A review of the literature for evidence of cost effectiveness of diagnosis and treatment options covered by “A” grade recommendations was carried out. The evidence for diagnostic approaches is minimal but a recent Health Technology Assessment (HTA)¹⁴⁶ provides some evidence on the cost effectiveness of treatment options.

We also offer a considered economic perspective on some aspects of service provision as they relate to our guideline recommendations.

7.1 Cost effectiveness of diagnostic approaches

Only three relevant economic papers on the use of DXA scanning were identified. These all involved modelling, rather than incorporation of economic evaluation into clinical trials.

There is some evidence that for relatively expensive medication, such as bisphosphonates, treatment programmes with prior bone density screening are likely to be more cost-effective than those without and, in some circumstances, become cost saving.^147,148

One recent paper concluded that diagnosis and treatment of women at risk of osteoporosis would be made more cost effective by targeting treatment to those with the lowest bone measurement results. Inclusion of another assessment, such as a risk profile, may improve the cost effectiveness of diagnosis.³²

7.2 Cost effectiveness of treatment

A recent Health Technology Assessment¹⁴⁶ examined the cost utility and cost effectiveness of different treatments for established osteoporosis. This study compared treatments using the cost per quality-adjusted life-year (QALY). It used a threshold of £30,000 or less per QALY to represent cost effectiveness. Using an economic model developed by the authors, at age 50 years only HRT and calcium plus vitamin D were likely to be considered cost-effective (assuming that the agent would decrease the risk of non-vertebral fractures at this age). In older age groups a wider range of treatments, including HRT, calcium with or without vitamin D and bisphosphonates were considered cost effective.

This HTA demonstrates that age is an important determinant of cost effectiveness since the risk of fractures increases with age. High costs of intervention are associated with poorer cost effectiveness since, in general, the variation in cost is greater than any proven variation in efficacy.

7.3 Implications for service provision

The volume of evidence, though small, does indicate that a cost-effective way of providing a good service in terms of diagnosis and treatment of osteoporosis involves prior bone density measurement by DXA scanning of patients at highest risk. One model costing for providing such a service is offered in Annex 3.