The direct and indirect costs of the chronic management of osteoporosis: a prospective follow-up of 3440 active subjects

Multimorbidity healthcare expenditure in Belgium: a 4-year analysis (COMORB study)

BACKGROUND

The complex management of health needs in multimorbid patients, alongside limited cost data, presents challenges in developing cost-effective patient-care pathways. We estimated the costs of managing 171 dyads and 969 triads in Belgium, taking into account the influence of morbidity interactions on costs.

METHODS

We followed a retrospective longitudinal study design, using the linked Belgian Health Interview Survey 2018 and the administrative claim database 2017-2020 hosted by the Intermutualistic Agency. We included people aged 15 and older, who had complete profiles (N = 9753). Applying a system costing perspective, the average annual direct cost per person per dyad/triad was presented in 2022 Euro and comprised mainly direct medical costs. We developed mixed models to analyse the impact of single chronic conditions, dyads and triads on healthcare costs, considering two-/three-way interactions within dyads/triads, key cost determinants and clustering at the household level.

RESULTS

People with multimorbidity constituted nearly half of the study population and their total healthcare cost constituted around three quarters of the healthcare cost of the study population. The most common dyad, arthropathies + dorsopathies, with a 14% prevalence rate, accounted for 11% of the total national health expenditure. The most frequent triad, arthropathies + dorsopathies + hypertension, with a 5% prevalence rate, contributed 5%. The average annual direct costs per person with dyad and triad were €3515 (95% CI 3093-3937) and €4592 (95% CI 3920-5264), respectively. Dyads and triads associated with cancer, diabetes, chronic fatigue, and genitourinary problems incurred the highest costs. In most cases, the cost associated with multimorbidity was lower or not substantially different from the combined cost of the same conditions observed in separate patients.

CONCLUSION

Prevalent morbidity combinations, rather than high-cost ones, made a greater contribution to total national health expenditure. Our study contributes to the sparse evidence on this topic globally and in Europe, with the aim of improving cost-effective care for patients with diverse needs.

Incremental costs of fragility fractures: a population-based matched -cohort study from Ontario, Canada

Using a matched cohort design, the 1-year excess cost of incident fragility fractures at any site was $26,341 per patient, with 43% of total excess costs attributed to hospitalization. The high economic burden of fractures in Ontario underscores the urgency of closing the secondary fracture prevention gap.

INTRODUCTION

This retrospective real-world observational study was conducted to document the incremental costs associated with fragility fractures in Ontario, Canada.

METHODS

Patients aged >65 years with an index fragility fracture occurring between January 2011 and March 2015 were identified from administrative databases and matched 1:1 to a cohort of similar patients without a fracture. Healthcare resource utilization data were extracted from healthcare records and associated costs were calculated on a per-patient level and for the province of Ontario. Costs were presented as 2017 Canadian dollars.

RESULTS

The eligible cohort included 115,776 patients with a fragility fracture. Of these, 101,773 patients were successfully matched 1:1 to a non-fracture cohort. Overall, hip fractures (n = 31,613) were the most common, whereas femur fractures (n = 3002) were the least common type. Hospitalization and continuing care/home care/long-term care accounted for more than 60% of 1-year direct costs, whereas 5% was attributed to medication costs. First-year costs per patient in the fracture cohort were approximately threefold higher versus the non-fracture cohort (mean $37,362 versus $11,020, respectively). The incremental first-year direct healthcare costs of fragility fractures for the province of Ontario were calculated at $724 million per year.

CONCLUSIONS

Fragility fractures were associated with a threefold increase in overall mean healthcare costs per patient compared to patients without fractures. With an aging population, there is an urgent need for improved prevention strategies for patients at high-risk of fracture to decrease the economic burden of fragility fractures on the Canadian healthcare system.

Economic burden of osteoporosis in the world: A systematic review

Background: Osteoporosis is a skeletal disease that is associated with a reduction in bone mass and microstructures and deterioration of bone tissue. It is also associated with an increased risk of fracture that is the most important complication of osteoporosis. The knowledge about costs and economic aspects of osteoporosis plays an important role in making policies and planning measures for the prevention and management of this disease; hence, this study systematically investigated the available evidence on the costs associated with osteoporosis worldwide. Methods: In this systematic review, electronic searches were performed on various online databases, including PubMed, Embase, Scopus, web of science, ProQuest, and Cochrane. The timeframe selected for searching articles was from 1980 to 2018. Results: Of a total of 1989 papers, 28 papers were included in the study on the basis of inclusion criteria. Based on the data extracted from the mentioned studies, the mean age of people with osteoporotic fractures was 50 years, with the highest costs associated with hip fractures. Conclusion: Our review indicated that the cost of osteoporosis carries a significant economic burden on countries in the world. The main cost drivers in this study were Fracture-related costs. The direct annual cost of treating osteoporotic fractures of people on average is reported to be between 5000 and 6500 billion USD in Canada, Europe and the USA alone, not taking into account indirect costs such as disability and loss of productivity. Prevention of this disease can significantly reduce the costs incurred by the health system.

The Role of Monocyte Percentage in Osteoporosis in Male Rheumatic Diseases

Osteoporosis is easily overlooked in male patients, especially in the field of rheumatic diseases mostly prevalent with female patients, and its link to pathogenesis is still lacking. Attenuated monocyte apoptosis from a transcriptome-wide expression study illustrates the role of monocytes in osteoporosis. This study tested the hypothesis that the monocyte percentage among leukocytes could be a biomarker of osteoporosis in rheumatic diseases. Eighty-seven males with rheumatic diseases were evaluated in rheumatology outpatient clinics for bone mineral density (BMD) and surrogate markers, such as routine peripheral blood parameters and autoantibodies. From the total number of 87 patients included in this study, only 15 met the criteria for diagnosis of osteoporosis. Both age and monocyte percentage remained independently associated with the presence of osteoporosis. Steroid dose (equivalent prednisolone dose) was negatively associated with BMD of the hip area and platelet counts were negatively associated with BMD and T score of the spine area. Besides age, monocyte percentage meets the major requirements for osteoporosis in male rheumatic diseases. A higher monocyte percentage in male rheumatic disease patients, aged over 50 years in this study, and BMD study should be considered in order to reduce the risk of osteoporosis-related fractures.

The impact of fragility fractures on work and characteristics associated with time to return to work

We examined the impact of fragility fractures on the work outcomes of employed patients. The majority successfully returned to their previous jobs in a short amount of time, and productivity loss at work was low. Our findings underscore the fast recovery rates of working fragility fracture patients.

INTRODUCTION

The purpose of this study is to describe the impact of fragility fractures on the work outcomes of patients who were employed at the time of their fracture.

METHODS

A self-report anonymous survey was mailed to fragility fracture patients over 50 who were screened as part of the quality assurance programs of fracture clinics across 35 hospitals in Ontario, Canada. Measures of return to work (RTW), at-work productivity loss (Work Limitations Questionnaire), and sociodemographic, fracture-related, and job characteristics were included in the survey. Kaplan-Meier estimates of the cumulative proportion of patients still off work were computed. Factors associated with RTW time following a fragility fracture were examined using Cox proportional hazards modeling.

RESULTS

Of 275 participants, 242 (88 %) returned to work. Of these, the median RTW time was 20.5 days. About 86 % returned to the same job, duties, and hours as before their injury. Among full-time workers, the median number of lost hours due to presenteeism was 2.9 h (Q1-Q3 0.4-8.1 h). The median cost of presenteeism was $75.30 based on the month prior to survey completion. In multivariable analyses, female gender, needing surgery, and medium/heavy work requirements were associated with longer RTW time. Earlier RTW time was associated with elbow fracture and feeling completely better at time of survey completion.

CONCLUSIONS

The majority of fragility fracture patients successfully returned to their previous jobs in a short amount of time, and productivity loss at work was low. Our findings underscore their fast recovery rates and give reason for optimism regarding the resilience of this population.

Comparing clinical and economic outcomes of biologic and conventional medications in postmenopausal women with osteoporosis

RATIONALE, AIMS AND OBJECTIVES

Biologics are substantially more expensive than their conventional counterparts but it is unclear whether extra costs deliver better health outcomes. We compare clinical and economic outcomes between teriparatide (monthly costs $1120) and bisphosphonates (monthly costs $14) among postmenopausal women with osteoporosis.

METHODS

From a 5% random sample of Medicare beneficiaries, we selected women newly diagnosed with osteoporosis between 1 January 2007 and 31 December 2011 and who initiated teriparatide or bisphosphonates after the diagnosis. We followed them up until one of these events: switching osteoporosis treatment, death, or the end of study period - 31 December 2011. Clinical outcomes included hip fracture, vertebral fracture, fracture of radius, ulna or carpal bones, other upper limb fractures, other lower limb fractures and any fracture. Economic outcomes included medical costs, pharmacy costs, and total costs associated with osteoporosis. Using conventional propensity score, high-dimensional propensity score and instrumental variable analysis, we constructed Cox proportional hazards models to evaluate the risk of fracture and two-part models to compare costs.

RESULTS

Teriparatide users had higher risk of fracture and higher costs, compared with similar bisphosphonates users. The hazard ratios of fracture for teriparatide relative to bisphosphonates ranged from 1.37 to 2.12, depending on methods. There was no difference in the risk of hip fracture between treatment groups. Total annual costs related to osteoporosis were between $2733 and $3352 higher for teriparatide users.

CONCLUSIONS

The biological agent, teriparatide, is more expensive yet less effective than conventional treatment, bisphosphonates.

Effect of intervening tissues on ultrasonic backscatter measurements of bone: An in vitro study

Ultrasonic backscatter techniques are being developed to diagnose osteoporosis. Tissues that lie between the transducer and the ultrasonically interrogated region of bone may produce errors in backscatter measurements. The goal of this study is to investigate the effects of intervening tissues on ultrasonic backscatter measurements of bone. Measurements were performed on 24 cube shaped specimens of human cancellous bone using a 5 MHz transducer. Measurements were repeated after adding a 1 mm thick plate of cortical bone to simulate the bone cortex and a 3 cm thick phantom to simulate soft tissue at the hip. Signals were analyzed to determine three apparent backscatter parameters (apparent integrated backscatter, frequency slope of apparent backscatter, and frequency intercept of apparent backscatter) and three backscatter difference parameters [normalized mean backscatter difference (nMBD), normalized slope of the backscatter difference, and normalized intercept of the backscatter difference]. The apparent backscatter parameters were impacted significantly by the presence of intervening tissues. In contrast, the backscatter difference parameters were not affected by intervening tissues. However, only one backscatter difference parameter, nMBD, demonstrated a strong correlation with bone mineral density. Thus, among the six parameters tested, nMBD may be the best choice for in vivo backscatter measurements of bone when intervening tissues are present.

Pulsed electromagnetic fields for postmenopausal osteoporosis and concomitant lumbar osteoarthritis in southwest China using proximal femur bone mineral density as the primary endpoint: study protocol for a randomized controlled trial

BACKGROUND

Osteoporosis (OP) and osteoarthritis (OA) are prevalent skeletal disorders among postmenopausal women. Coexistence is common especially that of postmenopausal osteoporosis (PMO) and lumbar OA. An hypothesis has been raised that OP and OA might share the same pathogenic mechanism, and pulsed electromagnetic fields (PEMFs) were reported to have anti-osteoporosis and anti-osteoarthritis properties, but this suggestion was based primarily on biomarker data. Therefore, whether these two effects could take place simultaneously has not yet been investigated. This randomized controlled trial (RCT) is designed to explore the effect of PEMFs for PMO and concomitant lumbar OA.

METHODS/DESIGN

The study will include PMO patients (postmenopausal women; aged between 50 and 70 years; have been postmenopausal for at least 5 years and diagnosed with OP using proximal femur T-score) with concomitant lumbar OA (patients with confounding disorders like diabetes, hypertension, hyperlipidemia, and previous fracture history, etcetera, will be excluded) will be randomly assigned to two arms: PEMFs group and sham PEMFs group. There will be 25 participants in each arm (50 in total) and the outcome assessment, including the primary endpoint (proximal femur bone mineral density), will be performed at 5 weeks, 3 months and 6 months after enrollment.

DISCUSSION

PMO and lumbar OA are prominent public health problem, especially for postmenopausal women. We hope this RCT will provide scientific evidence to primary care of the postmenopausal women regarding the use of these nonpharmaceutical, noninvasive modalities, PEMFs, in managing PMO and lumbar OA.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR-TRC-14005156 (28 August 2014).

Posthospital Discharge Medical Care Costs and Family Burden Associated with Osteoporotic Fracture Patients in China from 2011 to 2013

Objectives. This study collected and evaluated data on the costs of outpatient medical care and family burden associated with osteoporosis-related fracture rehabilitation following hospital discharge in China. Materials and Methods. Data were collected using a patient questionnaire from osteoporosis-related fracture patients (N = 123) who aged 50 years and older who were discharged between January 2011 and January 2013 from 3 large hospitals in China. The survey captured posthospital discharge direct medical costs, indirect medical costs, lost work time for caregivers, and patient ambulatory status. Results. Hip fracture was the most frequent fracture site (62.6%), followed by vertebral fracture (34.2%). The mean direct medical care costs per patient totaled 3,910¥, while mean indirect medical costs totaled 743¥. Lost work time for unpaid family caregivers was 16.4 days, resulting in an average lost income of 3,233¥. The average posthospital direct medical cost, indirect medical cost, and caregiver lost income associated with a fracture patient totaled 7,886¥. Patients' ambulatory status was negatively impacted following fracture. Conclusions. Significant time and cost of care are placed on patients and caregivers during rehabilitation after discharge for osteoporotic fracture. It is important to evaluate the role and responsibility for creating the growing and inequitable burden placed on patients and caregivers following osteoporotic fracture.

A systematic review of osteoporosis medication adherence and osteoporosis-related fracture costs in men

BACKGROUND AND OBJECTIVE

Male osteoporosis is an increasingly important public health concern. Although several medications are approved for the treatment of osteoporosis, medication non-adherence and the associated consequences are not well documented in male populations. Our objective was to identify and summarize the current knowledge related to osteoporotic medication adherence, the potential implications of non-adherence to the medication, and the cost of osteoporosis-related fractures and health-resource utilization in men.

METHODS

Two separate systematic searches were conducted concurrently: one to identify literature reporting male-specific adherence to anti-osteoporotic medication and the clinical consequence of non-adherence in men, and the other to identify literature reporting the cost and resource burden of osteoporosis-related fractures in men. The PubMed, MEDLINE, EMBASE, and Cochrane databases were searched using a date range of 1 January 1998 to 30 June 2012, and citations were screened based on pre-defined criteria.

RESULTS

The percentage of males adherent to bisphosphonates [medication possession ratio (MPR) >0.8] over a 1-year period ranged from 32% to 64%. The data imply worse clinical outcomes with treatment non-adherence. Costs and resource use associated with osteoporosis-related fractures in men are high, with hip fractures generating the most cost.

CONCLUSIONS

One-third to two-thirds of men are not adherent to bisphosphonates. Non-adherence is associated with increased fracture risk. Estimates of direct and indirect osteoporosis-related fracture costs are also substantial in men, and may even be more costly than in women. More robust data would better inform disease management initiatives that could improve adherence to medication and outcomes in men with osteoporosis.

Indirect costs account for half of the total costs of an osteoporotic fracture: a prospective evaluation

Data on direct and indirect costs of clinical fractures in 116 osteoporotic patients 50 years and older were prospectively collected using cost diaries. Indirect costs accounted for roughly half of the total costs, with a contribution of at least 81% of these costs in employed patients.

INTRODUCTION

The aim of this prospective study was to gain insight into the current total costs of clinical fractures in osteoporotic patients aged 50 years and older.

METHODS

In a study in the Netherlands, patients prospectively filled out cost diaries every 3 months, during 1 year after a clinical fracture. Primary analyses were performed on those patients with all four cost diaries returned. In-depth analyses of indirect costs were performed, dividing results for employed and unemployed patients. Sensitivity analyses using imputation techniques were performed on patients who returned two or three diaries

RESULTS

Of the 116 included patients, 69 completed all four diaries, 24 only two or three, and 23 patient completed one or no diaries. For all fractures, approximately 50% of the total costs were due to indirect costs; employed patients contributed for at least 81% of the indirect cost. Humerus fractures were most expensive with a total 1-year cost of €16.841 per patient. Indirect costs in the group with clinical spine fractures were highest (<euro>12.522), accounting for 89.1% of the total costs for this fracture.

CONCLUSION

Indirect costs account for roughly half of the total costs of clinical fractures, which are largely related to sick leave. When performing cost analyses in fracture patients, we advise a societal perspective in which indirect costs are also considered, and to apply a patient derived prospective data collection method to get a 'true' and complete image of the total costs due to clinical fractures.

The clinical and economic burden of poor adherence and persistence with osteoporosis medications in Ireland

OBJECTIVES

Medication nonadherence is common for osteoporosis, but its consequences have not been well described. This study aimed to quantify the clinical and economic impacts of poor adherence and to evaluate the potential cost-effectiveness of improving patient adherence by using hypothetical behavioral interventions.

METHODS

A previously validated Markov microsimulation model was adapted to the Irish setting to estimate lifetime costs and outcomes (fractures and quality-adjusted life-year [QALY]) for three adherence scenarios: no treatment, real-world adherence, and full adherence over 3 years. The real-world scenario employed adherence and persistence data from the Irish Health Services Executive-Primary Care Reimbursement Services pharmacy claims database. We also investigated the cost-effectiveness of hypothetical behavioral interventions to improve medication adherence (according to their cost and effect on adherence).

RESULTS

The number of fractures prevented and the QALY gain obtained at real-world adherence levels represented only 57% and 56% of those expected with full adherence, respectively. The costs per QALY gained of real-world adherence and of full adherence compared with no treatment were estimated at € 11,834 and € 6,341, respectively. An intervention to improve adherence by 25% would result in an incremental cost-effectiveness ratio of € 11,511 per QALY and € 54,182 per QALY, compared with real-world adherence, if the intervention cost an additional € 50 and € 100 per year, respectively.

DISCUSSION

Poor adherence with osteoporosis medications results in around a 50% reduction in the potential benefits observed in clinical trials and a doubling of the cost per QALY gained from these medications. Depending on their costs and outcomes, programs to improve adherence have the potential to be an efficient use of resources.

Impact of medication adherence on health care utilization and productivity: self-reported data from a cohort of postmenopausal women on osteoporosis therapy

BACKGROUND

Many pharmacologic agents are approved for the prevention and treatment of osteoporosis, which is common among postmenopausal women. Evidence exists relating treatment persistence to fracture risk. Less is known about treatment persistence and the use of health care service and individual productivity.

OBJECTIVE

This study was undertaken to describe health care use and productivity loss relative to osteoporosis medication persistence using women's self-reported data from the Prospective Observational Scientific Study Investigating Bone Loss Experience (POSSIBLE US™), a large, longitudinal (October 2004-December 2009) osteoporosis cohort study of postmenopausal women.

METHODS

Analyses included women on pharmacologic osteoporosis therapy (alendronate, risedronate, ibandronate, calcitonin, raloxifene, or teriparatide) who provided health care use/productivity data collected using semiannual questionnaires over 1 year of follow-up. Participant characteristics, use, and productivity metrics were summarized. Logistic regression models and generalized linear models were used to examine use, time missed from usual activities, number of days spent in bed, and lost work time relative to treatment persistence, adjusting for potential confounders.

RESULTS

At entry, of the 2528 women studied (91% white, 3.1% Hispanic/Latino, 2.3% African American/black, 1.1% Asian, and 2.1% American Indian/Native Alaskan, Native Hawaiian/Pacific Islander, or other; mean age, 64.6 [range, 37-97] years), 43.1% had osteoporosis and 23.4% had a previous fracture. After adjustment, subjects who switched therapies during follow-up were more likely to have had any kind of diagnostic testing (95.2% of switchers vs 91.2% of persistent subjects and 88.9% of discontinuers, P < 0.05). Discontinuers were less likely than persistent subjects to visit their primary care physicians (92.0% vs 94.4%, P = 0.0337). Variations in the number of days spent in bed, time missed from usual activities, and work loss (n = 852 employed subjects) by treatment persistence were not significant.

CONCLUSIONS

Use of diagnostic testing differed significantly by osteoporosis treatment status. Compared with women who persisted with treatment, primary care provider visits were less common among those who discontinued treatment. Treatment persistence was not associated with significant differences in productivity measures.

Current options for the management of postmenopausal osteoporosis

INTRODUCTION

Osteoporosis is a well-recognized disease with severe consequences if left untreated. The prevention of osteoporosis-associated fractures should include fall prevention, calcium supplementation and life-style advice, as well as pharmacological therapy using agents with proven antifracture efficacy.

AREAS COVERED

This manuscript offers an evidence-based critical assessment of the currently available efficacy data on all new chemical entities that have been granted a marketing authorization for the management of primary osteoporosis in women.

EXPERT OPINION

The availability of new therapeutic agents makes clinical decision making in osteoporosis more complex. Therapeutic decisions should be based on a balance between the benefits and risks of treatment, which must be carefully considered in each particular case, both by the physician and the patient. Indeed, no single agent is appropriate for all patients. Therefore, treatment decisions should be made on a tailor-made basis, taking into account all measures of treatment effect and risk, before making informed judgments about the best individual treatment option.

Antifracture efficacy of currently available therapies for postmenopausal osteoporosis

Osteoporosis is a systemic bone disease characterized by low bone mass and bone mineral density, and deterioration of the underlying structure of bone tissue. These changes lead to an increase in bone fragility and an increased risk for fracture, which are the clinical consequences of osteoporosis. The classical triad for consideration in osteoporosis is morbidity, mortality and cost. Vertebral fracture is an important source of morbidity in terms of pain and spinal deformity. On the other hand, hip fracture is associated with the worst outcomes and is widely regarded as a life-threatening event in the elderly; it is the source of the bulk of the cost of the disease in contemporary healthcare. The prevention of osteoporosis-associated fracture should include fall prevention, calcium supplementation and lifestyle advice, as well as pharmacological therapy using agents with proven antifracture efficacy. The most commonly used osteoporosis treatments in Europe are the bisphosphonates alendronate, risedronate, ibandronate and zoledronic acid; the selective estrogen receptor modulator (SERM) raloxifene; teriparatide; and strontium ranelate. Recent additions include the biological therapy denosumab and the SERM bazedoxifene. In this review, we explore the antifracture efficacy of these agents with the aim of simplifying treatment decisions. These treatments can be broadly divided according to their mode of action. The antiresorptive agents include the bisphosphonates, the SERMs and denosumab, while the bone-forming agents include parathyroid hormone and teriparatide. Strontium ranelate appears to combine both antiresorptive and anabolic activities. We collated data on vertebral and hip fracture efficacy from the pivotal 3-year phase III trials, all of which had a randomized, double-blind, placebo-controlled design. The relative reductions in risk in the osteoporosis trials range from 30% to 70% for vertebral fracture and 30% to 51% for hip fracture. This translates into 3-year number needed to treat values of between 9 and 21 for vertebral fracture and from 48 upwards for hip fracture. International guidelines agree that agents that have been shown to decrease vertebral, nonvertebral and hip fractures should be used preferentially over agents that only demonstrate vertebral antifracture efficacy. This is the case for alendronate, risedronate, zoledronic acid, denosumab and strontium ranelate. Finally, therapeutic decisions should be based on a balance between benefits and risks of treatment, which must be carefully considered in each particular case both by the physician and the patient. Indeed, no single agent is appropriate for all patients and, therefore, treatment decisions should be made on an individual basis, taking into account all measures of treatment effect and risk before making informed judgments about the best individual treatment option.

Economic burden of privately insured non-vertebral fracture patients with osteoporosis over a 2-year period in the US

This study assesses the costs of non-vertebral osteoporosis-related fractures patients compared with osteoporosis patients without fractures, focusing on the second year following a fracture. Since fracture patients remained more costly in the second year, their economic burden extends beyond the year in which the fracture occurs.

INTRODUCTION

The purpose of this study is to examine the comorbidity profile, resource use, and direct costs of patients who incur osteoporosis-related non-vertebral (NV) fractures in the United States during the 2 years following an incident fracture, focusing on the second year following a fracture.

METHODS

Osteoporosis patients (ICD-9-CM: 733.0) with a NV fracture (hip, femur, pelvis, lower leg, upper arm, forearm, rib, and multiple sites) were selected from a privately insured health insurance claims database (>8 million lives, ages 18-64, 1999-2006). These NV fracture patients were randomly matched 1:1 on age, gender, employment status, and geographic region to controls with osteoporosis but without a fracture history. Year-by-year and month-by-month rates of comorbidities, resource use, and direct costs were calculated for the matched sample (N = 3,781).

RESULTS

Comorbidity rates and resource use remained significantly higher among NV fracture patients during second year following an NV fracture compared with controls, although absolute rates of comorbidities and service utilization declined. Mean direct excess costs for NV fracture patients fell from $5,267 in the first year to $2,072 in the second year after a fracture, but remained statistically significant (p < 0.01). Patients with fractures of the pelvis, hip, and femur had the highest excess costs in the second year ($5,121, $3,930, and $3,828, respectively). Although hip fractures had highest excess costs over both years, non-vertebral, non-hip fracture patients made up a larger proportion of the sample and were significantly more costly than controls.

CONCLUSIONS

Patients with osteoporosis-related NV fractures have substantial excess costs beyond the first year in which the fracture occurs.

Femur ultrasound (FemUS)--first clinical results on hip fracture discrimination and estimation of femoral BMD

SUMMARY

A quantitative ultrasound (QUS) device for measurements at the proximal femur was developed and tested in vivo (Femur Ultrasound Scanner, FemUS). Hip fracture discrimination was as good as for DXA, and a high correlation with hip BMD was achieved. Our results show promise for enhanced QUS-based assessment of osteoporosis.

INTRODUCTION

Dual X-ray absorptiometry (DXA) at the femur is the best predictor of hip fractures, better than DXA measurements at other sites. Calcaneal quantitative ultrasound (QUS) can be used to estimate the general osteoporotic fracture risk, but no femoral QUS measurement has been introduced yet. We developed a QUS scanner for measurements at the femur (Femur Ultrasound Scanner, FemUS) and tested its in vivo performance.

METHODS

Using the FemUS device, we obtained femoral QUS and DXA on 32 women with recent hip fractures and 30 controls. Fracture discrimination and the correlation with femur bone mineral density (BMD) were assessed.

RESULTS

Hip fracture discrimination using the FemUS device was at least as good as with hip DXA and calcaneal QUS. Significant correlations with total hip bone mineral density were found with a correlation coefficient R (2) up to 0.72 and a residual error of about one half of a T-score in BMD.

CONCLUSIONS

QUS measurements at the proximal femur are feasible and show a good performance for hip fracture discrimination. Given the promising results, this laboratory prototype should be reengineered to a clinical applicable instrument. Our results show promise for further enhancement of QUS-based assessment of osteoporosis.

[Economic concepts for measuring the costs of illness of osteoporosis: an international comparison]

Worldwide osteoporosis is underestimated and despite availability of effective and cost effective treatments, these are often not implemented. Apart from a demographically driven increase in disease cases, failure to implement or tardy implementation of preventive measures as well as poor treatment compliance leads to a deterioration of the health economic outcomes. This in turn causes considerable costs to the health care system and to society, through ineffective intake of medication, diminished quality of life and inability to work as well as substantial costs of rehabilitation of patients. Health economic analyses and methods are increasingly used by decision makers to set priorities and evaluate alternative treatment measures about their cost-effectiveness. In order to be able to capture the costs of illness incurred by osteoporosis, different diseases specific models and methods have been developed, such as the reference model of the IOF, an osteoporosis-specific Markov model or internationally comparable intervention thresholds. Health economists estimate that osteoporosis-related costs will double by 2050 in both Europe and the individual countries. For Europe this means an increase from 40 billion Euro in 2000 to almost 80 billion Euro in 2050. In Austria, an aggregation of the different costs of osteoporosis is not possible, due to a lack of comparability and availability of data. The international ICUROS study and the Austrian Osteoporosis Report 2007 are the first steps towards counteracting this situation.

Critical issues in translational and clinical research for the study of new technologies to enhance bone repair

Osteoporosis increases fracture risk, especially in metaphyseal bone. Fractures seriously impair function and quality of life and incur large direct and indirect costs. Although the prevention of fractures is certainly the option, a fast and uneventful healing process is optimal when fractures do occur. Many new therapeutic strategies have been developed to accelerate fracture-healing or to diminish the complication rate during the course of fracture-healing. However, widely accepted guidelines are needed to demonstrate the positive or negative interactions of bioactive substances, drugs, and other agents that are being used to promote fracture-healing. For each study design, the primary study goal should be indicated. Outcome variables should include both objective and subjective parameters. The guidelines should be harmonized between European and American regulatory authorities to ensure comparability of results of studies and to foster global harmonization of regulatory requirements.

The burden of testosterone deficiency syndrome in adult men: economic and quality-of-life impact

INTRODUCTION

Testosterone deficiency syndrome (TDS) causes a wide range of symptoms that can lead to significant morbidity. Preliminary evidence has also linked TDS with premature mortality and with a number of comorbid diseases including diabetes and metabolic syndrome. Such associations can lead to substantial economic and quality-of-life implications, the magnitude of which remains largely unknown.

AIM

To review the economic and quality-of-life consequences of a largely untreated condition and to consider the likely health economic benefits of testosterone treatment.

METHODS

A systematic review of four main areas: epidemiological evidence of the magnitude of TDS, estimates of cost of illness, impact on quality-of-life, and cost-effectiveness of testosterone treatment.

MAIN OUTCOME MEASURE

Review of peer-reviewed literature.

RESULTS

The lack of clear universally accepted diagnostic criteria and the uncertainty surrounding the link between TDS and some of its consequences complicate the estimation of the burden of illness of TDS. Consequences of TDS that potentially lead to increased economic burden include depression, sexual dysfunction, mild cognitive impairment, osteoporosis, cardiovascular disease, and mortality. However, although good evidence exists demonstrating an association between TDS and sexual dysfunction and cognitive impairment, evidence is less strong for depression, the incidence of fractures and mortality, and highly controversial for cardiovascular disease. The consequences that are likely to impact on patients' quality of life include sexual function, energy levels, body composition, mood, and cognitive function.

CONCLUSION

Understanding the burden is only the first step decision makers need to take to decide whether to allocate scarce resources to treat the condition. To make informed decisions on when and who to treat information is also needed on the cost-effectiveness of available treatments. Such data would highlight the benefits of treatment of TDS to physicians, patients, and to society as a whole.