.K. Yip
  • J.C.S. Leung
  • T.C.Y. Kwok
Original Article

Abstract

Summary

Despite the high costs of hip fracture, many governments provide limited support for osteoporosis screening. We demonstrated that osteoporosis screening by dual-energy X-ray absorptiometry (DXA) with or without pre-screening by Fracture Risk Assessment Tool (FRAX) or calcaneal ultrasound are more cost-effective than no screening in Chinese people aged 65 or over in Hong Kong.

Introduction

To examine the cost-effective potential osteoporosis screening strategies for hip fracture prevention in Hong Kong.

Methods

Decision tree models were constructed to evaluate the cost per quality-adjusted life years (QALYs) of the different osteoporosis screening strategies followed by subsequent 5-year treatment with alendronate compared to no screening (but treat if a hip fracture occurs). The multiple osteoporosis screening strategies were composed of alternative tests and initiation age groups were evaluated with a 10-year horizon, and treatment were assigned if central dual-energy X-ray absorptiometry (DXA) T-score (at either the hip or spine) is − 2.5 or less. Strategies included DXA for all people and pre-screening with the Fracture Risk Assessment Tool (FRAX) at specific thresholds or by calcaneal quantitative ultrasonography (QUS) before taking DXA examination. All the model inputs were based on the Mr. OS and Ms. OS Hong Kong cohort; data are obtained from the Social Welfare Department or the published literature.

Results

All of the screening strategies, including the universal screening with DXA and the pre-screening with FRAX or QUS before DXA, were consistently more cost-effective than no screening for people aged 65 years old or over. One-way sensitivity analysis with a more optimistic assumption on treatment adherence or inclusion of other major osteoporotic fractures did not change the results materially. Probabilistic sensitivity analyses showed a dominant role of pre-screening with FRAX followed by subsequent osteoporosis drug treatment in people aged 70 years old or over in Hong Kong.

Conclusions

Osteoporosis screening strategies based on DXA with or without pre-screening are more cost-effective compared to no screening for Chinese people aged 65 or over in Hong Kong.

Keywords

Aging Decision tree model Osteoporosis Screening 

Notes

Acknowledgments

The authors wish to thank all participants who dedicated in contributing to the study and the Chinese University of Hong Kong Jockey Club Centre for Osteoporosis Care and Control for supporting the study. The support from the Social Welfare Department in Hong Kong is also acknowledged.

Funding information

The study was funded by the National Institutes of Health R01 grant AR049439–01A1 and the Research Grants Council Earmarked Grant CUHK4101/02 M.

Compliance with ethical standards

Conflicts of interest

None.

Ethical approval

All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

Supplementary material

198_2018_4543_MOESM1_ESM.docx (21 kb)
ESM 1 (DOCX 20 kb)
198_2018_4543_MOESM2_ESM.docx (15 kb)
ESM 2 (DOCX 14 kb)

References

  1. 1.
    Black DM, Rosen CJ (2016) Clinical practice. Postmenopausal osteoporosis. N Engl J Med 374:254–262CrossRefPubMedGoogle Scholar
  2. 2.
    Leung KS, Yuen WF, Ngai WK, Lam CY, Lau TW, Lee KB, Siu KM, Tang N, Wong SH, Cheung WH (2017) How well are we managing fragility hip fractures? A narrative report on the review with the attempt to setup a Fragility Fracture Registry in Hong Kong. Hong Kong Med J = Xianggang yi xue za zhi 23:264–271PubMedGoogle Scholar
  3. 3.
    Nayak S, Roberts MS, Greenspan SL (2011) Cost-effectiveness of different screening strategies for osteoporosis in postmenopausal women. Ann Intern Med 155:751–761CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Liu H, Michaud K, Nayak S, Karpf DB, Owens DK, Garber AM (2006) The cost-effectiveness of therapy with teriparatide and alendronate in women with severe osteoporosis. Arch Intern Med 166:1209–1217CrossRefPubMedGoogle Scholar
  5. 5.
    Schousboe JT (2007) Cost-effectiveness modeling research of pharmacologic therapy to prevent osteoporosis-related fractures. Curr Rheumatol Rep 9:50–56CrossRefPubMedGoogle Scholar
  6. 6.
    Nayak S, Greenspan SL (2016) Cost-effectiveness of osteoporosis screening strategies for men. J Bone Miner Res Off J Am Soc Bone Miner Res 31:1189–1199CrossRefGoogle Scholar
  7. 7.
    Kingkaew P, Maleewong U, Ngarmukos C, Teerawattananon Y (2012) Evidence to inform decision makers in Thailand: a cost-effectiveness analysis of screening and treatment strategies for postmenopausal osteoporosis. Value in Health: J Int Soc Pharmacoecon Outcomes Res 15:S20–S28CrossRefGoogle Scholar
  8. 8.
    Si L, Winzenberg TM, Chen M, Jiang Q, Neil A, Palmer AJ (2016) Screening for osteoporosis in Chinese post-menopausal women: a health economic modelling study. Osteoporosis Int: J Establ Result Coop European Foundation Osteoporos Nat Osteoporos Foundation USA 27:2259–2269CrossRefGoogle Scholar
  9. 9.
    Gullberg B, Johnell O, Kanis JA (1997) World-wide projections for hip fracture. Osteoporos Int: J Establ Result Coop Eur Foundation Osteoporos Nat Osteoporos Foundation 7:407–413CrossRefGoogle Scholar
  10. 10.
    Jha S, Wang Z, Laucis N, Bhattacharyya T (2015) Trends in media reports, oral bisphosphonate prescriptions, and hip fractures 1996–2012: an ecological analysis. J Bone Miner Res Off J Am Soc Bone Miner Res 30:2179–2187CrossRefGoogle Scholar
  11. 11.
    Elaine YN, Cheunga KCBT, Cheung C-L, Kung AWC (2016) Osteoporosis in East Asia: current issues in assessment and management. Osteoporos Sarcopenia 2:118–133CrossRefGoogle Scholar
  12. 12.
    Ambrish Mithal, Peter Ebeling, Kyer CS (2013) The Asia-Pacific Regional Audit. Epidemiology, costs & burden of osteoporosis in 2013. www.iofbonehealth.org. Accessed 20 Oct 2017
  13. 13.
    McCloskey EV, Kanis JA, Oden A et al (2015) Predictive ability of heel quantitative ultrasound for incident fractures: an individual-level meta-analysis. Osteoporosis Int: J Establ Result Coop European Foundation Osteoporos Nat Osteoporos Foundation USA 26:1979–1987CrossRefGoogle Scholar
  14. 14.
    Kanis JA, Hans D, Cooper C et al (2011) Interpretation and use of FRAX in clinical practice. Osteoporosis Int: J Establ Result Coop European Foundation Osteoporos Nat Osteoporos Foundation USA 22:2395–2411CrossRefGoogle Scholar
  15. 15.
    Cooper C, Campion G, Melton LJ 3rd (1992) Hip fractures in the elderly: a world-wide projection. Osteoporosis Int: J Establ Result Coop European Foundation Osteoporos Nat Osteoporos Foundation USA 2:285–289CrossRefGoogle Scholar
  16. 16.
    Lau EM, Lee JK, Suriwongpaisal P, Saw SM, De Das S, Khir A, Sambrook P (2001) The incidence of hip fracture in four Asian countries: the Asian Osteoporosis Study (AOS). Osteoporosis Int: J Establ Result Coop European Foundation Osteoporos Nat Osteoporos Foundation USA 12:239–243CrossRefGoogle Scholar
  17. 17.
    Tsang SW, Kung AW, Kanis JA, Johansson H, Oden A (2009) Ten-year fracture probability in Hong Kong Southern Chinese according to age and BMD femoral neck T-scores. Osteoporosis Int: J Establ Result Coop European Foundation Osteoporos Nat Osteoporos Foundation USA 20:1939–1945CrossRefGoogle Scholar
  18. 18.
    Cawthon PM (2011) Gender differences in osteoporosis and fractures. Clin Orthop Relat Res 469:1900–1905CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Su Y, Leung J, Hans D, Aubry-Rozier B, Kwok T (2017) Added clinical use of trabecular bone score to BMD for major osteoporotic fracture prediction in older Chinese people: the Mr. OS and Ms, OS cohort study in Hong Kong. Osteoporosis Int: J Establ Result Coop European Foundation Osteoporos Nat Osteoporos Foundation USA 28:151–160CrossRefGoogle Scholar
  20. 20.
    Melton LJ 3rd, Orwoll ES, Wasnich RD (2001) Does bone density predict fractures comparably in men and women? Osteoporosis Int: J Establ Result Coop European Foundation Osteoporos Nat Osteoporos Foundation USA 12:707–709CrossRefGoogle Scholar
  21. 21.
    Sanders GD, Neumann PJ, Basu A, Brock DW, Feeny D, Krahn M, Kuntz KM, Meltzer DO, Owens DK, Prosser LA, Salomon JA, Sculpher MJ, Trikalinos TA, Russell LB, Siegel JE, Ganiats TG (2016) Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine. JAMA 316:1093–1103CrossRefPubMedGoogle Scholar
  22. 22.
    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. Osteoporosis Int: J Establ Result Coop European Foundation Osteoporos Nat Osteoporos Foundation USAfor Osteoporosis and the National Osteoporosis Foundation of the USA 19:437–447CrossRefGoogle Scholar
  23. 23.
    Su Y, Leung J, Hans D, Lamy O, Kwok T (2017) The added value of trabecular bone score to FRAX(R) to predict major osteoporotic fractures for clinical use in Chinese older people: the Mr. OS and Ms. OS cohort study in Hong Kong. Osteoporosis Int: J Establ Result Coop European Foundation Osteoporos Nat Osteoporos Foundation USA 28:111–117CrossRefGoogle Scholar
  24. 24.
    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 280:2077–2082Google Scholar
  25. 25.
    Fraser LA, Vogt KN, Adachi JD, Thabane L (2011) Fracture risk associated with continuation versus discontinuation of bisphosphonates after 5 years of therapy in patients with primary osteoporosis: a systematic review and meta-analysis. Ther Clin Risk Manag 7:157–166CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Solomon DH, Avorn J, Katz JN, Finkelstein JS, Arnold M, Polinski JM, Brookhart MA (2005) Compliance with osteoporosis medications. Arch Intern Med 165:2414–2419CrossRefPubMedGoogle Scholar
  27. 27.
    Kwok AW, Gong JS, Wang YX, Leung JC, Kwok T, Griffith JF, Leung PC (2013) Prevalence and risk factors of radiographic vertebral fractures in elderly Chinese men and women: results of Mr. OS (Hong Kong) and Ms. OS (Hong Kong) studies. Osteoporosis Int: J Establ Result Coop European Foundation Osteoporos Nat Osteoporos Foundation USA 24:877–885CrossRefGoogle Scholar
  28. 28.
    Schott AM, Ganne C, Hans D, Monnier G, Gauchoux R, Krieg MA, Delmas PD, Meunier PJ, Colin C (2007) Which screening strategy using BMD measurements would be most cost effective for hip fracture prevention in elderly women? A decision analysis based on a Markov model. Osteoporosis Int: J Establ Result Coop European Foundation Osteoporos Nat Osteoporos Foundation USA 18:143–151CrossRefGoogle Scholar
  29. 29.
    Kanis JA, Borgstrom F, Zethraeus N, Johnell O, Oden A, Jonsson B (2005) Intervention thresholds for osteoporosis in the UK. Bone 36:22–32CrossRefPubMedGoogle Scholar
  30. 30.
    Bolland MJ, Grey AB, Gamble GD, Reid IR (2010) Effect of osteoporosis treatment on mortality: a meta-analysis. J Clin Endocrinol Metab 95:1174–1181CrossRefPubMedGoogle Scholar
  31. 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. Medical decision making: an international journal of the society for Med Decis Mak 26:391–400CrossRefGoogle Scholar
  32. 32.
    Brazier JE, Green C, Kanis JA (2002) A systematic review of health state utility values for osteoporosis-related conditions. Osteoporosis Int: J Establ Result Coop European Foundation Osteoporos Nat Osteoporos Foundation USA 13:768–776CrossRefGoogle Scholar
  33. 33.
    Caulin F, Kanis JA, Johnell O, Oden A (2002) Optimal age for preventing osteoporosis after menopause depends on effects of stopping treatment. Bone 30:754–758CrossRefPubMedGoogle Scholar
  34. 34.
    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 53:1697–1704CrossRefPubMedGoogle Scholar
  35. 35.
    (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group. World Health Organ Tech Rep Ser 843:1–129Google Scholar
  36. 36.
    (2002) Screening for osteoporosis in postmenopausal women: recommendations and rationale. Ann Intern Med 137:526–528Google Scholar
  37. 37.
    Hernlund E, Svedbom A, Ivergard M, Compston J, Cooper C, Stenmark J, McCloskey EV, Jonsson B, Kanis JA (2013) Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos 8:136CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Ding H, Koinuma N, Stevenson M, Ito M, Monma Y (2008) The cost-effectiveness of risedronate treatment in Japanese women with osteoporosis. J Bone Miner Metab 26:34–41CrossRefPubMedGoogle Scholar
  39. 39.
    Kung AW, Wu CH, Itabashi A, Lee JK, Park HM, Zhao Y, Chan WP, Kendler DL, Leib ES, Lewiecki EM, Bilezikian JP, Baim S, Asia Pacific Panel of ISCD (2010) International society for clinical densitometry official positions: Asia-Pacific Region consensus. J Clin Densitometry: Off J Int Soc Clin Densitometry 13:346–351CrossRefGoogle Scholar
  40. 40.
    Shepstone L, Lenaghan E, Cooper C, et al. (2018) Screening in the community to reduce fractures in older women (SCOOP): A randomised controlled trial. Lancet 391:741–747Google Scholar
  41. 41.
    Kwok T, Khoo CC, Leung J, Kwok A, Qin L, Woo J, Leung PC (2012) Predictive values of calcaneal quantitative ultrasound and dual energy X ray absorptiometry for non-vertebral fracture in older men: results from the MrOS study (Hong Kong). Osteoporosis Int: J Establ Result Coop European Foundation Osteoporos Nat Osteoporos Foundation USA 23:1001–1006CrossRefGoogle Scholar
  42. 42.
    Hiligsmann M, Ethgen O, Bruyère O, Reginster J-Y (2008) An economic evaluation of quantitative ultrasonometry as pre-screening test for the identification of patients with osteoporosis. Dis Manag Health Outcomes 16:429–438CrossRefGoogle Scholar
  43. 43.
    Moayyeri A, Adams JE, Adler RA, Krieg MA, Hans D, Compston J, Lewiecki EM (2012) Quantitative ultrasound of the heel and fracture risk assessment: an updated meta-analysis. Osteoporosis Int: J Establ Result Coop European Foundation Osteoporos Nat Osteoporos Foundation USA 23:143–153CrossRefGoogle Scholar
  44. 44.
    Brazier JE, Kohler B, Walters S (2000) A prospective study of the health related quality of life impact of hip fracture. ScHARR, University of Sheffield, SheffieldGoogle Scholar
  45. 45.
    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(1):20–26CrossRefPubMedGoogle Scholar
  46. 46.
    Dolan P, Torgerson D, Kumar Kakarlapudi T (1999) Health-related quality of life of Colles’ fracture patients. Osteoporos Int 9(3):196–199CrossRefPubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2018

Authors and Affiliations

  1. 1.Department of Medicine and Therapeutics, Prince of Wales HospitalThe Chinese University of Hong KongShatinChina
  2. 2.Jockey Club School of Public Health and Primary Care, Faculty of Medicine, Prince of Wales HospitalThe Chinese University of Hong KongShatinChina
  3. 3.Jockey Club Centre for Osteoporosis Care and ControlThe Chinese University of Hong KongShatinChina

Personalised recommendations