Cost-effectiveness of multifaceted evidence implementation programs for the prevention of glucocorticoid-induced osteoporosis

Abstract

Summary: Using a computer simulation model, we determined that an intervention aimed at improving the management of glucocorticoid-induced osteoporosis is likely to be cost-effective to third-party health insurers only if it focuses on individuals with very high fracture risk and the proportion of prescriptions for generic bisphosphonates increases substantially.

Introduction: The purpose of this study is to determine whether an evidence implementation program (intervention) focused on increasing appropriate management of glucocorticoid-induced osteoporosis (GIOP) might be cost-effective compared with current practice (no intervention) from the perspective of a third-party health insurer.

Methods: We developed a Markov microsimulation model to determine the cost-effectiveness of the intervention. The hypothetical patient cohort was of current chronic glucocorticoid users 50-65 years old and 70% female. Model parameters were derived from published literature, and sensitivity analyses were performed.

Results: The intervention resulted in incremental cost-effectiveness ratios (ICERs) of $298,000 per quality adjusted life year (QALY) and $206,000 per hip fracture averted. If the cohort's baseline risk of fracture was increased by 50% (10-year cumulative incidence of hip fracture of 14%), the ICERs improved significantly: $105,000 per QALY and $137,000 per hip fracture averted. The ICERs improved significantly if the proportion of prescriptions for generic bisphosphonates was increased to 75%, with $113,000 per QALY and $77,900 per hip fracture averted.

Conclusions: Evidence implementation programs for the management of GIOP are likely to be cost-effective to third-party health insurers only if they are targeted at individuals with a very high risk of fracture and the proportion of prescriptions for less expensive generic bisphosphonates increases substantially.

Fig. 1

Simplified structure of the Markov decision model for glucocorticoid-induced osteoporosis evidence implementation intervention. The square node represents the decision (intervention) point. The “M” circles represent the start of the Markov models with the four states shown. The empty circles represent chance nodes with probabilities derived from the published literature. The “L” circles represent logic nodes where an individual’s bisphosphonate treatment history determines the presence of a residual treatment effect. The triangles represent terminal nodes and denote the state in which individuals begin the subsequent cycle. Branch points marked by (A) and (B) are identical throughout the model and have been omitted to conserve space

Fig. 2

Cost-effectiveness acceptability curves for baseline model assumptions. The curves represent the proportion of second-order trials in which the evidence implementation intervention was cost-effective for the given willingness to pay. a Willingness to pay per QALY. b Willingness to pay per hip fracture averted

Fig. 3

Cost-effectiveness acceptability curves for model that assumed a 50% increase in baseline fracture risk and 75% generic bisphosphonate prescription rate. The curves represent the proportion of second-order trials in which the evidence implementation intervention was cost-effective for the given willingness to pay. a Willingness to pay per QALY. b Willingness to pay per hip fracture averted