Recommendations for the health economics analysis to be performed with a drug to be registered in prevention or treatment of osteoporosis

Recommendations for the conduct of economic evaluations in osteoporosis: outcomes of an experts' consensus meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the US branch of the International Osteoporosis Foundation

Economic evaluations are increasingly used to assess the value of health interventions, but variable quality and heterogeneity limit the use of these evaluations by decision-makers. These recommendations provide guidance for the design, conduct, and reporting of economic evaluations in osteoporosis to improve their transparency, comparability, and methodologic standards.

INTRODUCTION

This paper aims to provide recommendations for the conduct of economic evaluations in osteoporosis in order to improve their transparency, comparability, and methodologic standards.

METHODS

A working group was convened by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis to make recommendations for the design, conduct, and reporting of economic evaluations in osteoporosis, to define an osteoporosis-specific reference case to serve a minimum standard for all economic analyses in osteoporosis, to discuss methodologic challenges and initiate a call for research. A literature review, a face-to-face meeting in New York City (including 11 experts), and a review/approval by a larger group of experts worldwide (including 23 experts in total) were conducted.

RESULTS

Recommendations on the type of economic evaluation, methods for economic evaluation, modeling aspects, base-case analysis and population, excess mortality, fracture costs and disutility, treatment characteristics, and model validation were provided. Recommendations for reporting economic evaluations in osteoporosis were also made and an osteoporosis-specific checklist was designed that includes items to report when performing an economic evaluation in osteoporosis. Further, 12 minimum criteria for economic evaluations in osteoporosis were identified and 12 methodologic challenges and need for further research were discussed.

CONCLUSION

While the working group acknowledges challenges and the need for further research, these recommendations are intended to supplement general and national guidelines for economic evaluations, improve transparency, quality, and comparability of economic evaluations in osteoporosis, and maintain methodologic standards to increase their use by decision-makers.

A reference case for economic evaluations in osteoarthritis: an expert consensus article from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO)

BACKGROUND

General recommendations for a reference case for economic studies in rheumatic diseases were published in 2002 in an initiative to improve the comparability of cost-effectiveness studies in the field. Since then, economic evaluations in osteoarthritis (OA) continue to show considerable heterogeneity in methodological approach.

OBJECTIVES

To develop a reference case specific for economic studies in OA, including the standard optimal care, with which to judge new pharmacologic and non-pharmacologic interventions.

METHODS

Four subgroups of an ESCEO expert working group on economic assessments (13 experts representing diverse aspects of clinical research and/or economic evaluations) were charged with producing lists of recommendations that would potentially improve the comparability of economic analyses in OA: outcome measures, comparators, costs and methodology. These proposals were discussed and refined during a face-to-face meeting in 2013. They are presented here in the format of the recommendations of the recently published Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement, so that an initiative on economic analysis methodology might be consolidated with an initiative on reporting standards.

RESULTS

Overall, three distinct reference cases are proposed, one for each hand, knee and hip OA; with diagnostic variations in the first two, giving rise to different treatment options: interphalangeal or thumb-based disease for hand OA and the presence or absence of joint malalignment for knee OA. A set of management strategies is proposed, which should be further evaluated to help establish a consensus on the "standard optimal care" in each proposed reference case. The recommendations on outcome measures, cost itemisation and methodological approaches are also provided.

CONCLUSIONS

The ESCEO group proposes a set of disease-specific recommendations on the conduct and reporting of economic evaluations in OA that could help the standardisation and comparability of studies that evaluate therapeutic strategies of OA in terms of costs and effectiveness.

Cost-effectiveness of osteoporosis screening followed by treatment: the impact of medication adherence

OBJECTIVE

To estimate the impact of medication adherence on the cost-effectiveness of mass-screening by bone densitometry followed by alendronate therapy for women diagnosed with osteoporosis.

METHODS

A validated Markov microsimulation model with a Belgian health-care payer perspective and a lifetime horizon was used to assess the cost per quality-adjusted life year (QALY) gained of the screening/treatment strategy compared with no intervention. Real-world adherence to alendronate therapy and full adherence over 5 years were both investigated. The real-world adherence scenario employed adherence data from published observational studies, and medication adherence was divided into persistence, compliance, and primary adherence. Uncertainty was investigated using one-way and probabilistic sensitivity analyses.

RESULTS

At 65 years of age, the costs per QALY gained because of the screening/treatment strategy versus no intervention are euro32,008 and euro16,918 in the real-world adherence and full adherence scenarios, respectively. The equivalent values are euro80,836 and euro40,462 at the age of 55 years, and they decrease to euro10,600 and euro1229 at the age of 75 years. Sensitivity analyses show that the presence of the upfront cost of case finding has a substantial role in the impact of medication adherence on cost-effectiveness.

CONCLUSION

This study indicates that nonadherence with osteoporosis medications substantially increases the incremental cost-effectiveness ratio of osteoporosis screening strategies. All aspects of medication adherence (i.e., compliance, persistence, and primary adherence) should therefore be reported and included in pharmacoeconomic analyses, and especially in the presence of the upfront cost of case finding (such as screening cost).

Cost-effectiveness of strontium ranelate versus risedronate in the treatment of postmenopausal osteoporotic women aged over 75 years

OBJECTIVE

To estimate the cost-effectiveness of strontium ranelate in the treatment of postmenopausal osteoporotic women aged over 75 years.

MATERIALS AND METHODS

A validated Markov microsimulation model with a Belgian payer's perspective estimated the cost per quality-adjusted life-year (QALY) of a 3-year strontium ranelate treatment compared with no treatment and with the bisphosphonate risedronate. Data on the effect of both treatments on fracture risk were taken from the Cochrane Database of Systematic Reviews. Analyses were performed for postmenopausal women aged 75 and 80 years, either with a diagnosis of osteoporosis (i.e. bone mineral density T-score <or=-2.5 SD) or with prevalent vertebral fractures (PVF). Parameter uncertainty was evaluated using both one-way and probabilistic sensitivity analyses.

RESULTS

Strontium ranelate was dominant (i.e. more effective and less costly) versus risedronate for women with osteoporosis aged over 75 years and for women with PVF aged 80 years. The cost per QALY gained of strontium ranelate compared with risedronate at 75 years of age was euro 11,435 for women with PVF. When compared with no treatment, the costs per QALY gained of strontium ranelate were euro 15,588 and euro 7,708 at 75 and 80 years of age for women with osteoporosis; the equivalent values were euro 16,518 and euro 6,015 for women with PVF. Probabilistic sensitivity analyses showed that strontium ranelate was generally more cost-effective than risedronate, in the range of 60% in all cases.

CONCLUSION

The results of this study suggest that strontium ranelate is a cost-effective strategy, in a Belgian setting, for the treatment of postmenopausal osteoporotic women aged over 75 years.

Cost-utility of long-term strontium ranelate treatment for postmenopausal osteoporotic women

The results of this study suggested that long-term treatment with strontium ranelate over 5 years is cost-effective compared to no treatment for postmenopausal osteoporotic women.

INTRODUCTION

This study aims to estimate the cost-effectiveness of long-term strontium ranelate treatment for postmenopausal osteoporotic women.

METHODS

A validated Markov microsimulation model with a Belgian healthcare cost perspective was used to assess the cost per quality-adjusted life-year (QALY) of strontium ranelate compared to no treatment, on a basis of calcium/vit D supplementation if needed. Analyses were performed for women aged 70, 75, and 80 years either with a bone mineral density T-score <or= -2.5 SD or with prevalent vertebral fractures. The relative risk of fracture during therapy was derived from the Treatment of Peripheral Osteoporosis Study trial over 5 years of treatment. Parameter uncertainty was evaluated using both univariate and probabilistic sensitivity analyses.

RESULTS

Strontium ranelate was cost-saving at the age of 80 years in both populations. For women with a T-score <or= -2.5 SD, the costs per QALY gained of strontium ranelate were respectively euro 15,096 euro and 6,913 euro at 70 and 75 years of age while these values were 23,426 euro and 9,698 euro for women with prevalent vertebral fractures. Sensitivity analyses showed that the results were robust over a wide range of assumptions.

CONCLUSION

This study suggested that, compared to no treatment, long-term strontium ranelate treatment is cost-effective for postmenopausal osteoporotic women.

Development and validation of a Markov microsimulation model for the economic evaluation of treatments in osteoporosis

OBJECTIVE

Markov models are increasingly used in economic evaluations of treatments for osteoporosis. Most of the existing evaluations are cohort-based Markov models missing comprehensive memory management and versatility. In this article, we describe and validate an original Markov microsimulation model to accurately assess the cost-effectiveness of prevention and treatment of osteoporosis.

METHODS

We developed a Markov microsimulation model with a lifetime horizon and a direct health-care cost perspective. The patient history was recorded and was used in calculations of transition probabilities, utilities, and costs. To test the internal consistency of the model, we carried out an example calculation for alendronate therapy. Then, external consistency was investigated by comparing absolute lifetime risk of fracture estimates with epidemiologic data.

RESULTS

For women at age 70 years, with a twofold increase in the fracture risk of the average population, the costs per quality-adjusted life-year gained for alendronate therapy versus no treatment were estimated at €9105 and €15,325, respectively, under full and realistic adherence assumptions. All the sensitivity analyses in terms of model parameters and modeling assumptions were coherent with expected conclusions and absolute lifetime risk of fracture estimates were within the range of previous estimates, which confirmed both internal and external consistency of the model.

CONCLUSION

Microsimulation models present some major advantages over cohort-based models, increasing the reliability of the results and being largely compatible with the existing state of the art, evidence-based literature. The developed model appears to be a valid model for use in economic evaluations in osteoporosis.

Cost-Effectiveness Analysis of Various Screening Methods for Osteoporosis in Perimenopausal Thai Women

OBJECTIVE

To perform a health economics analysis of 5 screening programs for osteoporosis in perimenopausal Thai women comparing two alternatives; without intervention and universal treatment without screening.

DESIGN

A decision analysis was performed to evaluate five screening strategies: Dual energy X-ray absorptiometry (DXA), Quantitative ultrasound sonography (QUS), risk index (clinical risk factors), two-step screening with QUS followed by DXA, and screening with risk index followed by DXA, comparing outcomes without intervention and universal treatment without screening.

RESULTS

The costs for universal treatment, screening by DXA with treatment, screening by QUS with treatment, screening by Risk index with treatment, screening by QUS and DXA with treatment, and screening by Risk index and DXA with treatment strategies to prevent one fracture were 207.82, 88.42, 147.05, 127.67, 71.33, and 60.30 USD, respectively. The cost for no intervention to prevent one fracture is 8.49 USD (1 USD = 40 Thai baht).

CONCLUSION

At present, no intervention is the most cost effective strategy. However, screening with risk index and DXA with treatment became the most cost effective when the patients reached the postmenopausal period and had a high risk index, for which the prevalence of osteoporosis will increase. Cost effective screening guidelines still cannot be explicitly established until further data addressing the association between bone mass measurements in the hip and hip fracture risk, are available.

A cost-effectiveness evaluation of two continuous-combined hormone therapies for the management of moderate-to-severe vasomotor symptoms

OBJECTIVES

After the release of the results of the Women's Health Initiative, an emerging consensus suggests that continuous-combined hormone therapy (CCHT) should be limited to short-term management of moderate-to-severe vasomotor symptoms. This, in turn, raises the important question of the economic value, if any, of short-term CCHT for this indication. We conducted a cost-effectiveness analysis comparing a 1-year treatment course with 1 mg of norethindrone acetate/5 microg of ethinyl estradiol (1/5 NA/EE) or 0.625 mg/day of conjugated estrogens plus 2.5 mg of medroxyprogesterone (0.625/2.5 CEE/MPA) compared with no therapy for the management of moderate-to-severe vasomotor symptoms.

DESIGN

A literature-based Markov model was developed to compare these three options' cost and quality-of-life (QOL) benefits. The impact of therapy on vasomotor symptoms and breakthrough bleeding/spotting on the direct costs of care and QOL were considered.

RESULTS

Compared with no therapy, CCHTs resulted in net increases in quality-adjusted life-years (QALYs) gained (0.110 for 1/5 NA/NE v 0.104 for 0.625/2.5 CEE/MPA). Net costs (v no therapy) were $167 lower for 1/5 NA/NE compared with 0.625/2.5 CEE/MPA. Cost per QALY gained (compared with no therapy) were $6,200 and $8,200, respectively. Cost-effectiveness was most favorable for individuals with more severe symptoms who were less bothered by breakthrough bleeding/spotting.

CONCLUSIONS

A short-term course of CCHT for the sole purpose of managing moderate-to-severe vasomotor symptoms is cost-effective. However, 1/5 NA/NE seemed to be more cost-effective than 0.625/2.5 CEE/MPA. These findings can be used to further refine the role of CCHT and to improve formulary decisions.