Current Osteoporosis Reports

, Volume 8, Issue 1, pp 49–55 | Cite as

Is Osteoporosis Disease Management Cost Effective?

Article

Abstract

Can osteoporosis disease management be cost effective? To answer that question, we conducted an extensive review of osteoporosis and fragility fracture prevention literature in peer-reviewed scientific journals and evidence-based guidelines from professional societies and government health organizations. We explored different strategies suggested by the literature to find how programs can be structured to be cost effective and to decrease fracture rates. We focused on ways to cost effectively identify, risk stratify, treat, and then track patients at risk for osteoporosis and fragility fractures. Studies have shown that osteoporosis management can decrease the hip fracture rate by 25% to 50% and be cost effective at the same time.

Keywords

PTH Fracture Osteoporosis Hip Bisphosphonate FRAX 

References

Papers of particular interest, published recently, have been highlighted as follows: • Of importance, •• Of major importance

  1. 1.
    Office of the Surgeon General, US Department of Health and Human Services: Bone Health and Osteoporosis: A Report of the Surgeon General. Washington, DC: US Department of Health and Human Services; 2004.Google Scholar
  2. 2.
    •• Tosteson AN, Burge RT, Marshall DA, Lindsay R: Therapies for treatment of osteoporosis in US women: cost-effectiveness and budget impact considerations. Am J Manag Care 2008, 14:605–615. This paper evaluates the cost effectiveness of osteoporosis treatments for women at high fracture risk and estimates the population-level impact of providing bisphosphonate therapy to all eligible high-risk US women. Osteoporosis treatment of high-risk women is cost-effective, with bisphosphonates providing the most benefit at lowest cost. For highest-risk women, costs are offset by savings from fracture prevention. PubMedGoogle Scholar
  3. 3.
    Burge R, Dawson-Hughes B, Solomon DH, et al.: Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res 2007, 22:465–475.CrossRefPubMedGoogle Scholar
  4. 4.
    Dell R, Greene D, Schelkun SR, Williams K: Osteoporosis disease management: the role of the orthopaedic surgeon. J Bone Joint Surg Am 2008, 90(Suppl 4):188–194.CrossRefPubMedGoogle Scholar
  5. 5.
    Newman ED, Ayoub WT, Starkey RH, et al.: Osteoporosis disease management in a rural health care population: hip fracture reduction and reduced costs in postmenopausal women after 5 years. Osteoporos Int 2003, 14:146–151.PubMedGoogle Scholar
  6. 6.
    Gehlbach SH, Avrunin JS, Puleo E: Trends in hospital care for hip fractures. Osteoporos Int 2007, 18:585–591.CrossRefPubMedGoogle Scholar
  7. 7.
    • Leslie WD, O'Donnell S, Jean S, et al.: Trends in hip fracture rates in Canada. Osteoporosis Surveillance Expert Working Group. JAMA 2009, 302:883–889. Age-standardized rates of hip fracture have steadily declined in Canada since 1985 and more rapidly during the later study period. The factors primarily responsible for the earlier reduction in hip fractures are unknown.Google Scholar
  8. 8.
    Jaglal SB, Weller I, Mamdani M, et al.: Population trends in BMD testing, treatment, and hip and wrist fracture rates: are the hip fracture projections wrong? J Bone Miner Res 2005, 20:898–905.CrossRefPubMedGoogle Scholar
  9. 9.
    Kannus P, Niemi S, Parkkari J, et al.: Nationwide decline in incidence of hip fracture. J Bone Miner Res 2006, 21:1836–1838.CrossRefPubMedGoogle Scholar
  10. 10.
    • Curtis JR, Adachi JD, Saag KG: Bridging the osteoporosis quality chasm. J Bone Miner Res 2009, 24:3–7. There are a growing number of well-studied therapeutic options and emerging international consensus on what constitutes quality in osteoporosis and who needs to be treated. As a stark distinction from this evidence base, the care gap between adults at high osteoporosis risk and the delivery of optimal osteoporosis management is large. The osteoporosis care gap needs to be narrowed to reduce health care disparities and the burden of fractures. Evidence of implementation strategies that directly target providers, patients, and health care systems offer partial solutions.CrossRefPubMedGoogle Scholar
  11. 11.
    • Vondracek SF, Linnebur SA: Diagnosis and management of osteoporosis in the older senior. Clin Interv Aging 2009, 4:121–136. It is important for health care providers to be fully aware of the potential risks and benefits of diagnosing and treating osteoporosis in the older senior population. Data indicate that bone mineral density (BMD) testing is underutilized and drug therapy is often not initiated when indicated in this population. BMD testing with central DXA is essential and cost effective in this population.PubMedGoogle Scholar
  12. 12.
    Neuner JM, Binkley N, Sparapani RA, et al.: Bone density testing in older women and its association with patient age. J Am Geriatr Soc 2006, 54:485–489.CrossRefPubMedGoogle Scholar
  13. 13.
    • Geusens P, Dumitrescu B, van Geel T, et al.: Impact of systematic implementation of a clinical case-finding strategy on diagnosis and therapy of postmenopausal osteoporosis. J Bone Miner Res 2008, 23:812–818. By using the Osteoporosis Self-Assessment Index, based only on age and weight and fracture history, a case-finding strategy was developed for patients who needed DXA screening. This strategy nearly tripled referrals for DXA, and 96% of patients found to have osteoporosis had treatment. This indicates the need for better case-finding strategies with fewer barriers for referral for DXA and with higher accuracy for predicting osteoporosis.CrossRefPubMedGoogle Scholar
  14. 14.
    • Kurup HV, Andrew JG: Secondary prevention of osteoporosis after Colles fracture: current practice. Joint Bone Spine 2008, 75:50–52. The National Institute of Clinical Excellence in the United Kingdom recommends osteoporosis treatment in all fragility fractures in patients over 75 years of age without a DXA scan, and after a DXA scan in younger patients.CrossRefPubMedGoogle Scholar
  15. 15.
    • Ayoub WT, Newman ED, Blosky MA, et al.: Improving detection and treatment of osteoporosis: redesigning care using the electronic medical record and shared medical appointments. Osteoporos Int 2009, 20:37–42. The redesigned process was highly effective in improving BMD testing for women 65 years of age. The shared medical appointment was shown to be a more effective method to make calcium and vitamin D recommendations, to evaluate secondary causes of low bone density, and to prescribe prescription medications, compared with the usual care with the primary care physician.CrossRefPubMedGoogle Scholar
  16. 16.
    Harrington JT, Barash HL, Day S, Lease J: Redesigning the care of fragility fracture patients to improve osteoporosis management: a health care improvement project. Arthritis Rheum 2005, 53:198–204.CrossRefPubMedGoogle Scholar
  17. 17.
    National Osteoporosis Foundation: NOF’s Clinician’s Guide to Prevention and Treatment of Osteoporosis. Available at http://www.nof.org/Professionals/Clinicians_Guide.htm. Accessed August 22, 2009.
  18. 18.
    The International Society for Clinical Densitometry (ISCD): Official Positions. Available at http://iscd.org/Visitors/positions/OfficialPositionsText.cfm. Accessed August 22, 2009.
  19. 19.
    U.S. Department of Human and Health Services: U.S. Preventive Services Task Force Osteoporosis Screening. Available at http://www.ahrq.gov/clinic/3rduspstf/Osteoporosis/. Accessed August 22, 2009.
  20. 20.
    Schuit SC, van der Klift M, Weel AE, et al.: Fracture incidence and association with bone mineral density in elderly men and women: the Rotterdam Study. Bone 2004, 34:195–202.CrossRefPubMedGoogle Scholar
  21. 21.
    •• Dawson-Hughes B, Tosteson AN, Melton LJ 3rd, et al.: Implications of absolute fracture risk assessment for osteoporosis practice guidelines in the USA. National Osteoporosis Foundation Guide Committee. Osteoporos Int 2008, 19:449–458. The new WHO fracture prediction algorithm was combined with an updated economic analysis to evaluate existing NOF guidance for osteoporosis prevention and treatment. It is cost effective to treat patients with a fragility fracture and those with osteoporosis by WHO criteria, as well as older individuals at average risk and osteopenic patients with additional risk factors. However, the estimated 10-year fracture probability was lower in men and nonwhite women compared with postmenopausal white women.CrossRefPubMedGoogle Scholar
  22. 22.
    •• Ettinger B, Black DM, Dawson-Hughes B, et al.: Updated fracture incidence rates for the US version of FRAX. Osteoporos Int 2010, 21:25–33. Compared with rates used in the current FRAX tool, 2006 hip fracture rates are about 16% lower, with the greatest reductions observed among those below 65 years of age; major osteoporotic fracture rates are about one quarter lower, with similar reductions across all ages.CrossRefPubMedGoogle Scholar
  23. 23.
    • Kanis JA, McCloskey EV, Johansson H, Oden A: Approaches to the targeting of treatment for osteoporosis. Nat Rev Rheumatol 2009, 5:425–431. The article uses FRAX in a case-finding strategy, based on the assessment of fracture probability using CRFs and, where appropriate, additional testing such as BMD, is recommended. These case-finding strategies have been validated from a health-economic perspective.CrossRefPubMedGoogle Scholar
  24. 24.
    National Institute for Health and Excellence: Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. Available at http://www.nice.org.uk/nicemedia/pdf/TA161guidanceword.pdf. Accessed September 6, 2009.
  25. 25.
    •• Tosteson AN, Melton LJ 3rd, Dawson-Hughes B, et al.: Cost-effective osteoporosis treatment thresholds: the United States perspective. National Osteoporosis Foundation Guide Committee. Osteoporos Int 2008, 19:437–447. Osteoporosis treatment was cost effective when the 10-year hip fracture probability reached approximately 3%.CrossRefPubMedGoogle Scholar
  26. 26.
    • Kanis JA, Compston JE.: NICE continues to muddy the waters of osteoporosis. National Osteoporosis Guideline Group of the UK. Osteoporos Int 2008, 19:1105–1107. The osteoporosis guidelines from NICE and others mentioned earlier has raised some controversy. A major concern has been that despite a sixfold reduction in the price of alendronate, the estimates of cost effectiveness have barely changed. This has been achieved by alteration of some of the model assumptions, in the absence of new evidence, so that the cost effectiveness of alendronate has remained unchanged despite its fall in price. Furthermore, these changes to the model have had a negative impact on the cost effectiveness of the other treatments under consideration.CrossRefPubMedGoogle Scholar
  27. 27.
    Schousboe JT, Ensrud KE, Nyman JA, et al.: Universal bone densitometry screening combined with alendronate therapy for those diagnosed with osteoporosis is highly cost-effective for elderly women. J Am Geriatr Soc 2005, 53:1697–1704.CrossRefPubMedGoogle Scholar
  28. 28.
    Black DM, Palermo L, Grima DT: Developing better economic models of osteoporosis: considerations for the calculation of the relative risk of fracture. Value Health 2006, 9:54–58.CrossRefPubMedGoogle Scholar
  29. 29.
    • Compston J, Cooper A, Cooper C, et al.: Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK. National Osteoporosis Guideline Group (NOGG). Maturitas 2009, 62:105–108. Patients are identified opportunistically using a case-finding strategy on the finding of a previous fragility fracture or the presence of significant CRFs. Some of these risk factors act independently of BMD to increase fracture risk, whereas others increase fracture risk through their association with low BMD (eg, some of the secondary causes of osteoporosis).CrossRefPubMedGoogle Scholar
  30. 30.
    • Leslie WD, Tsang JF, Lix LM: Simplified system for absolute fracture risk assessment: clinical validation in Canadian women. Manitoba Bone Density Program. J Bone Miner Res 2009, 24:353–360. A simplified risk assessment system from sex, age, DXA, and two CRFs—prior fracture and systemic corticosteroid use—has been used in Canada since 2005. This simplified fracture risk assessment system provides an assessment of fracture risk that is consistent with observed fracture rates.CrossRefPubMedGoogle Scholar
  31. 31.
    • Donaldson MG, Cawthon PM, Lui LY, et al.: Estimates of the proportion of older white women who would be recommended for pharmacologic treatment by the new U.S. National Osteoporosis Foundation Guidelines. J Bone Miner Res 2009, 24:675–680. Application of NOF Guidelines to the Study of Osteoporotic Fractures data estimated that at least 72% of US white women ≥ 65 years of age and 93% of those ≥ 75 years of age would be recommended for drug treatment. Application of the new NOF Guidelines would result in recommending a very large proportion of white women in the United States for pharmacologic treatment of osteoporosis.CrossRefPubMedGoogle Scholar
  32. 32.
    Schousboe JT, Taylor BC, Fink HA, et al.: Cost-effectiveness of bone densitometry followed by treatment of osteoporosis in older men. JAMA 2007, 298:629–637.CrossRefPubMedGoogle Scholar
  33. 33.
    Hochberg MC, Thompson DE, Black DM, et al.: Effect of alendronate on the age-specific incidence of symptomatic osteoporotic fractures. FIT Research Group. J Bone Miner Res 2005, 20:971–976.CrossRefPubMedGoogle Scholar
  34. 34.
    van Staa TP, Kanis JA, Geusens P, et al.: The cost-effectiveness of bisphosphonates in postmenopausal women based on individual long-term fracture risks. Value Health 2007, 10:348–357.CrossRefPubMedGoogle Scholar
  35. 35.
    • Moayyeri A: Identification of factors influencing the intervention thresholds for treatment of osteoporosis based on 10-year absolute fracture risks. J Clin Densitom 2009, 12:1–4. Current guidelines are mainly based on offering cost-effective treatments to patients with certain characteristics ignoring their individual risk of fracture (which can be easily estimated by FRAX) and likeliness to benefit from treatment (determined by some other individual-level factors, such as compliance, preference, comorbidities).CrossRefPubMedGoogle Scholar
  36. 36.
    Kanis JA, Adams J, Borgström F, et al.: The cost-effectiveness of alendronate in the management of osteoporosis. Bone 2008, 42:4–15.CrossRefPubMedGoogle Scholar
  37. 37.
    Gallagher AM, Rietbrock S, Olson M, van Staa TP: Fracture outcomes related to persistence and compliance with oral bisphosphonates. J Bone Miner Res 2008, 23:1569–1575.CrossRefPubMedGoogle Scholar
  38. 38.
    Ström O, Borgström F, Kanis JA, Jönsson B: Incorporating adherence into health economic modelling of osteoporosis. Osteoporos Int 2009, 20:23–34.CrossRefPubMedGoogle Scholar
  39. 39.
    Majumdar SR, Lier DA, Beaupre LA, et al.: Osteoporosis case manager for patients with hip fractures: results of a cost-effectiveness analysis conducted alongside a randomized trial. Arch Intern Med 2009, 169:25–31.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Kaiser DowneyDowneyUSA

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