18F-Sodium Fluoride PET/CT and PET/MR Imaging of Bone and Joint Disorders.

18F-sodium fluoride (18F-NaF) PET/CT provides high sensitivity and specificity for the assessment of bone and joint diseases. It is able to accurately differentiate malignant from benign bone lesions, especially when using dynamic quantitative approaches. Its high-quality, clinical accuracy, and high feasibility for patient management and greater availability of PET/CT scanners as well as decreasing trend of the cost of radiotracer all indicate the need to consider the use of 18F-NaF PET/CT as standard bone imaging, particularly in malignant diseases of the skeleton.

Economic burden of skeletal-related events in patients with multiple myeloma: analysis of US commercial claims database.

AIMS: To estimate incremental healthcare resource utilization (HRU) and costs associated with skeletal-related events (SREs) secondary to multiple myeloma (MM), and HRU and cost differences in patients with one vs multiple SREs. METHODS: Adults with MM diagnosis between January 1, 2010-December 31, 2014, with benefits coverage ≥12 months pre- and ≥6 months post-diagnosis were followed to last coverage date or December 31, 2015, excluding patients with prior anti-myeloma treatment or cancers. SREs were identified by diagnosis or procedure codes (pathological fracture, spinal cord compression, radiation, or surgery to the bone). SRE patients (index = first post-diagnosis SRE) were propensity score matched 1:1 to patients without SRE (assigned pseudo-index) using baseline characteristics, and ≥1 month of continuous enrollment after index/pseudo-index date was required. Per-patient-per year (PPPY) HRU and costs (2016 US$) were determined for inpatient, outpatient, emergency department (ED), and outpatient pharmacy services during follow-up. Wilcoxon signed rank for means and McNemar's tests for proportions were used to assess differences. Negative binomial regression and generalized linear regression analyses estimated differences in HRU and costs, respectively, for the comparison of single vs multiple SREs. RESULTS: Each cohort included 848 patients (mean age = 61 - 62 years, 57% male) with no significant differences in pre-index demographic or clinical characteristics between matched cohorts. Versus non-SRE patients, SRE patients had significantly higher PPPY use (p < .0001) of inpatient hospitalizations, ED visits, outpatient pharmacy, and higher direct medical costs ($188,723 vs $108,160, p < .0001). Adjusted PPPY total costs were $209,820 in patients with multiple SREs; $159,797 in patients with one SRE. LIMITATIONS: SRE misclassification and residual confounding are possible. CONCLUSIONS: Among patients with MM, average annual costs were substantially higher in patients with SRE compared with matched non-SRE patients. The economic burden of SRE increased further with multiple events.

Short-term disability in solid tumor patients with bone metastases and skeletal-related events.

OBJECTIVE: The skeleton is a common site of metastasis in patients with solid tumors. These patients often experience pain and reduced quality-of-life. This analysis evaluated the time and costs associated with short-term disability use among solid tumor patients with bone metastases (BM) and skeletal-related events (SREs). METHODS: Data from patients 18-64 years old with solid tumors and BM, eligible for short-term disability benefits between January 1, 2002 and December 31, 2010, were extracted from MarketScan Research Databases. Short-term disability hours and costs associated with BM and SREs were evaluated. RESULTS: Overall, 1098 patients met the criteria. For all patients with BM, the monthly mean short-term disability hours were 17.7 h pre-BM diagnosis and increased to 60.2 h post-BM diagnosis (p < 0.001). The corresponding mean monthly short-term disability costs were $277 and $963 in the pre- and post-BM diagnosis periods, respectively (p < 0.001). Monthly mean short-term disability hours were higher for the cohort of patients with SREs (21.2 h pre-SRE diagnosis and 67.4 h post-SRE diagnosis) than for those without an SRE (8.6 h pre-SRE diagnosis and 14.4 h post-SRE diagnosis) (p < 0.001). Similarly, the corresponding monthly mean short-term disability costs were higher for patients with SREs ($625 and $1259 pre- and post-SRE diagnosis, respectively) than for patients without an SRE ($452 and $612 pre- and post-SRE diagnosis, respectively) (p < 0.001). RESULTS of a multivariate analysis indicated that SREs were associated with an additional 39.4 short-term disability hours and $613 in short-term disability costs per month (p < 0.001). CONCLUSION: Short-term disability hours and costs increased significantly when patients with solid tumors developed BM and SRE.

Healthcare costs associated with skeletal-related events in breast cancer patients with bone metastases.

BACKGROUND: Patients with bone metastases secondary to breast cancer are pre-disposed to skeletal-related events (SREs), including spinal cord compression (SCC), pathologic fracture (PF), surgery to bone (SB), and radiotherapy to bone (RT). OBJECTIVE: To document current patterns of healthcare utilization and costs of SREs in patients with breast cancer and bone metastases. METHODS: This was a retrospective, observational study using the Thomson MedStat MarketScan Commercial Claims and Encounters database from 9/2002 to 6/2011. Study subjects included all persons with claims for breast cancer and for bone metastases, and ≥1 claims for an SRE. Unique SRE episodes were identified based on a gap of at least 90 days without an SRE claim, and classified by treatment setting (inpatient or outpatient) and SRE type (SCC, PF, SB, or RT). RESULTS: Of 17,266 patients with breast cancer and bone metastases, 9142 (53%) had one or more SRE episodes. Among 5809 patients who met all other criteria, there were 7617 SRE episodes over mean (SD) follow-up of 17.2 (15.2) months. The percentage of episodes that required inpatient treatment ranged from 11% (RT) to 76% (SB). On average, inpatient SCC episodes (n=83 episodes) were most costly; while outpatient PF episodes (n=552 episodes) were least costly. Of the total SRE costs (mean [SE] $21,072 [$36,462]/episode), 36% were attributable to outpatient RT (n=5265 episodes) and 31% to inpatient PF (n=838 episodes). LIMITATIONS: The administrative claims data used in this study may lack sensitivity and specificity for identification of clinical events and may not be generalizable to other populations. Also, for some SRE episode categories, the number of events was small and cost estimates may lack precision. CONCLUSION: In patients with breast cancer and bone metastases, SREs are associated with high costs and hospitalizations.

Health state utilities for skeletal-related events secondary to bone metastases.

INTRODUCTION: Patients with bone metastases often experience skeletal-related events (SREs). Although cost-utility models are used to examine treatments for metastatic cancer, limited information is available on utilities of SREs. The purpose of this study was to estimate the disutility of four SREs: spinal cord compression, pathological fracture, radiation to bone, and surgery performed to stabilize a bone. METHODS: General population participants from the UK and Canada completed time trade-off (TTO) interviews to assess the utility of health states drafted based on literature review, clinician interviews, and patient interviews. Respondents first rated a health state describing cancer with bone metastases. Then, the SREs were added to this health state. RESULTS: Interviews were completed with 187 participants (50.8 % male, 80.2 % white). Cancer with bone metastases without an SRE had a mean utility of 0.47 (SD = 0.43) on a standard utility scale (1 = full health, 0 = death). Of the SREs, spinal cord compression was associated with the greatest disutility (i.e., the utility decrease): -0.32 with paralysis and -0.22 without paralysis. Surgery had a disutility of -0.07. Leg, arm, and rib fractures had disutilities of -0.06, -0.04, and -0.03. Two weeks of daily radiation treatment had a disutility of -0.06, while two radiation appointments had the smallest impact on utility (-0.02). CONCLUSION: All SREs were associated with statistically significant utility decreases, suggesting a perceived impact on quality of life beyond the impact of cancer with bone metastases. The resulting disutilities may be used in cost-utility models examining treatments to prevent SREs secondary to bone metastases.

The EOS 2D/3D X-ray imaging system: a cost-effectiveness analysis quantifying the health benefits from reduced radiation exposure.

OBJECTIVES: To evaluate the cost-effectiveness of the EOS(®) 2D/3D X-ray imaging system compared with standard X-ray for the diagnosis and monitoring of orthopaedic conditions. MATERIALS AND METHODS: A decision analytic model was developed to quantify the long-term costs and health outcomes, expressed as quality-adjusted life years (QALYs) from the UK health service perspective. Input parameters were obtained from medical literature, previously developed cancer models and expert advice. Threshold analysis was used to quantify the additional health benefits required, over and above those associated with radiation-induced cancers, for EOS(®) to be considered cost-effective. RESULTS: Standard X-ray is associated with a maximum health loss of 0.001 QALYs, approximately 0.4 of a day in full health, while the loss with EOS(®) is a maximum of 0.00015 QALYs, or 0.05 of a day in full health. On a per patient basis, EOS(®) is more expensive than standard X-ray by between £10.66 and £224.74 depending on the assumptions employed. The results suggest that EOS(®) is not cost-effective for any indication. Health benefits over and above those obtained from lower radiation would need to double for EOS to be considered cost-effective. CONCLUSION: No evidence currently exists on whether there are health benefits associated with imaging improvements from the use of EOS(®). The health benefits from radiation dose reductions are very small. Unless EOS(®) can generate additional health benefits as a consequence of the nature and quality of the image, comparative patient throughput with X-ray will be the major determinant of cost-effectiveness.

The economic burden associated with skeletal-related events in patients with bone metastases secondary to solid tumors in Belgium.

OBJECTIVES: More than 1.5 million patients worldwide are affected by bone metastases. Patients with bone metastases frequently develop skeletal-related events (SREs, including radiation to bone, non-vertebral fracture, vertebral fracture, surgery to bone, and spinal cord compression) that are associated with high healthcare costs. This study aims to provide an estimate of the cost per SRE in both the inpatient and outpatient settings in Belgian patients with bone metastases secondary to solid tumors (breast, prostate, and lung cancers). METHODS: Patients were retrieved from the IMS Hospital Disease database from 2005-2007. Inclusion was based on the International Classification of Diseases and Related Health Problems Version 9 (ICD-9) diagnosis and/or procedure codes covering patients with breast, prostate, or lung cancer with bone metastases who were hospitalized for one or more SREs. All costs were extrapolated to 2010 using progression in hospitalization costs since 2001. Additional outpatient costs resulting from radiation to bone and diagnostic tests performed in ambulatory settings were estimated by combining published unit costs with resource use data obtained from a Delphi panel. RESULTS: The average cost per SRE across solid tumor types based on the weighted average of inpatient and outpatient costs was €2653 for radiation to bone, €5015 for a vertebral fracture, and €7087 for a non-vertebral fracture. Costs were €12,885 and €15,267 for surgery to bone and spinal cord compression, respectively. LIMITATIONS: No patient follow-up across calendar years could be done. Also, details regarding the exact anatomic sites of SREs were not always available. CONCLUSIONS: SREs add a substantial cost to the management of patients with bone metastases. Avoiding SREs can lead to important cost-savings for the healthcare payer.

Pharmacoeconomics of bisphosphonates for skeletal-related event prevention in metastatic non-breast solid tumours.

Bisphosphonates reduce the risk of skeletal-related events (SREs; i.e. spinal cord compression, pathological fracture, radiation or surgery to the bone, and hypercalcaemia) in patients with metastatic cancer. A number of analyses have been conducted to assess the cost effectiveness of bisphosphonates in patients with bone metastases secondary to breast cancer, but few in other solid tumours. This is a review of cost-effectiveness analyses in patients with non-breast solid tumours and bone metastases. A literature search was conducted to identify cost-effectiveness analyses reporting the cost per QALY gained of bisphosphonates in patients with metastatic bone disease secondary to non-breast solid tumours. Four analyses met inclusion criteria. These included two in prostate cancer (one of which used a global perspective but expressed results in $US, and the other reported from a multiple country perspective: France, Germany, Portugal and the Netherlands). The remaining analyses were in lung cancer (in the UK, France, Germany, Portugal and the Netherlands), and renal cell carcinoma (in the UK, France and Germany). In each analysis, the cost effectiveness of zoledronic acid versus placebo was analysed. Zoledronic acid was found to be cost effective in all European countries across all three indications but not in the sole global prostate cancer analysis. Across countries and indications, assumptions regarding patient survival, drug cost and baseline utility (i.e. patient utility with metastatic disease but without an SRE) were the most robust drivers of modelled estimates. Assumptions of SRE-related costs were most often the second strongest cost driver. Further review indicated that particular attention should be paid to the inclusion or exclusion of nonsignificant survival benefits, whether health state utilities were elicited from community or patient samples or author assumptions, delineation between symptomatic and asymptomatic SREs, and the methods with which SRE disutility was modelled over time. While the field of cost-effectiveness analysis in solid tumours other than breast cancer is still evolving, outcomes will likely continue to be driven by drug cost and assumptions regarding treatment benefits. Although considerations such as adverse events and administration costs are important, they were not found to influence cost-effectiveness estimates greatly. As zoledronic acid will lose patent protection in 2013 and subsequently be greatly reduced in price, it is likely that the field of cost effectiveness will change with regard to SRE-limiting agents. Meanwhile, research should be conducted to improve our understanding of the impact on quality of life and medical costs of preventing SREs.

Cost effectiveness of bisphosphonates in the management of breast cancer patients with bone metastases.

BACKGROUND: Bisphosphonates are recommended to prevent skeletal related events (SREs) in patients with breast cancer and bone metastases (BCBM). However, their clinical and economic profiles vary from one agent to the other. MATERIALS AND METHODS: Using modeling techniques, we simulated from the perspective of the UK's National Health Service (NHS) the cost and quality adjusted survival (QALY) associated with five commonly-used bisphosphonates or no therapy in this patient population. The simulation followed patients into several health states (i.e. alive or dead, experiencing an SRE or no SRE, and receiving first or second line therapy). Drugs costs, infusion costs, SREs costs, and utility values were estimated from published sources. Utilities were applied to time with and without SREs to capture the impact on quality of life. RESULTS: Compared to no therapy, all bisphosphonates are either cost saving or highly cost-effective (with a cost per QALY < or = 6126 pounds sterlings). Within this evaluation, zoledronic acid was more effective and less expensive than all other options. CONCLUSIONS: Based on our model, the use of bisphosphonates in breast cancer patients with bone metastases should lead to improved patient outcomes and cost savings to the NHS and possibly other similar entities.

[Occupational diseases in Europe: diseases of the locomotor system]. / Berufskrankheiten in Europa: Erkrankungen des Bewegungsapparats.

The present regulations concerning the group of occupational illnesses for which compensation is payable in a number of European countries are presented with special reference to illnesses of the locomotor system and against the background of the harmonization process within the European community. With respect to this group of illnesses at least, the lists of occupational illnesses currently in use in the German-speaking countries could be a valuable basis for a "harmonized" system. It must admittedly be borne in mind that agreement will need to be reached on the extent to which the listed forms of "spinal degeneration attributable to mechanical overuse over a period of years" that are recognized in the German Democratic Republic are adequate as a basis for laws concerning occupational illnesses now or in the future.

Social and economic impacts of four musculoskeletal conditions. A study using national community-based data.

The present study uses data from a national, community-based survey to compare the social impact of and medical care use due to 4 musculoskeletal conditions: rheumatoid arthritis, osteoarthritis, lower back pain, and tendinitis. The study also compares the impacts experienced by persons with these conditions with those experienced by a sample of persons having a broader range of musculoskeletal conditions, and by an age-adjusted sample representing the entire U.S. population. Rheumatoid arthritis leads to the most frequent use of physician services; lower back pain results in the most hospitalizations and surgery. Rheumatoid arthritis also causes the most restriction in activity. We found that as a broad group, persons with musculoskeletal disease experience about the same amount of restriction in activity and use about the same amount of medical care as U.S. citizens as a whole. This study demonstrates that health planning on the basis of specific musculoskeletal conditions is necessary to serve the disparate needs of persons with particular, discrete conditions.

The impact of musculoskeletal disorders on the population of the United States.

Musculoskeletal disorders constitute such a large component of impairments of individuals in the working and geriatric population that good statistical data on them are essential for planning health care. We have collected the pertinent data, with references to recent source material, to determine the incidence, effect on the quality of life, and associated costs of these disorders in the United States.