Artificial intelligence; Chest radiographs; Cost-effectiveness; Health economics; Osteoporosis; Prevention; Screening; Humans; Female; Middle Aged; Aged; Germany; Quality-Adjusted Life Years; Markov Chains; Cost-Benefit Analysis; Deep Learning; Mass Screening/economics; Mass Screening/methods; Osteoporosis/diagnostic imaging; Osteoporosis/economics; Osteoporosis/diagnosis; Radiography, Thoracic/economics; Radiography, Thoracic/methods; Mass Screening; Radiography, Thoracic; Aging; Geriatrics and Gerontology
Abstract :
[en] [en] BACKGROUND: Osteoporosis is often underdiagnosed due to limitations in traditional screening methods, leading to missed early intervention opportunities. AI-driven screening using chest radiographs could improve early detection, reduce fracture risk, and improve public health outcomes.
AIMS: To assess the cost-effectiveness of deep learning models (hereafter referred to as AI-driven) applied to chest radiographs for opportunistic osteoporosis screening in German women aged 50 and older.
METHODS: A decision tree and microsimulation Markov model were used to calculate the cost per quality-adjusted life year (QALY) gained (€2024) for screening with AI-driven chest radiographs followed by treatment, compared to no screening and treatment. Patient pathways were based on AI model accuracy and German osteoporosis guidelines. Women with a fracture risk below 5% received no treatment, those with 5-10% risk received alendronate, and women 65 + with a risk above 10% received sequential treatment starting with romosozumab. Data was validated by a German clinical expert, incorporating real-world treatment persistence, DXA follow-up rates, and treatment initiation. Sensitivity analyses assessed parameter uncertainty.
RESULTS: The cost per QALY gained from screening was €13,340, far below the typical cost-effectiveness threshold of €60,000. Optimizing follow-up, treatment initiation, and medication adherence further improved cost-effectiveness, with dominance achievable by halving medication non-persistence, and in women aged 50-64.
CONCLUSION: AI-driven chest radiographs for opportunistic osteoporosis screening is a cost-effective strategy for German women aged 50+, with the potential to significantly improve public health outcomes, reduce fracture burdens and address healthcare disparities. Policymakers and clinicians should consider implementing this scalable and cost-effective screening strategy.
Disciplines :
Public health, health care sciences & services
Author, co-author :
Reginster, Jean-Yves ; Université de Liège - ULiège > Département des sciences de la santé publique ; Protein Research Chair, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
Schmidmaier, Ralf; Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
Alokail, Majed; Protein Research Chair, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
Hiligsmann, Mickael ; Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands. m.hiligsmann@maastrichtuniversity.nl
Language :
English
Title :
Cost-effectiveness of opportunistic osteoporosis screening using chest radiographs with deep learning in Germany.
Publication date :
13 May 2025
Journal title :
Aging Clinical and Experimental Research
ISSN :
1594-0667
eISSN :
1720-8319
Publisher :
Springer Science and Business Media Deutschland GmbH, Germany
JYR has received consulting fees from Promedius. RS is president of the German osteology association (DVO Dachverband Osteologie) and member of the DVO guideline committee for osteoporosis. He received consultancy funding from Alexion, Amgen, Sandoz and UCB, speeking fees from Alexion, Amgen, Blueprint, Takeda/Shire, Theramex and UCB. MA has no conflict of interest relevant to this paper. MH has received research grants (paid to institution) from Radius Health, and Angelini Pharma, lecture fees from IBSA (paid to institution) and Echolight, and was grant advisor for Pfizer (paid to institution) and consultant (paid to institution) for Gr\u00FCnenthal.This work was partly supported by the Distinguished Scientist Fellowship Program (DSFP) of the King Saud University, Riyadh, Kingdom of Saudi Arabia.
C. Beaudart C. Demonceau S. Sabico N. Veronese C. Cooper N. Harvey et al. Efficacy of osteoporosis Pharmacological treatments in men: a systematic review and meta-analysis Aging Clin Exp Res 35 9 1789 1806 10.1007/s40520-023-02478-9 37400668 10460304
F. Borgstrom L. Karlsson G. Ortsater N. Norton P. Halbout C. Cooper et al. Fragility fractures in Europe: burden, management and opportunities Arch Osteoporos 15 1 59 10.1007/s11657-020-0706-y 32306163 7166207
J.A. Kanis N. Norton N.C. Harvey T. Jacobson H. Johansson M. Lorentzon et al. SCOPE 2021: a new scorecard for osteoporosis in Europe Arch Osteoporos 16 1 82 10.1007/s11657-020-00871-9 34080059 8172408
P. Hadji E. Esterberg D. Obermuller R. Bartsch Bone evaluation study-2: update on the epidemiology of osteoporosis in Germany Arch Osteoporos 19 1 26 10.1007/s11657-024-01380-9 38592546 11003882
M. Jang M. Kim S.J. Bae S.H. Lee J.M. Koh N. Kim Opportunistic osteoporosis screening using chest radiographs with deep learning: development and external validation with a cohort dataset J Bone Min Res 37 2 369 377 10.1002/jbmr.4477
A. Paderno E.J. Ataide Gomes L. Gilberg L. Maerkisch B. Teodorescu A.M. Koc M. Meyer Artificial intelligence-enhanced opportunistic screening of osteoporosis in CT scan: a scoping review Osteoporos Int 35 10 1681 1692 10.1007/s00198-024-07179-1 38985200
M. Hiligsmann S.L. Silverman A.J. Singer L. Pearman Y. Wang J. Caminis J.Y. Reginster Comparison of the cost-effectiveness of sequential treatment with abaloparatide in US men and women at very high risk of fractures Aging Clin Exp Res 36 1 14 10.1007/s40520-023-02682-7 38289413 10827834
A. Pfeil U. Lange Update DVO-Leitlinie 2023 „prophylaxe, diagnostik und therapie der osteoporose Bei postmenopausalen Frauen und Bei Männern Ab dem 50. Lebensjahr– Was Ist Neu für die rheumatologie?? [Update on the DVO Guideline 2023 Prophylaxis, diagnosis and treatment of osteoporosis in postmenopausal women and in men aged over 50-What’s new for rheumatology?] Z Rheumatol 83 401 406 10.1007/s00393-024-01495-x 38512355 11147822
N. Veronese K. Briot N. Guanabens B.H. Albergaria M. Alokail N. Al-Daghri et al. Recommendations for the optimal use of bone forming agents in osteoporosis Aging Clin Exp Res 36 1 167 10.1007/s40520-024-02826-3 39120740 11315730
M. Hiligsmann J.Y. Reginster S. Silverman The value of a Patient-Level modeling approach and need for better reporting in economic evaluations of osteoporosis J Manag Care Spec Pharm 26 3 334 335 32105170
M. Hiligsmann J.Y. Reginster A.N.A. Tosteson S.V. Bukata K.G. Saag D.T. Gold et al. Recommendations for the conduct of economic evaluations in osteoporosis: outcomes of an experts’ consensus meeting organized by the European society for clinical and economic aspects of osteoporosis, osteoarthritis and musculoskeletal diseases (ESCEO) and the US branch of the international osteoporosis foundation Osteoporos Int 30 1 45 57 1:STN:280:DC%2BB3cvlsVamsw%3D%3D 10.1007/s00198-018-4744-x 30382319
J.Y. Reginster S.L. Silverman M. Alokail N. Al-Daghri M. Hiligsmann Cost-effectiveness of radiofrequency echographic multi-spectrometry for the diagnosis of osteoporosis in the united States JBMR Plus 9 1 ziae138 10.1093/jbmrpl/ziae138 39664931
D. Husereau M. Drummond F. Augustovski E. de Bekker-Grob A.H. Briggs C. Carswell et al. Consolidated health economic evaluation reporting standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluations Value Health 25 1 3 9 10.1016/j.jval.2021.11.1351 35031096
P. Haentjens J. Magaziner C.S. Colon-Emeric D. Vanderschueren K. Milisen B. Velkeniers S. Boonen Meta-analysis: excess mortality after hip fracture among older women and men Ann Intern Med 152 6 380 390 10.7326/0003-4819-152-6-201003160-00008 20231569 3010729
Bleibler F, Rapp K, Jaensch A, Becker C, König HH (2014) Expected lifetime numbers and costs of fractures in postmenopausal women with and without osteoporosis in Germany: a discrete event simulation model. Bmc Health Serv Res.;14
E. Soreskog O. Strom A. Spangeus K.E. Akesson F. Borgstrom J. Banefelt et al. Risk of major osteoporotic fracture after first, second and third fracture in Swedish women aged 50 years and older Bone 134 115286 10.1016/j.bone.2020.115286 32070789
M. Hiligsmann S.A. Williams L.A. Fitzpatrick S.S. Silverman R. Weiss J.Y. Reginster Cost-effectiveness of sequential treatment with abaloparatide followed by alendronate vs. alendronate monotherapy in women at increased risk of fracture: A US payer perspective Semin Arthritis Rheum 50 3 394 400 1:CAS:528:DC%2BB3cXkslCqtb4%3D 10.1016/j.semarthrit.2020.02.004 32160943
J.A. Kanis A. Oden O. Johnell C. De Laet B. Jonsson Excess mortality after hospitalisation for vertebral fracture Osteoporos Int 15 2 108 112 10.1007/s00198-003-1516-y 14598026
J.A. Kanis A. Oden O. Johnell C. De Laet B. Jonsson A.K. Oglesby The components of excess mortality after hip fracture Bone 32 5 468 473 1:STN:280:DC%2BD3s3jtVGhtg%3D%3D 10.1016/S8756-3282(03)00061-9 12753862
IQWIQ General methods. Version 6.1 of 24 January 2022. Accesible at: https://www.iqwig.de/methoden/general-methods_version-6-1.pdf
A. Svedbom P. Hadji E. Hernlund R. Thoren E. McCloskey R. Stad B. Stollenwerk Cost-effectiveness of Pharmacological fracture prevention for osteoporosis as prescribed in clinical practice in France, Germany, Italy, Spain, and the united Kingdom Osteoporos Int 30 9 1745 1754 1:STN:280:DC%2BB3MzjvVKrug%3D%3D 10.1007/s00198-019-05064-w 31270592
K. Rapp D. Rothenbacher J. Magaziner C. Becker P. Benzinger H.H. Konig et al. Risk of nursing home admission after femoral fracture compared with stroke, myocardial infarction, and pneumonia J Am Med Dir Assoc 16 8 715 10.1016/j.jamda.2015.05.013 e7- e12
O. Marten W. Greiner EQ-5D-5L reference values for the German general elderly population Health Qual Life Outcomes 19 1 76 10.1186/s12955-021-01719-7 33676523 7937199
T. Grochtdreis J. Dams H.H. Konig A. Konnopka Health-related quality of life measured with the EQ-5D-5L: Estimation of normative index values based on a representative German population sample and value set Eur J Health Econ 20 6 933 944 10.1007/s10198-019-01054-1 31030292
A. Svedbom F. Borgstom E. Hernlund O. Strom V. Alekna M.L. Bianchi et al. Quality of life for up to 18 months after low-energy hip, vertebral, and distal forearm fractures-results from the ICUROS Osteoporos Int 29 3 557 566 1:STN:280:DC%2BC1MzgsVOhsA%3D%3D 10.1007/s00198-017-4317-4 29230511
K.G. Saag J. Petersen M.L. Brandi A.C. Karaplis M. Lorentzon T. Thomas et al. Romosozumab or alendronate for fracture prevention in women with osteoporosis N Engl J Med 377 15 1417 1427 1:CAS:528:DC%2BC2sXhslWiurvP 10.1056/NEJMoa1708322 28892457
D. Willems M.K. Javaid R. Pinedo-Villanueva C. Libanati A. Yehoshua M. Charokopou Importance of time Point-Specific indirect treatment comparisons of osteoporosis treatments: A systematic literature review and network Meta-Analyses Clin Ther 44 1 81 97 10.1016/j.clinthera.2021.11.015 35058055
E. Gielen M. Aldven J.A. Kanis F. Borgstrom E. Senior D. Willems Cost-effectiveness of Romosozumab for the treatment of postmenopausal women with osteoporosis at high risk of fracture in Belgium Osteoporos Int 35 7 1173 1183 10.1007/s00198-024-07043-2 38565690 11211114
P. Hadji I. Kyvernitakis P.H. Kann C. Niedhart L.C. Hofbauer H. Schwarz et al. GRAND-4: the German retrospective analysis of long-term persistence in women with osteoporosis treated with bisphosphonates or denosumab Osteoporos Int 27 10 2967 2978 1:CAS:528:DC%2BC28XnvV2ls7c%3D 10.1007/s00198-016-3623-6 27172934 5042990
F. Borgstrom M. Lorentzon H. Johansson N.C. Harvey E. McCloskey D. Willems et al. Cost-effectiveness intervention thresholds for Romosozumab and teriparatide in the treatment of osteoporosis in the UK Osteoporos Int 35 12 2183 2193 10.1007/s00198-024-07251-w 39365433
L. Ryen M. Svensson The willingness to pay for a quality adjusted life year: A review of the empirical literature Health Econ 24 10 1289 1301 10.1002/hec.3085 25070495
N.R. Fuggle B. Curtis M. Clynes J. Zhang K. Ward M.K. Javaid et al. The treatment Gap: the missed opportunities for osteoporosis therapy Bone 144 115833 10.1016/j.bone.2020.115833 33359889
M.G. Bendtsen M.F. Hitz Opportunistic identification of vertebral compression fractures on CT scans of the chest and abdomen, using an AI algorithm, in a Real-Life setting Calcif Tissue Int 114 5 468 479 1:CAS:528:DC%2BB2cXmvFSjsr4%3D 10.1007/s00223-024-01196-2 38530406 11061033
T. Asamoto Y. Takegami Y. Sato S. Takahara N. Yamamoto N. Inagaki et al. External validation of a deep learning model for predicting bone mineral density on chest radiographs Arch Osteoporos 19 1 15 10.1007/s11657-024-01372-9 38472499
Sato Y, Yamamoto N, Inagaki N, Iesaki Y, Asamoto T, Suzuki T, Takahara S (2022) Deep learning for bone mineral density and T-Score prediction from chest X-rays: A multicenter study. Biomedicines.;10(9)
Y. He J. Lin S. Zhu J. Zhu Z. Xu Deep learning in the radiologic diagnosis of osteoporosis: a literature review J Int Med Res 52 4 3000605241244754 10.1177/03000605241244754 38656208
S. Ruhling J. Schwarting M.F. Froelich M.T. Loffler J. Bodden M.R. Hernandez Petzsche et al. Cost-effectiveness of opportunistic QCT-based osteoporosis screening for the prediction of incident vertebral fractures Front Endocrinol (Lausanne) 14 1222041 10.3389/fendo.2023.1222041 37576975
N. Li C. Beaudart J.A. Cauley S.W. Ing N.E. Lane J.Y. Reginster et al. Cost effectiveness analyses of interventions for osteoporosis in men: A systematic literature review PharmacoEconomics 41 4 363 391 10.1007/s40273-022-01239-2 36738425 10020287
