Cost-effectiveness of preventive care

An op-ed article in this Sunday’s New York Times by Alain Enthoven, PhD, professor of management at Stanford University, caught my attention and sent me to PubMed for more understanding. He wrote “… Mr. Obama proposes to save more than $80 billion a year by better management of chronic conditions like high blood pressure, heart disease, diabetes and asthma, and by preventing more disease in the first place. It is true that most American doctors are weak on prevention and chronic disease management. But they will not improve until they are given economic incentives to buy the equipment and hire the personnel to deliver these services.”

I was stung by the criticism and staggered by the predicted cost savings. During my PubMed search, three studies caught my attention; each of them was based on appropriate statistical models and each used patients at highest risk of fracture in the model — lower bone density, older age and previous osteoporosis-related fracture. (Similar models are available for prevention of heart attack and stroke.)

Earnshaw and colleagues demonstrated that monthly bisphosphonates avoided 58 fractures per 1,000 treated women compared with 34 per 1,000 with weekly bisphosphonates. Fracture care costs per woman were also lower — $7,317 for monthly and $ 7,548 for weekly. Compared with no therapy, the incremental cost per quality of life years was $13,749 with monthly bisphosphonates and $16,657 with weekly. The incremental cost per quality of life years of monthly vs. weekly bisphosphonate was $9,476.

In a Canadian study, Sander and colleagues offered data indicating that hiring a coordinator for inpatient and outpatient osteoporosis management would be cost-effective even if the coordinator was managing just 350 patients per year. I have not included dollar amounts that support this conclusion because I don’t know how they would translate to the U.S. health care system. I do know, however, that a number of institutions have already put such a system, or something similar, in place and hopefully we will be seeing some real-life cost saving figures some time soon. This is a good place to re-emphasize that the best predictor of future fracture is a history of prior fragility fracture, and that regrettably most osteoporosis-related fractures still go unrecognized as such.

Most recently, Tosteson and colleagues conducted a study to “evaluate the cost-effectiveness of osteoporosis treatments for women at high fracture risk and estimate the population-level impact of providing bisphosphonate therapy to all eligible high-risk U.S. women.” The bottom line was a 21% total cost increase — $5,563 million — resulting in almost 400,000 fewer fractures (a 35% decrease). The reduction in the number of fractures would more than offset the additional costs of therapy.

Prevention is expensive, but seemingly less so than care after an adverse event. Our priority needs to be detecting those patients with the highest risk of future fracture. There are many published guidelines to help us but the first step would seem to be to develop a mechanism whereby all patients presenting with a likely osteoporosis-related fracture (resulting from minimal trauma defined somewhat arbitrarily as trauma equal to or less than a fall from a standing height) are identified at the time of fracture diagnosis. Our next priority would seem to be improving patient adherence to therapy that prevents adverse health outcomes but does not make them feel better today.

* The PMID numbers for the three articles respectively are 17825128, 18519311, and 18778176. Typing the number into the search box takes you to the article more quickly than any other method I know. Once there you can be directed to related articles. There are many on this topic for many conditions where prevention is available.

Curr Med Res Opin. 2007;23:2517-2529.

J Bone Joint Surg Am. 2008;90:1197-1205.

Am J Manag Care. 2008;14:605-615.