Smita Nayak, MD; Mark S. Roberts, MD, MPP; Susan L. Greenspan, MD
Disclaimer: The contents of this article are solely the responsibility of the authors and do not necessarily represent the official view of the National Center for Research Resources or National Institutes of Health.
Acknowledgment: The authors thank Hau Liu, MD, MPH, MBA, and Kaleb Michaud, PhD, for assistance with development of the cost-effectiveness model and Dennis Black, PhD, for providing logistic regression equations to predict women's future fracture probabilities developed from Study of Osteoporotic Fractures data.
Grant Support: By grant KL2 RR024154 from the National Center for Research Resources (a component of the National Institutes of Health) and National Institutes of Health Roadmap for Medical Research (Dr. Nayak), grant 1R01AR060809-01 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (Dr. Nayak), and grant K24 DK062895 from the National Institute of Diabetes and Digestive and Kidney Diseases (Dr. Greenspan).
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-1567.
Reproducible Research Statement:Study protocol, statistical code, and data set: Not available.
Requests for Single Reprints: Smita Nayak, MD, University of Pittsburgh, 200 Meyran Avenue, Suite 200, Pittsburgh, PA 15213; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Nayak: University of Pittsburgh, 200 Meyran Avenue, Suite 200, Pittsburgh, PA 15213.
Dr. Roberts: University of Pittsburgh, A621 Crabtree Hall, 30 De Soto Street, Pittsburgh, PA 15361.
Dr. Greenspan: Osteoporosis Prevention and Treatment Center, Kaufmann Medical Building, Suite 1110, Pittsburgh, PA 15213.
Author Contributions: Conception and design: S. Nayak, M.S. Roberts, S.L. Greenspan.
Analysis and interpretation of the data: S. Nayak, M.S. Roberts, S.L. Greenspan.
Drafting of the article: S. Nayak.
Critical revision of the article for important intellectual content: S. Nayak, M.S. Roberts, S.L. Greenspan.
Final approval of the article: S. Nayak, M.S. Roberts, S.L. Greenspan.
Obtaining of funding: S. Nayak.
Collection and assembly of data: S. Nayak.
Nayak S, Roberts MS, Greenspan SL. Cost-Effectiveness of Different Screening Strategies for Osteoporosis in Postmenopausal Women. Ann Intern Med. 2011;155:751-761. doi: 10.7326/0003-4819-155-11-201112060-00007
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Published: Ann Intern Med. 2011;155(11):751-761.
The best strategies to screen postmenopausal women for osteoporosis are not clear.
To identify the cost-effectiveness of various screening strategies.
Individual-level state-transition cost-effectiveness model.
U.S. women aged 55 years or older.
Screening strategies composed of alternative tests (central dual-energy x-ray absorptiometry [DXA], calcaneal quantitative ultrasonography [QUS], and the Simple Calculated Osteoporosis Risk Estimation [SCORE] tool) initiation ages, treatment thresholds, and rescreening intervals. Oral bisphosphonate treatment was assumed, with a base-case adherence rate of 50% and a 5-year on/off treatment pattern.
Incremental cost-effectiveness ratios (2010 U.S. dollars per quality-adjusted life-year [QALY] gained).
At all evaluated ages, screening was superior to not screening. In general, quality-adjusted life-days gained with screening tended to increase with age. At all initiation ages, the best strategy with an incremental cost-effectiveness ratio (ICER) of less than $50 000 per QALY was DXA screening with a T-score threshold of −2.5 or less for treatment and with follow-up screening every 5 years. Across screening initiation ages, the best strategy with an ICER less than $50 000 per QALY was initiation of screening at age 55 years by using DXA −2.5 with rescreening every 5 years. The best strategy with an ICER less than $100 000 per QALY was initiation of screening at age 55 years by using DXA with a T-score threshold of −2.0 or less for treatment and then rescreening every 10 years. No other strategy that involved treatment of women with osteopenia had an ICER less than $100 000 per QALY. Many other strategies, including strategies with SCORE or QUS prescreening, were also cost-effective, and in general the differences in effectiveness and costs between evaluated strategies was small.
Probabilistic sensitivity analysis did not reveal a consistently superior strategy.
Data were primarily from white women. Screening initiation at ages younger than 55 years were not examined. Only osteoporotic fractures of the hip, vertebrae, and wrist were modeled.
Many strategies for postmenopausal osteoporosis screening are effective and cost-effective, including strategies involving screening initiation at age 55 years. No strategy substantially outperforms another.
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Endocrine and Metabolism, High Value Care, Metabolic Bone Disorders, Prevention/Screening.
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