The purpose of this modeling study was to estimate lifetime costs and health benefits of bone densitometry followed by five years of oral bisphosphonate therapy for men who are found to have osteoporosis compared with no intervention.
The authors used a Markov microsimulation model for hypothetical cohorts of white men with and without prior clinical fracture. Fracture disutility was modeled as a lower QALY value compared with the no-fracture state. Data for fracture rate and risk were derived from a variety of sources. The authors assumed a direct medical cost of $1,000 per year for oral bisphosphonates, published costs of acute clinical fractures, and long-term care costs after hip fracture.
The lifetime costs per QALY gained were less than $50,000 per year for men with prior fractures over 65 and for men over 80 without a fracture. For men without fractures up to age 80, costs per QALY exceeded $50,000 per year.
The analysis was especially sensitive to the cost of oral bisphosphonates. If the costs are reduced by half to $500 per year (this may be realistic because alendronate loses patent protection in 2008), then the cost per QALY for 70-year-old men without prior clinical fracture is less than $50,000 per year (versus $70,000 per year at a cost of $1,000 per year).
Will this study offer any guidance for clinical decisions? Probably like many rheumatologists, I obtain BMD testing on men who suffer a fragility fracture or who are on corticosteroids or have other risk factors, such as hypogonadism. This study confirms the cost effectiveness of this strategy after clinical fracture, but doesn’t speak to the cost effectiveness of routine screening and treating of men with other risk factors.
Importantly, the study will probably make me consider offering BMD testing to men 80 and older regardless of other risk factors. However, an important consideration that must be addressed before this becomes widespread practice is reimbursement. Currently, Medicare covers BMD scanning for men who have a prior fracture, are on glucocorticoids, or have height loss. Unless these restrictions are loosened, more widespread screening probably will not occur. The results published here could provide an impetus for Medicare to add the indication for men over 80.
References
- Olszynski WP, Shawn Davidson K, Adachi JD, et al. Osteoporosis in men. Clin Ther. 2004;26(1):15-28.
- Trombetti A, Herrmann F, Hoffmeyer P, et al. Survival and potential years of life lost after hip fracture in men and age-matched women. Osteoporosis Int. 2002;13(9);731-737.
- Schousboe JT, et al. Universal bone densitometry screening combined with alendronate therapy for those diagnosed with osteoporosis is highly cost-effective for elderly women. J Am Geriatric Soc. 2005;53(10):1697-1704.
