Cost effectiveness of ultrasound and bone densitometry for osteoporosis screening in post-menopausal women.
BACKGROUND
According to a new German guideline, decisions about bisphosphonate treatment for post-menopausal women should be based on 10-year fracture risk, and bone density should be measured by dual x-ray absorptiometry (DXA). Recently, there has been growing interest in quantitative ultrasound (QUS) as a less expensive screening alternative.


OBJECTIVE
To determine the cost effectiveness of osteoporosis screening with QUS as a pre-test for DXA and treatment with alendronate compared with (i) immediate access to DXA and (ii) no screening in women of the general population aged 50-90 years in Germany.


METHODS
A cost-utility analysis and a budget impact analysis were performed from the perspective of the statutory health insurance (SHI). A Markov model with a 1-year cycle length was used to simulate costs and benefits (QALYs), discounted at 3% per annum, over a lifetime. The number of women correctly diagnosed by QUS and DXA as being above a 10-year risk of > or =30% was estimated for different age groups (50-60, 60-70, 70-80 and 80-90 years, respectively). The robustness of the results was tested by a probabilistic Monte Carlo simulation.


RESULTS
Compared with no screening, the cost effectiveness of QUS plus DXA was found to be Euro 3529, Euro 9983, Euro 4382 and Euro 1987 per QALY for 50-, 60-, 70- and 80-year-old women, respectively (year 2006 values). This screening strategy results in annual costs of Euro 96 million or 0.07% of the SHI's annual budget. The cost effectiveness of DXA alone compared with DXA plus QUS is Euro 5331, Euro 60, 804, Euro 14, 943 and Euro 3654 per QALY for 50-, 60-, 70- and 80-year-old women, respectively. DXA alone results in a higher number of QALYs in all age groups. The results were robust in the sensitivity analysis.


CONCLUSIONS
Compared with no screening, the cost effectiveness of QUS and DXA in sequence is very favourable in all age groups. However, direct access to DXA is also a cost-effective option, as it increases the number of QALYs at an acceptable cost compared with pre-testing by QUS (except for women aged 60-70 years). Therefore, QUS as a pre-test for DXA can be clearly recommended only in women aged 60-70 years. For the other age groups, the cost effectiveness of QUS as a pre-test depends on the global budget constraint and the accessibility of DXA.
Mueller
Dirk
D
Institute of Health Economics and Clinical Epidemiology, University of Cologne, Cologne, Germany. dirkwmueller@gmx.de
Gandjour
Afschin
A
D015502:Absorptiometry, Photon / Q000191:economics*; D000368:Aged; D000369:Aged, 80 and over; D019386:Alendronate / Q000191:economics / Q000627:therapeutic use; D015519:Bone Density; D050071:Bone Density Conservation Agents / Q000191:economics / Q000627:therapeutic use; D001842:Bone and Bones / Q000000981:diagnostic imaging*; D003362:Cost-Benefit Analysis; D005260:Female; D050723:Fractures, Bone / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control; D005858:Germany; D006801:Humans; D007348:Insurance, Health; D008390:Markov Chains; D008875:Middle Aged; D009010:Monte Carlo Method; D015663:Osteoporosis, Postmenopausal / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000191:economics*; D017410:Practice Guidelines as Topic; D019057:Quality-Adjusted Life Years; D012307:Risk Factors; D014463:Ultrasonography / Q000191:economics*
D050071:Bone Density Conservation Agents; D019386:Alendronate