Predicting the intervention threshold for initiating osteoporosis treatment among postmenopausal women in China: a cost-effectiveness analysis based on real-world data

Abstract

This study built a micro-simulation Markov model to determine the treatment threshold of osteoporosis in postmenopausal women in Mainland China. Treatment with zoledronate is cost-effective when FRAX-based (Fracture risk assessment tool) fracture probability is over 7%. Introduction The purpose of this study is to estimate FRAX-based fracture probabilities in Mainland China using real-world data, at which intervention could be cost-effective. Methods We developed a micro-simulation Markov model to capture osteoporosis states and relevant morbidities including hip fracture, vertebral fracture, and wrist fracture. Baseline characteristics including incidences of osteoporosis and distribution of risk factors were derived from the Peking Vertebral Fracture study, the largest prospective cohort study of postmenopausal women in Mainland China. We projected incidences of fractures and deaths by age groups under two treatment scenarios: 1) no treatment, and 2) zoledronate. We also projected total quality-adjusted life-years (QALY) and total costs including fracture management and osteoporosis drugs for cost-effectiveness analysis. Cost-effective intervention thresholds were calculated based on the Chinese FRAX model. Results Treatment with zoledronate was cost-effective when the 10-year probability of major osteoporotic fracture based on FRAX was above 7%. The FRAX threshold increased by age from 51 to 65 years old, and decreased in elder age groups, ranging from 4% to 9%. Conclusions Using real-world data, our model indicated that widespread use of zoledronate was of both clinical and economic benefit among Chinese postmenopausal women. Using a FRAX-based intervention threshold of 7% with zoledronate should permit cost-effective access to therapy to patients and contribute to reducing the disease burden of osteoporosis in Mainland China.

An Updated Systematic Review of Cost-Effectiveness Analyses of Drugs for Osteoporosis

“…Variation in drug costs could lead to different cost-effectiveness results of anti-osteoporosis drugs. The strong effect of drug cost was reported in several studies [ 13 , 14 , 20 , 23 , 27 – 30 , 33 , 34 ]. Mori et al [ 20 ] compared sequential therapy (teriparatide followed by alendronate) to alendronate alone and reported that results were most sensitive to the changes in the estimated cost of teriparatide.…”

“…The ICERs of bisphosphonates in patients with previous fracture or with rheumatoid arthritis were estimated at MYR 108,603 and MYR 25,699 per QALY gained, respectively. Given the WTP threshold (MYR 26,317), bisphosphonates were cost effective in patients with rheumatoid arthritis Cui et al [ 34 ] Postmenopausal osteoporotic women Zoledronic acid vs no treatment 2019 One-way In comparison with no treatment, zoledronic acid had ICERs of US$26,637, US$22,129, US$20,338, US$19,285, US$18,181, US$16,680, US$15,047, and US$14,447 per QALY at FRAX threshold 0.02, 0.06, 0.07,0.08, 0.09, 0.1, 0.5, and 1, respectively. Zoledronic acid was cost effective when the 10-year probability of major osteoporotic fracture based on FRAX was above 7% Taheri et al [ 33 ] Women aged 70 years, BMD T-score − 2.5 with previous fracture or BMD T-score -3.0 without prior fracture Teriparatide vs no treatment 2018 One-way probabilistic In comparison with no treatment, teriparatide was indicated to be more costly and associated with fewer fractures, more life-years, and more QALYs, with an ICER of IRR 254,750,619 per QALY gained.…”

“…Oral bisphosphonates were included in 11 studies [ 13 – 15 , 18 , 21 , 22 , 24 – 26 , 29 , 30 ] and compared with other active interventions. There were three studies [ 16 , 20 , 28 ] considering sequential therapies as comparators, while six studies [ 15 , 17 , 30 – 32 , 36 ] made the comparison between active osteoporotic drugs and calcium/vitamin D 3 and ten studies [ 12 , 18 , 19 , 23 – 25 , 27 – 29 , 33 , 34 ] included no treatment as the comparator. Treatment duration in most studies was similar to randomized controlled trials, indications, or guidelines (e.g., 3 or 5 years for anti-resoptive agents, 12–24 months for anabolic agents).…”

“…Both a deterministic sensitivity analysis (e.g., one-way, multivariate) and a probabilistic sensitivity analysis were conducted in 17 studies. Two studies [ 24 , 26 ] applied only a probabilistic sensitivity analysis and three studies applied only a one-way sensitivity analysis [ 13 , 32 , 34 ]. Sensitivity analysis was not conducted in five studies [ 10 – 12 , 17 , 35 ].…”

“…Anti-osteoporosis medications have shown to be effective in reducing fracture risk; however, as a chronic disease, non-adherence to pharmacological treatment in osteoporosis is a well-recognized problem, which would result not only in deteriorating clinical outcomes, but also in decreased cost effectiveness of pharmacotherapy. Several studies [ 18 , 20 , 27 , 29 , 31 , 34 ] reported that the persistence and adherence rates of osteoporosis medications have marked effects on the cost-effectiveness ratios. For instance, Mori et al [ 18 ] indicated that denosumab was cost effective or even cost saving in comparison with weekly oral alendronate, mainly driven by the higher persistence rate of denosumab leading to higher efficacy.…”