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Iqbal SM, Qamar I, Zhi C, Nida A, Aslam HM. Role of Bisphosphonate Therapy in Patients with Osteopenia: A Systemic Review. Cureus 2019; 11:e4146. [PMID: 31058029 PMCID: PMC6488345 DOI: 10.7759/cureus.4146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
By contrast to clinical trials exploring osteoporosis, clinical trials specifically designed for the osteopenic population are limited. Thus, less clinical data are available regarding treatment benefits and cost-effectiveness of treating a patient population with a bone mass density in the osteopenic range (T-score between -1 and -2.5). In this article, we aimed to highlight this high-risk population with a low bone mass density (BMD) susceptible to high fracture risk by reviewing different national and international guidelines for treating osteopenia. The cost-effectiveness of the therapy for the above-mentioned patient population is also discussed. By reviewing different clinical trials, we have specifically highlighted the role of bisphosphonate therapy for fracture risk reduction and increment in bone mineral density (BMD) in patients with osteopenia.
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Affiliation(s)
- Shumaila M Iqbal
- Internal Medicine, University at Buffalo / Sisters of Charity Hospital, Buffalo, USA
| | - Iqra Qamar
- Internal Medicine, Brigham and Women's Hospital, Boston, USA
| | - Cassandra Zhi
- Internal Medicine, Drexel University College of Medicine, Philadelphia, USA
| | - Anum Nida
- Internal Medicine, University at Buffalo / Sisters of Charity Hospital, Buffalo, USA
| | - Hafiz M Aslam
- Internal Medicine, Hackensack Meridian School of Medicine at Seton Hall University, Trenton, USA
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2
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Darbà J, Kaskens L, Sorio Vilela F, Lothgren M. Cost-utility of denosumab for the treatment of postmenopausal osteoporosis in Spain. CLINICOECONOMICS AND OUTCOMES RESEARCH 2015; 7:105-17. [PMID: 25709480 PMCID: PMC4330002 DOI: 10.2147/ceor.s78349] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The objective of this study was to estimate the cost-effectiveness of denosumab for fracture prevention compared with no treatment, generic bisphosphonates, and strontium ranelate in a cohort of osteoporotic postmenopausal women in Spain. METHODS A Markov model represented the possible health state transitions of Spanish postmenopausal women from initiation of fracture prevention treatment until age 100 years or death. The perspective was that of the Spanish National Health System. Fracture efficacy data for denosumab were taken from a randomized controlled trial. Fracture efficacy data for alendronate, ibandronate, risedronate, and strontium ranelate were taken from an independent meta-analysis. Data on the incidence of fractures in Spain were either taken from the published literature or derived from Swedish data after applying a correction factor based on the reported incidence from each country. Resource use in each health state was obtained from the literature, or where no data had been published, conservative assumptions were made. Utility values for the various fracture health states were taken from published sources. The primary endpoints of the model were life-years gained, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios for denosumab against the comparators. RESULTS Denosumab reduced the risk of fractures compared with either no treatment or the other active interventions, and produced the greatest gains in life-years and QALYs. With an annual acquisition cost of €417.34 for denosumab, the incremental cost-effectiveness ratios for denosumab versus no treatment, alendronate, risedronate, and ibandronate were estimated at €6,823, €16,294, €4,895, and €2,205 per QALY gained, respectively. Denosumab dominated strontium ranelate. Sensitivity analyses confirmed the robustness of these findings. CONCLUSION Our analyses show that denosumab is a cost-effective intervention for fracture prevention in osteoporotic postmenopausal women in Spain compared with alendronate and risedronate, and is a dominant treatment option compared with strontium ranelate.
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Affiliation(s)
- Josep Darbà
- Department of Economics, Universitat de Barcelona, Barcelona, Spain
| | - Lisette Kaskens
- BCN Health Economics and Outcomes Research SL, Barcelona, Spain
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Bischof M, Sendi P. How much bone for the buck? The importance of compliance issues in economic evaluations of bisphosphonates. Expert Rev Pharmacoecon Outcomes Res 2014; 5:369-71. [DOI: 10.1586/14737167.5.4.369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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4
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Mao PJ, Zhang C, Tang L, Xian YQ, Li YS, Wang WD, Zhu XH, Qiu HL, He J, Zhou YH. Effect of calcium or vitamin D supplementation on vascular outcomes: a meta-analysis of randomized controlled trials. Int J Cardiol 2013; 169:106-11. [PMID: 24035175 DOI: 10.1016/j.ijcard.2013.08.055] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 08/07/2013] [Accepted: 08/18/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND Whether calcium or vitamin D supplementation reduces serious vascular outcomes in older people remains unclear. We conducted a meta-analysis based on randomized controlled trials to evaluate the effect of calcium or vitamin D supplementation on the risk of major cardiovascular outcomes. METHODS We performed electronic searches in PubMed, Embase, and the Cochrane Library to identify relevant randomized controlled trials. Odds ratios (ORs) were used to measure the effect of calcium or vitamin D supplementation on the risk of major vascular outcomes with a random-effect model. RESULTS Of the 1643 identified studies, we included 11 trials reporting data on 50,252 individuals. These studies reported 2685 major cardiovascular events, 1097 events of myocardial infarction, and 1350 events of stroke. Calcium or vitamin D supplementation did not have an effect on major cardiovascular events (OR, 1.03; 95% confidence interval [CI]: 0.94-1.12; P=0.54), myocardial infarction (OR, 1.08; 95% CI: 0.96-1.22; P=0.21), or stroke (OR, 1.01; 95% CI: 0.91-1.13; P=0.80) when compared to the effect with a placebo. Subgroup analysis indicated that calcium supplementation alone might play an important role in increasing the risk of major cardiovascular events, myocardial infarction, and stroke, but this difference could not be identified as statistically significant. Furthermore, males seem to experience more harmful effects with supplements of calcium or vitamin D than the effects experienced by females. CONCLUSIONS Calcium supplementation might increase the risk of major cardiovascular events, myocardial infarction, and stroke compared to the risk with a placebo.
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Affiliation(s)
- Pei-Juan Mao
- Department of VIP Special Clinic, Shanghai Seventh People's Hospital, Shanghai, China
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5
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Goltz L, Degenhardt G, Maywald U, Kirch W, Schindler C. Evaluation of a program of integrated care to reduce recurrent osteoporotic fractures. Pharmacoepidemiol Drug Saf 2013; 22:263-70. [DOI: 10.1002/pds.3399] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 10/16/2012] [Accepted: 12/04/2012] [Indexed: 12/20/2022]
Affiliation(s)
- Lisa Goltz
- Institute of Clinical Pharmacology, Medical Faculty; Technical University Dresden; Fiedlerstrasse 27 D- 01307 Dresden Germany
| | - Gabriel Degenhardt
- Institute of Clinical Pharmacology, Medical Faculty; Technical University Dresden; Fiedlerstrasse 27 D- 01307 Dresden Germany
| | - Ulf Maywald
- AOK PLUS; Sternplatz 7 D- 01067 Dresden Germany
| | - Wilhelm Kirch
- Institute of Clinical Pharmacology, Medical Faculty; Technical University Dresden; Fiedlerstrasse 27 D- 01307 Dresden Germany
| | - Christoph Schindler
- Institute of Clinical Pharmacology, Medical Faculty; Technical University Dresden; Fiedlerstrasse 27 D- 01307 Dresden Germany
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6
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Simoens S. Public health and prevention in Europe: is it cost-effective? JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2011. [DOI: 10.1111/j.1759-8893.2011.00052.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Abstract
Objectives
In the public debate surrounding public health and prevention, it is sometimes assumed that preventive interventions are by definition cost-effective. This paper aims to explore whether preventive pharmaceutical interventions are more cost-effective than a curative approach to diseases.
Methods
A descriptive study identified European economic evaluations in the Tufts Medical Center Cost-Effectiveness Analysis Registry between 2000 and 2007. Data were extracted on publication year, target population, intervention, patient sample, disease, prevention stage and incremental cost-utility ratio of each economic evaluation. Preventive interventions were defined as measures preventing disease onset. Curative interventions related to measures identifying patients with risk factors or preclinical disease or interventions limiting disability after harm has occurred. Results were expressed in terms of costs (valued in Euros at 2008 prices) per quality-adjusted life year. The association between incremental cost-utility ratios and prevention stage was examined by means of the Mann–Whitney U test.
Key findings
The analysis included 231 studies that reported information about 608 incremental cost-effectiveness ratios. Preventive interventions included interventions that were more effective and less expensive than comparators (41% of incremental cost-effectiveness ratios), and interventions that improved outcomes and increased costs (59%). Both preventive and curative interventions covered the full range of cost-effectiveness results. However, preventive interventions had a significantly lower median ratio of €6255 per quality-adjusted life year and were thus more cost-effective than curative interventions (€12 917 per quality-adjusted life year) (P=0.002).
Conclusions
Although the cost-effectiveness of preventive interventions varies substantially, preventive interventions tended to be more cost-effective than curative interventions.
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Affiliation(s)
- Steven Simoens
- Research Centre for Pharmaceutical Care and Pharmaco-economics, Katholieke Universiteit Leuven, Leuven, Belgium
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Price MJ, Welton NJ, Briggs AH, Ades AE. Model averaging in the presence of structural uncertainty about treatment effects: influence on treatment decision and expected value of information. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2011; 14:205-218. [PMID: 21402291 DOI: 10.1016/j.jval.2010.08.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Revised: 08/27/2010] [Accepted: 08/30/2010] [Indexed: 05/30/2023]
Abstract
BACKGROUND Standard approaches to estimation of Markov models with data from randomized controlled trials tend either to make a judgment about which transition(s) treatments act on, or they assume that treatment has a separate effect on every transition. An alternative is to fit a series of models that assume that treatment acts on specific transitions. Investigators can then choose among alternative models using goodness-of-fit statistics. However, structural uncertainty about any chosen parameterization will remain and this may have implications for the resulting decision and the need for further research. METHODS We describe a Bayesian approach to model estimation, and model selection. Structural uncertainty about which parameterization to use is accounted for using model averaging and we developed a formula for calculating the expected value of perfect information (EVPI) in averaged models. Marginal posterior distributions are generated for each of the cost-effectiveness parameters using Markov Chain Monte Carlo simulation in WinBUGS, or Monte-Carlo simulation in Excel (Microsoft Corp., Redmond, WA). We illustrate the approach with an example of treatments for asthma using aggregate-level data from a connected network of four treatments compared in three pair-wise randomized controlled trials. RESULTS The standard errors of incremental net benefit using structured models is reduced by up to eight- or ninefold compared to the unstructured models, and the expected loss attaching to decision uncertainty by factors of several hundreds. Model averaging had considerable influence on the EVPI. CONCLUSIONS Alternative structural assumptions can alter the treatment decision and have an overwhelming effect on model uncertainty and expected value of information. Structural uncertainty can be accounted for by model averaging, and the EVPI can be calculated for averaged models.
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Affiliation(s)
- Malcolm J Price
- School of Social and Community-Based Medicine, University of Bristol, Bristol, UK.
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Kremers HM, Gabriel SE, Drummond MF. Principles of health economics and application to rheumatic disorders. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00003-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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9
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An evaluation of the NICE guidance for the prevention of osteoporotic fragility fractures in postmenopausal women. Arch Osteoporos 2010. [DOI: 10.1007/s11657-010-0045-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
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10
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Ohsfeldt RL. Estimating the cost effectiveness of alternative drug treatments for postmenopausal osteoporosis. Expert Rev Pharmacoecon Outcomes Res 2010; 4:637-44. [PMID: 19807537 DOI: 10.1586/14737167.4.6.637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The burden of postmenopausal osteoporosis is substantial and is likely to grow as the baby-boom generation ages. A greater understanding of the costs and clinical benefits of alternative therapies for postmenopausal osteoporosis is needed to develop informed health policies to reduce the future burden of osteoporosis. However, much of the data needed to evaluate the cost effectiveness of alternative therapies for postmenopausal osteoporosis are not available from clinical trials. Thus, cost-effectiveness models must cope with a high degree of uncertainty. This article provides a brief summary of the methodologic issues in cost-effectiveness analyses of current osteoporosis therapies, a review of the findings in published cost-effectiveness studies, and a discussion of challenges likely to be encountered in future economic evaluations of emerging osteoporosis therapies.
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Affiliation(s)
- Robert L Ohsfeldt
- University of Iowa, College of Public Health, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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11
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Risedronate versus alendronate in older patients with osteoporosis at high risk of fracture: an Italian cost-effectiveness analysis. Aging Clin Exp Res 2010; 22:179-88. [PMID: 20145427 DOI: 10.1007/bf03324794] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND AIMS This evaluation of the cost-effectiveness of risedronate vs generic alendronate is based on effectiveness data from a large real practice study. Applying a published cost-effectiveness model, we found that risedronate is cost-effective vs generic alendronate in an Italian population aged > or =65 years, and becomes dominant, saving costs and avoiding fractures, in patients aged > or =75 years. The aim of this work was to assess the cost-effectiveness and health utility of risedronate vs generic alendronate in clinical practice in Italy, using effectiveness data from the REAL study. METHODS A pre-existing model of osteoporosis was used to predict numbers of fractures, quality-adjusted life-years (QALYs), and costs associated with risedronate or alendronate treatment in post-menopausal (PMO) women aged > or =65 years with a previous vertebral fracture, within the Italian National Health System (NHS). Duration of treatment with risedronate or alendronate was assumed to occur for one year and patients were followed for an additional five years to capture longterm costs and outcomes, with a discount rate of 3% for costs and outcomes. Comprehensive sensitivity analyses were run. RESULTS The lower fracture rate among risedronate patients with respect to alendronate patients resulted in savings of euro 19,083, a reduction of 8.91 hip fractures and an associated benefit of 7.46 QALYs, in an Italian cohort of 1,000 patients. Sensitivity analyses confirmed the robustness of these results. CONCLUSIONS This economic analysis showed that risedronate is a cost-effective treatment in a population of Italian women aged 65 years and older at high risk of PMO-related fractures. Risedronate becomes dominant over generic alendronate in patients of 75 years or older and its cost-effectiveness even appears improved in patients with BMD score < or = -3 or < or = -3.5, with/without maternal history of fractures. Risedronate should be considered as a cost-effective option vs generic alendronate, in the Italian NHS' perspective.
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Borgström F, Ström O, Coelho J, Johansson H, Oden A, McCloskey EV, Kanis JA. The cost-effectiveness of risedronate in the UK for the management of osteoporosis using the FRAX. Osteoporos Int 2010; 21:495-505. [PMID: 19565175 DOI: 10.1007/s00198-009-0989-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Accepted: 04/23/2009] [Indexed: 11/24/2022]
Abstract
SUMMARY The study estimated the cost-effectiveness of risedronate compared to no treatment in UK women using the FRAX algorithm for fracture risk assessment. A Markov cohort model was used to estimate the cost-effectiveness. Risedronate was found cost-effective from the age of 65 years, assuming a willingness to pay for a QALY of 30,000 pounds. INTRODUCTION The aim of this study was to assess the cost-effectiveness of risedronate for the prevention and treatment in a UK setting using the FRAX algorithm for fracture risk assessment. A further aim was to establish intervention thresholds with risedronate treatment. METHODS The cost-effectiveness of risedronate was compared to no treatment in post-menopausal women with clinical risk factors for fracture using a Markov cohort model populated with data relevant for the UK. The model incorporated the features of FRAX (the WHO risk assessment tool). The analysis had a health care perspective and quality adjusted life years was used as the main outcome measure. RESULTS Treatment was cost-effective from the age of 65 years, assuming a willingness to pay for a QALY of 30,000 pounds. Treatment was also cost-effective at all ages in women who had previously sustained a fragility fracture or in women with a parental history of hip fracture with a bone mineral density set at the threshold of osteoporosis. At the 30,000 pounds threshold value for a QALY, risedronate was on average found to cost-effective below the 10-year probability of a major osteoporotic fractures of 13.0%. CONCLUSIONS Risedronate is a cost-effective agent for the treatment of established osteoporosis (osteoporosis and a prior fragility fracture) in women from the age of 50 years and older and above 65 years in women with osteoporosis alone. The results support the treatment recommendations in recent UK guidelines for osteoporosis.
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Affiliation(s)
- F Borgström
- Medical Management Centre, Karolinska Institute, Stockholm, Sweden.
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13
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Fleurence RL, Spackman DE, Hollenbeak C. Does the funding source influence the results in economic evaluations? A case study in bisphosphonates for the treatment of osteoporosis. PHARMACOECONOMICS 2010; 28:295-306. [PMID: 20222753 DOI: 10.2165/11530530-000000000-00000] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Research sponsored by the pharmaceutical industry is often assumed to be more likely to report favourable cost-effectiveness results. To determine whether there was a relationship between the source of funding and the reporting of positive results. We conducted a systematic review of the literature to identify economic evaluations of bisphosphonates for the treatment of osteoporosis. We extracted the source of funding, region of study, the journal name and impact factor, and all reported incremental cost-effectiveness ratios (ICERs). We identified which ICERs were under the thresholds of $US20 000, $US50 000 and $US100 000 per QALY. A quality score between 0 and 7 was also given to each of the studies. We used generalized estimating equations for the analysis. The systematic review yielded 532 potential abstracts; 17 of these met our final eligibility criteria. Ten studies (59%) were funded by non-industry sources. A total of 571 ICERs were analysed. There was no significant difference between the number of industry- and non-industry-funded studies reporting ICERs below the thresholds of $US20 000 and $US50 000. However, industry-sponsored studies were more likely to report ICERs below $US100 000 (odds ratio = 4.69, 95% CI 1.77, 12.43). Studies of higher methodological quality (scoring >4.5 of 7) were less likely to report ICERs below $US20 000 and $US50 000 than studies of lower methodological quality (scores <4). Methodological quality was not significantly different between studies reporting ICERs under $US100 000. In this relatively small sample of studies of bisphosphonates, the funding source (industry vs non-industry) did not seem to significantly affect the reporting of ICERs below the $US20 000 and $US50 000 thresholds. We hypothesize that methodological quality might be a more significant factor than the source of funding in differentiating which studies are likely to report favourable ICERs, with the higher-quality studies significantly less likely to report ICERs below $US20 000 and $US50 000 per QALY. Further research should explore this finding.
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Affiliation(s)
- Rachael L Fleurence
- United BioSource Corporation, 7101 Wisconsin Avenue, Bethesda, MD 20814, USA.
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14
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Thompson M, Pasquale M, Grima D, Moehrke W, Kruse HP. The impact of fewer hip fractures with risedronate versus alendronate in the first year of treatment: modeled German cost-effectiveness analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2010; 13:46-54. [PMID: 19883401 DOI: 10.1111/j.1524-4733.2009.00666.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND The Risedronate and Alendronate (REAL) cohort study provides unique comparative effectiveness data for real world bisphosphonate treatment of osteoporosis. OBJECTIVE The objective of this analysis was to assess the cost-effectiveness of risedronate compared to generic alendronate in Germany applying the REAL effectiveness data. MATERIALS AND METHODS A validated Markov model of osteoporosis was populated with REAL effectiveness data and German epidemiological, cost, and utility data. To estimate the impact of therapy on hip fractures, costs, and quality adjusted life years (QALYs), the analysis included women>or=65 years, treated with risedronate or alendronate and followed for 4 additional years. Country-specific data included population mortality, fracture costs, and annual drug costs, using a German social insurance perspective. Costs and outcomes were discounted at 3%. A differential hip fracture relative risk reduction of 43% was applied to risedronate vs. alendronate. RESULTS The model predicted that treatment with risedronate would result in fewer hip fractures and more QALYs at a reduced cost (savings of euro278 per treated woman) compared to treatment with generic alendronate. Sensitivity analysis assuming 2 years of treatment and equivalence of effect after 1 year show cost savings as well (euro106 per treated woman). DISCUSSION Whereas previous economic evaluations involving bisphosphonates have mainly relied on efficacy data from noncomparative clinical trials, this study's strength is in the use of comparative effectiveness data from one data source. The magnitude of the cost savings observed were sensitive to alternative assumptions regarding treatment duration, therapy discontinuation and cost of generic alendronate. CONCLUSIONS Based on "real world" data the analysis supports the first line use of risedronate for the treatment of osteoporotic women in Germany.
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15
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Iglesias CP, Manca A, Torgerson DJ. The health-related quality of life and cost implications of falls in elderly women. Osteoporos Int 2009; 20:869-78. [PMID: 18846400 DOI: 10.1007/s00198-008-0753-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Accepted: 08/25/2008] [Indexed: 10/21/2022]
Abstract
SUMMARY Fractures and falls are serious cause of morbidity and cost to society. Our results suggest that the main burden to morbidity, measured as impact on health-related quality of life, is due to fear of falling rather than falls or their sequelae, such as fractures. INTRODUCTION Fractures and falls are serious cause of morbidity and cost to society. We investigated the impact on health-related quality of life (HRQoL) associated with falls, fractures and fear of falling and falls and fractures cost. METHODS Three datasets providing longitudinal data on fear of falling, HRQoL and a common set of baseline risk factors for fracture (smoking status, weight and age) were analysed. Multilevel random effects models were used to estimate the long-term impact on HRQoL associated with falls, fractures and fear of falling. Healthcare resource use primary data were collected to estimate falls and fractures cost. RESULTS Older, low weight and smoking women reported lower HRQoL. The impact on HRQoL of a fracture was at least twice as large as that associated with falls. The largest negative effect on HRQoL was associated with self-reported fear of falling. The cost of falls was 1088 pounds. Similarly, the cost of falls leading to a fracture was 15,133 pounds, 2,753 pounds, 1,863 pounds, 1,331 pounds and 3,498 pounds for hip, wrist, arm, vertebral and other fractures, respectively. DISCUSSION The main burden to morbidity is due to fear of falling. Interventions aimed at reducing fear of falling may produce larger gains in HRQoL.
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Affiliation(s)
- C P Iglesias
- Department of Health Sciences, University of York, Seebohm Rowntree Building Room 148, York YO10 5DD, UK.
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16
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Mansel R, Locker G, Fallowfield L, Benedict A, Jones D. Cost-effectiveness analysis of anastrozole vs tamoxifen in adjuvant therapy for early stage breast cancer in the United Kingdom: the 5-year completed treatment analysis of the ATAC ('Arimidex', Tamoxifen alone or in combination) trial. Br J Cancer 2007; 97:152-61. [PMID: 17622238 PMCID: PMC2360294 DOI: 10.1038/sj.bjc.6603804] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2006] [Revised: 04/23/2007] [Accepted: 04/23/2007] [Indexed: 11/23/2022] Open
Abstract
Results from the completed treatment analysis of the ATAC (Arimidex, Tamoxifen alone or in combination) trial indicated that anastrozole was significantly superior to tamoxifen in terms of efficacy and safety in the adjuvant treatment of postmenopausal women with hormone receptor-positive (HR+) early breast cancer. On the basis of these results, this study estimated the cost-effectiveness of anastrozole vs tamoxifen, from the perspective of the UK National Health Service (NHS). A Markov model was developed using the 5-year completed treatment analysis from the ATAC trial (ISRCTN18233230), as well as data obtained from published literature and expert opinion. Resource utilisation data and associated costs (2003-4 UK pound) were compiled from standard sources and expert opinion. Utility scores for a number of health states were obtained from a cross-sectional study of 26 representative patients using the standard gamble technique. The utility scores were then inserted into the model to obtain cost per quality adjusted life-year (QALY) gained. Costs and benefits were discounted at recommended annual rates of the UK Treasury (3.5%). Modelled for 25 years, anastrozole, relative to generic tamoxifen, was estimated to result in 0.244 QALYs gained per patient at an additional cost of pound4315 per patient). The estimated incremental cost-effectiveness of anastrozole compared with tamoxifen was pound17 656 per QALY gained. There was a greater than 90% probability that the cost-effectiveness of anastrozole was below pound30 000 per QALY gained and of the order of 65% that it was below pound20 000 per QALY gained. The results were robust to all parameters tested in sensitivity analysis. Compared with commonly accepted thresholds, anastrozole is a cost-effective alternative to generic tamoxifen in adjuvant treatment of postmenopausal women with HR+ early breast cancer from the UK NHS perspective.
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Affiliation(s)
- R Mansel
- Department of Surgery, Wales College of Medicine, Cardiff University, Heath Park, Cardiff, UK.
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17
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Kennedy CC, Papaioannou A, Adachi JD. Treating osteoporosis: economic aspects of bisphosphonate therapy. Expert Opin Pharmacother 2007; 7:1457-67. [PMID: 16859429 DOI: 10.1517/14656566.7.11.1457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Each year, fractures associated with osteoporosis place a significant burden on healthcare spending and result in unnecessary morbidity, mortality and reductions in quality of life for individual patients. Several treatments are available that can improve the course of this chronic bone disease, and lead to significant reductions in fractures. Bisphosphonates have proven efficacy, are widely available and currently recommended as the first-line of therapy for osteoporosis in many practice guidelines. In addition to demonstrating clinical benefit, from a health-policy perspective, the economic benefits regarding prevention and treatment must be established. In recent years, several health economic studies have examined the cost-effectiveness and cost-utility of bisphosphonates in various patient groups. This paper reviews a number of these studies regarding the economic benefits of treating osteoporosis with bisphosphonates and considers for whom prevention and/or treatment is most warranted.
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Zethraeus N, Borgström F, Ström O, Kanis JA, Jönsson B. Cost-effectiveness of the treatment and prevention of osteoporosis--a review of the literature and a reference model. Osteoporos Int 2007; 18:9-23. [PMID: 17093892 DOI: 10.1007/s00198-006-0257-0] [Citation(s) in RCA: 149] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2006] [Accepted: 10/11/2006] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The purpose of the paper is to update and review the latest developments related to modelling and economic evaluation of osteoporosis in the period 2002-2005 and further to present a reference model for the assessment of the cost-effectiveness of the prevention and treatment of osteoporosis. DISCUSSION The reference model is intended to be used for fracture specific interventions affecting the risk of fracture. An interface version and an extensive description of the model is available on the internet ( http://www.healtheconomics.se ) and also accessible via the International Osteoporosis Foundation ( http://www.osteofound.org ). The purpose of the reference model is to improve the quality and comparability of cost-effectiveness analysis in the osteoporosis field and to serve as a tool for validation of present and future cost-effectiveness models. The reference model allows the cost-effectiveness analysis to be carried out from a societal perspective including intervention, morbidity and mortality costs. The model has been extensively tested and calibrated, and meets the properties of good decision analytic modelling. The model is a state transition Markov cohort model, which is characterised by a 50-year time horizon divided into one year cycle lengths. The following health states are included: "healthy", "hip fracture", "spine fracture", "wrist fracture", "other fracture", and "dead". CONCLUSION The model is flexible and allows for the estimation of the cost-effectiveness over different ranges for a selected number of variables (e.g., age, fracture risk, cost of intervention).
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Affiliation(s)
- N Zethraeus
- Centre for Health Economics, Stockholm School of Economics, P.O. Box 6501, S-113 83 Stockholm, Sweden.
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Häussler B, Gothe H, Göl D, Glaeske G, Pientka L, Felsenberg D. Epidemiology, treatment and costs of osteoporosis in Germany--the BoneEVA Study. Osteoporos Int 2007; 18:77-84. [PMID: 17048064 DOI: 10.1007/s00198-006-0206-y] [Citation(s) in RCA: 166] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2006] [Accepted: 07/10/2006] [Indexed: 12/18/2022]
Abstract
INTRODUCTION In Germany, accurate data on the prevalence and treatment of osteoporosis, as well as the cost of this illness, are not available. The aim of this study is to give a valid estimation of these items for the year 2003. METHODS Routine data from a German sickness fund covering 1.5 million beneficiaries and billing data for outpatient visits were used to obtain estimates of prevalence for osteoporosis. Claims data for patients with osteoporosis (M80, M81) or an osteoporosis-related fracture diagnosis (S22, S32, S42, S52, S72, S82) or treatment with anti-osteoporosis drugs were examined. Costs were calculated from the perspective of the German health insurance system and the German nursing care insurance system, respectively. Only direct costs of osteoporosis were considered. RESULTS In 2003, 7.8 million Germans (6.5 million women) were affected by osteoporosis. Of them, 4.3% experienced at least one clinical fracture. Only 21.7% were treated with an anti-osteoporosis drug. The total direct costs attributable to osteoporosis amounted to euros 5.4 billion. CONCLUSION This study confirms that osteoporosis is underdiagnosed, undertreated and imposes a considerable economic burden on the health system in Germany. Effective strategies for the prevention and management of this disease are needed.
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Affiliation(s)
- B Häussler
- IGES Institute for Healthcare and Social Research Ltd., Wichmannstrasse 5, 10787 Berlin, Germany.
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Schousboe JT, Ensrud KE, Nyman JA, Kane RL, Melton LJ. Cost-effectiveness of vertebral fracture assessment to detect prevalent vertebral deformity and select postmenopausal women with a femoral neck T-score>-2.5 for alendronate therapy: a modeling study. J Clin Densitom 2006; 9:133-43. [PMID: 16785071 DOI: 10.1016/j.jocd.2005.11.004] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2005] [Revised: 10/07/2005] [Accepted: 11/01/2005] [Indexed: 01/13/2023]
Abstract
Most fractures occur in postmenopausal women who do not have osteoporosis by bone density criteria (T-score>-2.5). Prevalent vertebral deformity is a strong risk factor for incident fractures independent of bone mineral density, yet the majority of these deformities are clinically unapparent. Spine imaging on a dual-energy densitometer, called vertebral fracture assessment (VFA), can accurately detect these deformities. The purpose of this modeling study was to estimate the lifetime societal costs and health benefits of VFA and confirmatory follow-up radiography to detect prevalent vertebral deformity in osteopenic (T-score -1.5, -2.0, or -2.4) postmenopausal women, followed by anti-resorptive drug therapy for those with one or more deformities. We compared three strategies; no initial drug therapy, 5 yr of initial alendronate therapy, or VFA followed by 5 yr of alendronate therapy in those with one or more vertebral deformities confirmed on radiography (VFA strategy). Results for the base-case analyses showed that the cost per quality adjusted life year (QALY) gained for the VFA strategy relative to no initial drug therapy ranged from 18,000 US dollars (for a 60-yr-old with a femoral neck T-score of -2.4) to 77,000 US dollars (for an 80-yr-old with a T-score of -1.5). VFA with selective confirmatory radiography is cost-effective, assuming a societal willingness to pay per QALY gained of 50,000 US dollars, for postmenopausal women aged 60 to 80 yr with femoral neck T-scores between -2.0 and -2.4, and for women age 60 or 70 yr with a T-score of -1.5. Assuming a societal willingness to pay of 100,000 US dollars per QALY gained, VFA is also cost-effective for women age 80 yr with a T-score of -1.5. These conclusions are robust to reasonable changes in fracture rates, assumed fracture disutility, discount rates, relative risk of fracture attributable to vertebral deformity, alendronate cost, and drug adherence.
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Borgström F, Carlsson A, Sintonen H, Boonen S, Haentjens P, Burge R, Johnell O, Jönsson B, Kanis JA. The cost-effectiveness of risedronate in the treatment of osteoporosis: an international perspective. Osteoporos Int 2006; 17:996-1007. [PMID: 16570118 DOI: 10.1007/s00198-006-0094-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2005] [Accepted: 02/15/2006] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Risedronate, a bisphosphonate for treatment and prevention of osteoporosis, has been shown in several clinical trials to reduce the risk of fractures in postmenopausal women with osteoporosis. The cost-effectiveness of risedronate treatment has previously been evaluated within different country settings using different model and analysis approaches. The objective of this study was to assess the cost-effectiveness of risedronate in postmenopausal women in four European countries -- Sweden, Finland, Spain, and Belgium -- by making use of the same modelling framework and analysis setup. METHODS A previously developed Markov cohort model for the evaluation of osteoporosis treatments was used to estimate the cost-effectiveness of risedronate treatment. For each country, the model was populated with local mortality, fracture incidence, and cost data. Hip fractures, clinical vertebral fractures, and wrist fractures were included in the model. RESULTS The incremental cost per quality-adjusted life years (QALY) gained from a 5-year intervention with risedronate compared to "no intervention" in 70-year-old women at the threshold of osteoporosis [T-score = -2.5 based on National Health and Nutrition Examination Survey (NHANES) III data] and previous vertebral fracture was estimated to be euro 860, euro 19,532, euro 11,782, and euro 32,515 in Sweden, Finland, Belgium, and Spain, respectively. Among 70-year-old women at the threshold of osteoporosis without previous fracture the estimated cost per QALY gained ranged from euro 21,148 (Sweden) to euro 80,100 (Spain). The differences in cost-effectiveness between countries are mainly explained by different costs (fracture and treatment costs), fracture risks, and discount rates. Based on cost per QALY gained threshold values found in the literature, the study results indicated risedronate to be cost effective in the treatment of elderly women with established osteoporosis in all the included countries. CONCLUSIONS At a hypothetical threshold value of euro 40,000 per QALY gained, the results in this study indicate that risedronate is a cost-effective treatment in elderly women at the threshold of osteoporosis (i.e., a T-score of -2.5) with prevalent vertebral fractures in Sweden, Finland, Belgium, and Spain.
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Affiliation(s)
- F Borgström
- Stockholm Health Economics, Klarabergsgatan 333tr, SE-111 21, Stockholm, Sweden.
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22
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Fleurence RL, Iglesias CP, Torgerson DJ. Economic evaluations of interventions for the prevention and treatment of osteoporosis: a structured review of the literature. Osteoporos Int 2006; 17:29-40. [PMID: 15981019 DOI: 10.1007/s00198-005-1943-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2005] [Accepted: 05/03/2005] [Indexed: 12/31/2022]
Abstract
Economic evaluations are increasingly being used by decision-makers to estimate the cost-effectiveness of interventions. The objective of this study was to conduct a structured review of economic evaluations of interventions to prevent and treat osteoporosis. Articles were identified independently by two reviewers through searches on MEDLINE, the bibliographies of reviews and identified economic models, and expert opinion, using predefined inclusion and exclusion criteria. Data on country, type and level of interventions, type of fractures, interventions, study population and the authors' stated conclusions were extracted. Forty-two relevant studies were identified. The majority of studies (71%) were conducted in Sweden, the UK and the US. The main interventions investigated were hormone replacement therapy (27%), bisphosphonates (17%) and combinations of vitamin D and calcium (16%). In 38% of studies, hip fracture was the sole fracture outcome. Eighty-eight percent (88%) of studies investigated female populations only. A relatively large number of economic evaluations were identified in the field of osteoporosis. Major changes have recently occurred in the treatment of this disease, following the publication of the results of the Women's Health Initiative trial. Methodological developments in economic evaluations, such as the use of probabilistic sensitivity analysis and cost-effectiveness acceptability curves, have also taken place. Such changes are reflected in the studies that were reviewed. The development of economic models should be an iterative process that incorporates new information, whether clinical or methodological, as it becomes available.
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Schousboe JT, Ensrud KE, Nyman JA, Kane RL, Melton LJ. Potential cost-effective use of spine radiographs to detect vertebral deformity and select osteopenic post-menopausal women for amino-bisphosphonate therapy. Osteoporos Int 2005; 16:1883-93. [PMID: 16133649 DOI: 10.1007/s00198-005-1956-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2004] [Accepted: 05/19/2005] [Indexed: 11/30/2022]
Abstract
Prevalent vertebral deformities are predictive of future clinical fractures independent of bone density. We used a Markov model with eight health states to estimate from the societal perspective the cost-effectiveness of using spine radiographs to identify postmenopausal women age 60 or older with one or more vertebral deformities and then treat them with anti-resorptive drug therapy to prevent fractures. We compared three strategies: 5 years of amino-bisphosphonate (alendronate) therapy for all, 5 years of alendronate therapy for only those with prevalent a radiographic vertebral deformity or no initial alendronate treatment. Lifetime direct medical and indirect costs, quality adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) were tracked. For women with one or more prevalent vertebral deformities, the costs per QALY gained ranged from 5,084 dollars (for an 80 year old with a T-score of -2.4) to 61,192 dollars (for a 60 year old with a T-score of -1.0). For women without prevalent vertebral deformity, the costs per QALY gained ranged from 41,897 dollars (for a 60 year old with a T-score of -2.4) to 166,219 dollars (for an 80 year old with a T-score of -1.0). These results were modestly sensitive to reasonable changes in fracture rates, disutility, discount rates and assumptions about the accuracy of spinal radiographs for detecting vertebral deformity. Assuming a societal willingness to pay per QALY gained of 50,000 dollars, the strategy of performing spine radiographs in post-menopausal osteopenic women with T-scores at or below -1.5 and treating those with 1 or more prevalent vertebral deformities is likely to be cost-effective. However, further research on the accuracy of vertebral deformity ascertainment from routine clinical radiographs and on the efficacy of amino-bisphosphonate drugs for reducing the risk of non-vertebral fractures in osteopenic women is needed to define more precisely the subset of osteopenic post-menopausal women in whom use of spinal radiographs is most cost-effective.
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Schousboe JT, Ensrud KE, Nyman JA, Melton LJ, Kane RL. 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; 53:1697-704. [PMID: 16181168 DOI: 10.1111/j.1532-5415.2005.53504.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To investigate the cost-effectiveness of universal bone densitometry in women aged 65 and older combined with alendronate treatment for those diagnosed with osteoporosis (femoral neck T-score < or = -2.5). DESIGN A Markov model with a lifetime time horizon and eight health states (no fracture, distal forearm fracture, radiographic (but clinically inapparent) vertebral fracture, clinical vertebral fracture, hip fracture, hip and vertebral fracture, and other fractures), using the societal perspective. SETTING Women living independently and those in nursing homes. PARTICIPANTS Caucasian women aged 65, 75, 85, or 95. INTERVENTION Bone densitometry of the hip, with 5 years of alendronate therapy for those found to have osteoporosis versus no intervention (densitometry or drug therapy). MEASUREMENTS Lifetime accumulated quality adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios. RESULTS The cost per QALY gained for the screen-and-treat strategy was 43,000 dollars per QALY gained for 65-year-old women and 5,600 dollars per QALY gained for 75-year-old women. For 85- and 95-year-old women, the screen-and-treat strategy was cost saving. Sensitivity analyses showed that the screen-and-treat strategy was cost-effective even under assumptions of reduced adherence to drug therapy, reduced fracture reduction benefit from alendronate therapy, or reduced QALYs saved by preventing fracture. CONCLUSION Universal bone densitometry combined with alendronate therapy for those found to have osteoporosis is highly cost-effective for women aged 65 and older and may be cost saving for ambulatory women aged 85 and older (whether independently living or residing in nursing homes).
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Affiliation(s)
- John T Schousboe
- Park Nicollet Health Services, Minneapolis, Minnesota 55416, USA.
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25
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Stern N, Korotkova M, Strandvik B, Oxlund H, Oberg M, Håkansson H, Lind PM. Cost-effectiveness of alendronate in the prevention of osteoporotic fractures in Danish women. Basic Clin Pharmacol Toxicol 2005; 96:453-64. [PMID: 15910409 DOI: 10.1111/j.1742-7843.2005.pto_08.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Pharmacological interventions for osteoporosis may reduce morbidity and mortality, but they incur additional health care costs. The aim was to quantify the additional costs and health benefits of prescribing alendronate 10 mg and calcium/vitamin D daily for 71-year-old women with a fracture risk twice that of the population average in stead of calcium/vitamin D alone. A state transition model based primarily on Scandinavian data was developed. Women were followed from age of 71 years until 100. Alendronate was assumed to reduce the fracture risk by 50%. Health benefits from the interventions were expressed in terms of life years, quality adjusted life years, and fractures avoided. Societal costs were estimated using literature estimates and Danish tariffs. All costs were measured in 2002 Danish Kroner (DKK). Future costs and benefits were discounted at 5% per year. The incremental cost per QALY gained was DKK125,000 while the cost per life year gained was DKK 374,000. The use of alendronate was cost-saving when 1) the treatment was extended to five years, 2) the risk of fracture was four times the population average, 3) the effect of alendronate was assumed to persist for three years after discontinuation of treatment, 4) a greater proportion had severe sequelae after a hip fracture, or 5) the start of therapy was delayed until age of 77 years. In conclusion, the use of alendronate compares well with other well established therapies in terms of cost-effectiveness in older women with high risk of fracture.
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Affiliation(s)
- Natalia Stern
- Institute of Environmental Medicine, Karolinska Institutet, A-17177 Stockholm, Sweden
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Grant AM, Avenell A, Campbell MK, McDonald AM, MacLennan GS, McPherson GC, Anderson FH, Cooper C, Francis RM, Donaldson C, Gillespie WJ, Robinson CM, Torgerson DJ, Wallace WA. Oral vitamin D3 and calcium for secondary prevention of low-trauma fractures in elderly people (Randomised Evaluation of Calcium Or vitamin D, RECORD): a randomised placebo-controlled trial. Lancet 2005; 365:1621-8. [PMID: 15885294 DOI: 10.1016/s0140-6736(05)63013-9] [Citation(s) in RCA: 581] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Elderly people who have a fracture are at high risk of another. Vitamin D and calcium supplements are often recommended for fracture prevention. We aimed to assess whether vitamin D3 and calcium, either alone or in combination, were effective in prevention of secondary fractures. METHODS In a factorial-design trial, 5292 people aged 70 years or older (4481 [85%] of whom were women) who were mobile before developing a low-trauma fracture were randomly assigned 800 IU daily oral vitamin D3, 1000 mg calcium, oral vitamin D3 (800 IU per day) combined with calcium (1000 mg per day), or placebo. Participants who were recruited in 21 UK hospitals were followed up for between 24 months and 62 months. Analysis was by intention-to-treat and the primary outcome was new low-energy fractures. FINDINGS 698 (13%) of 5292 participants had a new low-trauma fracture, 183 (26%) of which were of the hip. The incidence of new, low-trauma fractures did not differ significantly between participants allocated calcium and those who were not (331 [12.6%] of 2617 vs 367 [13.7%] of 2675; hazard ratio (HR) 0.94 [95% CI 0.81-1.09]); between participants allocated vitamin D3 and those who were not (353 [13.3%] of 2649 vs 345 [13.1%] of 2643; 1.02 [0.88-1.19]); or between those allocated combination treatment and those assigned placebo (165 [12.6%] of 1306 vs 179 [13.4%] of 1332; HR for interaction term 1.01 [0.75-1.36]). The groups did not differ in the incidence of all-new fractures, fractures confirmed by radiography, hip fractures, death, number of falls, or quality of life. By 24 months, 2886 (54.5%) of 5292 were still taking tablets, 451 (8.5%) had died, 58 (1.1%) had withdrawn, and 1897 (35.8%) had stopped taking tablets but were still providing data for at least the main outcomes. Compliance with tablets containing calcium was significantly lower (difference: 9.4% [95% CI 6.6-12.2]), partly because of gastrointestinal symptoms. However, potentially serious adverse events were rare and did not differ between groups. INTERPRETATION The findings do not support routine oral supplementation with calcium and vitamin D3, either alone or in combination, for the prevention of further fractures in previously mobile elderly people.
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Affiliation(s)
- A M Grant
- Health Services Research Unit, University of Aberdeen, UK
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Kanis JA, Borgström F, Johnell O, Oden A, Sykes D, Jönsson B. Cost-effectiveness of raloxifene in the UK: an economic evaluation based on the MORE study. Osteoporos Int 2005; 16:15-25. [PMID: 15672210 DOI: 10.1007/s00198-004-1688-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2004] [Accepted: 06/04/2004] [Indexed: 10/26/2022]
Abstract
Raloxifene treatment has been shown to reduce the risk of vertebral fractures and breast cancer in postmenopausal women. The long-term economic implications of treatment with raloxifene have not yet been investigated. The aim of this study was to assess the cost-effectiveness of treating postmenopausal women in the UK with raloxifene. A previously developed computer simulation model was used to estimate the cost-effectiveness of osteoporotic treatments with extra skeletal benefits. The model was populated with epidemiological data and cost data relevant for a UK female population. Data on the effect of treatment were taken from the Multiple Outcomes of Raloxifene (MORE) study, which recruited women with low bone mineral density or with a prior vertebral fracture. Cost-effectiveness was estimated using Quality Adjusted Life Years (QALYs) and life years gained as primary outcome measures. The cost per QALY gained of treating postmenopausal women without prior vertebral fractures was 18,000 pounds, 23,000 pounds , 18,000 pounds and 21,000 pounds at 50, 60, 70 and 80 years of age. Corresponding estimates for women with prior vertebral fractures were 10,000 pounds, 24,000 pounds, 18,000 pounds and 20,000 pounds. In relation to threshold values that are recommended in the UK, the analysis suggests that raloxifene is cost-effective in the treatment of postmenopausal women at an increased risk of vertebral fractures.
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Affiliation(s)
- J A Kanis
- WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK.
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Kanis JA, Borgstrom F, Johnell O, Jonsson B. Cost-effectiveness of risedronate for the treatment of osteoporosis and prevention of fractures in postmenopausal women. Osteoporos Int 2004; 15:862-71. [PMID: 15175846 DOI: 10.1007/s00198-004-1643-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2004] [Accepted: 03/31/2004] [Indexed: 11/28/2022]
Abstract
Randomized, double-blind, controlled studies have shown that treatment with risedronate reduces the risk of vertebral fracture in postmenopausal women with established vertebral osteoporosis. They also show that the drug decreases the risk of non-vertebral fractures in women with osteoporosis. The aim of this study was to investigate the cost-effectiveness of risedronate in postmenopausal women with osteoporosis. A Markov model was applied to a UK setting. Treatment effects were computed by meta-analysis of randomized, controlled trials and given over 5 years to subjects aged between 60 and 80 years. Quality-adjusted life years (QALYs) and life years gained were used as outcome measures. Intervention with risedronate was cost-effective in women aged 60 years and older. Cost savings were also found for postmenopausal women aged 70 years and older with established vertebral osteoporosis (a prior spine fracture and BMD T-score < or =-2.5 SD). This treatment was cost-effective for women aged 65 years and older who had a prior vertebral fracture and a BMD T-score at the threshold of osteoporosis ( T-score=-2.5 SD), and in women with a T-score < or =-2.5 SD, but without a prior vertebral fracture. In women aged 60-80 years and at the threshold of osteoporosis ( T-score=-2.5 SD) but without a prior vertebral fracture, treatment exceeded the threshold for cost-effectiveness. However, if an additional, independent risk factor was assumed (e.g., corticosteroid use) treatment became cost-effective.
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Affiliation(s)
- J A Kanis
- WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, S10 2RX, Sheffield, UK.
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Torgerson DJ, Sykes D, Puffer S, Brown P, Cooper C. Pharmaceutical treatment of symptomatic vertebral fractures in primary care. Ann Rheum Dis 2004; 63:853-6. [PMID: 15194583 PMCID: PMC1755056 DOI: 10.1136/ard.2003.013508] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Vertebral fractures are associated with a reduction in quality of life and are an important predictor of other non-spine fractures. Previous work has shown that up to 60% of patients with a vertebral fracture identified in primary care remain untreated. OBJECTIVE To examine the prevalence of pharmaceutical treatment and predictors of treatment in a primary care setting. METHODS Case-control study using the general practice research database (GPRD). All women aged 50 years and over with a first diagnosis of a vertebral fracture since 1990 were identified and matched with a control by age and practice. Appropriate use of a pharmaceutical agent was defined as a prescription occurring within 30 days of the diagnosis being recorded. RESULTS We identified 2719 women with the same number of controls. Within 30 days of diagnosis 61% of women were prescribed treatment, compared with only 3% of the controls. Bisphosphonate was the single most important treatment prescribed. Predictors of any drug treatment included: year of fracture (most recent year increased the likelihood of treatment); age (younger patients were more likely to receive treatment); history of back pain; low body weight; history of steroid use. CONCLUSIONS Treatment of diagnosed vertebral fractures is becoming more common. Treated patients tend to be younger but to have a higher prevalence of clinical risk factors than untreated patients. There remain significant numbers of patients who are not offered treatment.
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Affiliation(s)
- D J Torgerson
- Department of Health Sciences, University of York, York YO10 5DD.
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31
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Mathoo JMR, Cranney A, Papaioannou A, Adachi JD. Rational use of oral bisphosphonates for the treatment of osteoporosis. Curr Osteoporos Rep 2004; 2:17-23. [PMID: 16036078 DOI: 10.1007/s11914-004-0010-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Osteoporosis has become a major public health concern worldwide. Significant morbidity, mortality, and health expenditures are associated with osteoporotic fractures. Evidence from randomized controlled trials and meta- analyses supports the efficacy and safety of oral bisphosphonates as first-line pharmacologic agents for the prevention and treatment of osteoporosis. This article reviews the evidence demonstrating the beneficial effects of etidronate, alendronate, and risedronate on improving bone mass and preventing fractures in individuals with or at risk for osteoporosis. Issues surrounding dosing intervals and optimal duration of therapy are also discussed. We conclude that the nitrogen-containing bisphosphonates alendronate and risedronate are safe and efficacious agents in preventing and treating osteoporosis. They are superior to cyclical etidronate in improving appendicular bone mass, and in reducing future risk for nonvertebral fractures. Once-weekly dosing options with alendronate and risedronate are effective and reduce serious adverse drug effects, and therefore, are welcome additions to our therapeutic armamentarium.
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Affiliation(s)
- Julian M R Mathoo
- McMaster University, 201-25 Charlton Ave E., Hamiton, Ontario, L8N 1Y2 Canada
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32
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Borgström F, Johnell O, Kanis JA, Oden A, Sykes D, Jönsson B. Cost effectiveness of raloxifene in the treatment of osteoporosis in Sweden: an economic evaluation based on the MORE study. PHARMACOECONOMICS 2004; 22:1153-1165. [PMID: 15612833 DOI: 10.2165/00019053-200422170-00005] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
BACKGROUND The Multiple Outcomes of Raloxifene Evaluation (MORE) study showed that treatment with raloxifene reduces the risk of vertebral fracture and breast cancer in postmenopausal women with osteoporosis. OBJECTIVE Based on the MORE study the aim of the present study was to assess the cost effectiveness of raloxifene (compared with no treatment) for the treatment of osteoporosis in postmenopausal women in Sweden. DESIGN A revised version of a previously developed computer simulation model was used. The impact of the risk-reducing effect of raloxifene on vertebral fractures and breast cancer on cost effectiveness was analysed using a clinical and a morphometric definition of vertebral fracture. Benefits of raloxifene treatment were measured in quality-adjusted life-years (QALYs) and life-years gained. The study estimated the cost effectiveness mainly from a healthcare perspective but the cost effectiveness taking a societal perspective was also analysed. RESULTS Intervention costs (in Swedish kronor [SEK] and euros [euro], year 2001 values) in postmenopausal women with a relative risk of vertebral fracture of 2 were SEK372000 (euro40000), SEK303000 (euro33000) and SEK263000 (euro28000) per QALY for women aged 60, 70 and 80 years, at start of treatment, respectively, when the clinical vertebral definition was used. The cost effectiveness using a clinical morphometric vertebral fracture definition was similar to the cost effectiveness using a clinical vertebral fracture definition. CONCLUSIONS In relation to accepted threshold values for cost per QALY in Sweden, this model indicates, with its underlying assumptions and data, that raloxifene (compared with no treatment) is cost effective for the treatment of postmenopausal women at an increased risk of vertebral fracture, from the Swedish healthcare and societal perspectives.
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Affiliation(s)
- Fredrik Borgström
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
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Liberato NL, Marchetti M, Barosi G. Clinical and economic issues in the treatment of advanced breast cancer with bisphosphonates. Drugs Aging 2003; 20:631-42. [PMID: 12831288 DOI: 10.2165/00002512-200320090-00001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
An ideal palliative therapy for bone metastases would successfully reduce skeletal complications in several thousands of breast cancer patients. Second- and third-generation bisphosphonates are effective in reducing the overall skeletal complication rate and the time to first skeletal complication. Nevertheless, not enough evidence supports their benefit on quality of life. Furthermore, bisphosphonates are expensive (up to 775 US dollars per month, 2002 value) and cost-effectiveness evaluations have been limited to pamidronate (pamidronic acid). In economic evaluations of pamidronate, resulting incremental dollar per quality-adjusted life year gained ranged from cost savings to 108,000 US dollars per quality-adjusted life year. The data were quite sensitive to quality-of-life estimates and country-specific cost values. Because of the wide range of the cost-effectiveness ratio, it is uncertain whether the universal prescription of bisphosphonates in this setting represents an efficient use of healthcare resources. Probably, country- and drug-specific policies might increase the efficiency of this treatment. Further outcomes research is required to assess these agents more fully.
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Tella MN, Feinglass J, Chang RW. Cost-effectiveness, cost-utility, and cost-benefit studies in rheumatology: a review of the literature, 2001-2002. Curr Opin Rheumatol 2003; 15:127-31. [PMID: 12598799 DOI: 10.1097/00002281-200303000-00007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Economic analyses of prevention and treatment interventions in rheumatology are potentially powerful tools for evaluating many complex decisions facing clinical and public policy makers. Cost-effectiveness, cost-utility, and cost-benefit analyses allow for the assessment of the trade-offs between expended resources and expected health benefits. This review describes 12 cost-effectiveness analyses done in the past year. Each relates to a different intervention for a variety of rheumatologic conditions including osteoporosis, rheumatoid arthritis, the use of cyclooxygenase-II inhibitors, infected total joint replacements, back pain, and Lyme disease. While cost-effectiveness analyses of the use of the new biologic agents in rheumatoid arthritis have been presented at national meetings, these have yet to be published. Proper use of cost-effectiveness analysis could provide valuable evidence about treatment decisions for clinical and public policy makers in rheumatology.
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Affiliation(s)
- Mallik N Tella
- Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA
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