title: Primary prevention of osteoporosis: mass screening scenario or prescreening with questionnaires? An economic perspective.
abstract: This study focuses on the controversy surrounding selective approaches to screen for osteoporosis. Seven screening approaches were compared in terms of cost-effectiveness and incremental cost-effectiveness ratios in a sample of 4035 postmenopausal women. Our results show that certain prescreening strategies are more efficient than DXA-based approaches. These results are of considerable value for health policy decision-makers and the scientific community.
  
  
  BACKGROUND
  There is no general consensus on the most efficient strategy to use bone densitometry for osteoporosis screening. Two distinct approaches have progressively emerged: mass screening using DXA and prescreening strategies using user-friendly risk indices. This study was designed to compare the efficiency of these approaches.
  
  
  METHODS
  A database of 4035 medical records from postmenopausal women above 45 years was analyzed. In the first scenario, women were systematically referred to DXA if above 45, 50, or 65 years of age. The second scenario involved the validated prescreening tools SCORE, ORAI, OST, and OSIRIS and assessed two separate ways of handling their results (theoretical and pragmatic). The cost of a DXA test was set as the median Belgian value: 40.14 Euros. All strategies were compared in terms of cost exposed per osteoporotic patient detected and in terms of incremental cost-effectiveness ratios.
  
  
  RESULTS
  In the systematic DXA strategies, the cost per patient detected ranged from 123 Euros when measuring all women >45 years of age to 91 Euros when focusing on women >65 years of age. The corresponding percentage of cases detected ranged from 100% (age > 45 years) to 50% (age > 65 years). When considering prescreening under the theoretical and pragmatic scenarios, the OSIRIS index provided the best efficiency, with costs of 74 Euros (theoretical) to 85 Euros (pragmatic) per case detected, followed by ORAI (75 Euros and 96 Euros), OST (84 Euros and 94 Euros), and SCORE (96 Euros and 103 Euros). The corresponding percentage of cases detected ranged from 89% (SCORE) to 75% (OSIRIS). The cost-effectiveness analysis showed that mass screening strategies over 50 and 65 years of age and using ORAI were best.
  
  
  CONCLUSIONS
  Our study sets the grounds for considering, in a health economics perspective, prescreening tools as valuable, cost-effective, approaches to significantly reduce the economic burden of osteoporosis screening.
authors.affiliation: University of Liège, Faculty of Science, Department of Public Health, Epidemiology and Health Economics, CHU B23 Sart-Tilman B-4000, Belgium. florent.richy@ulg.ac.be
authors.forename: Florent
authors.initials: F
authors.lastname: Richy
authors.forename: Olivier
authors.initials: O
authors.lastname: Ethgen
authors.forename: Olivier
authors.initials: O
authors.lastname: Bruyere
authors.forename: Audrey
authors.initials: A
authors.lastname: Mawet
authors.forename: Jean-Yves
authors.initials: JY
authors.lastname: Reginster
mesh_terms: D015502:Absorptiometry, Photon; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015519:Bone Density; D003362:Cost-Benefit Analysis; D019992:Databases as Topic; D003661:Decision Support Techniques; D003720:Densitometry; D005188:False Negative Reactions; D005260:Female; D006801:Humans; D008403:Mass Screening / Q000191:economics*; D008875:Middle Aged; D015233:Models, Statistical; D010024:Osteoporosis / Q000175:diagnosis / Q000517:prevention & control*; D015663:Osteoporosis, Postmenopausal / Q000175:diagnosis / Q000517:prevention & control; D011322:Primary Prevention; D011795:Surveys and Questionnaires