Bone Densitometry Followed by Osteoporosis Treatment Cost-Effective in Some Older Men

Laurie Barclay, MD
August 7, 2007 — Bone densitometry screening followed by bisphosphonate treatment of those with osteoporosis may be cost-effective in some older men, according to the results of a study reported in the August 8 issue of the Journal of the American Medical Association.
"Osteoporotic fractures are common among elderly men," write John T. Schousboe, MD, MS, from the Park Nicollet Health Services in Minneapolis, Minnesota, and colleagues. "For these reasons, the International Society for Clinical Densitometry and the Canadian Osteoporosis Society, respectively, have advocated (based on expert opinion) bone densitometry for all men older than 70 and 65 years. However, the US Preventive Services Task Force and the Canadian Task Force on Preventive Health Care have made no recommendations on use of bone densitometry among elderly men."
The goal of this study was to compare the cost-effectiveness vs no intervention of bone densitometry in older men followed by 5 years of oral bisphosphonate therapy for those found to have osteoporosis, defined as a femoral neck T score of -2.5 or less.
Using a societal perspective and a lifetime horizon, the investigators performed computer Markov microsimulations for hypothetical cohorts of white men aged 65, 70, 75, 80, or 85 years, with or without previous clinical fracture. These simulations incorporated data regarding fracture costs and population-based, age-specific fracture rates from the Rochester Epidemiology Project; associations among previous fractures, bone density, and incident fractures from published meta-analyses and the Osteoporotic Fractures in Men (MrOS) study; and published studies of fracture disutility.
Primary endpoints were costs per quality-adjusted life-year (QALY) gained with densitometry and follow-up treatment for osteoporosis vs no intervention.
For men 65 years of age or older with a previous self-reported clinical fracture, and for men 80 years of age or older without a previous fracture, lifetime costs per QALY gained for bone densitometry and follow-up bisphosphonate treatment were less than $50,000. Factors that most affected this projected cost were the cost of oral bisphosphonate treatment, fracture reduction efficacy, degree of association between bone mineral density and fractures, fracture rates and disutility, and adherence to medication.
Limitations of the study include applicability to a treatment duration of only 5 years and only to white men living in the United States; lack of generalizability to treatment decisions based on bone mineral density (BMD) measured at skeletal sites other than the femoral neck; estimates of fracture disutility and fracture costs based on studies in which a minority of the participants were men; lack of precise estimates of nonvertebral fracture reduction efficacy of oral bisphosphonate treatment in elderly men; and failure to consider other risk factors for fracture, such as long-term use of systemic glucocorticoids.
"Bone densitometry followed by bisphosphonate therapy for those with osteoporosis may be cost-effective for men aged 65 years or older with a self-reported prior clinical fracture and for men aged 80 to 85 years with no prior fracture," the authors write. "This strategy may also be cost-effective for men as young as 70 years 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."
The National Institutes of Health supported the MrOS study. Some of the authors have disclosed various financial relationships with Hologic Inc, Eli Lilly, Merck, Amgen, Novartis, Procter & Gamble, Pfizer, Zelos, Aventis, GlaxoSmithKline, Solvay, and Bionovo.
JAMA. 2007;298:629-637.