The potential economic benefits of improved postfracture care: a cost-effectiveness analysis of a fracture liaison service in the US health-care system

Abstract

Fractures related to osteoporosis are associated with $20 billion in cost in the United States, with the majority of cost born by federal health-care programs, such as Medicare and Medicaid. Despite the proven fracture reduction benefits of several osteoporosis treatments, less than one-quarter of patients older than 65 years of age who fracture receive such care. A postfracture liaison service (FLS) has been developed in many health systems but has not been widely implemented in the United States. We developed a Markov state-transition computer simulation model to assess the cost-effectiveness of an FLS using a health-care system perspective. Using the model, we projected the lifetime costs and benefits of FLS, with or without a bone mineral density test, in men and women who had experienced a hip fracture. We estimated the costs and benefits of an FLS, the probabilities of refracture while on osteoporosis treatment, as well as the utilities associated with various health states from published literature. We used multi-way sensitivity analyses to examine impact of uncertainty in input parameters on cost-effectiveness of FLS. The model estimates that an FLS would result in 153 fewer fractures (109 hip, 5 wrist, 21 spine, 17 other), 37.43 more quality-adjusted life years (QALYs), and save $66,879 compared with typical postfracture care per every 10,000 postfracture patients. Doubling the cost of the FLS resulted in an incremental cost-effectiveness ratio (ICER) of $22,993 per QALY. The sensitivity analyses showed that results were robust to plausible ranges of input parameters; assuming the least favorable values of each of the major input parameters results in an ICER of $112,877 per QALY. An FLS targeting patients post-hip fracture should result in cost savings and reduced fractures under most scenarios.

Keywords: COST-EFFECTIVENESS; FRACTURE LIAISON SERVICE; HIP FRACTURE; OSTEOPOROSIS.

Fig. 1

Model structure. Patients enter the model with a prior hip fracture (primary analysis) or distributed between prior fracture types (secondary analysis), with the percent “on treatment” determined by treatment strategy. In each simulated 3-month cycle, patients may experience no clinical event, a fracture, or death. Patients who remain alive and have been on treatment can remain on treatment or discontinue treatment; patients who have been off treatment can remain off treatment or reinitiate treatment. Patients begin the next cycle in a state determined by their clinical event history and most recent medication events. The process is repeated until all patients are dead.

Fig. 2

This threshold analysis examined how different annual costs for zoledronic acid affected the ICER for the FLS program comparing it with generic alendronate. When the annual cost of zoledronic acid was reduced to $240, it resulted in cost savings; at approximately $800, its ICER was $100,000 per QALY.