Which screening strategy using BMD measurements would be most cost effective for hip fracture prevention in elderly women? A decision analysis based on a Markov model

IntroductionHip fractures are responsible for excessive mortality, decreasing the 5-year survival rate by about 20%. From an economic perspective, they represent a major source of expense, with direct costs in hospitalization, rehabilitation, and institutionalization. The incidence rate sharply increases after the age of 70, but it can be reduced in women aged 70–80 years by therapeutic interventions. Recent analyses suggest that the most efficient strategy is to implement such interventions in women at the age of 70 years. As several guidelines recommend bone mineral density (BMD) screening of postmenopausal women with clinical risk factors, our objective was to assess the cost-effectiveness of two screening strategies applied to elderly women aged 70 years and older.MethodsA cost-effectiveness analysis was performed using decision-tree analysis and a Markov model. Two alternative strategies, one measuring BMD of all women, and one measuring BMD only of those having at least one risk factor, were compared with the reference strategy “no screening”. Cost-effectiveness ratios were measured as cost per year gained without hip fracture. Most probabilities were based on data observed in EPIDOS, SEMOF and OFELY cohorts.ResultsIn this model, which is mostly based on observed data, the strategy “screen all” was more cost effective than “screen women at risk.” For one woman screened at the age of 70 and followed for 10 years, the incremental (additional) cost-effectiveness ratio of these two strategies compared with the reference was 4,235 euros and 8,290 euros, respectively.ConclusionThe results of this model, under the assumptions described in the paper, suggest that in women aged 70–80 years, screening all women with dual-energy X-ray absorptiometry (DXA) would be more effective than no screening or screening only women with at least one risk factor. Cost-effectiveness studies based on decision-analysis trees maybe useful tools for helping decision makers, and further models based on different assumptions should be performed to improve the level of evidence on cost-effectiveness ratios of the usual screening strategies for osteoporosis.

[1]  O. Johnell,et al.  Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures , 1996 .

[2]  S. Wilson.  Methods for the economic evaluation of health care programmes , 1987 .

[3]  S. Cummings,et al.  Bone mineral density predicts non-spine fractures in very elderly women , 1994, Osteoporosis International.

[4]  O. Johnell,et al.  Ten Year Probabilities of Osteoporotic Fractures According to BMD and Diagnostic Thresholds , 2001, Osteoporosis International.

[5]  D. Hans,et al.  Risk factors for hip fracture in women with high BMD: EPIDOS study , 2005, Osteoporosis International.

[6]  O. Johnell,et al.  Ten-year risk of osteoporotic fracture and the effect of risk factors on screening strategies. , 2002, Bone.

[7]  S. Goemaere,et al.  Limited Clinical Utility of a Self-Evaluating Risk Assessment Scale for Postmenopausal Osteoporosis: Lack of Predictive Value of Lifestyle-Related Factors , 1999, Calcified Tissue International.

[8]  H. Meyer,et al.  Factors Associated with Mortality after Hip Fracture , 2000, Osteoporosis International.

[9]  Sundeep Khosla,et al.  Evaluation of a Prediction Model for Long‐Term Fracture Risk , 2004, Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research.

[10]  S. Gabriel,et al.  Health-related Quality of Life in Economic Evaluations for Osteoporosis , 1999, Medical decision making : an international journal of the Society for Medical Decision Making.

[11]  Jacques P. Brown,et al.  Evaluation of decision rules for referring women for bone densitometry by dual-energy x-ray absorptiometry. , 2001, JAMA.

[12]  W. O'Fallon,et al.  Long‐term fracture prediction by bone mineral assessed at different skeletal sites , 1993, Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research.

[13]  S. Cummings,et al.  Bone density at various sites for prediction of hip fractures , 1993, The Lancet.

[14]  Hahn Bh.  Osteoporosis: diagnosis and management. , 1988 .

[15]  S. Papapoulos,et al.  A New Approach to the Development of Assessment Guidelines for Osteoporosis , 2002, Osteoporosis International.

[16]  George R. Bergus,et al.  Medical Decision Making: Medical Decision Making , 2008 .

[17]  D. Hanley,et al.  The Canadian SCORE questionnaire: optimizing the use of technology for low bone density assessment. Simple Calculated Osteoporosis Risk Estimate. , 2000, Journal of clinical densitometry : the official journal of the International Society for Clinical Densitometry.

[18]  K. Ensrud,et al.  Universal Bone Densitometry Screening Combined with Alendronate Therapy for Those Diagnosed with Osteoporosis Is Highly Cost‐Effective for Elderly Women , 2005, Journal of the American Geriatrics Society.

[19]  G A Darlington,et al.  Development and validation of the Osteoporosis Risk Assessment Instrument to facilitate selection of women for bone densitometry , 2000 .

[20]  S. Gabriel,et al.  Impact of Hip and Vertebral Fractures on Quality-Adjusted Life Years , 2001, Osteoporosis International.

[21]  O. Johnell,et al.  Cost-Effectiveness of Preventing Hip Fracture in the General Female Population , 2001, Osteoporosis International.

[22]  François Duboeuf,et al.  Vitamin D3 and Calcium to Prevent Hip Fractures in Elderly Women , 1992 .

[23]  Niklas Zethraeus,et al.  Advantages of Using the Net-Benefit Approach for Analysing Uncertainty in Economic Evaluation Studies , 2003, PharmacoEconomics.

[24]  O Johnell,et al.  Intervention thresholds for osteoporosis. , 2002, Bone.

[25]  D. Hans,et al.  How Hip and Whole-Body Bone Mineral Density Predict Hip Fracture in Elderly Women: The EPIDOS Prospective Study , 1998, Osteoporosis International.

[26]  S. Cummings.  Prevention of hip fractures in older women: a population-based perspective. , 1998, Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA.

[27]  G. Dinant,et al.  Screening for Osteoporosis Using Easily Obtainable Biometrical Data: Diagnostic Accuracy of Measured, Self-Reported and Recalled BMI, and Related Costs of Bone Mineral Density Measurements , 2000, Osteoporosis International.

[28]  M. Weinstein,et al.  Foundations of cost-effectiveness analysis for health and medical practices. , 1977, The New England journal of medicine.

[29]  E. Lévy.  Cost analysis of osteoporosis related to untreated menopause , 1989, Clinical Rheumatology.

[30]  R. Rizzoli,et al.  Diagnosis and management of osteoporosis in postmenopausal women: clinical guidelines. International Committee for Osteoporosis Clinical Guidelines. , 1999, Clinical therapeutics.

[31]  M. Chapuy,et al.  Effect of calcium and cholecalciferol treatment for three years on hip fractures in elderly women , 1994, BMJ.

[32]  P Geusens,et al.  Effect of risedronate on the risk of hip fracture in elderly women. Hip Intervention Program Study Group. , 2001, The New England journal of medicine.

[33]  Dami,et al.  EFFECT OF RISEDRONATE ON THE RISK OF HIP FRACTURE IN ELDERLY WOMEN EFFECT OF RISEDRONATE ON THE RISK OF HIP FRACTURE IN ELDERLY WOMEN , 2001 .

[34]  P. Lips,et al.  Quality of life in patients with osteoporosis , 2005, Osteoporosis International.

[35]  C. Cooper,et al.  Comparison of the European and USA Practice Guidelines for Osteoporosis , 2000, Trends in Endocrinology & Metabolism.

[36]  R. Rizzoli,et al.  Diagnosis and management of osteoporosis in postmenopausal women: clinical guidelines. International Committee for Osteoporosis Clinical Guidelines. , 1999, Clinical therapeutics.

[37]  S. Watt.  [The cost of screening for breast and cervical cancer in France]. , 2003, Bulletin du cancer.

[38]  C. Baudoin,et al.  Fractures of the proximal femur in Picardy, France, in 1987 , 2005, Osteoporosis International.

[39]  J R Beck,et al.  Markov Models in Medical Decision Making , 1993, Medical decision making : an international journal of the Society for Medical Decision Making.

[40]  B. McGrory,et al.  Fractures of the Proximal Femur , 2002 .

[41]  C. Cooper,et al.  Guidelines for diagnosis and management of osteoporosis , 2005, Osteoporosis International.

[42]  O. Johnell,et al.  Cost-effectiveness of risedronate for the treatment of osteoporosis and prevention of fractures in postmenopausal women , 2004, Osteoporosis International.

[43]  C. Baudoin,et al.  Clinical outcomes and mortality after hip fracture: a 2-year follow-up study. , 1996, Bone.

[44]  Claus Christiansen,et al.  Diagnosis of Osteoporosis , 1992, Southern medical journal.

[45]  J. Kanis,et al.  Economic Evaluation of Interventions for Osteoporosis , 2002, Osteoporosis International.

[46]  J. Jensen,et al.  Long-term social prognosis after hip fractures. , 1982, Acta orthopaedica Scandinavica.

[47]  K. Pun,et al.  Loss of bone mass in patients with Klinefelter's syndrome despite sufficient testosterone replacement , 2005, Osteoporosis International.

[48]  F. Clavel-Chapelon,et al.  Estimated number of women likely to benefit from bone mineral density measurement in France. , 2004, Joint, bone, spine : revue du rhumatisme.

[49]  M. Chapuy,et al.  Calcium-vitamin D3 supplementation is cost-effective in hip fractures prevention. , 2003, Maturitas.

[50]  S. Cummings,et al.  Bone mineral density predicts non-spine fractures in very elderly women. Study of Osteoporotic Fractures Research Group. , 1994, Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA.

[51]  S. Cummings,et al.  Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures , 1996, The Lancet.

[52]  P. Vestergaard,et al.  Discordance Between Changes in Bone Mineral Density Measured at Different Skeletal Sites in Perimenopausal Women—Implications for Assessment of Bone Loss and Response to Therapy: The Danish Osteoporosis Prevention Study , 2001, Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research.

[53]  R. Écochard,et al.  Should age influence the choice of quantitative bone assessment technique in elderly women? The EPIDOS study , 2004, Osteoporosis International.

[54]  D. Felsenberg,et al.  Multinational, Placebo-Controlled, Randomized Trial of the Effects of Alendronate on Bone Density and Fracture Risk in Postmenopausal Women with Low Bone Mass: Results of the FOSIT Study , 1999, Osteoporosis International.

[55]  O. Johnell,et al.  Optimal age for preventing osteoporosis after menopause depends on effects of stopping treatment. , 2002, Bone.

[56]  O. Johnell,et al.  Effect and Offset of Effect of Treatments for Hip Fracture on Health Outcomes , 1999, Osteoporosis International.