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. 2018 May 29:10:279-292.
doi: 10.2147/CEOR.S163237. eCollection 2018.

Cost-effectiveness of pulse-echo ultrasonometry in osteoporosis management

Erkki Soini  1 , Ossi Riekkinen  2 , Heikki Kröger  3   4 , Petri Mankinen  1 , Taru Hallinen  1 , Janne P Karjalainen  2
Affiliations

Cost-effectiveness of pulse-echo ultrasonometry in osteoporosis management

Erkki Soini et al. Clinicoecon Outcomes Res. .

Abstract

Purpose: Osteoporosis is asymptomatic morbidity of the elderly which develops slowly over several years. Osteoporosis diagnosis has typically involved Fracture Risk Assessment (FRAX) followed by dual energy X-ray absorptiometry (DXA) in specialist care. Point-of-care pulse-echo ultrasound (PEUS) was developed to overcome DXA-related access issues and to enable faster fracture prevention treatment (FPT) initiation. The objective of this study was to evaluate the cost-effectiveness of two proposed osteoporosis management (POMs: FRAX→PEUS-if-needed→DXA-if-needed→FPT-if-needed) pathways including PEUS compared with the current osteoporosis management (FRAX→DXA-if-needed→FPT-if-needed).

Materials and methods: Event-based probabilistic cost-utility model with 10-year duration for osteoporosis management was developed. The model consists of a decision tree for the screening, testing, and diagnosis phase and is followed by a Markov model for the estimation of incidence of four fracture types and mortality. Five clinically relevant patient cohorts (potential primary FPT in women aged 75 or 85 years, secondary FPT in women aged 65, 75, or 85 years) were modeled in the Finnish setting. Generic alendronate FPT was used for those diagnosed with osteoporosis, including persistence overtime. Discounted (3%/year) incremental cost-effectiveness ratio was the primary outcome. Discounted quality-adjusted life-years (QALYs), payer costs (year 2016 value) at per patient and population level, and cost-effectiveness acceptability frontiers were modeled as secondary outcomes.

Results: POMs were cost-effective in all patient subgroups with noteworthy mean per patient cost savings of €121/76 (ranges €107-132/52-96) depending on the scope of PEUS result interpretation (test and diagnose/test only, respectively) and negligible differences in QALYs gained in comparison with current osteoporosis management. In the cost-effectiveness acceptability frontiers, POMs had 95%-100% probability of cost-effectiveness with willingness to pay €24,406/QALY gained. The results were robust in sensitivity analyses. Even when assuming a high cost of PEUS (up to €110/test), POMs were cost-effective in all cohorts.

Conclusion: The inclusion of PEUS to osteoporosis management pathway was cost-effective.

Keywords: Fracture Risk Assessment tool; PICOSTEPS; diagnostics; dual-energy X-ray absorptiometry; economic evaluation; screening.

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Conflict of interest statement

Disclosure ES, PM, or TH did not receive any direct financial support as individuals. HK works as an invited member of the national Käypä Hoito care guidance working group for osteoporosis. HK has received consultancy fees and lecture payments from Amgen Ltd and Eli Lilly ltd, and is a partner of Bone Index. ES, PM, and TH are employees of ESiOR Oy, Kuopio, Finland. ES and TH are also partners and directors of ESiOR. OR and JPK are employees and partners of Bone Index. Bone Index is the manufacturer and marketer of PEUS (Bindex®). The authors report no other conflicts of interest in this work.

Figures

Figure 1
Figure 1
Decision tree: POM pathways are on the left-hand side and the COM pathway is on the right-hand side. Notes: The upper part of (A) presents the POMA strategy, where PEUS is used for osteoporosis testing and diagnosis.– The lower part of (B) presents the alternative, POMB strategy, where PEUS is used for osteoporosis testing only and a positive diagnosis is confirmed with DXA. Abbreviations: COM, conventional osteoporosis management; DXA, dual-energy X-ray absorptiometry; FRAX, Fracture Risk Assessment; PEUS, pulse-echo ultrasound technology; POM, proposed osteoporosis management; POMA, proposed osteoporosis management pathway A; POMB, proposed osteoporosis management pathway B.
Figure 2
Figure 2
Markov model. Notes: The bold green arrow points to the starting state of primary prevention of osteoporotic fractures, and the bold yellow arrows point to the starting state of secondary prevention. The black arrows correspond to fracture events, and the blue arrows indicate health-state transitions without new fractures. aTransitions to the absorbing dead state are possible from any state.
Figure 3
Figure 3
Cost-effectiveness acceptability frontiers with sensible willingness-to-pay values of €0–36,609 per quality-adjusted life year gained present high probabilities (82%–100%) of cost-effectiveness for POMA (upper part [A], PEUS is used for the osteoporosis testing and diagnosis) and POMB (lower part [B], patient tested with PEUS). Abbreviations: PEUS, pulse-echo ultrasound technology; POMA, proposed osteoporosis management pathway A; POMB, proposed osteoporosis management pathway B.
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