Clinical burden and incremental cost of fractures in postmenopausal women in the United Kingdom

Background Giant cell arteritis (GCA) is a relatively common form of primary systemic vasculitis, which, if left untreated, can lead to permanent sight loss. We compared ultrasound as an alternative diagnostic test with temporal artery biopsy, which may be negative in 9–61% of true cases. Objective To compare the clinical effectiveness and cost-effectiveness of ultrasound with biopsy in diagnosing patients with suspected GCA. Design Prospective multicentre cohort study. Setting Secondary care. Participants A total of 381 patients referred with newly suspected GCA. Main outcome measures Sensitivity, specificity and cost-effectiveness of ultrasound compared with biopsy or ultrasound combined with biopsy for diagnosing GCA and interobserver reliability in interpreting scan or biopsy findings. Results We developed and implemented an ultrasound training programme for diagnosing suspected GCA. We recruited 430 patients with suspected GCA. We analysed 381 patients who underwent both ultrasound and biopsy within 10 days of starting treatment for suspected GCA and who attended a follow-up assessment (median age 71.1 years; 72% female). The sensitivity of biopsy was 39% [95% confidence interval (CI) 33% to 46%], which was significantly lower than previously reported and inferior to ultrasound (54%, 95% CI 48% to 60%); the specificity of biopsy (100%, 95% CI 97% to 100%) was superior to ultrasound (81%, 95% CI 73% to 88%). If we scanned all suspected patients and performed biopsies only on negative cases, sensitivity increased to 65% and specificity was maintained at 81%, reducing the need for biopsies by 43%. Strategies combining clinical judgement (clinician’s assessment at 2 weeks) with the tests showed sensitivity and specificity of 91% and 81%, respectively, for biopsy and 93% and 77%, respectively, for ultrasound; cost-effectiveness (incremental net monetary benefit) was £485 per patient in favour of ultrasound with both cost savings and a small health gain. Inter-rater analysis revealed moderate agreement among sonographers (intraclass correlation coefficient 0.61, 95% CI 0.48 to 0.75), similar to pathologists (0.62, 95% CI 0.49 to 0.76). Limitations There is no independent gold standard diagnosis for GCA. The reference diagnosis used to determine accuracy was based on classification criteria for GCA that include clinical features at presentation and biopsy results. Conclusion We have demonstrated the feasibility of providing training in ultrasound for the diagnosis of GCA. Our results indicate better sensitivity but poorer specificity of ultrasound compared with biopsy and suggest some scope for reducing the role of biopsy. The moderate interobserver agreement for both ultrasound and biopsy indicates scope for improving assessment and reporting of test results and challenges the assumption that a positive biopsy always represents GCA. Future work Further research should address the issue of an independent reference diagnosis, standards for interpreting and reporting test results and the evaluation of ultrasound training, and should also explore the acceptability of these new diagnostic strategies in GCA. Funding The National Institute for Health Research Health Technology Assessment programme.

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“…The unit costs of AEs were obtained from published studies [98][99][100][101] and are shown in Table 66.…”

Section: Steroid-related Adverse Eventsmentioning

confidence: 99%

The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study

Luqmani

Lee

Singh

et al. 2016

Health Technol Assess

364

404

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“…The Health Improvement Network (THIN) database has been used to characterize the risk of fracture associated with several chronic conditions and drug exposures in adults and children (19)(20)(21)(22)(23)(24)(25)(26). The objectives of this large population-based study were to determine whether urolithiasis is associated with a higher risk of incident fracture and to delineate age and sex effects.…”

Section: Introductionmentioning

confidence: 99%

Risk of Fracture in Urolithiasis

Denburg

Leonard

Haynes

et al. 2014

Clinical Journal of the American Society of Nephrology

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Background and objectives Studies have shown decreased bone mineral density in individuals with urolithiasis, but their burden of fracture remains unclear. This study sought to determine whether urolithiasis is associated with increased fracture risk across the lifespan and to delineate sex effects.Design, setting, participants, & measurements A population-based retrospective cohort study using The Health Improvement Network was performed. The median calendar year for the start of the observation period was 2004 (1994-2012). This study identified 51,785 participants with $1 of 87 diagnostic codes for urolithiasis and 517,267 randomly selected age-, sex-, and practice-matched participants. Cox regression was used to estimate the hazard ratio (HR) for first fracture. Fractures identified using diagnostic codes were classified by anatomic site.Results Median age was 53 years, and 67% of participants were men, confirming their greater urolithiasis burden. Median time from urolithiasis diagnosis to fracture was 10 years. The HR for fracture associated with urolithiasis differed by sex and age (P for interactions, P#0.003). In men, the adjusted HR was greatest in adolescence (1.55; 95% confidence interval [95% CI], 1.07 to 2.25) with an overall HR of 1.10 (95% CI, 1.05 to 1.16). Urolithiasis was associated with higher fracture risk in women aged 30-79 years (HR, 1.17-1.52), and was highest in women aged 30-39 years (HR, 1.52; 95% CI, 1.23 to 1.87). Peak background fracture rates were highest in boys aged 10-19 years and in women aged 70-79 years. The incidence per 10,000 person-years in participants with versus without urolithiasis was 392 versus 258 in male participants aged 10-19 years, and 263 versus 218 in women aged 70-79 years. Distribution of fracture site within sex did not differ between participants with versus without urolithiasis.Conclusions Urolithiasis was associated with higher incident fracture risk. The significantly higher risk at times of peak background fracture incidence in adolescent boys and elderly women has profound public health implications.

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“…Unit costs for A&E vary by fracture type as different costs were applied for admitted and non-admitted patients and these proportions vary by fracture type. Unit costs for prescriptions were calculated by dividing the difference in total prescription cost by the difference in the mean number of prescriptions using data from Gutierrez et al 234 However, this detailed information …”

Section: Resource Use and Costs Of Fracturementioning

confidence: 99%

“…The study was reported in two separate papers, with the first reporting the costs attributable to hip fracture 233 and the second reporting the costs attributable to vertebral fracture, non-hip non-vertebral fracture and also some less detailed results for wrist and proximal humerus fracture. 234 The study examined hospitalisations, accident and emergency (A&E) visits, referrals, prescriptions and GP contacts in the year following fracture. It did not examine any costs falling within PSS, such as nursing home admission or home help.…”

Section: Resource Use and Costs Of Fracturementioning

confidence: 99%

“…This was supplemented by ad hoc searches for UK studies published since 2006, as this was when a DSU report detailing several different methods to estimate fracture costs was published. 174 Resource use attributable to fracture was based on a UK study by Gutierrez et al, 233,234 which used a GP database (The Health Improvement Network) to estimate resource use for those who fractured compared with matched controls. Patients were matched on age, GP practice and comorbidity score.…”

Section: Resource Use and Costs Of Fracturementioning

confidence: 99%

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Corrigendum: A systematic review and economic evaluation of bisphosphonates for the prevention of fragility fractures

Davis

James

Sanderson

et al. 2018

Health Technol Assess

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During the course of providing additional analyses for the National Institute for Health and Care Excellence Technology Appraisal Committee, two errors were identified in the data entered in the network meta-analysis that informed the cost-effectiveness analysis described in the original report. This corrigendum notice describes the errors identified and the impact of correcting these errors on the main analyses presented in the original report.

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Clinical burden and incremental cost of fractures in postmenopausal women in the United Kingdom

Cited by 24 publications

References 23 publications

The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study

The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study

Risk of Fracture in Urolithiasis

Corrigendum: A systematic review and economic evaluation of bisphosphonates for the prevention of fragility fractures

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