Cost-effectiveness of Virtual Bone Strength Testing in Osteoporosis Screening Programs for Postmenopausal Women in the United States

Abstract

Purpose To investigate whether assessment of bone strength with quantitative computed tomography (CT) in combination with dual-energy x-ray absorptiometry (DXA) is cost-effective as a screening tool for osteoporosis in postmenopausal women. Materials and Methods A state-transition microsimulation model of osteoporosis for postmenopausal women aged 55 years or older was developed with a lifetime horizon and U.S. societal perspective. All model inputs were derived from published literature. Three strategies were compared: no screening, DXA with T score–dependent rescreening intervals, and a combination of DXA and quantitative CT with different intervals (3, 5, and 10 years) at different screening initiation ages (55–65 years). Oral bisphosphonate therapy was started if DXA hip T scores were less than or equal to −2.5, 10-year risk for hip fracture was greater than 3% (World Health Organization Fracture Risk Assessment Tool score, or FRAX), 10-year risk for major osteoporotic fracture was greater than 20% (FRAX), quantitative CT femur bone strength was less than 3000 N, or occurrence of first fracture (eg, hip, vertebral body, wrist). Outcome measures were incremental cost-effectiveness ratios (ICERs) in 2015 U.S. dollars per quality-adjusted life year (QALY) gained and number of fragility fractures. Probabilistic sensitivity analysis was also performed. Results The most cost-effective strategy was combined DXA and quantitative CT screening starting at age 55 with quantitative CT screening every 5 years (ICER, $2000 per QALY). With this strategy, 12.8% of postmenopausal women sustained hip fractures in their remaining life (no screening, 18.7%; DXA screening, 15.8%). The corresponding percentages of vertebral fractures for DXA and quantitative CT with a 5-year interval, was 7.5%; no screening, 11.1%; DXA screening, 9%; for wrist fractures, 14%, 17.8%, and 16.4%, respectively; for other fractures, 22.6%, 30.8%, and 27.3%, respectively. In probabilistic sensitivity analysis, DXA and quantitative CT at age 55 years with quantitative CT screening every 5 years was the best strategy in more than 90% of all 1000 simulations (for thresholds of $50 000 per QALY and $100 000 per QALY). Conclusion Combined assessment of bone strength and bone mineral density is a cost-effective strategy for osteoporosis screening in postmenopausal women and has the potential to prevent a substantial number of fragility fractures.

Osteoporosis and Hip Fracture Risk From Routine Computed Tomography Scans: The Fracture, Osteoporosis, and CT Utilization Study (FOCUS)

“…Our results demonstrate that BCT analysis of previously taken routine abdominal or pelvic CT is at least as effective as DXA testing in a large clinical setting. A recent cost‐effectiveness study concluded that BCT analysis, when performed on a dedicated hip CT scan (ordered specifically for BCT analysis), should be cost‐effective when the charge for the BCT analysis is set at $100 over the cost of a dedicated hip CT scan . At that pricing, ancillary BCT should be even more cost‐effective because there is no need for a dedicated hip CT scan.…”

Cost-Effectiveness of Osteoporosis Screening Using Biomechanical Computed Tomography for Patients With a Previous Abdominal CT

“…We assumed QALY values for the no fracture state of 0.84 for women and 0.87 for men. Disutility values for the first and subsequent years after hip fracture were obtained using multipliers of 0.797 and 0.899, respectively ( Table 1 (1,5,7,10,11,17,25,26,(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46) ). As noted above, these parameter values are conservative because we did not consider QALY gains associated with preventing any other major osteoporotic fractures (e.g.…”

“…BCT testing (per test performed) $100 $150-250 Agten and colleagues (25) ; Viceconti and colleagues (26)…”

“…We sought to assess the clinical and economic benefits of such an ancillary BCT‐based, standing‐order screening program in women and men age 65 years and older. Two recent cost‐effectiveness analyses for women showed that BCT can be cost effective (versus usual care) when used for screening generally, by using both DXA and a dedicated hip CT scan ordered specifically for the BCT analysis . In those analyses, the overall cost of the BCT test would be the sum of the costs for acquiring the CT scan and then analyzing the scan with BCT analysis.…”

“…Two recent costeffectiveness analyses for women showed that BCT can be cost effective (versus usual care) when used for screening generally, by using both DXA and a dedicated hip CT scan ordered specifically for the BCT analysis. (25,26) In those analyses, the overall cost of the BCT test would be the sum of the costs for acquiring the CT scan and then analyzing the scan with BCT analysis. Those cost-effective analyses did not address an ancillary approach for patients already undergoing CT and did not address men.…”