DIAGNOSIS
AND
TREATMENT
Cost Effectiveness of Screening Perimenopausal White Women for Osteoporosis: Bone Densitometry and Hormone Replacement Therapy Anna N . A. Tosteson, S c D ; Daniel I. Rosenthal, M D ; L. Joseph Melton, III, M D ; and Milton C. Weinstein, PhD
Bone mass measurement at menopause to identify and selectively prescribe hormone replacement therapy for women at high risk for fractures has seen limited clinical use. We used epidemiologic, clinical, and economic data in a decision-analytic model to compare the following clinical strategies for perimenopausal, asymptomatic, white women with intact uteri: no intervention; bone mineral density measurement followed by selective, long-term (15-year) estrogen-progestin therapy in women with low bone mass; and unselective, universal hormone replacement therapy. Life expectancy and direct medical cost per patient were estimated for each strategy. Strategies for screening and treating women with perimenopausal bone mineral density < 0.9 g/cm2 or < 1.0 g/cm2 would cost $11 700 or $22 100, respectively, per year of additional life gained. If the cost of screening is less than $84, then resource savings from hip fractures prevented would be more than the cost of screening and treatment. Universal treatment without screening would prevent additional fatal fractures but would expose many more women to the adverse effects of hormone replacement therapy and would cost an additional $349 000 per year of life gained compared with the screening strategies. When quality of life was considered, screening was found to be cost effective over a wide range of assumptions. The choice between universal treatment and screening depends on the risks (breast cancer), perceived side effects (menstrual bleeding), and benefits (prevention of ischemic heart disease) of estrogen-progestin therapy. We conclude that screening asymptomatic, perimenopausal white women to detect low bone mass and to target hormone replacement therapy at women who are at the greatest risk for fracture is a reasonably cost-effective use of health care resources. However, cost-effective screening guidelines cannot be explicitly established until further data addressing the association between bone mass measurements in the hip and hip fracture risk are available.
Annals of Internal Medicine. 1990;113:594-603. From Beth Israel Hospital, Brigham and Women's Hospital, Harvard Medical School, Massachusetts General Hospital, and the Harvard School of Public Health, Boston, Massachusetts; and the Mayo Clinic, Rochester, Minnesota. For current author addresses, see end of text. 594
© 1990 American College of Physicians
Downloaded From: https://annals.org/ by a Tulane University User on 08/07/2018
1 he presence of osteoporosis among an estimated 15 to 20 million persons in the United States is manifested each year by the occurrence of hundreds of thousands of fractures of the proximal femur (hip), distal forearm (Colles fracture), and vertebrae (1). These complications of osteoporosis, estimated to cost over $6 billion dollars annually (2), are most prominent among postmenopausal women (3). Growing public awareness of osteoporosis and its associated morbidity and mortality; the development of noninvasive modalities to measure bone mass (4-8); and the existence of hormone replacement therapies that are effective in stopping or slowing bone loss (9-12) and in reducing the risk for osteoporotic fractures (13-19) have led to a discussion over whether screening for osteoporosis is warranted (20-24). Although mass screening of unselected populations for osteoporosis has been discouraged (20-24), the use of bone mass measurements in estrogen-deficient women (including perimenopausal women) to facilitate decisions about hormone replacement therapy may have merit (24, 25). The rationale for such use is that knowledge of bone mass would allow for selective treatment of women at the highest risk for fracture and would spare low-risk women the costs and risks of therapy, which have been described elsewhere (26-29). The role for screening is strengthened by prospective studies linking bone mass to fracture risk (30-34) and the inability of any combination of risk factors to predict bone mass accurately (35-37). Failures to predict bone mass accurately include a prediction rule that did not identify 30% of women at high risk for fracture because of many risk factors (37), including obesity, which have been associated with hip fracture (19, 38). Nonetheless, screening for low bone mass has not been widely adopted in practice. Barriers include the absence of accepted screening protocols (25) and concern about the clinical and economic dimensions of screening, given the many perimenopausal white women potentially affected. The crucial questions are how much benefit would result from screening this population and at what cost. The objective of our study was to answer these questions for asymptomatic perimenopausal women (that is, women not already receiving hormone replacement therapy for menopausal symptoms) by evaluating and comparing the clinical effectiveness and economic costs of the following clinical strategies: no intervention; bone mass measurement at the menopause, followed by selective, long-term hormone replacement therapy in women with bone mineral density below a specified threshold; and universal hormone replacement therapy at the menopause.
Table 1. Clinical Strategies No intervention Screen and treat if BMD Screen and treat if BMD Screen and treat if BMD Screen and treat if BMD Universal treatment
< < <
AND
TREATMENT
Cost Effectiveness of Screening Perimenopausal White Women for Osteoporosis: Bone Densitometry and Hormone Replacement Therapy Anna N . A. Tosteson, S c D ; Daniel I. Rosenthal, M D ; L. Joseph Melton, III, M D ; and Milton C. Weinstein, PhD
Bone mass measurement at menopause to identify and selectively prescribe hormone replacement therapy for women at high risk for fractures has seen limited clinical use. We used epidemiologic, clinical, and economic data in a decision-analytic model to compare the following clinical strategies for perimenopausal, asymptomatic, white women with intact uteri: no intervention; bone mineral density measurement followed by selective, long-term (15-year) estrogen-progestin therapy in women with low bone mass; and unselective, universal hormone replacement therapy. Life expectancy and direct medical cost per patient were estimated for each strategy. Strategies for screening and treating women with perimenopausal bone mineral density < 0.9 g/cm2 or < 1.0 g/cm2 would cost $11 700 or $22 100, respectively, per year of additional life gained. If the cost of screening is less than $84, then resource savings from hip fractures prevented would be more than the cost of screening and treatment. Universal treatment without screening would prevent additional fatal fractures but would expose many more women to the adverse effects of hormone replacement therapy and would cost an additional $349 000 per year of life gained compared with the screening strategies. When quality of life was considered, screening was found to be cost effective over a wide range of assumptions. The choice between universal treatment and screening depends on the risks (breast cancer), perceived side effects (menstrual bleeding), and benefits (prevention of ischemic heart disease) of estrogen-progestin therapy. We conclude that screening asymptomatic, perimenopausal white women to detect low bone mass and to target hormone replacement therapy at women who are at the greatest risk for fracture is a reasonably cost-effective use of health care resources. However, cost-effective screening guidelines cannot be explicitly established until further data addressing the association between bone mass measurements in the hip and hip fracture risk are available.
Annals of Internal Medicine. 1990;113:594-603. From Beth Israel Hospital, Brigham and Women's Hospital, Harvard Medical School, Massachusetts General Hospital, and the Harvard School of Public Health, Boston, Massachusetts; and the Mayo Clinic, Rochester, Minnesota. For current author addresses, see end of text. 594
© 1990 American College of Physicians
Downloaded From: https://annals.org/ by a Tulane University User on 08/07/2018
1 he presence of osteoporosis among an estimated 15 to 20 million persons in the United States is manifested each year by the occurrence of hundreds of thousands of fractures of the proximal femur (hip), distal forearm (Colles fracture), and vertebrae (1). These complications of osteoporosis, estimated to cost over $6 billion dollars annually (2), are most prominent among postmenopausal women (3). Growing public awareness of osteoporosis and its associated morbidity and mortality; the development of noninvasive modalities to measure bone mass (4-8); and the existence of hormone replacement therapies that are effective in stopping or slowing bone loss (9-12) and in reducing the risk for osteoporotic fractures (13-19) have led to a discussion over whether screening for osteoporosis is warranted (20-24). Although mass screening of unselected populations for osteoporosis has been discouraged (20-24), the use of bone mass measurements in estrogen-deficient women (including perimenopausal women) to facilitate decisions about hormone replacement therapy may have merit (24, 25). The rationale for such use is that knowledge of bone mass would allow for selective treatment of women at the highest risk for fracture and would spare low-risk women the costs and risks of therapy, which have been described elsewhere (26-29). The role for screening is strengthened by prospective studies linking bone mass to fracture risk (30-34) and the inability of any combination of risk factors to predict bone mass accurately (35-37). Failures to predict bone mass accurately include a prediction rule that did not identify 30% of women at high risk for fracture because of many risk factors (37), including obesity, which have been associated with hip fracture (19, 38). Nonetheless, screening for low bone mass has not been widely adopted in practice. Barriers include the absence of accepted screening protocols (25) and concern about the clinical and economic dimensions of screening, given the many perimenopausal white women potentially affected. The crucial questions are how much benefit would result from screening this population and at what cost. The objective of our study was to answer these questions for asymptomatic perimenopausal women (that is, women not already receiving hormone replacement therapy for menopausal symptoms) by evaluating and comparing the clinical effectiveness and economic costs of the following clinical strategies: no intervention; bone mass measurement at the menopause, followed by selective, long-term hormone replacement therapy in women with bone mineral density below a specified threshold; and universal hormone replacement therapy at the menopause.
Table 1. Clinical Strategies No intervention Screen and treat if BMD Screen and treat if BMD Screen and treat if BMD Screen and treat if BMD Universal treatment
< < <
