title: Cost-effectiveness of training rural providers to identify and treat patients at risk for fragility fractures.
abstract: This is a cost-effectiveness analysis of training rural providers to identify and treat osteoporosis. Results showed a slight cost savings, increase in life years, increase in treatment rates, and decrease in fracture incidence. However, the results were sensitive to small differences in effectiveness, being cost-effective in 70 % of simulations during probabilistic sensitivity analysis.
  
  
  BACKGROUND
  We evaluated the cost-effectiveness of training rural providers to identify and treat veterans at risk for fragility fractures relative to referring these patients to an urban medical center for specialist care. The model evaluated the impact of training on patient life years, quality-adjusted life years (QALYs), treatment rates, fracture incidence, and costs from the perspective of the Department of Veterans Affairs.
  
  
  METHODS
  We constructed a Markov microsimulation model to compare costs and outcomes of a hypothetical cohort of veterans seen by rural providers. Parameter estimates were derived from previously published studies, and we conducted one-way and probabilistic sensitivity analyses on the parameter inputs.
  
  
  RESULTS
  Base-case analysis showed that training resulted in no additional costs and an extra 0.083 life years (0.054 QALYs). Our model projected that as a result of training, more patients with osteoporosis would receive treatment (81.3 vs. 12.2 %), and all patients would have a lower incidence of fractures per 1,000 patient years (hip, 1.628 vs. 1.913; clinical vertebral, 0.566 vs. 1.037) when seen by a trained provider compared to an untrained provider. Results remained consistent in one-way sensitivity analysis and in probabilistic sensitivity analyses, training rural providers was cost-effective (less than $50,000/QALY) in 70 % of the simulations.
  
  
  CONCLUSIONS
  Training rural providers to identify and treat veterans at risk for fragility fractures has a potential to be cost-effective, but the results are sensitive to small differences in effectiveness. It appears that provider education alone is not enough to make a significant difference in fragility fracture rates among veterans.
authors.affiliation: Salt Lake City Veterans Affairs Health Care System, 500 Foothill Blvd, Salt Lake City, UT, 84148, USA, Scott.Nelson@pharm.utah.edu.
authors.forename: S D
authors.initials: SD
authors.lastname: Nelson
authors.forename: R E
authors.initials: RE
authors.lastname: Nelson
authors.forename: G W
authors.initials: GW
authors.lastname: Cannon
authors.forename: P
authors.initials: P
authors.lastname: Lawrence
authors.forename: M J
authors.initials: MJ
authors.lastname: Battistone
authors.forename: M
authors.initials: M
authors.lastname: Grotzke
authors.forename: Y
authors.initials: Y
authors.lastname: Rosenblum
authors.forename: J
authors.initials: J
authors.lastname: LaFleur
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003362:Cost-Benefit Analysis; D004502:Education, Medical, Continuing / Q000191:economics* / Q000379:methods; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008390:Markov Chains; D010024:Osteoporosis / Q000175:diagnosis / Q000188:drug therapy / Q000191:economics*; D058866:Osteoporotic Fractures / Q000191:economics* / Q000517:prevention & control; D058007:Physicians, Primary Care / Q000191:economics / Q000193:education*; D011320:Primary Health Care / Q000191:economics; D019057:Quality-Adjusted Life Years; D019035:Rural Health Services / Q000191:economics*; D012680:Sensitivity and Specificity; D014481:United States; D058014:Veterans Health / Q000191:economics