[en] 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. Pre-screening 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.
Disciplines :
Public health, health care sciences & services Special economic topics (health, labor, transportation...)
Author, co-author :
Hiligsmann, Mickaël ; Université de Liège - ULiège > HEC - École de gestion de l'ULiège > Economie industrielle
Ethgen, Olivier ; Université de Liège - ULiège > Département des sciences de la santé publique > Santé publique : aspects spécifiques
Bruyère, Olivier ; Université de Liège - ULiège > Département des sciences de la santé publique > Epidémiologie et santé publique - Département des sciences de la santé publique
Reginster, Jean-Yves ; Université de Liège - ULiège > Département des sciences de la santé publique > Epidémiologie et santé publique
Language :
English
Title :
An Economic Evaluation of Quantitative Ultrasonometry as Pre-Screening Test for the Identification of Patients with Osteoporosis
US Preventive Services Task Force. Screening for osteoporosis in postmenopausal women: recommendations and rationale. Ann Intern Med 2002; 137: 526-8
Kanis J, Burlet N, Cooper C, et al. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 2008; 19: 429-35
National Osteoporosis Foundation. Clinician's guide to prevention and treatment of osteoporosis. Washington, DC: NOF, 2008
Boonen S, Nijs J, Borghs H, et al. Identifying postmenopausal women with osteoporosis by calcaneal ultrasound, metacarpal digital X-ray radiogrammetry and phalangeal radiographic absorptiometry: a comparative study. Osteoporos Int 2005; 16: 93-100
Ben Sedrine W, Broers P, Devogelaer JP, et al. Interest of a prescreening questionnaire to reduce the cost of bone densitometry. Osteoporos Int 2002; 13: 434-42
Nayak S, Olkin I, Liu H, et al. Meta-analysis: accuracy of quantitative ultrasound for identifying patients with osteoporosis. Ann Intern Med 2006; 144: 832-41
Bauer DC, Ewing SK, Cauley JA, et al. Quantitative ultrasound predicts hip and non-spine fracture in men: the MrOS study. Osteoporos Int 2007; 18: 771-7
Bauer DC, Gluer CC, Cauley JA, et al. Broadband ultrasound attenuation predicts fractures strongly and independently of densitometry in older women: a prospective study. Study of Osteoporotic Fractures Research Group. Arch Intern Med 1997; 157: 629-34
Khaw KT, Reeve J, Luben R, et al. Prediction of total and hip fracture risk in men and women by quantitative ultrasound of the calcaneus: EPIC-Norfolk prospective population study. Lancet 2004; 363: 197-202
Hans D, Dargent-Molina P, Schott AM, et al. Ultrasonographic heel measurements to predict hip fracture in elderly women: the EPIDOS prospective study. Lancet 1996; 348: 511-4
Reginster JY, Dethor M, Pirenne H, et al. Reproducibility and diagnostic sensitivity of ultrasonometry of the phalanges to assess osteoporosis. Int J Gynaecol Obstet 1998; 63: 21-8
Wuster C, Heilmann P, Pereira-Lima J, et al. Quantitative ultrasonometry (QUS) for the evaluation of osteoporosis risk: reference data for various measurement sites, limitations and application possibilities. Exp Clin Endocrinol Diabetes 1998; 106: 277-88
Damilakis J, Perisinakis K, Gourtsoyiannis N. Imaging ultrasonometry of the calcaneus: optimum T-score thresholds for the identification of osteoporotic subjects. Calcif Tissue Int 2001; 68: 219-24
Frost ML, Blake GM, Fogelman I. Can the WHO criteria for diagnosing osteoporosis be applied to calcaneal quantitative ultrasound? Osteoporos Int 2000; 11: 321-30
Kraemer DF, Nelson HD, Bauer DC, et al. Economic comparison of diagnostic approaches for evaluating osteoporosis in older women. Osteoporos Int 2006; 17: 68-76
Dargent-Molina P, Piault S, Breart G. A comparison of different screening strategies to identify elderly women at high risk of hip fracture: results from the EPIDOS prospective study. Osteoporos Int 2003; 14: 969-77
Marin F, Lopez-Bastida J, Diez-Perez A, et al. Bone mineral density referral for dual-energy X-ray absorptiometry using quantitative ultrasound as a prescreening tool in postmenopausal women from the general population: a cost-effectiveness analysis. Calcif Tissue Int 2004; 74: 277-83
Looker AC, Orwoll ES, Johnston CC, et al. Prevalence of low femoral bone density in older US adults from NHANES III. J Bone Miner Res 1997; 12: 1761-8
Boonen S, Kaufman JM, Reginster JY, et al. Patient assessment using standardized bone mineral density values and a national reference database: implementing uniform thresholds for the reimbursement of osteoporosis treatments in Belgium. Osteoporos Int 2003; 14: 110-5
Hiligsmann M, Bruyère O, Pire G, et al. Economic evaluation of osteoporosis screening strategy conducted in the Province of Liège with the cooperation of Liège Province Santé [in French]. Rev Med Liege 2008; 63: 588-94
Hiligsmann M, Ethgen O, Bruyère O, et al. Development and validation of a Markov microsimulation model for the economic evaluation of treatments in osteoporosis. Value Health. In press.
Cleemput I, Crott R, Vrijens F, et al. Recommandations provisoires pour les évaluations pharmaco-économiques en Belgique. Health Technology Assessment (HTA) [KCE reports 78B (D/2008/10.273/24)]. Bruxelles: Centre Fédéral d'Expertise des Soins de Santé (KCE), 2008
Weinstein MC. Recent developments in decision-analytic modelling for economic evaluation. Pharmacoeconomics 2006; 24 (11): 1043-53
Kanis JA, Brazier JE, Stevenson M, et al. Treatment of established osteoporosis: a systematic review and cost-utility analysis. Health Technol Assess 2002; 6: 1-146
Vanness DJ, Tosteson AN, Gabriel SE, et al. The need for microsimulation to evaluate osteoporosis interventions. Osteoporos Int 2005; 16: 353-8
Hiligsmann M, Bruyère O, Ethgen O, et al. Lifetime absolute risk of hip and other osteoporotic fracture in Belgian women. Bone 2008; 43: 991-94
Klotzbuecher CM, Ross PD, Landsman PB, et al. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 2000; 15: 721-39
Black DM, Arden NK, Palermo L, et al. Prevalent vertebral deformities predict hip fractures and new vertebral deformities but not wrist fractures: study of Osteoporotic Fractures Research Group. J Bone Miner Res 1999; 14: 821-8
Johnell O, Kanis JA, Oden A, et al. Fracture risk following an osteoporotic fracture. Osteoporos Int 2004; 15: 175-9
Kanis JA, Johnell O, De Laet C, et al. A meta-analysis of previous fracture and subsequent fracture risk. Bone 2004; 35: 375-82
Kanis JA, Johnell O, Oden A, et al. Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000; 27: 585-90
Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 1996; 312: 1254-9
Johnell O, Kanis JA, Oden A, et al. Predictive value of BMD for hip and other fractures. J Bone Miner Res 2005; 20: 1185-94
Directorate-general Statistics and Economic Information. Mortality tables 2004 and 2002-2004. Brussels: FPS Economy, 2006
Oden A, Dawson A, Dere W, et al. Lifetime risk of hip fractures is underestimated. Osteoporos Int 1998; 8: 599-603
Cauley JA, Thompson DE, Ensrud KC, et al. Risk of mortality following clinical fractures. Osteoporos Int 2000; 11: 556-61
Johnell O, Kanis JA, Oden A, et al. Mortality after osteoporotic fractures. Osteoporos Int 2004; 15: 38-42
Kanis JA, Oden A, Johnell O, et al. Excess mortality after hospitalisation for vertebral fracture. Osteoporos Int 2004; 15: 108-12
Kanis JA, Oden A, Johnell O, et al. The components of excess mortality after hip fracture. Bone 2003; 32: 468-73
Hiligsmann M, Ethgen O, Richy F, et al. Utility values associated with osteoporotic fracture: a systematic review of the literature. Calcif Tissue Int 2008; 82: 288-92
Fechtenbaum J, Cropet C, Kolta S, et al. The severity of vertebral fractures and health-related quality of life in osteoporotic postmenopausal women. Osteoporos Int 2005; 16: 2175-9
Oleksik A, Lips P, Dawson A, et al. Health-related quality of life in postmenopausal women with low BMD with or without prevalent vertebral fractures. J Bone Miner Res 2000; 15: 1384-92
Silverman SL, Minshall ME, Shen W, et al. The relationship of health-related quality of life to prevalent and incident vertebral fractures in postmenopausal women with osteoporosis: results from the Multiple Outcomes of Raloxifene Evaluation Study. Arthritis Rheum 2001; 44: 2611-9
Tosteson AN, Gabriel SE, Grove MR, et al. Impact of hip and vertebral fractures on quality-adjusted life years. Osteoporos Int 2001; 12: 1042-9
Reginster JY, Gillet P, Ben Sedrine W, et al. Direct costs of hip fractures in patients over 60 years of age in Belgium. Pharmacoeconomics 1999; 15 (5): 507-14
Autier P, Haentjens P, Bentin J, et al. Costs induced by hip fractures: a prospective controlled study in Belgium: Belgian Hip Fracture Study Group. Osteoporos Int 2000; 11: 73-80
Gabriel SE, Tosteson AN, Leibson CL, et al. Direct medical costs attributable to osteoporotic fractures. Osteoporos Int 2002; 13: 323-30
Melton 3rd LJ, Gabriel SE, Crowson CS, et al. Cost-equivalence of different osteoporotic fractures. Osteoporos Int 2003; 14: 383-8
Bouee S, Lafuma A, Fagnani F, et al. Estimation of direct unit costs associated with non-vertebral osteoporotic fractures in five European countries. Rheumatol Int 2006; 26: 1063-72
Meerding WJ, Looman CW, Essink-Bot ML, et al. Distribution and determinants of health and work status in a comprehensive population of injury patients. J Trauma 2004; 56: 150-61
SMEs, independent professions and energy, labour force survey. Brussels: FPS Economy, 2004
Directorate-general Statistics and Economic Information. Structure and distribution of earnings survey. Brussels: FPS Economy, 2007
Stevenson M, Jones ML, De Nigris E, et al. A systematic review and economic evaluation of alendronate, etidronate, risedronate, raloxifene and teriparatide for the prevention and treatment of postmenopausal osteoporosis. Health Technol Assess 2005; 9 (22): 1-160
Rabenda V, Mertens R, Fabri V, et al. Adherence to bisphosphonates therapy and hip fracture risk in osteoporotic women. Osteoporos Int 2008; 19: 811-8
Black DM, Cummings SR, Karpf DB, et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet 1996; 348: 1535-41
Black DM, Thompson DE, Bauer DC, et al. Fracture risk reduction with alendronate in women with osteoporosis: the Fracture Intervention Trial. FIT Research Group. J Clin Endocrinol Metab 2000; 85: 4118-24
Drummond M, O'Brien B, Stoddart G, et al. Methods for the economic evaluation of health care programmes. 2nd ed. Oxford University Press: Oxford, 2005
Langton CM, Ballard PA, Langton DK, et al. Maximising the cost effectiveness of BMD referral for DXA using ultrasound as a selective population pre-screen. Technol Health Care 1997; 5: 235-41
Langton CM, Langton DK, Beardsworth SA. Comparison of accuracy and cost effectiveness of clinical criteria and BUA for referral for BMD assessment by DXA in osteoporotic and osteopenic perimenopausal subjects. Technol Health Care 1999; 7: 319-30
Lippuner K, Fuchs G, Ruetsche AG, et al. How well do radiographic absorptiome-try and quantitative ultrasound predict osteoporosis at spine or hip? A cost-effectiveness analysis. J Clin Densitom 2000; 3: 241-9
Sim MF, Stone M, Johansen A, et al. Cost effectiveness analysis of BMD referral for DXA using ultrasound as a selective pre-screen in a group of women with low trauma Colles' fractures. Technol Health Care 2000; 8: 277-84
Sim MF, Stone MD, Phillips CJ, et al. Cost effectiveness analysis of using quantitative ultrasound as a selective pre-screen for bone densitometry. Technol Health Care 2005; 13: 75-85
Lopez-Rodriguez F, Mezquita-Raya P, de Dios Luna J, et al. Performance of quantitative ultrasound in the discrimination of prevalent osteoporotic fractures in a bone metabolic unit. Bone 2003; 32: 571-8
Hans D, Hartl F, Krieg MA. Device-specific weighted T-score for two quantitative ultrasounds: operational propositions for the management of osteoporosis for 65 years and older women in Switzerland. Osteoporos Int 2003; 14: 251-8
Siris ES, Chen YT, Abbott TA, et al. Bone mineral density thresholds for pharmacological intervention to prevent fractures. Arch Intern Med 2004; 164: 1108-12
Wainwright SA, Marshall LM, Ensrud KE, et al. Hip fracture in women without osteoporosis. J Clin Endocrinol Metab 2005; 90: 2787-93
Cranney A, Jamal SA, Tsang JF, et al. Low bone mineral density and fracture burden in postmenopausal women. CMAJ 2007; 177 (6): 575-80
Richy F, Gourlay M, Ross PD, et al. Validation and comparative evaluation of the osteoporosis self-assessment tool (OST) in a Caucasian population from Belgium. QJM 2004; 97 (1): 39-46
