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Cost-Effectiveness of Alendronate Therapy for Osteopenic Postmenopausal Women

John T. Schousboe, MD, MS; John A. Nyman, PhD; Robert L. Kane, MD; and Kristine E. Ensrud, MD, MPH
[+] Article and Author Information

From Park Nicollet Health Services, University of Minnesota, and Veterans Administration Medical Center, Minneapolis, Minnesota.


Potential Financial Conflicts of Interest: Grants received: J.T. Schousboe (Hologic, Inc.), K.E. Ensrud (Eli Lilly & Co., Pfizer, NPB Pharmaceuticals).

Requests for Single Reprints: John T. Schousboe, MD, MS, Park Nicollet Clinic, 3800 Park Nicollet Boulevard, Minneapolis, MN 55416; e-mail, schouj@parknicollet.com.

Current Author Addresses: Dr. Schousboe: Park Nicollet Clinic, 3800 Park Nicollet Boulevard, Minneapolis, MN 55416.

Drs. Nyman and Kane: Division of Health Services Research and Policy, School of Public Health, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455.

Dr. Ensrud: Department of Medicine, Minneapolis Veterans Administration Medical Center, 1 Veterans Drive, Minneapolis, MN 55417.

Author Contributions: Conception and design: J.T. Schousboe, R.L. Kane.

Analysis and interpretation of the data: J.T. Schousboe, J.A. Nyman, K.E. Ensrud.

Drafting of the article: J.T. Schousboe.

Critical revision of the article for important intellectual content: J.T. Schousboe, R.L. Kane, K.E. Ensrud.

Final approval of the article: J.T. Schousboe, R.L. Kane, K.E. Ensrud.

Administrative, technical, or logistic support: J.T. Schousboe, R.L. Kane.

Collection and assembly of data: J.T. Schousboe.


Ann Intern Med. 2005;142(9):734-741. doi:10.7326/0003-4819-142-9-200505030-00008
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We constructed a Markov cost-utility model that contained 8 health states and compared 5 years of treatment with alendronate (1 of the most commonly prescribed antiresorptive agents) with no drug therapy for women 55 to 75 years of age with varying levels of BMD T-scores (−1.5 to −2.4). The health states we used were no fracture, post-distal forearm fracture, post-clinical vertebral fracture (that is, clinically evident at onset), post-radiographic vertebral fracture (that is, not clinically evident at onset), post-hip fracture, post-other fractures (that is, fracture of the proximal forearm, humerus, scapula, clavicle, sternum, ribs, pelvis, distal femur, patella, tibia, or proximal fibula), post-hip and vertebral fracture, and death. Women in the no fracture state can develop a distal forearm, hip, clinical vertebral, radiographic vertebral, or other fracture, at which time transition to that post-fracture state occurs. We assigned the direct and indirect costs of that fracture as transition costs. We modeled the disutility associated with these fractures as a lower value of a quality-adjusted life-year (QALY) associated with that fracture state. We assigned long-term care costs beyond the first year after hip fracture as a cost per year in the post-hip and vertebral fracture or post-hip fracture state. Individuals are eligible (at risk) to move to a different state once every 6 months. We assumed a discount rate of 3% for both costs and health benefits and a drug adherence rate of 100%. For the base-case analyses, we ran the model with 9 different combinations of starting age (55, 65, and 75 years) and femoral neck T-score (−1.5, −2.0, and −2.4) until age 105 years, using Monte Carlo simulations with 40 000 trials each, by using Data Pro HealthCare software (TreeAge Software, Inc., Williamstown, Massachusetts).

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Figures

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Figure 1.
Effect of additional risk factors and offset of fracture reduction benefit on incremental cost-effectiveness ratios for drug therapy versus no drug therapy.

Data are based on 65-year-old women with T-scores of -2.0. Cost is in 2001 U.S. dollars. BMD = bone mineral density; QALY = quality-adjusted life-year.

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Figure 2.
Cost per quality-adjusted life-year (QALY) saved according to relative risks for vertebral and nonvertebral fractures during alendronate therapy.

Data are based on 65-year-old women with T-scores of -2.0. Cost is in 2001 U.S. dollars.

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Figure 3.
Cost-effectiveness acceptability curves.

Left. Data are based on 65-year-old women with T-scores of −2.0 and no additional risk factors. Right. Data are based on 65-year-old women with T-scores of −1.5 and additional fracture risk factors (aggregate bone mineral density-adjusted relative risk, 2.5).

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Appendix Figure 1.
Overall Markov model structure.

DFF = distal forearm fracture.

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Appendix Figure 2.
Expanded subtree for the no fracture state-no drug therapy strategy.

p_HipFx2d, p_VertFx2d, p_OtherFx2d, p_DFF2d, p_VertFx2dd, and p_Death1 are the transition probabilities of incident hip fracture, clinical vertebral fracture, other fracture, distal forearm fracture, radiographic (but clinically unapparent) vertebral fracture, or death, respectively, from the no fracture state without alendronate therapy. p_Death2 is the transition probability of death from the hip fracture state in excess of the age- and sex-specific death rate. DFF = distal forearm fracture.

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Appendix Figure 3.
Hip fracture rate power curve.
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Appendix Figure 4.
Clinical vertebral fracture rate power curve.
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Appendix Figure 5.
Distal forearm fracture (DFF) rate power curve.
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Appendix Figure 6.
Other fracture rate power curve.
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Comments

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Alendronate therapy and cost
Posted on May 6, 2005
Lonnie B. Hanauer
No Affiliation
Conflict of Interest: None Declared

To the Editor:

I agree that "osteopenia" is a "non-disease" (according to the British Mediacl J.) and that treatment as desired by the pharmaceutical industry and those owning bone density machines is seldom if ever justified, especially when cost-effectiveness is given consideration.

Nevertheless, I note that the article by Schousboe, et.al. lists the annual cost of alendronate in 2001 as $842 or about $16 per week, which I assume is for one 35 mg tablet weekly, the dose that Merck advises for treatment of osteopenia. In 2005, my local pharmacy advises that one 70 mg tablet of alendronate costs $23.39. One 35 mg tablet costs $24.39 (they sell fewer of this strength) and one 10 mg tablet, $3.48.

Any physician who feels compelled, despite the evidence, to treat "osteopenia" with a 35 mg dose should at least consider telling the patient to cut a 70 mg tablet in half or take three or four 10 mg tablets weekly at a cost of $11-14 tablets. Just because pharmaceutical companies believe physicians are too obtuse to be aware of the cost of drugs, we should occasionally try to not let them get away with it. Lonnie B. Hanauer, M.D., F.A.C.P., 116 Millburn Ave, Millburn, NJ 07041

Conflict of Interest:

None declared

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Summary for Patients

Cost-Effectiveness of Alendronate in Postmenopausal Women with Low Bone Mass without Osteoporosis or Previous Fracture

The summary below is from the full report titled “Cost-Effectiveness of Alendronate Therapy for Osteopenic Postmenopausal Women.” It is in the 3 May 2005 issue of Annals of Internal Medicine (volume 142, pages 734-741). The authors are J.T. Schousboe, J.A. Nyman, R.L. Kane, and K.E. Ensrud.

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