Alfred K. Pfister

Cost-effectiveness strategies to treat osteoporosis in elderly women

Background: Comparing the cost-effectiveness of various antiosteoporotic drugs has not been defined. Methods: We determined the cost-effectiveness of calcitonin, raloxifene, bisphosphates and PTH in a base-case cohort of women aged 65 or older with osteoporosis. After bone densitometry, women were stratified into groups of treatment or no treatment. Our outcome goal was a value of

Screening for osteoporosis: U.S. Preventive Services Task Force recommendation statement.

100,000 or less per quality-adjusted life years (QALY). A sensitivity analysis varied nonvertebral fracture reduction and compliance between the two most effective strategies to test various cost per QALY thresholds. Results: Bisphosphonates displayed the most favorable incremental cost saving and prevented more fractures in our base-case analysis. In a sensitivity analysis, virtually all values of bisphosphonates were under

An approach to identify rural women aged 60 to 64 for osteoporosis treatment.

100,000 per QALY and parathyroid hormone (PTH) was between

Changes in Nonosteoporotic Bone Density and Subsequent Fractures in Women.

100,000 and

Significance of high- and low-distal energy forearm fractures.

200,000 per QALY. Conclusions: Only bisphosphonates are cost-effective for fracture prevention in osteoporotic women aged 65 or older and this economic advantage is also maintained in subsets who have a lower relative risk of future fracture.

Factors determining calcium intake in elderly women of Appalachia.

Recommendations: The USPSTF recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. (Grade B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men. (I statement)

Risk factors predicting fractures in early postmenopausal women.

Objectives The US Preventive Services Task Force recently recommended that women younger than 65 years undergo a bone mineral density screening if clinical risk factors (CRFs) of a major osteoporotic fracture are ≥9.3% for a period of 10 years. We sought the most cost-effective approach to identify older, rural women who are eligible for osteoporosis treatment. Methods We evaluated CRFs and peripheral forearm densitometry (pDXA) in 277 rural women aged 60 to 64 years for treatment eligibility. We compared three strategies of universal screening—pDXA, CRFs, and exclusion of pDXA in specific situations (prior fracture and CRFs ≥20%)—followed by CRF evaluation with pDXA confirmation in the residual population. Results Our sample showed that 37.5% of women had CRFs at a ≥9.3% cutoff threshold. Only osteoporotic pDXA values were significantly higher at this threshold. Current estrogen use was significantly associated with diminished treatment eligibility (P = 0.001). Body mass index correlated poorly with pDXA values (r = 0.12) and CRFs (r = 0.21). Although a cost-savings strategy nonsignificantly identified more women who were eligible for treatment using the three strategies (P = 0.25), significantly fewer pDXA examinations were required (P < 0.001). Conclusions Initiating treatment in rural women aged 60 to 64 years who had a prior fracture or CRFs ≥20% without pDXA confirmation, followed by pDXA evaluations in the residual population with CRFs between ≥9.3% and 20%, significantly reduced the number of pDXA examinations and the cost of screening.

The economics of fragility fractures in West Virginia.

Objectives Osteopenia is considerably more common than osteoporosis and accounts for most of the fracture burden in women older than 50 years. It is uncertain when to initiate treatment in osteopenia. We sought to determine in women with osteopenia what effect transitioning to lower categories had on subsequent fracturing. Methods We surveyed 1150 women from office-based practices who had initial normal or osteopenic bone mineral densities (BMDs) and who were retested after 5.75 years. We classified categories related to baseline T scores as follows: normal (>−1.0), mild osteopenia (−1.0 to −1.49), moderate osteopenia (−1.5 to −1.99), and severe osteopenia (−2.0 to −2.49). We determined during a 9.6-year follow-up period the fracture occurrence in those who maintained their initial category status or transitioned into lower categories. Results Transitioning to lower categories was not significantly different among baseline osteopenic categories but significantly more than normal baseline BMDs. Total fractures, individuals fracturing, and major fractures were significantly more, with baseline T scores of ⩽−1.5 (<0.001). Although only 10.2% transitioned to osteoporosis, 90.5% of these transitions occurred with baseline T scores ⩽−1.5 and accounted for significantly more fractures than baseline T scores of >−1.5. Conclusions Most subsequent fractures and transitions to osteoporosis occurred with baseline T scores ⩽−1.5. Clinical risk factors need to be used to determine at what T score threshold treatment would be cost effective.

An Assessment of Postmenopausal Women's Adherence to Calcium With Vitamin D Supplements

Objective To determine in men and women aged 50 years or older the proportion of distal forearm fractures related to high- or low-energy events and subsequent fracturing. Methods We reviewed records of patients presenting to emergency departments and urgent care facilities with distal forearm fractures occurring during a 7-year entry period and studied for an additional 3.5 years. Results High-energy events proportionally were 3.25 times more likely in men, whereas low-energy distal forearm fractures proportionally were 7.98 times more likely in women. Although 25% received bone densitometry evaluations, only 3.59% were performed within the first year after a distal forearm fracture. Osteoporosis and osteopenia did not differ between high- and low-energy distal forearm fractures. In logistic regression, subsequent fractures were associated with prior fracture and age 80 years or older. The occurrence of individuals subsequently fracturing was similar in men and women. Compared with controls, the odds ratio of individuals subsequently fracturing was 1.74 (95% confidence interval 1.32–2.30) in women and 1.9 (95% confidence interval 1.07–3.43) in men. Approximately 60% of total subsequent fractures occurred within 3 years. Osteoporosis was significantly more in patients with distal forearm fractures than controls (P < 0.001), but control patients had significantly more osteopenia (P < 0.001). No differences were noted in therapeutic intervention between those with prior distal forearm fractures and controls. Conclusions Regardless of trauma occurrence, both men and women age 50 years and older with recent distal forearm fractures should be evaluated early for treatment by bone densitometry and clinical risk factors because the majority of recurrent fractures occur within 3 years.