Cost effectiveness of secondary vs tertiary prevention for post-menopausal osteoporosis

Background

The aging of the population is likely to increase the number of osteoporosis-related fractures, such as hip fractures, and hence the economic burden for society. Therefore, strategies to identify women at increased risk are of major interest.

Objective

The aim of this study was to determine the cost effectiveness of preventive services for osteoporosis, comparing secondary plus tertiary prevention (SP/TP) versus tertiary prevention (TP) alone in post-menopausal women in Germany.

Methods

A cost-utility analysis and a budget-impact analysis were performed from the perspective of the German statutory health insurance (SHI). A Markov model simulated costs and benefits discounted at 3% over a lifetime horizon.

Results

Cost effectiveness of TP compared with no screening was ?69, ?77 and ?85 per QALY for women aged 60, 70 and 80 years, respectively (year 2010 values). In women aged 50 years, TP dominated no prevention. Cost effectiveness of SP/TP compared with TP was ?543, ?9 791, ?670 and ?368 for women aged 50, 60, 70 and 80 years, respectively. SP/TP resulted in additional costs of ?09 million or 0.10% of the SHI’s annual budget (TP alone = ? million).

Conclusion

Compared with TP, a strategy based on SP/TP appears to be more expensive but more effective in each age group. Given that cost effectiveness seems acceptable, allocation of resources to SP/TP to decrease post-menopausal osteoporotic fracture risk may be justified.     

Cost effectiveness of ultrasound and bone densitometry for osteoporosis screening in post-menopausal women

Background

According to a new German guideline, decisions about bisphosphonate treatment for post-menopausal women should be based on 10-year fracture risk, and bone density should be measured by dual x-ray absorptiometry (DXA). Recently, there has been growing interest in quantitative ultrasound (QUS) as a less expensive screening alternative.

Objective

To determine the cost effectiveness of osteoporosis screening with QUS as a pre-test for DXA and treatment with alendronate compared with (i) immediate access to DXA and (ii) no screening in women of the general population aged 50-90 years in Germany.

Methods

A cost-utility analysis and a budget impact analysis were performed from the perspective of the statutory health insurance (SHI). A Markov model with a 1-year cycle length was used to simulate costs and benefits (QALYs), discounted at 3% per annum, over a lifetime. The number of women correctly diagnosed by QUS and DXA as being above a 10-year risk of ≥30% was estimated for different age groups (50–60, 60–70, 70–80 and 80–90 years, respectively). The robustness of the results was tested by a probabilistic Monte Carlo simulation.

Results

Compared with no screening, the cost effectiveness of QUS plus DXA was found to be €3529, €9983, €4382 and €1987 per QALY for 50-, 60-, 70- and 80-year-old women, respectively (year 2006 values). This screening strategy results in annual costs of €96 million or 0.07% of the SHI’s annual budget. The cost effectiveness of DXA alone compared with DXA plus QUS is €5331, €60 804, €14943 and €3654 per QALY for 50-, 60-, 70- and 80-year-old women, respectively. DXA alone results in a higher number of QALYs in all age groups. The results were robust in the sensitivity analysis.

Conclusion

Compared with no screening, the cost effectiveness of QUS and DXA in sequence is very favourable in all age groups. However, direct access to DXA is also a cost-effective option, as it increases the number of QALYs at an acceptable cost compared with pre-testing by QUS (except for women aged 60–70 years). Therefore, QUS as a pre-test for DXA can be clearly recommended only in women aged 60–70 years. For the other age groups, the cost effectiveness of QUS as a pre-test depends on the global budget constraint and the accessibility of DXA.     

Quality of life in post-menopausal osteoporosis

Background  

To evaluate the impact of osteoporosis on the patients' quality of life, particularly in the absence of fractures.     

A cost effectiveness analysis of stepped care treatment for bulimia nervosa

Background:

The cost effectiveness of various treatment strategies for bulimia nervosa (BN) is unknown.

Aims:

To examine the cost effectiveness of stepped care treatment for BN.

Method:

Randomized trial conducted at four clinical centers with intensive measurement of direct medical costs and repeated measurement of subject quality of life and family/significant other time involvement. Two hundred ninety‐three women who met DSM‐IV criteria for BN received stepped care treatment or cognitive behavioral therapy. Cost effectiveness ratios were compared.

Results:

The cost per abstinent subject was $12,146 for stepped care, and $20,317 for cognitive behavioral therapy. Quality of life ratings improved significantly with treatment, and family/significant other time burden diminished substantially.

Discussion:

In this trial, stepped care for BN appeared cost effective in comparison to cognitive behavioral therapy. Treatment was associated with improved quality of life and diminished time costs of illness. © 2013 by Wiley Periodicals, Inc. (Int J Eat Disord 2013)     

Will cost effectiveness analysis worsen the cost effectiveness of health care?

Cost effectiveness analysis is increasingly advocated as a basis for health policy. Analysts often compare expensive interventions with highly cost-effective programs such as hypertension screening, implying that if the former were curtailed resources would be reallocated to the latter and the efficiency of health care would improve. However, in practice, savings are unlikely to be targeted in this way. We present refined policy models that take into account actual patterns of resource allocation in the United States, and provide more realistic estimates of the likely uses of savings. We illustrate the implications of these models in an analysis of the effects of diverting funds from an expensive but effective practice. Eliminating such a practice would actually worsen the overall cost-effectiveness of U.S. health care unless there are radical changes in health policy. Cost effectiveness analysis incorrectly predicts health and cost outcomes of policy initiatives because it ignores the political constraints to health care decision-making.     

Update on osteoporosis management in long-term care: focus on bisphosphonates

Osteoporotic fractures are potentially devastating and associated with high morbidity and substantial economic burden. Residents of long-term care facilities are at greater risk of osteoporosis and its related fractures than those living in the community, yet osteoporosis is underdiagnosed and undertreated in these settings. Bisphosphonates are approved by the Food and Drug Administration for the treatment and prevention of osteoporosis in postmenopausal women. As a class, bisphosphonates have been shown to increase bone mineral density, decrease the markers of bone resorption, and reduce the risk of osteoporotic fractures. The 3 approved bisphosphonates are alendronate, risedronate, and ibandronate. Alendronate and risedronate are dosed daily or weekly and ibandronate, the most recently approved bisphosphonate, has been approved for monthly oral dosing or as an intravenous formulation to be given intermittently (every 3 months). In addition, other products with different mechanisms of action are in the pharmaceutical pipeline and may offer additional management options.     

Alendronate in the treatment of osteoporosis: a review of the clinical trials

Osteoporosis is a highly prevalent disease. More than half of postmenopausal women will experience fractures. Women at high risk (osteoporosis as measured by bone density, low trauma fractures of any type, or certain other risk factors) often require pharmacological therapy. However, surveys show that most women who have recently had fractures are currently not being treated. Recent results from the first megatrial of osteoporosis with >6400 participants, the Fracture Intervention Trial (FIT), have provided important advances in our understanding of osteoporosis and the efficacy of alendronate. The FIT study and other large clinical trials show that alendronate effectively increases bone density, reduces the risk of hip and vertebral fractures by approximately half within the first 12-18 months, and, most importantly, reduces the health consequences of fractures. Alendronate is also effective for preventing bone loss in early postmenopausal women. Thus, alendronate represents an important option for preventing and treating this common and debilitating disease. This article summarizes the wealth of data from FIT and other studies of alendronate in the context of the burden of illness associated with osteoporosis.     

Assessing the effectiveness and cost effectiveness of adaptive e-Learning to improve dietary behaviour: protocol for a systematic review

Background  

The composition of habitual diets is associated with adverse or protective effects on aspects of health. Consequently, UK public health policy strongly advocates dietary change for the improvement of population health and emphasises the importance of individual empowerment to improve health. A new and evolving area in the promotion of dietary behavioural change is e-Learning, the use of interactive electronic media to facilitate teaching and learning on a range of issues, including diet and health. The aims of this systematic review are to determine the effectiveness and cost-effectiveness of adaptive e-Learning for improving dietary behaviours.     

The cost of depression-complicated alcoholism: Health-Care utilization and treatment effectiveness

Clinical and epidemiologic evidence suggests that alcoholism complicated by concurrent or a lifetime history of depression is slower to remit and more prone to relapse than uncomplicated alcoholism. Consequently, alcoholics with a history of depressive illness, on average, are likely to use more health care and to have higher treatment costs than those without depression complications. This article contrasts evidence of the suitability of three models for predicting the impact of depression on an alcoholic’s health-care use: a null model (assuming no differences) a cumulative-effect model (arguing for a linear increase associated with comorbid depression), and a synergistic model (wherein alcoholism complicated with depression is qualitatively as well as quantitatively different than uncomplicated alcoholism). To test these models, health-care costs and utilization of 491 “pure” alcoholics (those with no history of depression diagnosis) and 199 depression-complicated alcoholics, who received alcohol treatment while enrolled in a self-insured health-care program of a major U.S. manufacturing company, were compared. Results are discussed in terms of the implications for cost containment and the likelihood of relapse among the depression-complicated alcoholism group.     

DM program attacks the high cost of osteoporosis

Considering the huge costs and the painful debilitation associated with osteoporosis, some physicians are starting to ask why more attention is not paid to the healthy care and nurturing of good bones in younger women.     

Study of cost by type of diagnosis in Switzerland.

Lengths of stay, for a given diagnosis, are poorly correlated between Switzerland, the USA., and Australia; and between 5 hospitals within Switzerland. Three different sets of DRG cost weightings (U.S., French A, French B) are also poorly correlated. Hospital operating efficiencies, standardized by DRG, were estimated and compared. The three sets of cost weightings used all yielded very similar estimates of hospital operating efficiency. The use of current existing systems of cost weightings may, therefore, provide a rapid and cheap means of comparing hospital operating efficiency. In the long run, more precise and detailed cost data will enable national cost weightings to be obtained. Associated issues, such as costing methodologies and perspectives on utilization, are also discussed.