OSTEOPOROSIS
More Men Could Benefit from Osteoporosis Screening
Schousboe JT, Taylor BC, Fink HA, et al. Cost-effectiveness of bone densitometry followed by treatment of osteoporosis in older men. JAMA. 2007;298(6):629-637.
Abstract
Objective: To evaluate among older men the cost-effectiveness of bone densitometry followed by five years of oral bisphosphonate therapy to prevent fractures for those found to have osteoporosis (femoral neck T-score <-2.5), compared with no intervention.
Design, Setting, Population: Computer Markov microsimulation model using a societal perspective and a lifetime horizon. Simulations were performed for hypothetical cohorts of white men with or without prior clinical fracture. Data sources for model parameters included the Rochester Epidemiology Project for fracture costs and population-based age-specific fracture rates; the Osteoporotic Fractures in Men study and published meta-analyses for the associations among prior fractures, bone density, and incident fractures; and published studies of fracture disutility.
Main Outcome Measures: Costs per quality-adjusted life-year (QALY) gained for the densitometry and follow-up treatment strategy compared with no intervention, calculated from lifetime costs and accumulated QALYs for each strategy.
Results: Lifetime costs per QALY gained for the densitometry and follow-up treatment strategy were less than $50,000 for men 65 or older with a prior clinical fracture and for men 80 or older without a prior fracture. These results were most sensitive to oral bisphosphonate cost and fracture reduction efficacy, the strength of association between bone mineral density (BMD) and fractures, fracture rates and disutility, and medication adherence.
Conclusions: Bone densitometry followed by bisphosphonate therapy for those with osteoporosis may be cost effective for men 65 or older with a self-reported prior clinical fracture and for men aged 80 to 85 with no prior fracture. This strategy may also be cost effective for men as young as 70 without a prior clinical fracture if oral bisphosphonate costs are less than $500 per year or if the societal willingness to pay per QALY gained is $100,000.
Commentary
The impact of osteoporosis in older men is being belatedly recognized.1 Sixty-year-old white men have a 29% chance of osteoporotic fracture before they die. One-third of all hip fractures occur in men and are associated with higher mortality than those in women.2
Universal bone densitometry for women 65 and older has been shown to be cost-effective and is widely advocated.3 However, because the age-specific prevalence of osteoporosis and incident fracture rates are much lower in men than women, it is not obvious that bone density screening followed by treatment of men with osteoporosis is cost effective at any age. The lack of cost-effectiveness analyses and, therefore, consensus on screening for osteoporosis in men may be responsible for low rates of clinical intervention.
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.
