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Cost effectiveness of secondary vs tertiary prevention for post-menopausal osteoporosis |
Mueller D, Gandjour A |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary This study examined the cost-effectiveness and budget impact of secondary plus tertiary prevention of osteoporosis by identifying post-menopausal women who were at increased risk of fractures, compared with tertiary prevention alone. The authors concluded that both prevention strategies were cost-effective compared with no prevention. Secondary plus tertiary prevention was more effective and more expensive, but good value for money, compared with tertiary prevention alone. The study was generally well presented and its methods were valid, making the authors’ conclusions robust. Type of economic evaluation Study objective This study examined the cost-effectiveness and budget impact of services to prevent osteoporosis by identifying post-menopausal women at increased risk of osteoporosis-related fractures. Secondary plus tertiary prevention was compared with tertiary prevention alone. Interventions Secondary prevention was provided when accelerated bone loss started, this included during menopause, immobilisation, or corticosteroid use. Secondary plus tertiary prevention consisted of screening by clinical risk factors and dual X-ray absorptiometry (DXA), for women aged 50 to 80 years, and treatment with alendronate if their risk was 30% or higher.
Tertiary prevention was provided during the period of bone loss or fracture. Treatment consisted of DXA for women with fractures, which it was suspected were due to osteoporosis, and alendronate if their bone density T-score was below -2.5.
No prevention was considered. Location/setting Germany/secondary and tertiary care. Methods Analytical approach:The analysis was based on a Markov model, with a lifetime horizon, for four cohorts of women aged 50, 60, 70, and 80 years. The authors stated that the analysis was carried out from the perspective of German statutory health insurance (SHI).
Effectiveness data:The clinical data were from a selection of relevant studies, including a meta-analysis of clinical trials, which supplied the effectiveness of alendronate. The primary clinical input was the incidence of women diagnosed as having a high risk of fracture. This was based on the gradient of risk, which was the increase in fracture risk for each standard deviation (T-score) change in bone density. Another key input for the model was the diagnostic validity of the assessment, which was from published studies. German studies were used, where possible. Some assumptions were needed and these were generally conservative.
Monetary benefit and utility valuations:The utility values were from published estimates for the general population for the initial health state. The values for fracture health states were from a published study that used the European Quality of life (EQ-5D) questionnaire, in a Swedish population, aged over 65 years.
Measure of benefit:Quality-adjusted life-years (QALYs) were the summary benefit measure and they were discounted at an annual rate of 3%.
Cost data:The economic analysis included the costs of screening (tests, false-positive results, and check-ups during treatment), fractures (hip, vertebra, or forearm), and health care in added years of life. The long-term costs of hip fractures were considered. The assessment of risk factors was assumed to take place during routine visits and did not require additional visits. The costs of fractures were from a German study. Co-payments by patients were subtracted. Other costs were from official national sources. All costs were in Euros (EUR) and a 3% annual discount rate was applied. The price year was 2010.
Analysis of uncertainty:One-way sensitivity analyses were carried out on all the model inputs, using ranges from published sources or authors’ opinions. A Monte Carlo simulation was performed, using conventional distributions for the model inputs. Results In the cohort of women aged 50 to 60 years, the total costs were EUR 71,852 with no prevention, EUR 71,788 with tertiary prevention, and EUR 72,162 with secondary and tertiary prevention. The QALYs were 12.05 with no prevention, 12.10 with tertiary prevention, and 12.18 with secondary and tertiary prevention.
Tertiary prevention dominated no prevention, as it was more effective and less expensive. The incremental cost per QALY gained with secondary and tertiary prevention was EUR 2,361 over no prevention and EUR 4,543 over tertiary prevention.
In the other age ranges up to 80 to 90 years, with tertiary over no prevention the incremental cost per QALY gained ranged from EUR 669 to EUR 385, with secondary and tertiary over no prevention it ranged from EUR 14,132 to EUR 1,635, and with secondary and tertiary over tertiary prevention it ranged from EUR 19,791 to EUR 3,368.
The budget impact analysis showed that the total costs to German SHI to screen and treat all eligible women would be EUR 109 million (0.10% of SHI’s total annual budget) with secondary and tertiary prevention and EUR 8 million (0.007% of SHI’s total annual budget) with tertiary prevention alone.
When comparing either screening strategy with no screening, the cost-effectiveness results were robust. The most influential inputs were the efficacy of alendronate, the 10-year fracture risk for women at increased risk, and the discount rate. Each screening strategy had a high probability of being cost-effective or cost-saving, compared with no screening. Authors' conclusions The authors concluded that both prevention strategies were cost-effective, compared with no prevention. Secondary plus tertiary prevention was more effective and more expensive, but good value for money, compared with tertiary prevention alone. CRD commentary Interventions:The selection of the comparators was appropriate as the usual and the proposed screening strategies were considered.
Effectiveness/benefits:No literature review to identify the data sources was reported. The authors stated that German studies were selected for the epidemiological data and this was valid. The drug efficacy was from a meta-analysis of randomised controlled trials, ensuring high internal validity, but little information was given on the other data sources. The authors conducted an extensive sensitivity analysis on the most uncertain clinical parameters. QALYs were an appropriate and validated benefit measure for the osteoporotic population. The EQ-5D was an appropriate instrument to elicit preferences from women who had experienced a fracture, but it was unclear whether the Swedish data could be transferred to the German population.
Costs:The economic analysis included a wide range of costs that were relevant to the public health payer. The cost items were reported, with most of the unit costs, but the costs of fractures and added years of life were presented as category totals. Country-specific sources were used for most of the economic data. The impact of variations in the cost estimates was tested in the sensitivity analysis. The authors stated that a societal perspective was unlikely to change their findings. Hip fracture costs over the long-term were included, where they were not in some previous economic evaluations. Details, such as the price year and discount rate, were given.
Analysis and results:The results were extensively presented for all age groups. An incremental approach was used to synthesise the costs and benefits of the strategies. The uncertainty was investigated, using appropriate deterministic and probabilistic analyses. A description of the decision model was provided, with a diagram. Some conservative assumptions were made and the preventive strategies might have been more cost-effective. The results cannot be easily transferred to other settings, given the use of German epidemiological and cost data.
Concluding remarks:The study was generally well presented and its methods were valid, making the authors’ conclusions robust. Bibliographic details Mueller D, Gandjour A. Cost effectiveness of secondary vs tertiary prevention for post-menopausal osteoporosis. Applied Health Economics and Health Policy 2011; 9(4): 259-273 Indexing Status Subject indexing assigned by NLM MeSH Aged; Aged, 80 and over; Bone Density Conservation Agents /economics; Cohort Studies; Cost-Benefit Analysis; Female; Fractures, Bone /economics /prevention & Germany; Humans; Markov Chains; Middle Aged; Osteoporosis, Postmenopausal /complications /economics /prevention & Secondary Prevention /economics /statistics & Tertiary Prevention /economics /statistics & control; control; numerical data; numerical data AccessionNumber 22011001117 Date bibliographic record published 20/10/2011 Date abstract record published 07/12/2011 |
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