An Economic Evaluation of Quantitative Ultrasonometry as Pre-Screening Test for the Identification of Patients with Osteoporosis

in Disease Management & Health Outcomes (2008), 16(6), 429-438

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 ... [more ▼]

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. [less ▲]

Efficience d'un dépistage de masse de l'ostéoporose par ultrasons: approche économique par microsimulation

in Revue du Rhumatisme (2007, December), 74(10-11), 1072-3

Cost-effectiveness of osteoporosis screening campaign for Belgian women

in Value in Health (2007, October), 10(6), 395

Prevention of hip fractures in osteoporosis

in Minerva Ortopedica e Traumatologica (2007), 58(5), 423-437

Hip fracture is the major clinical consequence of osteoporosis. It is linked with decreased life expectancy and quality of life, placing an ever increasing burden on health services. Few medications have ... [more ▼]

Hip fracture is the major clinical consequence of osteoporosis. It is linked with decreased life expectancy and quality of life, placing an ever increasing burden on health services. Few medications have unequivocally demonstrated their ability to reduce hip fracture risk in osteoporotic subjects. Daily alendronate and risedronate reduce hip fracture in patients with low bone mineral density and prevalent vertebral fractures. Intravenous bisphosphonates have been developed, in response to long-term poor adherence to oral anti-osteoporotic treatments. Once-yearly zoledronic acid reduces fracture rates at the spine, non-spine and hip locations. Strontium ranelate, the first drug to uncouple bone formation from bone resorption has also demonstrated its ability to reduce hip fractures in patients above 74 years old, with prevalent low bone mineral density. Calcium and vitamin D supplementation are prerequisite for the management of elderly subjects and should always been associated to anti-resorptive or bone forming agents. Non-pharmacological management of osteoporosis is recommended cannot be considered a substitute for pharmacological treatment of osteoporosis, not even in old age. [less ▲]

A naturalistic study of the determinants of healthrelated quality of life improvement in osteoarthritic patients treated with non-specific non-steroidal anti-inflammatory drugs

in Osteoporosis International (2005, March), 16(Suppl.3), 100-101

Physical functionning is the most severely affected health-related quality of life dimension during the aging process

in Osteoporosis International (2005, March), 16(Suppl.3), 25-26

Screening for osteoporosis: systematic DXA or pre-screening with questionnaires? An economic point of view

in Osteoporosis International (2005, March), 16(Suppl.3), 101

Vitamin D analogs versus native vitamin D in preventing bone loss and osteoporosis-related fractures: A comparative meta-analysis

in Calcified Tissue International (2005), 76(3), 176-186

It has been suggested that early postmenopausal women and patients treated with steroids should receive preventive therapy (calcium, vitamin D, vitamin D analogs, estrogens, or bisphosphonates) to ... [more ▼]

It has been suggested that early postmenopausal women and patients treated with steroids should receive preventive therapy (calcium, vitamin D, vitamin D analogs, estrogens, or bisphosphonates) to preserve their bone mineral density (BMD) and to avoid fragility fractures. We designed the present study to compare the effects of native vitamin D to its hydroxylated analogs alfacalcidol 1-alpha(OH)D and calcitriol 1,25(OH)(2)D. All randomized, controlled, double-blinded trials comparing oral native vitamin D and its analogs, alfacalcidol or calcitriol, to placebo or head-to-head trials in primary or corticosteroids-induced osteoporosis were included in the meta-analysis. Sources included the Cochrane Controlled Trials Register, EMBASE, MEDLINE, and a hand search of abstracts and references lists. The study period January 1985 to January 2003. Data were abstracted by two investigators, and methodological quality was assessed in a similar manner. Heterogeneity was extensively investigated. Results were expressed as effect-size (ES) for bone loss and as rate difference (RD) for fracture while allocated to active treatment or control. Publication bias was investigated. Fourteen studies of native vitamin D, nine of alfacalcidol, and ten of calcitriol fit the inclusion criteria. The two vitamin D analogs appeared to exert a higher preventive effect on bone loss and fracture rates in patients not exposed to glucocorticoids. With respect to BMD, vitamin D analogs versus placebo studies had an ES of 0.36 (P < 0.0001), whereas native vitamin D versus placebo had an ES of 0.17 (P = 0.0005), the interclass difference being highly significant (ANOVA-1, P < 0.05). When restricted to the lumbar spine, this intertreatment difference remained significant: ES = 0.43 (P = 0.0002) for vitamin D analogs and ES = 0.21 (P = 0.001) for native vitamin D (analysis of variance [ANOVA-1], P = 0.047). There were no significant differences regarding their efficacies on other measurement sites (ANOVA-1, P = 0.36). When comparing the adjusted global relative risks for fracture when allocated to vitamin D analogs or native vitamin D, alfacalcidol and calcitriol provided a more marked preventive efficacy against fractures: RD = 10% (95% Confidence interval [CI-2] to 17) compared to RD = 2% (95% CI, 1 to 2), respectively. The analysis of the spinal and nonspinal showed that fracture rates differed between the two classes, thereby confirming the benefits of vitamin D analogs, with significant 13.4% (95% CI 7.7 to 19.8) and. 6% (95% CI 1 to 12) lower fracture rates for vitamin D analogs, respectively. In patients receiving corticosteroid therapy, both treatments provided similar global ESs for BMD: ES = 0.38 for vitamin D analogs and ES = 0.41 for native vitamin D (ANOVA-1, P = 0.88). When restriced to spinal BMD, D analogs provided significant effects, whereas native vitamin D did not: ES = 0.43 (P < 0.0001) and ES = 0.33 (P = 0.21), respectively. The intertreatment difference was nonsignificant (ANOVA-1, P = 0.52). Neither D analogs for native vitamin D significantly prevented fractures in this subcategory of patients: RD = 2.6 (95%CI, -9.5 to 4.3) and RD = 6.4 (95%CI, -2.3 to 10), respectively. In head-to-head studies comparing D analogs and native vitamin D in patients receiving corticosteroids, significant effects favoring D analogs were found for femoral neck BMD: ES = 0.31 at P = 0.02 and spinal fractures: RD = 15% (95%CI, 6.5 to 25). Publication bias was not significant. Our analysis demonstrates a superiority of the D analogs atfacalcidol and calcitriol in preventing bone loss and spinal fractures in primary osteoporosis, including postmenopausal women. In corticosteroid-induced osteoporosis, the efficacy of D analogs differed depending on the comparative approach: indirect comparisons led to nonsignificant differences, whereas direct comparison did provide significant differences. In this setting, D analogs seem to prevent spinal fractures to a greater extent than do native vitamin D, but this assumption should be confirmed on a comprehensive basis in multiarm studies including an inactive comparator. [less ▲]

Primary prevention of osteoporosis: Mass screening scenario or prescreening with questionnaires? An economic perspective

in Journal of Bone and Mineral Research (2004), 19(12), 1955-1960

This study focuses on the controversy surrounding selective approaches to screen for osteoporosis. Seven screening approaches were compared in terms of cost-effectiveness and incremental cost ... [more ▼]

This study focuses on the controversy surrounding selective approaches to screen for osteoporosis. Seven screening approaches were compared in terms of cost-effectiveness and incremental cost-effectiveness ratios in a sample of 4035 postmenopausal women. Our results show that certain prescreening strategies are more efficient than DXA-based approaches. These results are of considerable value for health policy decision-makers and the scientific community. [less ▲]

Time dependent risk of gastrointestinal complications induced by non-steroidal anti-inflammatory drug use: a consensus statement using a meta-analytic approach

in Annals of the Rheumatic Diseases (2004), 63(7), 759-766

OBJECTIVES: To provide an updated document assessing the global, NSAID-specific, and time dependent risk of gastrointestinal (GI) complications through meta-analyses of high quality studies. METHODS: An ... [more ▼]

OBJECTIVES: To provide an updated document assessing the global, NSAID-specific, and time dependent risk of gastrointestinal (GI) complications through meta-analyses of high quality studies. METHODS: An exhaustive systematic search was performed. Inclusion criteria were: RCT or controlled study, duration of 5 days at least, inactive control, assessment of minor or major NSAID adverse effects, publication range January 1985 to January 2003. The publications retrieved were assessed during a specifically dedicated WHO meeting including leading experts in all related fields. Statistics were performed conservatively. Meta-regression was performed by regressing NSAID adjusted estimates against study duration categories. RESULTS: Among RCT data, indolic derivates provided a significantly higher risk of GI complications related to NSAID use than for non-users: RR = 2.25 (1.00; 5.08) than did other compounds: naproxen: RR = 1.83 (1.25; 2.68); diclofenac: RR = 1.73 (1.21; 2.46); piroxicam: RR = 1.66 (1.14; 2.44); tenoxicam: RR = 1.43 (0.40; 5.14); meloxicam: RR = 1.24 (0.98; 1.56), and ibuprofen: RR = 1.19 (0.93; 1.54). Indometacin users had a maximum relative risk for complication at 14 days. The other compounds presented a better profile, with a maximum risk at 50 days. Significant additional risk factors included age, dose, and underlying disease. The controlled cohort studies provided higher estimates: RR = 2.22 (1.7; 2.9). Publication bias testing was significant, towards a selective publication of deleterious effects of NSAIDs from small sized studies. CONCLUSION: This meta-analysis characterised the "compound" and "time" aspects of the GI toxicity of non-selective NSAIDs. The risk/benefit ratio of such compounds should thus be carefully and individually evaluated at the start of long term treatment. [less ▲]