Abstract
Falls and osteoporosis share the potential clinical end point of fractures among older patients. To date, few fall prevention guidelines incorporate screening for osteoporosis to reduce fall-related fractures. To assess the cost-effectiveness of screening for osteoporosis using dual-energy x-ray absorptiometry (DXA) followed by osteoporosis treatment in older men with a history of falls. In this economic evaluation, a Markov model was developed to simulate the incidence of major osteoporotic fractures in a hypothetical cohort of community-dwelling men aged 65 years who had fallen at least once in the past year. Data sources included literature published from January 1, 1946, to July 31, 2020. The model adopted a societal perspective, a lifetime horizon, a 1-year cycle length, and a discount rate of 3% per year for both health benefits and costs. The analysis was designed and conducted from October 1, 2019, to September 30, 2020. Screening with DXA followed by treatment for men diagnosed with osteoporosis compared with usual care. Incremental cost-effectiveness ratio (ICER), measured by cost per quality-adjusted life-year (QALY) gained. Among the hypothetical cohort of men aged 65 years, the screening strategy had an ICER of $33 169/QALY gained and was preferred over usual care at the willingness-to-pay threshold of $100 000/QALY gained. The number needed to screen to prevent 1 hip fracture was 1876; to prevent 1 major osteoporotic fracture, 746. The screening strategy would become more effective and less costly than usual care for men 77 years and older. The ICER for the screening strategy did not substantially change across a wide range of assumptions tested in all other deterministic sensitivity analyses. At a willingness-to-pay threshold of $50 000/QALY gained, screening was cost-effective in 56.0% of simulations; at $100 000/QALY gained, 90.8% of simulations; and at $200 000/QALY gained, 99.6% of simulations. These findings suggest that for older men who have fallen at least once in the past year, screening with DXA followed by treatment for those diagnosed with osteoporosis is a cost-effective use of resources. Fall history could be a useful cue to trigger assessment for osteoporosis in men.
Highlights
Falls and osteoporosis are geriatric syndromes that share the potential clinical end point of fractures.[1]
INTERVENTIONS Screening with dual-energy x-ray absorptiometry (DXA) followed by treatment for men diagnosed with osteoporosis compared with usual care
These findings suggest that for older men who have fallen at least once in the past year, screening with DXA followed by treatment for those diagnosed with osteoporosis is a cost-effective use of resources
Summary
Falls and osteoporosis are geriatric syndromes that share the potential clinical end point of fractures.[1]. Performing dual-energy x-ray absorptiometry (DXA) in those who have fallen could be crucial because a history of falls does not necessarily indicate osteoporosis and a need for osteoporosis treatment. Few fall prevention guidelines incorporate screening for osteoporosis to reduce fall-related fractures.[10,11,12] several professional organizations have advocated routine screening for osteoporosis in older men, the US Preventive Services Task Force continues to conclude that evidence was insufficient to justify this practice.[13,14,15,16] Medicare coverage for DXA is rather restrictive in men unless they have known skeletal abnormalities or secondary causes of osteoporosis.[17] Despite a predicted rise in the number of hip fractures, osteoporosis remains underdiagnosed and undertreated in men.[18] Recent clinical trials suggested that population-based screening for osteoporosis could reduce hip and osteoporotic fractures in older women.[19,20,21,22] A similar clinical trial would be ideal to evaluate the efficacy of a screening practice in older men but unrealistic because of the need for a larger sample size. We developed a simulation model to evaluate the long-term health and economic effect of screening with DXA followed by treatment for those diagnosed with osteoporosis in older men with a history of falls
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