Solomon Daniel H, Patrick Amanda R, Schousboe John, Losina Elena
Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA; Division of Pharmacoepidemiology, Brigham and Women's Hospital, Boston, MA, USA.
J Bone Miner Res. 2014 Jul;29(7):1667-74. doi: 10.1002/jbmr.2180.
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.
在美国，与骨质疏松症相关的骨折造成的花费高达200亿美元，其中大部分费用由联邦医疗保健项目承担，如医疗保险和医疗补助。尽管多种骨质疏松症治疗方法已被证实具有减少骨折的益处，但65岁以上发生骨折的患者中，接受此类治疗的不到四分之一。许多医疗系统都设立了骨折后联络服务（FLS），但在美国尚未得到广泛实施。我们开发了一个马尔可夫状态转换计算机模拟模型，从医疗保健系统的角度评估FLS的成本效益。利用该模型，我们预测了接受或未接受骨密度测试的髋部骨折男性和女性接受FLS后的终生成本和效益。我们根据已发表的文献估算了FLS的成本和效益、骨质疏松症治疗期间再次骨折的概率，以及与各种健康状态相关的效用值。我们采用多因素敏感性分析来检验输入参数的不确定性对FLS成本效益的影响。该模型估计，与每10000名骨折后患者的典型骨折后护理相比，FLS将减少153例骨折（109例髋部骨折、5例腕部骨折、21例脊柱骨折、17例其他骨折），增加37.43个质量调整生命年（QALY），并节省66879美元。将FLS的成本翻倍后，每获得一个QALY的增量成本效益比（ICER）为22993美元。敏感性分析表明，结果对合理的输入参数范围具有稳健性；假设每个主要输入参数取最不利值时，每获得一个QALY的ICER为112877美元。在大多数情况下，针对髋部骨折后患者的FLS应能节省成本并减少骨折。
