Cost effectiveness of teriparatide and PTH(1-84) in the treatment of postmenopausal osteoporosis

Figures & data

Figure 1.  Health state structure of the Markov model. Note: From each of the six health states above, transition to the seventh state (Dead) was possible.

Table 1.  Annual direct cost in different age groups, € (95% CI).

	Age (years)
Event	50–64	65–74	75–84	85–
	Mean (95% CI)*
1st year after event
Hip fracture1	9161	10,764	10,909	11,319
	(6596–12,459)	(8288–14,100)	(9382–12,546)	(9055–13,696)
Clinical vertebral fracture1	2405		7519
	(1323–3896)		(4136–12,181)
Wrist fracture1	2138
	(1754–2673)
Other osteoporotic fractures2	6455
	(5296–8070)**
2nd year after event
Hip fracture – Nursing home cost3***	3057	6209	10,354	13,123
	(2243–3940)	(5344–7089)	(9570–11,111)	(11,934–14,311)
Hip fracture – excluding living arrangements1	1690	119	153	2934
	(1217–2299)	(919–1563)	(1315–1758)	(2347–3550)
Clinical vertebral fracture1	1266		4624
	(696–2051)		(2543–7490)

*Confidence intervals were obtained by the bias-corrected accelerated (bca) percentile bootstrapping method47.

**Assumed to be same proportional variance as for wrist fracture.

***The cost at 57, 70, 80 and 85 years respectively.

138,39; 234 and own estimations; 317.

Table 2.  Fracture related quality-of-life loss.

Event	Mean (95% CI)*
1st year after event
Hip fracture1	0.80
	(0.77–0.85)
Clinical vertebral fracture1	0.65
	(0.56–0.74)
Wrist fracture1	0.94
	(0.92–0.98)
Other osteoporotic fractures2	0.87
	(0.85–0.91)**
2nd year after event
Hip fracture1	0.90
	(0.87–0.95)
Clinical vertebral fracture3	0.93
	(0.84–1.0)***

* Confidence intervals were obtained by the bias-corrected accelerated (bca) percentile bootstrapping method47.

**assumed to be same proportional variance as for wrist fracture.

***assumed to be same proportional variance as for vertebral fracture the first year.

1.38,39; 234 and own estimations; 334.

Table 3.  Sensitivity analysis.

	Teriparatide		PTH(1-84)
	Cost per QALY gained	% change compared to base case	Cost per QALY gained	% change compared to base case
Base case estimates	43,473	0	104,396	0
Assuming no effect on hip fractures with teriparatide	88,379	103	–	–
Assuming lowest effect on vertebral fracture with PTH(1-84) from the TOP study	–	–	163,576	57
Discount rate 0%	34,465	–21	86,196	−17
Discount rate 5%	49,938	15	117,181	12
Other osteoporotic fractures excluded	47,616	10	104,396	0
12 months treatment duration	32,782	−25	89,477	−14
24 months treatment duration	50,363	16	114,357	10
No offset time	108,067	149	190,370	82
Doubled offset time	21,185	−51	77,367	−26
100% persistence	38,528	−11	92,248	−12
50% persistence	52,611	21	113,817	9
100% compliance	58,915	36	127,946	23
No co-morbidity	28,816	−34	58,883	−44
No excess mortality after fracture	65,876	52	194,823	87
Increased mortality after other osteoporotic fracture	41,629	−4	110,913	6
Hypercalcaemia related adverse events included	45,284	4	126,954	22
Calcium monitoring costs included	54,439	25	124,966	20
Costs related to vertebral fractures beyond the 2nd year after fracture included	34,153	−21	87,160	−17
Costs related to hip fractures other than nursing home beyond the second year after fracture included	42,032	−3	–	–
Costs related to hip and vertebral fractures beyond the second year after fracture included	32,735	−25	87,342	−16
Adjusting long-term nursing home costs related to hip fracture for the population incidence of moving to nursing home	49,120	13	–
No quality of loss beyond the first year after vertebral fracture	49,821	15	137,079	31

Table 4.  Simulated average costs and effects per patient in base-case analysis (€).

	No treatment	Teriparatide	PTH(1-84)
Costs
Fracture costs	47,473	45,619	47,251
Treatment costs	0	4,993	4,010
Costs in added  life years	281,252	282,478	281,999
Total costs	328,725	333,090	333,260
Effects
Life years	11.977	12.023	12.005
Quality-adjusted  life-years	8.008	8.080	8.044

Table 5.  Base-case incremental cost-effectiveness analysis.

Comparators	teriparatide vs. no treatment	PTH(1-84) vs. no treatment	teriparatide vs. PTH(1-84)
Incremental cost including CALYs	4,365	4,535	−170
Incremental cost excluding CALYs	3,139	3,787	−649
Life-years gained	0.046	0.028	0.018
QALYs gained	0.072	0.036	0.036
Cost per life-year gained including CALYs	94,409	161,716	−9,345 (teriparatide dominant)
Cost per life-year gained excluding CALYs	43,473	104,396	−18,061 (teriparatide dominant)
Cost per QALY gained including CALYs	60,450	124,987	−4,732 (teriparatide dominant)
Cost per QALY gained excluding CALYs	43,473	104,396	−18,061 (teriparatide dominant)

CALY, costs in added life years.

Figure 2.  Acceptability curves for the base-case scenarios.

Figure 3.  Cost per QALY gained (€) for different starting ages of treatment.

Figure 4.  Sensitivity tornado diagram over variation of fracture related quality of life loss ±50% from baseline estimates based on teriparatide (effect on all fractures) vs. no treatment.

Kanis JA, Burlet N, Cooper C, et al. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 2008;19:399-428

 PubMed Web of Science ®Google Scholar

Delmas PD, Marin F, Marcus R, et al. Beyond hip: importance of other nonspinal fractures. Am J Med 2007;120:381-387

 PubMed Web of Science ®Google Scholar

Cummings SR, Melton LJ. Epidemiology and outcomes of osteoporotic fractures. Lancet 2002;359:1761-1767

 PubMed Web of Science ®Google Scholar

Briggs AH, Wonderling DE, Mooney CZ. Pulling cost-effectiveness analysis up by its bootstraps: a non-parametric approach to confidence interval estimation. Health Econ 1997;6:327-340

 PubMed Web of Science ®Google Scholar

Borgstrom F, Zethraeus N, Johnell O, et al. Costs and quality of life associated with osteoporosis-related fractures in Sweden. Osteoporos Int 2006;17:637-650

 PubMed Web of Science ®Google Scholar

Strom O, Borgstrom F, Zethraeus N, et al. Long-term cost and effect on quality of life of osteoporosis-related fractures in Sweden. Acta Orthop 2008;79:269-280

 PubMed Web of Science ®Google Scholar

Kanis JA, Johnell O, Oden A, et al. The risk and burden of vertebral fractures in Sweden. Osteoporos Int 2004;15:20-26

 PubMed Web of Science ®Google Scholar

Zethraeus N, Strom O, Borgstrom F. What is the risk of institutionalization after hip fracture? Osteoporos Int 2006;17:57-58

 Google Scholar