The Impact of Fewer Hip Fractures with Risedronate Versus Alendronate in the First Year of Treatment: Modeled German Cost-Effectiveness Analysis

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 ≥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 €278 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 (€106 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.     

Cost-Effectiveness of Using Clinical Risk Factors with and without DXA for Osteoporosis Screening in Postmenopausal Women

Background:  According to several guidelines, the assessment of postmenopausal fracture risk should be based on clinical risk factors (CRFs) and bone density. Because measurement of bone density by dual x-ray absorptiometry (DXA) is quite expensive, there has been increasing interest to estimate fracture risk by CRFs.
Objective:  The aim of this study was to determine the cost-effectiveness of osteoporosis screening of CRFs with and without DXA compared with no screening in postmenopausal women in Germany.
Methods:  A cost-utility analysis and a budget-impact analysis were performed from the perspective of the statutory health insurance. A Markov model simulated costs and benefits discounted at 3% over lifetime.
Results:  Cost-effectiveness of CRFs compared with no screening is €4607, €21,181, and €10,171 per quality-adjusted life-year (QALY) for 60-, 70-, and 80-year-old women, respectively. Cost-effectiveness of DXA plus CRFs compared with CRFs alone is €20,235 for 60-year-old women. In women above the age of 70, DXA plus CRFs dominates CRFs alone. DXA plus CRFs results in annual costs of €175 million, or 0.4% of the statutory health insurance's annual budget.
Conclusion:  Funders should be careful in adopting a strategy based on CRFs alone instead of DXA plus CRFs. Only if DXA is not available, assessing CRFs only is an acceptable option in predicting a woman's risk of fracture.     

Cost-Utility Analysis of Eprosartan Compared to Enalapril in Primary Prevention and Nitrendipine in Secondary Prevention in Europe—The HEALTH Model

Objective:  To investigate the cost-utility of eprosartan versus enalapril (primary prevention) and versus nitrendipine (secondary prevention) on the basis of head-to-head evidence from randomized controlled trials.
Methods:  The HEALTH model (Health Economic Assessment of Life with Teveten^® for Hypertension) is an object-oriented probabilistic Monte Carlo simulation model. It combines a Framingham-based risk calculation with a systolic blood pressure approach to estimate the relative risk reduction of cardiovascular and cerebrovascular events based on recent meta-analyses. In secondary prevention, an additional risk reduction is modeled for eprosartan according to the results of the MOSES study ("Morbidity and Mortality after Stroke—Eprosartan Compared to Nitrendipine for Secondary Prevention"). Costs and utilities were derived from published estimates considering European country-specific health-care payer perspectives.
Results:  Comparing eprosartan to enalapril in a primary prevention setting the mean costs per quality adjusted life year (QALY) gained were highest in Germany (€24,036) followed by Belgium (€17,863), the UK (€16,364), Norway (€ 13,834), Sweden (€ 11,691) and Spain (€ 7918). In a secondary prevention setting (eprosartan vs. nitrendipine) the highest costs per QALY gained have been observed in Germany (€9136) followed by the UK (€6008), Norway (€1695), Sweden (€907), Spain (€−2054) and Belgium (€−5767).
Conclusions:  Considering a €30,000 willingness-to-pay threshold per QALY gained, eprosartan is cost-effective as compared to enalapril in primary prevention (patients ≥50 years old and a systolic blood pressure ≥160 mm Hg) and cost-effective as compared to nitrendipine in secondary prevention (all investigated patients).     

Management of Childhood Urinary Tract Infections: An Economic Modeling Study

Childhood urinary tract infections (UTIs) can lead to renal scarring and ultimately to terminal renal failure, which has a high impact on quality of life, survival, and health-care costs. Variation in the treatment of UTIs between practices is high.
Objective:  To assess the cost-effectiveness of a maximum care model for UTIs in children, implying more testing and antibiotic treatment, compared with current practice in primary care in The Netherlands.
Methods:  We performed a probabilistic modeling study using Markov models. Figures used in the model were derived from a systematic review of the research literature. Multidimensional Monte Carlo simulation was used for the probabilistic analyses.
Results:  Maximum care gained 0.00102 (males) and 0.00219 (girls) QALYs (quality-adjusted life-years) and saved €42.70 (boys) and €77.81 (girls) in 30 years compared with current care, and was thus dominant. Net monetary benefit of maximum care ranged from €20 to €200 for a willingness to pay for a QALY ranging from €0 to €80,000, respectively. Maximum care was also dominant over improved current care, although less dominant than to current care.
Conclusions:  This study suggested that maximum care for childhood UTI was dominant in the long run to current care, meaning that it delivered more quality of life at lower costs. Nevertheless, making firm conclusions is not possible, given the limitations of the input data.     

Prevention and Treatment of Osteoporosis in Postmenopausal Women

Postmenopausal osteoporosis is characterized by an increased rate of bone turnover accompanied by a reduction in bone mineral density (BMD) that results in an increased risk of fracture, especially of the vertebrae, hip, or wrist. Alendronate (Fosamax®, Fosamax Once-Weekly®), an oral bisphosphonate that inhibits osteoclast-mediated bone resorption and modulates bone metabolism, is a first-line therapy for the management of postmenopausal women with, or at risk of developing, osteoporosis.Alendronate produces sustained increases in BMD and reductions in bone turnover from baseline, and reduces the risk of vertebral, hip, wrist, and other fractures in women with postmenopausal osteoporosis. It also prevents bone loss, and reduces the risk of radiographic or clinical vertebral fracture in postmenopausal osteopenia. Provided administration instructions are followed, alendronate is generally well tolerated. Adverse events are usually transient and are associated with the upper gastrointestinal tract (abdominal pain, nausea, acid regurgitation, dyspepsia); moreover, the incidence of these adverse events with alendronate was similar to those with placebo. More serious events (esophagitis, gastric or duodenal ulceration or bleeding) are uncommon. Once-weekly formulations are as effective and as well tolerated as once-daily alendronate in postmenopausal women.Pharmacoeconomic evaluations suggest that alendronate is a viable treatment option in postmenopausal osteoporosis. The reduction in fracture-related healthcare utilization seen with alendronate results in decreased direct costs, including inpatient or long-term care. Markov state-transition models suggest that this could at least partially offset costs incurred with alendronate therapy. Treatment of women with osteoporosis aged 65 years and older, and postmenopausal women with a previous osteoporotic fracture, are cost-effective strategies. Alendronate is also likely to increase quality-adjusted life-years in any postmenopausal women with osteoporosis.In conclusion, clinical and economic data support the use of alendronate in postmenopausal osteoporosis. It effectively reduces bone turnover, increases BMD, and reduces the risk of osteoporotic fracture in postmenopausal women with established osteoporosis, especially older women with a higher risk of fracture. Although its cost effectiveness in postmenopausal women with osteopenia is not clearly established, alendronate is clinically effective in these patients. In addition, it is generally well tolerated when taken as recommended. Consequently, alendronate should be considered a therapy of choice in the prevention and treatment of osteoporosis in postmenopausal women.     

Costs and Effects of Various Analgesic Treatments for Patients with Rheumatoid Arthritis and Osteoarthritis in The Netherlands

Objective:  To assess the balance between costs and upper gastrointestinal (GI) side effects of treatment with celecoxib, nonsteroidal antiinflammatory drugs (NSAIDs) alone, NSAID plus misoprostol, NSAID plus histamine-2 receptor antagonist (H₂RA), NSAID plus proton pump inhibitor (PPI), and Arthrotec in The Netherlands.
Methods:  A model was used to convene data from various sources on the probability of GI side effects and resource use. The probabilities of GI side effects for celecoxib and NSAIDs alone were derived from trial data. Calculations were based on 6 months of treatment, and were from a societal perspective. Distinction was made between low-, medium-, and high-risk patients. An extensive probabilistic sensitivity analysis was performed to address uncertainty.
Results:  Assuming an average patient, the total costs per 6 months of therapy were: celecoxib €255, NSAIDs alone €166, NSAID plus misoprostol €285, NSAID plus H₂RA €284, NSAID plus PPI €243, and Arthrotec €187. Treatment with celecoxib was associated with the lowest number of GI side effects and related deaths. Incremental costs per life-year saved for Arthrotec compared to NSAIDs alone were €5676 for all patients and €526 for medium-to-high-risk patients, whereas for high-risk patients, Arthrotec dominated NSAID alone. For celecoxib compared to Arthrotec, the incremental cost-effectiveness ratios (ICERs) were €56,667, €33,684, and €15,429, respectively.
Conclusion:  Assuming a limit of €20,000 per life-year gained, from an economic point of view, Arthrotec is the preferred treatment when all patients or medium-to-high-risk patients are considered. In high-risk patients, celecoxib is the preferred treatment strategy.     

Modeling Length of Stay in Hospital and Other Right Skewed Data: Comparison of Phase-Type, Gamma and Log-Normal Distributions

Objectives:  To present a relatively novel method for modeling length-of-stay data and assess the role of covariates, some of which are related to adverse events. To undertake critical comparisons with alternative models based on the gamma and log-normal distributions. To demonstrate the effect of poorly fitting models on decision-making.
Methods:  The model has the process of hospital stay organized into Markov phases/states that describe stay in hospital before discharge to an absorbing state. Admission is via state 1 and discharge from this first state would correspond to a short stay, with transitions to later states corresponding to longer stays. The resulting phase-type probability distributions provide a flexible modeling framework for length-of-stay data which are known to be awkward and difficult to fit to other distributions.
Results:  The dataset consisted of 1901 patients' lengths of stay and values for a number of covariates. The fitted model comprised six Markov phases, and provided a good fit to the data. Alternative gamma and log-normal models did not fit as well, gave different coefficient estimates, and statistical significance of covariate effects differed between the models.
Conclusions:  Models that fit should generally be preferred over those that do not, as they will produce more statistically reliable coefficient estimates. Poor coefficient estimates may mislead decision-makers by either understating or overstating the cost of some event or the cost savings from preventing that event. There is no obvious way of identifying a priori when coefficient estimates from poorly fitting models might be misleading.     

Cost-Effectiveness of Treatments Reducing Coronary Heart Disease Mortality in Ireland, 2000 to 2010

Objective:  Coronary heart disease (CHD) is associated with a large burden of disease in Ireland and is responsible for more than 6000 deaths annually. This study examined the cost-effectiveness of specific CHD treatments in Ireland.
Methods:  Irish epidemiological data on patient numbers and median survival in specific groups, plus the uptake, effectiveness, and costs of specific interventions, all stratified by age and sex, were incorporated into a previously validated CHD mortality model, the IMPACT model. This model calculates the number of life-years gained (LYGs) by specific cardiology interventions to generate incremental cost-effectiveness ratios (ICERs) per LYG for each intervention.
Results:  In 2000, medical and surgical treatments together prevented or postponed approximately 1885 CHD deaths in patients aged 25 to 84 years, and thus generated approximately 14,505 extra life-years (minimum 7270, maximum 22,475). In general, all the cardiac interventions investigated were highly cost-effective in the Irish setting. Aspirin, beta-blockers, ACE inhibitors, spironolactone, and warfarin for specific conditions were the most cost-effective interventions (<€3000/LYG), followed by the statins for secondary prevention (<€6500/LYG). Revascularization for chronic angina and primary angioplasty for myocardial infarction, although still cost-effective, had the highest ICER (between €12,000 and €20,000/LYG).
Conclusions:  Using a comprehensive standardized methodology, cost-effectiveness ratios in this study clearly favored simple medical treatments for myocardial infarction, secondary prevention, angina, and heart failure.     

Lifetime fracture risk: an approach to hip fracture risk assessment based on bone mineral density and age

Hip fractures occur late in life following a substantial reduction in skeletal mass. If risk for such fractures could be predicted early, efforts to prevent excessive bone loss would be more successful and could be directed at the individuals most likely to be affected. With this objective in mind, we devised an approach to estimating the lifetime risk of a proximal femur fracture based on age and on current femoral bone mineral density, using population-based data from ongoing studies of osteoporosis and fractures among Rochester, Minnesota, women. Our calculations indicate that, at any given age, the lifetime risk of a proximal femur fracture rises as current bone density diminishes. At any given level of femoral bone density, lifetime risk rises with younger age and increasing life expectancy. While these trends seem robust, estimates of risk vary substantially with the assumptions that underlie the model. Consequently, these assumptions must be validated before our findings can be applied clinically to predict risk for individual patients.     

Service Utilization and Health-Care Costs in the Advanced Elderly

Objectives:  Despite their increasing importance, the advanced elderly are often neglected in service utilization and costing studies. The purpose of this study was to analyze from societal perspective service utilization and direct health-care costs and its predictors in the advanced elderly population.
Methods:  A bottom-up costing study was conducted using a cross-sectional primary care sample aged 75+ (n = 452) in Germany. The main instruments were a questionnaire of service utilization and costs administered by an interviewer and the chronic disease score (CDS). Predictors were derived by means of multivariate regression models.
Results:  Respondents caused mean direct costs of €3730 (95% CI 3203–4257) in prices of 2004/2005. This included inpatient care 34%, pharmaceuticals 29%, outpatient physician services 15%, nursing care 10%, medical supply and dentures 6%, outpatient nonphysician providers 5%, assisted living 1%, and transportation 2%. A shift from lower to middle education and a one-point increase in CDS were associated with an increase of €1678 (95% CI 250–3369) and €482 (95% CI 316–654), respectively. Total mean direct costs did not differ significantly between sexes. Ischemic heart disease and diabetes mellitus were associated with excess costs of €711 and €290, both being not significant. Altogether 55% of the respondents accounted for 90% of total direct costs.
Conclusions:  Advanced elderly used a wide range of health services. Our study still underestimates the true costs to society. Further research should focus on economic evaluation of new health-care programs for this increasingly important age group.     

Utility Estimates for Decision–Analytic Modeling in Chronic Heart Failure—Health States Based on New York Heart Association Classes and Number of Rehospitalizations

Objectives:  For economic evaluations of chronic heart failure (CHF) management strategies, utilities are not currently available for disease proxies commonly used in Markov models. Our objective was to estimate utilities for New York Heart Association (NYHA) classification and number of cardiovascular rehospitalizations.
Methods:  EuroQol 5D data from the Eplerenone Post-acute Myocardial Infarction Heart Failure Efficacy and Survival Study trial were used to estimate utilities as a function of NYHA classification and number of cardiovascular rehospitalizations.
Results:  In multivariate regression analyses adjusted for age (60 years), female sex and absence of further comorbidities, utilities for NYHA classes I–IV were 0.90, 0.83, 0.74, and 0.60 ( P -value < 0.001 for trend). For cardiovascular rehospitalizations 0, 1, 2 and ≥3, the associated utilities were 0.88, 0.85, 0.84, and 0.82 ( P -value < 0.001 for trend).
Conclusions:  NYHA class and number of cardiovascular rehospitalizations are established proxies for CHF progression and can be linked to utilities when used as health states in a Markov model. NYHA class should be used when feasible.     

Management of Postmenopausal Osteoporosis

Postmenopausal osteoporosis is a very common disease, and approximately half of all women aged >50 years will experience an osteoporotic fracture during the remainder of their lifetime. The predominant cause of postmenopausal osteoporosis is the decline in estrogen levels, which causes an increase in bone turnover, and results in a loss of bone mass throughout the entire skeleton. Fragility fractures, either vertebral or nonvertebral, have a considerable adverse effect on quality of life in women with osteoporosis and place a significant burden on society in terms of healthcare costs.Management of postmenopausal osteoporosis includes alteration of modifiable risk factors (e.g. lifestyle and propensity to fall), ensuring adequate calcium and vitamin D intake, and pharmacological treatment to decrease fracture risk by slowing or preventing bone loss and preserving bone strength. Raloxifene (Evista®), a selective estrogen receptor modulator that partially mimics the effects of estrogen on bone and lipid metabolism and acts as an antiestrogen in the breast and endometrium, is indicated for the prevention and treatment of postmenopausal osteoporosis. Raloxifene increases bone mineral density at vertebral and nonvertebral sites, and decreases the risk of vertebral fracture to a similar extent to the bisphosphonates alendronate and risedronate. However, effects on nonvertebral fracture risk, including the risk of hip fracture, have not been observed.Raloxifene appears to reduce breast cancer risk (in women at average risk) and cardiovascular risk (in women at increased risk) without stimulating the endometrium, and does not cause vaginal bleeding or breast pain. However, the drug causes hot flashes in some women, and increases the risk of venous thromboembolic events by about the same amount as hormone replacement therapy (HRT).In economic models, raloxifene is cost effective compared with no treatment, HRT, calcitonin, or alendronate for the prevention or treatment of postmenopausal osteoporosis.In conclusion, raloxifene is a valuable and cost-effective therapy for preventing the progression of osteoporosis and for reducing vertebral fracture risk in osteoporotic postmenopausal women. The tendency for raloxifene to cause hot flashes, and its apparent lack of effect on hip fracture risk, may preclude its use in women with vasomotor symptoms and in patients at high risk for hip fracture. Results from large ongoing trials are needed to confirm the effects of raloxifene on breast cancer and cardiovascular disease. However, the effects of raloxifene on breast cancer and cardiovascular risk without stimulating the endometrium make the drug an attractive therapy for the prevention and treatment of postmenopausal osteoporosis.     

Cost Effectiveness of Denosumab versus Oral Bisphosphonates for Postmenopausal Osteoporosis in the US

Background

In the US, 26 % of women aged ≥65 years, and over 50 % of women aged ≥85 years are affected with postmenopausal osteoporosis (PMO). Each year, the total direct health care costs are estimated to be $US12–18 billion.

Objective

The cost effectiveness of denosumab versus oral bisphosphonates in postmenopausal osteoporotic women from a US third-party payer perspective was evaluated.

Methods

A lifetime cohort Markov model was developed with seven health states: ‘well’, hip fracture, vertebral fracture, ‘other’ osteoporotic fracture, post-hip fracture, post-vertebral fracture, and dead. During each cycle, patients could have a fracture, remain healthy, remain in a post-fracture state or die. Relative fracture risk reductions, background fracture risks, mortality rates, treatment-specific persistence rate, utilities, and medical and drug costs were derived using published sources. Expected costs and quality-adjusted life years (QALYs) were estimated for generic alendronate, denosumab, branded risedronate, and branded ibandronate in the overall PMO population and high-risk subgroups: (a) ≥2 of the following risks: >70 years of age, bone mineral density (BMD) T score less than or equal to ?3.0, and prevalent vertebral fracture; and (b) ≥75 years of age. Costs and QALYs were discounted at 3 % annually, and all costs were inflated to 2012 US dollars. Sensitivity analyses were conducted by varying parameters e.g., efficacies of interventions, costs, utilities, and the medication persistence ratio.

Results

In the overall PMO population, total lifetime costs for alendronate, denosumab, risedronate, and ibandronate were $US64,400, $US67,400, $US67,600 and $US69,200, respectively. Total QALYs were 8.2804, 8.3155, 8.2735 and 8.2691, respectively. The incremental cost-effectiveness ratio (ICER) for denosumab versus generic alendronate was $US85,100/QALY. Risedronate and ibandronate were dominated by denosumab. In the high-risk subgroup (a), total costs for alendronate, denosumab, risedronate and ibandronate were $US70,400, $US70,800, $US74,000 and $US76,900, respectively. Total QALYs were 7.2006, 7.2497, 7.1969 and 7.1841, respectively. Denosumab had an ICER of $US7,900/QALY versus generic alendronate and dominated all other strategies. Denosumab dominated all strategies in women aged ≥75 years. Base-case results between denosumab and generic alendronate were most sensitive to the relative risk of hip fracture for both drugs and the cost of denosumab.

Conclusion

In each PMO population examined, denosumab represented good value for money compared with branded bisphosphonates. Furthermore, denosumab was either cost effective or dominant compared with generic alendronate in the high-risk subgroups.     

Cost–Effectiveness of Osteoporosis Screening Followed by Treatment: The Impact of Medication Adherence

ObjectiveTo estimate the impact of medication adherence on the cost–effectiveness of mass-screening by bone densitometry followed by alendronate therapy for women diagnosed with osteoporosis.MethodsA validated Markov microsimulation model with a Belgian health-care payer perspective and a lifetime horizon was used to assess the cost per quality-adjusted life year (QALY) gained of the screening/treatment strategy compared with no intervention. Real-world adherence to alendronate therapy and full adherence over 5 years were both investigated. The real-world adherence scenario employed adherence data from published observational studies, and medication adherence was divided into persistence, compliance, and primary adherence. Uncertainty was investigated using one-way and probabilistic sensitivity analyses.ResultsAt 65 years of age, the costs per QALY gained because of the screening/treatment strategy versus no intervention are €32,008 and €16,918 in the real-world adherence and full adherence scenarios, respectively. The equivalent values are €80,836 and €40,462 at the age of 55 years, and they decrease to €10,600 and €1229 at the age of 75 years. Sensitivity analyses show that the presence of the upfront cost of case finding has a substantial role in the impact of medication adherence on cost–effectiveness.ConclusionThis study indicates that nonadherence with osteoporosis medications substantially increases the incremental cost–effectiveness ratio of osteoporosis screening strategies. All aspects of medication adherence (i.e., compliance, persistence, and primary adherence) should therefore be reported and included in pharmacoeconomic analyses, and especially in the presence of the upfront cost of case finding (such as screening cost).     

The Burden of Ankylosing Spondylitis in Spain

Objective:  To investigate the burden of ankylosing spondylitis (AS) in Spain, as baseline for economic evaluation of the use of biological agents.
Methods:  A cross-sectional retrospective observational study was performed in 601 patients with AS in Spain, using a methodology developed in studies in the United Kingdom and Canada. Patients were mailed a questionnaire asking about their health-care consumption, out-of-pocket expenses, work capacity, need for informal care during the past 3 months, as well as quality of life. Patient's current functional status and disease activity level was assessed using the Bath functional and disease activity indexes (BASFI and BASDAI).
Results:  The mean age (median) was 47.8 (12.4) years, and the mean disease duration was 18.8 years. Eighty percent of patients were male, and slightly more than half of patients below 65 years of age were working. The mean (median) BASDAI and BASFI scores were 4.3 (2.5) and 3.8 (2.9),respectively, and all levels of disease severity were represented. The mean (median) total annual cost per patient is estimated at €20,328 (€7920). Direct health care represented 22.8%, investments (adaptations of house and devices) and informal care 43.5%, and productivity losses 33.7%. Costs increased significantly with worsening disease, in particular diminishing physical function, covering a range between €5000 and €75,000 per patient and year. The mean (median) utility was 0.59 (0.30). Utility showed a significant inverse relation with BASFI and BASDAI, covering a range from 0.80 for patients with BASFI/BASDAI below 3 to 0.25 for patients with BASFI/BASDAI greater than 7.
Conclusions:  As in studies in other countries, all types of costs accelerate steeply with worsening disease while utility decreases significantly, indicating the need to prevent disease progression.     

An Economic Evaluation of Quantitative Ultrasonometry as Pre-Screening Test for the Identification of Patients with Osteoporosis

Background

Screening for osteoporosis has been recommended to identify patients at high risk of fracture in order to provide preventative treatment. Given the limited availability of dual-energy x-ray absorptiometry (DXA) and health resources, quantitative ultrasonometry (QUS) has emerged as an attractive tool for the mass screening scenario. The objective of this study was to evaluate whether a screening strategy using QUS as a pre-screening tool for bone densitometry would be cost effective and, if so, at what cut-off thresholds.

Methods

Decision analytic models were used to compare the cost effectiveness and cost utility of several screening strategies: DXA measurement alone and pre-screening strategies that use different QUS index cut-off thresholds. For each strategy, and for hypothetical cohorts of women, we estimated the number of DXA scans required, the number of osteoporotic patients detected and missed, the total screening cost, and the incremental cost per patient detected. A validated Markov microsimulation model with a lifetime horizon and from a healthcare perspective was also computed in order to estimate the cost per quality-adjusted life-year (QALY) gained of the alternative screening strategies combined with 5 years of alendronate therapy for women who have osteoporosis (T-score -2.5 or less).

Results

The DXA strategy had the highest cost and the highest number of patients with osteoporosis detected. Prescreening strategies using QUS reduced the number of DXA scans per patient with osteoporosis detected and the total screening cost but they also missed patients with osteoporosis as the QUS index decreased. Pre-screening strategies using QUS T-scores of 0.0, ?0.5, ?2.0, and ?2.5 were dominated by extended dominance, as their incremental cost-effectiveness ratios (ICERs) and incremental cost-utility ratios (ICURs) were higher than that of the next more effective alternative. The cost-effectiveness and cost-utility frontiers included no screening, pre-screening using QUS T-scores of ?1.0 and ?1.5, and DXA measurement alone.

Conclusion

These results suggest that QUS may be useful as a pre-screening tool for bone densitometry given the limited availability of DXA and health resources, and that the QUS index T-scores of ?1.0 and ?1.5 are the most appropriate index.

     

The Health and Economic Consequences of Moderate Alcohol Consumption in Germany 2002

Objective:  Moderate alcohol consumption is associated with both positive and negative health effects. This study aims to estimate the positive and negative consequences on mortality, years of potential life (YPL), quality-adjusted life-years (QALYs), resource utilization, and societal costs attributable to moderate alcohol consumption in Germany in 2002.
Methods:  The concept of attributable risks and a prevalence-based approach was used to calculate age- and sex-specific alcohol attributable mortality and resource utilization for a wide range of disorders, and avoided mortality and resource utilization for diabetes mellitus, coronary heart disease, stroke, and cholelithiasis. The literature provided prevalence of moderate alcohol consumption in Germany by age and sex and relative risks. Direct costs were calculated using routine utilization and expenditure statistics. Indirect costs were calculated using the human capital approach.
Results:  Due to moderate alcohol consumption, 14,457 lives, 205,691 YPL, and 179,964 QALYs were lost, whereas 29,918 lives, 300,382 YPL, and 258,284 QALYs were gained. Up to an age of 55 to 60 (62.5–67.5) years, more lives were lost than gained among men (women), whereas in older age groups more lives were gained than lost. Moderate alcohol consumption caused €3049 million of direct and €2630 million of indirect costs, whereas €2094 million of direct and €2604 million of indirect costs were avoided.
Conclusion:  Despite considerable uncertainty, moderate alcohol consumption seems to result in an overall net effect of gained lives, YPL, and QALYs, realized among the elderly, but overall increased societal costs. Thus, moderate alcohol consumption should still be seen critical, especially among youths.