title: Vertebral fracture assessment (VFA) by lateral DXA scanning may be cost-effective when used as part of fracture liaison services or primary care screening.
abstract: CONCLUSIONS
  We identified that use of VFA may be cost-effective in either selected women from primary care or women attending after a low trauma fracture.
  
  
  BACKGROUND
  Lateral DXA scanning of the spine for vertebral fracture assessment (VFA) is used for research, but its wider role is unclear. We aimed to establish whether VFA is cost-effective in women based on two different scenarios: following a low-trauma fracture, and after screening of high-risk women identified in primary care.
  
  
  METHODS
  The fracture cohort (FC) consisted of 377 women and the primary care cohort (PCC) of 251. Vertebral fractures were identified on VFA images by quantitative morphometry (QM). Outcome was cost-effectiveness of VFA, based on predicted change in clinical management defined as the identification of a vertebral fracture in a patient who otherwise falls below the threshold for treatment. FRAX treatment thresholds assessed were (1) 20/3 % thresholds and (2) National Osteoporosis Guidelines Group (NOGG) thresholds.
  
  
  RESULTS
  As a result, 9.8 % from FC and 13.9 % from PCC were identified with vertebral fractures. Management was changed in 21 to 22/377 (5.6-5.8 %) in FC and 12 to 26/251 (4.8-10.4 %) from PCC depending on which thresholds were used. Sensitivity analyses identified medication adherence as the assumption which most influenced the model. The best-estimate cost-per-QALY for use of VFA in FC was £3,243 for 20/3 threshold and £2,130 for NOGG; for PCC, this was £7,831 for 20/3 and was cost-saving for NOGG. Further analyses to adjust for potential false-positive vertebral fracture identification with QM showed VFA was no longer cost-effective.
  
  
  CONCLUSIONS
  VFA appears to be cost-effective in routine clinical practise, particularly when relatively inaccurate methods of identification of vertebral fractures are used such as QM.
authors.affiliation: Musculoskeletal Research Unit, Avon Orthopaedic Centre, Southmead Hospital, University of Bristol, Bristol, BS10 5NB, UK, Emma.Clark@bristol.ac.uk.
authors.forename: E M
authors.initials: EM
authors.lastname: Clark
authors.forename: L
authors.initials: L
authors.lastname: Carter
authors.forename: V C
authors.initials: VC
authors.lastname: Gould
authors.forename: L
authors.initials: L
authors.lastname: Morrison
authors.forename: J H
authors.initials: JH
authors.lastname: Tobias
mesh_terms: D015502:Absorptiometry, Photon / Q000191:economics; D000368:Aged; D000369:Aged, 80 and over; D003362:Cost-Benefit Analysis; D004739:England; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D008403:Mass Screening / Q000191:economics / Q000379:methods; D008875:Middle Aged; D017059:Models, Econometric; D015663:Osteoporosis, Postmenopausal / Q000150:complications / Q000175:diagnosis / Q000191:economics; D058866:Osteoporotic Fractures / Q000175:diagnosis* / Q000191:economics / Q000209:etiology; D010044:Outpatient Clinics, Hospital / Q000191:economics; D011320:Primary Health Care / Q000191:economics*; D019057:Quality-Adjusted Life Years; D016103:Spinal Fractures / Q000175:diagnosis* / Q000191:economics / Q000209:etiology