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Incorporating adherence into health economic modelling of osteoporosis

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An Erratum to this article was published on 16 July 2008

Abstract

Summary

Osteoporosis medications are seldom taken according to the recommendations of health-care providers. A theoretical model was constructed to investigate the variables of drug adherence that affect the cost-effectiveness of drugs, using osteoporosis treatment as a model. Important variables were the magnitude of drug effect, drug price, and fracture-related costs.

Introduction

Adherence to anti-fracture medication is far from optimal and poses a challenge in osteoporosis management. The objectives of this study were to develop a model that could address adherence and identify the important drivers of cost-effectiveness.

Methods

An individual state transition model was constructed to compare two theoretical medications, one of which conferred optimal adherence and was 50% more costly. Adherence was divided into persistence and compliance. Partial compliance was assumed to be associated with a 20% loss of anti-fracture effect. Non-persistent patients had an offset time as long as their time on medication, to a maximum of 5 years.

Results

The potentially important drivers of cost-effectiveness include reduced drug effectiveness due to poor compliance, offset time, fracture risk, anti-fracture drug effect, and drug price. Optimal adherence was associated with fewer osteoporotic fractures, and the impact was more evident among those with prior fractures. However, the health benefits of adherence were often partially offset by increased intervention costs associated with the improved drug-taking behaviour.

Conclusions

High adherence is likely to be associated with added value for health-care systems, but should be used with care as a central health economic argument.

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References

  1. Osterberg L, Blaschke T (2005) Adherence to medication. N Engl J Med 353:487–497

    Article  PubMed  CAS  Google Scholar 

  2. Cramer JA, Amonkar MM, Hebborn A, Altman R (2005) Compliance and persistence with bisphosphonate dosing regimens among women with postmenopausal osteoporosis. Curr Med Res Opin 21:1453–1460

    Article  PubMed  CAS  Google Scholar 

  3. Seeman E, Compston J, Adachi J, Brandi ML et al (2007) Non-compliance: the Achilles’ heel of anti-fracture efficacy. Osteoporos Int 18:711–719

    Article  PubMed  CAS  Google Scholar 

  4. Huybrechts KF, Ishak KJ, Caro JJ (2006) Assessment of compliance with osteoporosis treatment and its consequences in a managed care population. Bone 38:922–928

    Article  PubMed  Google Scholar 

  5. Gold DT, Silverman S (2006) Review of adherence to medications for the treatment of osteoporosis. Curr Osteoporos Rep 4:21–27

    Article  PubMed  Google Scholar 

  6. Jonsson B, Christiansen C, Johnell O, Hedbrandt J et al (1996) Cost-effectiveness of fracture prevention in established osteoporosis. Scand J Rheumatol Suppl 103:30–38

    Article  PubMed  CAS  Google Scholar 

  7. Kanis JA, Borgstrom F, Johnell O, Odén A et al (2005) Cost-effectiveness of raloxifene in the UK: an economic evaluation based on the MORE study. Osteoporos Int 16:15–25

    Article  PubMed  CAS  Google Scholar 

  8. Stevenson M, Lloyd Jones M, De Nigris E, Brewer N et al (2005) A systematic review and economic evaluation of alendronate, etidronate, risedronate, raloxifene and teriparatide for the prevention and treatment of postmenopausal osteoporosis. Health Technol Assess 9:1–160

    PubMed  CAS  Google Scholar 

  9. Borgstrom F, Jonsson B, Strom O, Kanis JA (2006) An economic evaluation of strontium ranelate in the treatment of osteoporosis in a Swedish setting: based on the results of the SOTI and TROPOS trials. Osteoporos Int 17:1781–1793

    Article  PubMed  CAS  Google Scholar 

  10. Strom O, Borgstrom F, Sen SS, Boonen S et al (2007) Cost-effectiveness of alendronate in the treatment of postmenopausal women in 9 European countries—an economic evaluation based on the fracture intervention trial. Osteoporos Int 18:1047–1061

    Article  PubMed  CAS  Google Scholar 

  11. Fayers PM, Hand DJ (1997) Generalisation from phase III clinical trials: survival, quality of life, and health economics. Lancet 350:1025–1027

    Article  PubMed  CAS  Google Scholar 

  12. Simon G, Wagner E, Vonkorff M (1995) Cost-effectiveness comparisons using “real world” randomized trials: the case of new antidepressant drugs. J Clin Epidemiol 48:363–373

    Article  PubMed  CAS  Google Scholar 

  13. Solomon DH, Avorn J, Katz JN, Finkelstein JS et al (2005) Compliance with osteoporosis medications. Arch Intern Med 165:2414–2419

    Article  PubMed  Google Scholar 

  14. Weycker D, Macarios D, Edelsberg J, Oster G (2006) Compliance with drug therapy for postmenopausal osteoporosis. Osteoporos Int 17:1645–1652

    Article  PubMed  CAS  Google Scholar 

  15. Jones ML, Wilkinson A (2006) Adverse effects and persistence with therapy in patients taking oral alendronate, etidronate or risedronate: systematic reviews (NICE). University of Sheffield, School of Health and Related Research (http://www.nice.org.uk/guidance/index.jsp?action=download&o=36718)

  16. Weycker D, Macarios D, Edelsberg J, Oster G (2007) Compliance with osteoporosis drug therapy and risk of fracture. Osteoporos Int 18:271–277

    Article  PubMed  CAS  Google Scholar 

  17. Siris ES, Genant HK, Laster AJ, Chen P et al (2007) Enhanced prediction of fracture risk combining vertebral fracture status and BMD. Osteoporos Int 18:761–770

    Article  PubMed  CAS  Google Scholar 

  18. McCloskey E, De Takats D, Orgee J, Aropinn S et al (2005) Characteristics associated with non-persistence during daily therapy. Experience from the placebo wing of a community based clinical trial. J Bone Miner Res 20 [Suppl 1]:S282

    Google Scholar 

  19. Kanis JA, Borgstrom F, De Laet C, Johansson H et al (2005) Assessment of fracture risk. Osteoporos Int 16:581–589

    Article  PubMed  Google Scholar 

  20. Ekedahl A, Mansson N (2004) Unclaimed prescriptions after automated prescription transmittals to pharmacies. Pharm World Sci 26:26–31

    Article  PubMed  Google Scholar 

  21. Black DM, Schwartz AV, Ensrud KE, Cauley JA et al (2006) Effects of continuing or stopping alendronate after 5 years of treatment: the Fracture Intervention Trial Long-term Extension (FLEX): a randomized trial. JAMA 296:2927–2938

    Article  PubMed  CAS  Google Scholar 

  22. Borgstrom F, Johnell O, Kanis JA, Odén A et al (2004) Cost effectiveness of raloxifene in the treatment of osteoporosis in Sweden: an economic evaluation based on the MORE study. Pharmacoeconomics 22:1153–1165

    Article  PubMed  Google Scholar 

  23. Johnell O, Jonsson B, Jonsson L, Black D (2003) Cost effectiveness of alendronate (Fosamax) for the treatment of osteoporosis and prevention of fractures. Pharmacoeconomics 21:305–314

    Article  PubMed  Google Scholar 

  24. Ortolani S, Vai S (2006) Strontium ranelate: an increased bone quality leading to vertebral antifracture efficacy at all stages. Bone 38:19–22

    Article  PubMed  CAS  Google Scholar 

  25. Wallace DJ (2005) Rapid prevention of vertebral fractures associated with osteoporosis. Orthopedics 28:291–298

    PubMed  Google Scholar 

  26. Statistics Sweden. Swedens Statistical Databases. http://wwwscbse/eng/databaser/ssdasp

  27. Kanis JA, Johnell O, Odén A, Sembo I et al (2000) Long-term risk of osteoporotic fracture in Malmo. Osteoporos Int 11:669–674

    Article  PubMed  CAS  Google Scholar 

  28. Kanis JA, Johnell O, Odén A, Jonsson B et al (2000) Risk of hip fracture derived from relative risks: an analysis applied to the population of Sweden. Osteoporos Int 11:120–127

    Article  PubMed  CAS  Google Scholar 

  29. De Laet CE, van Hout BA, Burger H, Hofman A et al (1997) Bone density and risk of hip fracture in men and women: cross sectional analysis. Br Med J 315:221–225

    Google Scholar 

  30. Borgstrom F, Zethraeus N, Johnell O, Lidgren L et al (2005) Costs and quality of life associated with osteoporosis-related fractures in Sweden. Osteoporos Int 1–14

  31. Johnell O, Gullberg B, Kanis JA (1997) The hospital burden of vertebral fracture in Europe: a study of national register sources. Osteoporos Int 7:138–144

    Article  PubMed  CAS  Google Scholar 

  32. Zethraeus N, Strom O, Borgstrom F (2006) What is the risk of institutionalization after hip fracture? Osteoporosis Int 17 [Suppl 2] :S60

    Google Scholar 

  33. Stockholms stads budgetavräkning 2003. http://www.stockholm.se/files/71600-71699/file_71645.pdf. Accessed 20 December 2004

  34. Ström O, Borgstrom F, Zethraeus N, Johnell O et al (2008) Long-term cost and effect on quality of life of osteoporosis-related fractures in Sweden. Acta Orthop (accepted)

  35. Oleksik A, Lips P, Dawson A, Minshall ME et al (2000) Health-related quality of life in postmenopausal women with low BMD with or without prevalent vertebral fractures. J Bone Miner Res 15:1384–1392

    Article  PubMed  CAS  Google Scholar 

  36. Odén A, Dawson A, Dere W, Johnell O et al (1998) Lifetime risk of hip fractures is underestimated. Osteoporos Int 8:599–603

    Article  PubMed  Google Scholar 

  37. Johnell O, Kanis JA, Odén A, Sernbo I et al (2004) Mortality after osteoporotic fractures. Osteoporos Int 15:38–42

    Article  PubMed  CAS  Google Scholar 

  38. Parker MJ, Anand JK (1991) What is the true mortality of hip fractures? Public Health 105:443–446

    Article  PubMed  CAS  Google Scholar 

  39. Kanis JA, Odén A, Johnell O, De Laet C et al (2003) The components of excess mortality after hip fracture. Bone 32:468–473

    Article  PubMed  CAS  Google Scholar 

  40. Cauley JA, Thompson DE, Ensrud KC, Scott JC et al (2000) Risk of mortality following clinical fractures. Osteoporos Int 11:556–561

    Article  PubMed  CAS  Google Scholar 

  41. Zethraeus N, Borgstrom F, Strom O, Kanis JA et al (2007) Cost-effectiveness of the treatment and prevention of osteoporosis—a review of the literature and a reference model. Osteoporos Int 18:9–23

    Article  PubMed  CAS  Google Scholar 

  42. IOF Cost-effectiveness reference model (http://www.iofbonehealth.org/health-professionals/health-economics/iof-cost-effectiveness-reference-model.html

  43. Van den Boogaard CH, Breekveldt-Postma NS, Borggreve SE, Goettsch WG et al (2006) Persistent bisphosphonate use and the risk of osteoporotic fractures in clinical practice: a database analysis study. Curr Med Res Opin 22:1757–1764

    Article  PubMed  CAS  Google Scholar 

  44. Gujarati DN (1995) Basic econometrics. McGraw Hill, Singapore

    Google Scholar 

  45. Kanis JA, Stevenson M, McCloskey EV, Davis S et al (2007) Glucocorticoid-induced osteoporosis: a systematic review and cost-utility analysis. Health Technol Assess 11:1–256

    Google Scholar 

  46. Stevenson M, Davies S (2006) DSU economic evaluation of pooled alendronate and risedronate compared with strontium ranelate, raloxifene, etidronate and teriparatide. http://guidance.nice.org.uk/page.aspx?o=370643

  47. Black DM, Delmas PD, Eastell R, Reid IR et al (2007) Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med 356:1809–1822

    Article  PubMed  CAS  Google Scholar 

  48. Liel Y, Castel H, Bonneh DY (2003) Impact of subsidizing effective anti-osteoporosis drugs on compliance with management guidelines in patients following low-impact fractures. Osteoporos Int 14:490–495

    Article  PubMed  CAS  Google Scholar 

  49. Lillard LA, Rogowski J, Kington R (1999) Insurance coverage for prescription drugs: effects on use and expenditures in the Medicare population. Med Care 37:926–936

    Article  PubMed  CAS  Google Scholar 

  50. Zethraeus N, Stromberg L, Jonsson B, Svensson O et al (1997) The cost of a hip fracture. Estimates for 1,709 patients in Sweden. Acta Orthop Scand 68:13–17

    Article  PubMed  CAS  Google Scholar 

  51. Kanis JA, Johnell O, Odén A, Sembo I et al (2000) Long-term risk of osteoporotic fracture in Malmö. Osteoporos Int 11:669–674

    Article  PubMed  CAS  Google Scholar 

  52. Melton LJ III, Gabriel SE, Crowson CS, Tosteson AN et al (2003) Cost-equivalence of different osteoporotic fractures. Osteoporos Int 14:383–388

    Article  PubMed  Google Scholar 

  53. McCombs JS, Thiebaud P, McLaughlin-Miley C, Shi J (2004) Compliance with drug therapies for the treatment and prevention of osteoporosis. Maturitas 48:271–287

    Article  PubMed  CAS  Google Scholar 

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Acknowledgements

We thank Enkhe Badamgarav and David Marcarios for their critical evaluation and helpful comments on the manuscript. Holly Zoog provided editorial support.

Conflicts of interest

Research for this manuscript was supported by Amgen Inc.

Author information

Authors and Affiliations

  1. i3 Innovus, Vasagatan 38 2 tr, 111 20, Stockholm, Sweden

    O. Ström & F. Borgström

  2. Medical Management Centre, Karolinska Institutet, Stockholm, Sweden

    O. Ström & F. Borgström

  3. Centre for Metabolic Bone Diseases (WHO Collaborating Centre), University of Sheffield Medical School, Sheffield, UK

    J. A. Kanis

  4. Stockholm School of Economics, Stockholm, Sweden

    B. Jönsson

Authors
  1. O. Ström
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  2. F. Borgström
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  3. J. A. Kanis
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  4. B. Jönsson
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Corresponding author

Correspondence to O. Ström.

Additional information

An erratum to this article can be found at http://dx.doi.org/10.1007/s00198-008-0693-0

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Ström, O., Borgström, F., Kanis, J.A. et al. Incorporating adherence into health economic modelling of osteoporosis. Osteoporos Int 20, 23–34 (2009). https://doi.org/10.1007/s00198-008-0644-9

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