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Cost-Effectiveness of Different Screening Strategies for Osteoporosis in Postmenopausal Women

Smita Nayak, MD; Mark S. Roberts, MD, MPP; and Susan L. Greenspan, MD
[+] Article, Author, and Disclosure Information

From the University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, Pennsylvania.

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, nayaks@upmc.edu.

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.

Ann Intern Med. 2011;155(11):751-761. doi:10.7326/0003-4819-155-11-201112060-00007
Text Size: A A A

Background: The best strategies to screen postmenopausal women for osteoporosis are not clear.

Objective: To identify the cost-effectiveness of various screening strategies.

Design: Individual-level state-transition cost-effectiveness model.

Data Sources: Published literature.

Target Population: U.S. women aged 55 years or older.

Time Horizon: Lifetime.

Perspective: Payer.

Intervention: 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.

Outcome Measures: Incremental cost-effectiveness ratios (2010 U.S. dollars per quality-adjusted life-year [QALY] gained).

Results of Base-Case Analysis: 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.

Results of Sensitivity Analysis: Probabilistic sensitivity analysis did not reveal a consistently superior strategy.

Limitations: 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.

Conclusion: 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.

Primary Funding Source: National Center for Research Resources.


Grahic Jump Location
Model schematic.

This is a simplified and partial representation of the full model. The model evaluates 7 screening strategies, each of which was evaluated as a 1-time strategy, as a strategy repeated every 5 years, and as a strategy repeated every 10 years. Additionally, no screening was also considered, resulting in a total of 22 screening options at each screening initiation age; these are described in more detail in Table 1. The screening result is either positive, in which case the individual is offered treatment with a bisphosphonate, or negative, in which case usual care of calcium and vitamin D is offered. We assume that at the time of initial screening, individuals are in the “no fracture” state, with no known history of osteoporotic fracture. Whether on or off treatment, patients may experience a series of events over time, including a new osteoporotic fracture, the results of which may be death, transfer to a long-term care facility, or recovery. Patients may also experience medication adverse events. Individuals move through the outcomes and fracture states portions of the model on a 3-month cycle. DXA = dual-energy x-ray absorptiometry; NOS = National Osteoporosis Foundation; QUS = quantitative ultrasonography; SCORE = Simple Calculated Osteoporosis Risk Estimation.

Grahic Jump Location




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Bone Mineral Density and Osteoporosis. What else?
Posted on December 13, 2011
FranciscoRamirez Lafita, MD, FACP, Rheumatologist, Belinda Garcia, MD
Clinica Monegal
Conflict of Interest: None Declared

Osteoporosis represents an important burden in modern society as life expectancy increases. The incidence of osteoporotic fractures in the life- time of postmenopausal women and the subsequent morbidity can result in devastating physical, psychosocial and economical consequences. Despite the negative effects of this condition, osteoporosis is frequently overlooked and undertreated until the appearing of fractures. Prevention (diagnosis and treatment) of osteoporosis constitutes a thrilling topic in modern clinical practice. The study by Nayak (1) and colleagues suggests the cost-effectiveness of screening for osteoporosis in women starting at age 55 years, initiating therapy if DXA T-score was found to be -2.0 or less and rescreening every 10 years.

Nayak and colleagues findings could be enforced with accompanying lab -work on bone mineral metabolism. In fact, bone mineral density (BMD) is an important predictor of fracture risk but, DXA measurement represents current BMD and cannot anticipate rate of bone loss. (2) Young menopausal women can hold normal BMD values but, they can present hypovitaminosis D or increased bone resorption markers. Significant positive correlations between 25OHD level and BMD and significant negative correlations with parathyroid hormone levels have been widely described (3). Many studies supports the assessment of serum 25OH D in the context of specific symptoms, low bone mineral density or biochemical abnormalities in Ca homeostasis (4). By the other hand, persistence de hyperparathyroidism secondary to hypovitaminosis D in patiens with osteoporosis, reduced BMD response to bisphosphonates (5)

Periodic BMD determinations can be actually spaced when previous values are found to be normal or unchanging and evidence of hypovitaminosis D or active bone resorption markers are not present. A normal BMD with lab findings of hypovitaminosis D and secondary hyperparathyroidism deserves treatment and further controls.


1. Nayak S, Roberts MS, Greenspan SL. Cost-Effectiveness of Different Screening Strategies for Osteoporosis in Postmenopausal Women. Ann Intern Med. 2011; 155: 751-761

2. Brown JP, Albert C, Nassar BA, Adachi JD, Cole D, Davison KS et al; Bone turnover markers in the management of postmenopausal osteoporosis. Clin Biochem. 2009; 42: 929-942 (ISSN: 1873-2933)

3. Sadat-Ali M, Al Elq AH, Al-Turki HA, Al-Mulhim FA, Al-Ali AK. Influence of Vitamin D levels on bone mineral density and osteoporosis. Ann Saudi Med. 2011; 31:602-608

4. Holroyd CR, Cooper C, Harvey NC. Vitamin D and the postmenopausal population. Menopause Int. 2011;17:102-107.

5. Barone A, Giusti A, Pioli G, Girasole G, Razzano M, Pizzonia M, Palummeri E, Bianchi G. Secondary hyperparathyroidism due to hypovitaminosis D affects bone mineral density response to alendronate in elderly women with osteoporosis: a randomized controlled trial. J Am Geriatr Soc. 2007;55:752-757.

Conflict of Interest:

None declared

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