Recombinant Parathyroid Hormone Versus Usual Care: Do the Outcomes Justify the Cost?

BACKGROUND: Hypoparathyroidism is a potential outcome of anterior neck surgery. Commonly it is managed by calcium and vitamin D supplementation in large doses, with attendant side effects. A recombinant human parathyroid hormone (rhPTH) is now available in the USA, offering a potentially more effective treatment. No cost-effectiveness model investigating this new medication versus standard care has yet been published. METHODS: We constructed a decision analytic model comparing usual care versus rhPTH treatment for postsurgical hypoparathyroidism. Threshold and sensitivity analyses on key parameters were conducted to assess robustness of the model. Costs and health outcomes were represented in US dollars and quality-adjusted life-years (QALYs). RESULTS: The rhPTH strategy was both more costly and more effective than the usual care (UC) strategy. In the base case, UC cost $37,196 and provided 7.54 QALYs. The rhPTH strategy cost $777,224 and provided 8.46 QALYs for an incremental cost-effectiveness ratio of $804,378/QALY. As this was above our willingness-to-pay of $100,000, treatment with rhPTH was not considered cost-effective. The model was robust to all other parameters. CONCLUSIONS: To our knowledge, this is the first formal cost-effectiveness analysis of rhPTH in comparison with UC. Our model suggests that although the new treatment is slightly more effective than UC, the modest gain in quality of life for patients who are reasonably well-managed by UC does not justify the cost. However, consideration must be given to rhPTH for patients who have failed UC, as the expenditure may be justified in that context.

Economic evaluation of vitamin D and calcium food fortification for fracture prevention in Germany.

OBJECTIVE: The study evaluates the economic benefit of population-wide vitamin D and Ca food fortification in Germany. DESIGN: Based on a spreadsheet model, we compared the cost of a population-wide vitamin D and Ca food-fortification programme with the potential cost savings from prevented fractures in the German female population aged 65 years and older. SETTING: The annual burden of disease and the intervention cost were assessed for two scenarios: (i) no food fortification; and (ii) voluntary food fortification with 20 µg (800 IU) of cholecalciferol (vitamin D3) and 200 mg of Ca. The analysis considered six types of fractures: hip, clinical vertebral, humerus, wrist, other femur and pelvis. SUBJECTS: Subgroups of the German population defined by age and sex. RESULTS: The implementation of a vitamin D and Ca food-fortification programme in Germany would lead to annual net cost savings of €315 million and prevention of 36 705 fractures in the target population. CONCLUSIONS: Vitamin D and Ca food fortification is an economically beneficial preventive health strategy that has the potential to reduce the future health burden of osteoporotic fractures in Germany. The implementation of a vitamin D and Ca food-fortification programme should be a high priority for German health policy makers because it offers substantial cost-saving potential for the German health and social care systems.

Calcium requirements from dairy foods in France can be met at low energy and monetary cost.

Inadequate Ca intakes are a concern for global public health. In France, most dietary Ca is provided by dairy products: milks, fermented milks (mostly yogurts), dairy desserts and cheeses. The present dairy database (n 837) included milks (n 101), fermented milks, yogurts and other fresh dairy products (n 326), desserts (n 162) and a wide variety of cheeses (n 248). Energy and nutrient values were obtained from industry sources and the French national nutrient composition database. Retail prices were from Paris supermarkets. Products in each group were aggregated into twenty-one categories using clustering analyses. The costs in energy (kJ (kcal)), euros (€), and in SFA, added sugar and Na (defined here as nutrients to LIMit) associated with providing 120 mg of Ca (equivalent to 15 % daily value (15 % DV)) were calculated for each product group and category. The milk group supplied Ca at the lowest energy, monetary and LIM cost. Fresh plain and 'light' yogurts and fermented milks were next, followed by sweetened yogurts and flavoured milks. Light dairy desserts provided Ca with relatively few energy but were more expensive. Cheeses were a heterogeneous group. Hard cheeses (Comté) provided the most Ca per serving. Semi-hard cheeses (Camembert) and cream and blue cheeses (Roquefort) provided Ca at a cost comparable with sweetened yogurts and flavoured milks. Double cream, soft and goat cheeses were not optimal Ca sources. New value metrics can help identify affordable dairy foods that provide Ca without excessive energy or nutrients to limit. These conditions were satisfied by a wide variety of dairy products in France.

Cost-effectiveness of vitamin D and calcium supplementation in the treatment of elderly women and men with osteoporosis.

BACKGROUND: The supplementation with vitamin D and calcium has been recommended for elderly, specifically those with increased risk of fractures older than 65 years. This study aims to assess the cost-effectiveness of vitamin D and calcium supplementation in elderly women and men with osteoporosis and therefore to assess if this recommendation is justified in terms of cost-effectiveness. METHODS: A validated model for economic evaluations in osteoporosis was used to estimate the cost per quality-adjusted life-year (QALY) gained of vitamin D/calcium supplementation compared with no treatment. The model was populated with cost and epidemiological data from a Belgian health-care perspective. Analyses were conducted in women and men with a diagnosis of osteoporosis (i.e. bone mineral density T-score ≤-2.5). A literature search was conducted to describe the efficacy of vitamin D and calcium in terms of fracture risk reduction. RESULTS: The cost per QALY gained of vitamin D/calcium supplementation was estimated at €40 578 and €23 477 in women and men aged 60 years, respectively. These values decreased to €7912 and €10 250 at the age of 70 years and vitamin D and calcium supplementation was cost-saving at the age of 80 years, meaning that treatment cost was less than the costs of treating osteoporotic fractures of the no-treatment group. CONCLUSION: This study suggests that vitamin D and calcium supplementation is cost-effective for women and men with osteoporosis aged over 60 years. From an economic perspective, vitamin D and calcium should therefore be administrated in these populations including those also taking other osteoporotic treatments.

Vitamin K supplementation for the primary prevention of osteoporotic fractures: is it cost-effective and is future research warranted?

UNLABELLED: Lifetime supplementation with vitamin K, vitamin D(3), and calcium is likely to reduce fractures and increase survival in postmenopausal women. It would be a cost-effective intervention at commonly used thresholds, but high uncertainty around the cost-effectiveness estimates persists. Further research on the effect of vitamin K on fractures is warranted. INTRODUCTION: Vitamin K might have a role in the primary prevention of fractures, but uncertainties about its effectiveness and cost-effectiveness persist. METHODS: We developed a state-transition probabilistic microsimulation model to quantify the cost-effectiveness of various interventions to prevent fractures in 50-year-old postmenopausal women without osteoporosis. We compared no supplementation, vitamin D(3) (800 IU/day) with calcium (1,200 mg/day), and vitamin K(2) (45 mg/day) with vitamin D(3) and calcium (at the same doses). An additional analysis explored replacing vitamin K(2) with vitamin K(1) (5 mg/day). RESULTS: Adding vitamin K(2) to vitamin D(3) with calcium reduced the lifetime probability of at least one fracture by 25%, increased discounted survival by 0.7 quality-adjusted life-years (QALYs) (95% credible interval (CrI) 0.2; 1.3) and discounted costs by $8,956, yielding an incremental cost-effectiveness ratio (ICER) of $12,268/QALY. At a $50,000/QALY threshold, the probability of cost-effectiveness was 95% and the population expected value of perfect information (EVPI) was $28.9 billion. Adding vitamin K(1) to vitamin D and calcium reduced the lifetime probability of at least one fracture by 20%, increased discounted survival by 0.4 QALYs (95% CrI -1.9; 1.4) and discounted costs by $4,014, yielding an ICER of $9,557/QALY. At a $50,000/QALY threshold, the probability of cost-effectiveness was 80% while the EVPI was $414.9 billion. The efficacy of vitamin K was the most important parameter in sensitivity analyses. CONCLUSIONS: Lifetime supplementation with vitamin K, vitamin D(3), and calcium is likely to reduce fractures and increase survival in postmenopausal women. Given high uncertainty around the cost-effectiveness estimates, further research on the efficacy of vitamin K on fractures is warranted.

Use of parathormone as a predictor of hypoparathyroidism after total thyroidectomy.

BACKGROUND: Post-operative hypoparathyroidism is the most frequent complication after total thyroidectomy. It represents one of the main causes of prolonged hospital-stay and is associated with a significant increase in health costs. The identification of patients with higher risk of suffering this complication allows early treatment, reduces clinical complications and adequate the use of health resources. Throughout history, several predictors have been used to stratify patients at risk. In recent years the use of parathormone parathyroid hormone (PTH) has taken particular interest. OBJECTIVE: To review the existing literature on the use of PTH as a predictor of hypocalcemia after thyroidectomy. METHOD: A medline search was performed. We reviewed the existing evidence on efficacy of PTH as a predictor of post-operative hypocalcemia, economic impact, optimal time for sampling and implementation mode. CONCLUSION: The use of PTH predicts with adequate sensitivity, specificity, negative and positive predictive value the risk for the patients to suffer post-operative hypocalcemia. Cut-off values and sampling number and time vary among authors; as a result, more data is needed to reach a conclusion about the standardization of use after a total thyroidectomy procedure. It use could be beneficial not only for patients but also for care providers as health cost might be diminished.

ANTECEDENTES: El hipoparatiroidismo posoperatorio constituye la complicación más frecuente de la tiroidectomía total. Se asocia, entre otras cosas, a internación prolongada y múltiples pruebas de laboratorio, y con ello a un incremento en los costos de salud. La identificación de pacientes con mayor riesgo de padecer esta complicación permite realizar un tratamiento precoz, disminuyendo el costo económico y evitando complicaciones asociadas a un retraso en la externación. Se han descrito diversos predictores para identificar tempranamente a los pacientes en riesgo; en los últimos años, ha tomado particular relevancia el uso de la parathormona (PTH). OBJETIVO: El objetivo del presente trabajo es revisar la literatura existente sobre la utilidad de la PTH como predictor de hipocalcemia postiroidectomía. MÉTODO: Se realizó una búsqueda en PubMed revisando la evidencia existente sobre eficacia de la PTH como predictor de hipocalcemia posoperatoria, su repercusión económica, el tiempo óptimo para la toma de muestra y el modo de implementación. CONCLUSIÓN: El uso de la PTH permite predecir con adecuada sensibilidad, especificidad, valor predictivo negativo y valor predictivo positivo los pacientes en riesgo de padecer hipocalcemia posoperatoria. Sin embargo, los valores de corte, los tiempos de toma de muestra y la cantidad de estas varían entre los autores, por lo que persisten algunos interrogantes acerca de la estandarización de su uso.

A comparative cost-utility analysis of postoperative calcium supplementation strategies used in the current management of hypocalcemia.

BACKGROUND: Symptomatic hypocalcemia is a common complication of total thyroidectomy. Management strategies include responsive treatment initiation for symptoms or prevention by routine or parathyroid hormone-directed calcium supplementation. The comparative cost-effectiveness of even the most often utilized strategies is unclear. METHODS: A Markov cohort model was created to compare routine supplementation with calcium alone (RS), postoperative parathyroid hormone-based selective supplementation with calcium and calcitriol (SS), and no supplementation (NS) in asymptomatic patients. Patients could remain asymptomatic or develop symptomatic hypocalcemia, managed with outpatient oral supplementation or intravenous calcium infusion and administered either inpatient or outpatient. Effectiveness was measured in quality-adjusted life years. Sensitivity analyses were performed to test model parameter assumptions. RESULTS: RS was the preferred strategy, costing $329/patient and resulting in 0.497 quality-adjusted life years, which was only marginally better compared to SS ($373 for 0.495 quality-adjusted life years). NS was most costly at $4,955 for 0.491 quality-adjusted life years. Preference for RS over SS was sensitive to the probability of developing symptoms and the probability of symptom treatment with intravenous supplementation. On probabilistic sensitivity analysis, RS was preferred in 75.4% of scenarios. CONCLUSION: After total thyroidectomy, a preventative calcium supplementation strategy should be strongly considered. In this data-driven theoretical model, RS was the least costly option and resulted in an incremental gain in quality-adjusted life years.

Randomized trials assessing calcium supplementation in healthy children: relationship between industry sponsorship and study outcomes.

OBJECTIVE: To explore the relationship between industry sponsorship of Ca supplementation studies in healthy children and study outcomes. DESIGN: An electronic search for published randomized controlled trials (RCT) was conducted. We collected data on study design features aimed at reducing bias, statistical significance of results, authors' conclusions and financial sponsorship of study. We used Fischer's exact test to examine associations between sponsorship and study results and conclusions. SUBJECTS: Healthy children between the ages of 9 and 18 years. RESULTS: Nineteen trials met our inclusion criteria. Seventeen out of nineteen studies reported a statistically significant improvement of supplementation on bone mineral density. Subjects in eight of the seventeen studies had a baseline daily Ca intake of 800-1300 mg. There was no significant association between study design features and the results or conclusions of the studies. Three studies received government funding, two of which (66.7%) concluded in favour of additional supplementation. Sixteen studies were either industry-funded or had mixed industry funding, thirteen (81.3%) of which had a conclusion supporting Ca supplementation in children. There was no significant association between study sponsorship and authors' conclusions. CONCLUSIONS: The majority of RCT assessing the effects of Ca supplementation in healthy children are industry-funded and support Ca supplementation. The clinical significance of the outcomes measured in Ca supplementation studies should be considered when examining associations between study design and results. Further non-industry funded research is needed to thoroughly assess the impact of funding on authors' conclusions in nutrition research.

Can calcium chemoprevention of adenoma recurrence substitute or serve as an adjunct for colonoscopic surveillance?

OBJECTIVES: The aim of this study was to examine the potential cost-effectiveness of calcium chemoprevention post-polypectomy as a substitute or adjunct for surveillance. METHODS: We constructed a Markov model of post-polypectomy adenoma recurrence and colorectal cancer (CRC) development, calibrated to data from prospective chemoprevention trials of fiber, calcium, antioxidants, and aspirin. We modeled four scenarios for 50-year-old patients immediately after polypectomy: (i) natural history with no further intervention; (ii) elemental calcium 1,200 mg/day from age 50-80; (iii) surveillance colonoscopy from age 50-80 every 5 years, or 3 years for large adenoma; (iv) calcium + surveillance. Patients were followed up until age 100 or death. RESULTS: Calcium was cost-effective compared to natural history ($49,900/life-year gained). However, surveillance was significantly more effective than calcium (18.729 versus 18.654 life-years/patient; 76 percent versus 14 percent reduction in CRC incidence) at an incremental cost of $15,900/life-year gained. Calcium + surveillance yielded a very small benefit (0.0003 incremental life-years/patient) compared with surveillance alone, at a substantial incremental cost of $3,090,000/life-year gained. CONCLUSION: Post-polypectomy calcium chemoprevention is unlikely to be a reasonable substitute for surveillance. It may be cost-effective in patients unwilling or unable to undergo surveillance.

Cost effectiveness of ibandronate for the prevention of fractures in inflammatory bowel disease-related osteoporosis: cost-utility analysis using a Markov model.

BACKGROUND: Osteoporosis is a frequent complication in patients with inflammatory bowel disease. Recent studies have shown bisphosphonates to considerably reduce fracture risk in patients with osteoporosis, and preventing fractures with bisphosphonates has been reported to be cost effective in older populations. However, no studies of the cost effectiveness of these agents in preventing fractures in patients with inflammatory bowel disease are available. OBJECTIVE: To investigate the cost effectiveness of the bisphosphonate ibandronate combined with calcium/colecalciferol ('ibandronate') in patients with osteopenia or osteoporosis due to inflammatory bowel disease in Germany. Treatment strategies used for comparison were sodium fluoride combined with calcium/colecalciferol ('fluoride') and calcium/colecalciferol ('calcium') alone. STUDY DESIGN AND METHODS: A cost-utility analysis was conducted using data from a randomized controlled trial (RCT). Changes in bone mineral density (BMD) were adjusted and predicted for a standardized population receiving each respective treatment. A Markov model was developed, with probabilities of transition to fracture states consisting of BMD-dependent and -independent components. The BMD-dependent component was assessed using predicted change in BMD from the RCT. The independent component captured differences in bone quality and micro-architecture resulting from prevalent fractures or treatment with anti-resorptive drugs. The analysis was conducted for a population with a mean age of the RCT patients (women aged 36 years, men aged 38 years) with osteopenia (T-score about -2.0 at baseline), a population of the same age with osteoporosis (T-score of -3.0 at baseline) and for an older population (both sexes aged 65 years) with osteoporosis (T-score of -3.0). Outcomes were measured as costs per QALY gained from a societal perspective. The treatment duration in the RCT was 42 months. A 5-year period was assumed to follow, during which the treatment effects linearly declined to 0. The simulation time was 10 years. Prices for medication and treatment were presented as year 2004 values; costs and effects were discounted at 5%. To test the robustness of the results, univariate and probabilistic sensitivity analyses (Monte Carlo simulation) were conducted. RESULTS: The calcium strategy dominated the fluoride strategy. When the ibandronate strategy was compared with the calcium strategy, the base-case cost-effectiveness ratios (costs per QALY gained) were between euro 407 375 for an older female population with osteoporosis and euro 6 516 345 for a younger female population with osteopenia. Univariate sensitivity analyses resulted in variations between 4% of base-case results and dominance of calcium. In Monte Carlo simulations, conducted for the various populations, the probability of an ICER of ibandronate below euro 50 000 per QALY was never greater than 20.2%. CONCLUSION: The ibandronate strategy is unlikely to be considered cost effective by decision makers in men or women with characteristics of those in the target population of the RCT, or in older populations with osteoporosis.

START (screening tool to alert doctors to the right treatment)--an evidence-based screening tool to detect prescribing omissions in elderly patients.

BACKGROUND: Inappropriate prescribing encompasses acts of commission i.e. giving drugs that are contraindicated or unsuitable, and acts of omission i.e. failure to prescribe drugs when indicated due to ignorance of evidence base or other irrational basis e.g. ageism. There are considerable published data on the prevalence of inappropriate prescribing; however, there are no recent published data on the prevalence of acts of omission. The aim of this study was to calculate the prevalence of acts of prescribing omission in a population of consecutively hospitalised elderly people. METHODS: A screening tool (screening tool to alert doctors to the right treatment acronym, START), devised from evidence-based prescribing indicators and arranged according to physiological systems was prepared and validated for identifying prescribing omissions in older adults. Data on active medical problems and prescribed medicines were collected in 600 consecutive elderly patients admitted from the community with acute illness to a teaching hospital. On identification of an omitted medication, the patient's medical records were studied to look for a valid reason for the prescribing omission. RESULTS: Using the START list, we found one or more prescribing omissions in 57.9% of patients. In order of prevalence, the most common prescribing omissions were: statins in atherosclerotic disease (26%), warfarin in chronic atrial fibrillation (9.5%), anti-platelet therapy in arterial disease (7.3%) and calcium/vitamin D supplementation in symptomatic osteoporosis (6%). CONCLUSION: Failure to prescribe appropriate medicines is a highly prevalent problem among older people presenting to hospital with acute illness. A validated screening tool (START) is one method of systematically identifying appropriate omitted medicines in clinical practice.

[The necessity of cost-effectiveness analysis in osteoporosis]. / De la nécessité des études coût-efficacité en ostéoporose.

Economic evaluations are increasingly being used by decision-makers to estimate the cost-effectiveness of interventions. Major changes have recently occurred in the treatment of osteoporosis. The development of a valid economic model (Markov) in the field of osteoporosis is discussed, as well as these limitations. Intervention, such hip protectors, calcium and vitamin D, bisphosphonates, hormonal replacement therapy, SERMs, strontium ranélate, analogue of parathyroid hormone are analysed in the light of cost-effectiveness analyses.

Is there a difference in efficacy, safety, and cost-effectiveness between 3-factor and 4-factor prothrombin complex concentrates among trauma patients on oral anticoagulants?

PURPOSE: The aim of this study was to compare the efficacy, safety, and cost-effectiveness of 3-factor prothrombin complex concentrate (3F-PCC) vs 4-factor prothrombin complex concentrate PCC (4F-PCC) in trauma patients requiring reversal of oral anticoagulants. MATERIALS AND METHODS: All consecutive trauma patients with coagulopathy (international normalized ratio [INR] ≥1.5) secondary to oral anticoagulants who received either 3F-PCC or 4F-PCC from 2010 to 2014 at 2 trauma centers were reviewed. Efficacy was determined by assessing the first INR post-PCC administration, and successful reversal was defined as INR less than 1.5. Safety was assessed by reviewing thromboembolic events, and cost-effectiveness was calculated using total treatment costs (drug acquisition plus transfusion costs) per successful reversal. RESULTS: Forty-six patients received 3F-PCC, and 18 received 4F-PCC. Baseline INR was similar for 3F-PCC and 4F-PCC patients (3.1 ± 2.3 vs 3.4 ± 3.7, P = .520). The initial PCC dose was 29 ± 9 U/kg for 3F-PCC and 26 ± 6 U/kg for 4F-PCC (P = .102). The follow-up INR was 1.6 ± 0.6 for 3F-PCC and 1.3 ± 0.2 for 4F-PCC (P = .001). Successful reversal rates in patients were 83% for 4F-PCC and 50% for 3F-PCC (P = .022). Thromboembolic events were observed in 15% of patients with 3F-PCC vs 0% with 4F-PCC (P = .177). Cost-effectiveness favored 4F-PCC ($5382 vs $3797). CONCLUSIONS: Three-factor PCC and 4F-PCC were both safe in correcting INR, but 4F-PCC was more effective, leading to better cost-effectiveness. Replacing 3F-PCC with 4F-PCC for urgent coagulopathy reversal may benefit patients and institutions.

Economic Benefit of Calcium and Vitamin D Supplementation: Does It Outweigh the Cost of Nonunions?

OBJECTIVES: The purpose was to evaluate economic benefit of calcium and vitamin D supplementation in orthopaedic trauma patients. We hypothesized that reduced nonunion rates could justify the cost of supplementing every orthopaedic trauma patient. DESIGN: Retrospective, economic model. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Adult patients over 3 consecutive years presenting with acute fracture. INTERVENTION: Operative or nonoperative fracture management. MAIN OUTCOME MEASUREMENTS: Electronic medical records were queried for ICD-9 code for diagnosis of nonunion and for treatment records of nonunion for fractures initially treated within our institution. RESULTS: In our hospital, a mean of 92 (3.9%) fractures develop nonunion annually. A 5% reduction in nonunion risk from 8 weeks of vitamin D supplementation would result in 4.6 fewer nonunions per year. The mean estimate of cost for nonunion care is $16,941. Thus, the projected reduction in nonunions after supplementation with vitamin D and calcium would save $78,030 in treatment costs per year. The resulting savings outweigh the $12,164 cost of supplementing all fracture patients during the first 8 weeks of fracture healing resulting in a net savings of $65,866 per year. CONCLUSIONS: Vitamin D and calcium supplementation of orthopaedic trauma patients for 8 weeks after fracture seems to be cost effective. Supplementation may also reduce the number of subsequent fractures, enhance muscular strength, improve balance in the elderly, elevate mood leading to higher functional outcome scores, and diminish hospital tort liability by reducing the number of nonunions. LEVEL OF EVIDENCE: Economic Level V. See Instructions for Authors for a complete description of levels of evidence.

A review of calcium preparations.

There are more than a dozen commonly prescribed calcium supplements and hundreds of different formulations commercially available. Numerous factors need to be considered when selecting a calcium preparation. Physical properties such as solubility, interference from coingested medications or foodstuffs, dosage, and timing can all affect the bioavailability of calcium. Medical conditions such as lactose intolerance, impaired gastric acid secretion, and high risk profile for kidney stone formation may impact on selection of a calcium supplement. This article will review the available literature and make general recommendations for the optimal use of calcium preparations.

Supplemental calcium for the prevention of hip fracture: potential health-economic benefits.

We assessed the cost-effectiveness of daily calcium supplementation for the prevention of primary osteoporotic hip fractures. The assessment was based on our meta-analysis of the published relative-risk estimates from 3 double-masked, placebo-controlled, clinical trials and our analysis of raw data from the National Health and Nutrition Examination Survey 1988-1994 on the daily intake of calcium supplements by adults in the United States. These data were then used to estimate the preventable proportion of hip fractures. The 1995 National Hospital Discharge Survey database provided the number and demographic characteristics of patients discharged with a primary diagnosis of hip fracture, as well as their discharge destination. The 1990 itemized costs of hip fractures, as estimated by the US Congress Office of Technology Assessment, were inflated to 1995 dollars using the medical care component of the Consumer Price Index. Using these inflated itemized costs, we then estimated the weighted average expenditures, reflecting both the types of services associated with specific hospital-discharge destinations and the demographic characteristics of discharged patients. The cost of supplements containing 1200 mg/d of elemental calcium for the mean duration (34 months) of the 3 clinical trials was calculated on the basis of 1998 unit-price and market-share data for 6 representative products. For 1995, the data indicate that 290,327 patients aged > or =50 years were discharged from US hospitals with a primary diagnosis of hip fracture, at our estimated direct cost of $5.6 billion. Based on the risk reductions seen in the 3 trials, we estimated that 134,764 hip fractures and $2.6 billion in direct medical costs could have been avoided if individuals aged > or =50 years consumed approximately 1200 mg/d of supplemental calcium. Additional savings could be expected, because this intervention is also associated with significant reductions in the risk for all nonvertebral fractures. Comparing the cost of calcium with the expected medical savings from hip fractures avoided, it is cost-effective to give 34 months of calcium supplementation to women aged > or =75 years in the United States. If, as the published studies suggest, shorter periods of supplementation result in an equivalent reduction in the risk of hip fractures, calcium supplementation becomes cost-effective for all adults aged > or =65 years in the United States. The data support encouraging older adults to increase their intake of dietary calcium and to consider taking a daily calcium supplement. Even small increases in the usage rate of supplementation are predicted to yield significant savings and to reduce the morbidity and mortality associated with hip fracture at an advanced age.

Cost effectiveness of multi-therapy treatment strategies in the prevention of vertebral fractures in postmenopausal women with osteoporosis.

OBJECTIVE: The aim of this study was to evaluate the cost effectiveness of multi-therapy treatment strategies in the prevention of vertebral fractures in postmenopausal women with osteoporosis. DESIGN: A retrospective, incremental cost-effectiveness analysis was conducted from a societal perspective. It compared 9 treatment strategies over 3 years and incorporated the willingness of patients to initiate and continue each therapy. MAIN OUTCOME MEASURES AND RESULTS: Four nondominated strategies formed the efficient frontier in the following order: (i) calcium-->no therapy; (ii) ovarian hormone therapy (OHT)-->calcium-->no therapy [166 Canadian dollars ($Can)]; (iii) OHT-->etidronate-->calcium-->no therapy ($Can2331); and (iv) OHT-->alendronate-->calcium-->no therapy ($Can40,965). The figures in parentheses are the incremental costs per vertebral fracture averted to move to that strategy from the previous strategy for patients who had undergone a hysterectomy. CONCLUSIONS: We identified 4 efficient multi-therapy strategies for the treatment of vertebral osteoporosis in postmenopausal women, 2 of which were consistent with the practice guidelines of the Osteoporosis Society of Canada. Decision-makers may select from among these efficient strategies on the basis of incremental cost effectiveness.

Using economics to prioritize research: a case study of randomized trials for the prevention of hip fractures due to osteoporosis.

OBJECTIVES: To assess the role of economics, in combination with clinical judgement, for setting research priorities, using osteoporosis prevention (and, as a result, hip fracture prevention) as an example. METHODS: Modelling the cost and effectiveness of each of six potential interventions to prevent hip fractures over the 5-year length of a randomized trial (vitamin D injection; thiazide diuretics; hormone replacement therapy; oral calcium and vitamin D; calcium alone; calcitonin). Drug costs were derived from the Monthly Index of Medical Specialties (MIMS); averted fracture costs and estimates of effectiveness were derived from published sources. RESULTS: Vitamin D injection proved to be the most potentially cost-effective treatment with a cost-effectiveness ratio of 584 Pounds. If averted costs are included, this leads to a saving of 9,176,496 Pounds per 100,000 women treated. By contrast, the most expensive therapy was calcitonin (marginal cost-effectiveness ratio of 433,548 Pounds). This suggests that priority should be given to trials assessing the effectiveness of vitamin D injections. CONCLUSIONS: Relatively simple economic modelling exercises can inform research priorities and could help optimize the use of scarce research resources.

[Costs of different intervention strategies to prevent hip fractures]. / Okonomiske omkostninger ved forskellige interventionsregimer til forebyggelse af hoftebrud.

The cost of primary prevention and the number of hip fractures prevented was compared in different scenarios. Primary prevention with hormonal replacement therapy (HRT) in women over the age of 50 years, secondary prevention with HRT in women over 50 years with low bone mineral on screening, use of external hip protectors in nursing home residents, use of calcium and vitamin D in nursing home residents and tertiary prevention with bisphosphonates (alendronate) or external hip protectors in subjects with a previous hip fracture were evaluated. External hip protectors or calcium plus vitamin D were cheap in nursing home residents. The economic cost of bisphosphonate treatment was high even in tertiary prevention in the high risk group with previous hip fracture. It was doubtful whether potential savings in prevention would out-weigh the cost in younger individuals even in high-risk groups.