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Reassessment of the cost-effectiveness of hormone replacement therapy in Sweden: Results based on the Women's Health Initiative randomized controlled trial

Published online by Cambridge University Press:  25 October 2005

Niklas Zethraeus ,
Fredrik Borgström ,
Bengt Jönsson  and
John Kanis
Niklas Zethraeus
Affiliation:
Stockholm School of Economics
Fredrik Borgström
Affiliation:
Karolinska Institute and Stockholm Health Economics
Bengt Jönsson
Affiliation:
Stockholm School of Economics
John Kanis
Affiliation:
University of Sheffield Medical School
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Abstract

Objectives: The purpose of the study is to reassess the cost-effectiveness of hormone replacement therapy (HRT) based on new medical evidence found in the Women's Health Initiative (WHI). Within a model framework using an individual state transition model, the cost-effectiveness of 50- to 60-year-old women with menopausal symptoms is assessed based on a societal perspective in Sweden.

Methods: The model has a 50-year time horizon divided into a cycle length of 1 year. The model consists of the following disease states: coronary heart disease, stroke, venous thromboembolic events, breast cancer, colorectal cancer, hip fracture, vertebral fracture, and wrist fracture. An intervention is modeled by its impact on the disease risks during and after the cessation of therapy. The model calculates costs and quality-adjusted life years (QALYs) with and without intervention. The resulting cost per QALY gained is compared with the value of a QALY gained, which is set to SEK 600,000. The model requires data on clinical effects, risks, mortality rates, quality of life weights, and costs valid for Sweden.

Results: The cost-effectiveness ratios are estimated at approximately SEK 10,000, which is below the threshold value of cost-effectiveness. On the condition that HRT increases the quality of life weight more than 0.013 units, the therapy is cost-effective.

Conclusions: In conclusion, given the new evidence in WHI, there is still a high probability that HRT is a cost-effective strategy for women with menopausal symptoms.

Keywords

Cost-effectiveness analysisHormone replacement therapyMarkov model
Type
GENERAL ESSAYS
Information
International Journal of Technology Assessment in Health Care , Volume 21 , Issue 4 , October 2005 , pp. 433 - 441
Copyright
© 2005 Cambridge University Press

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References

Anderson GL, Limacher M, Assaf AR, et al. 2004 Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: The Women's Health Initiative randomized controlled trial. JAMA. 291: 1701– 1712.Google Scholar
Armstrong K, Chen TM, Albert D, et al. 2001 Cost-effectiveness of raloxifene and hormone replacement therapy in postmenopausal women: Impact of breast cancer risk. Obstet Gynecol. 98: 996– 1003.Google Scholar
Bagger YZ, Tanko LB, Alexandersen P, et al. 2004 Two to three years of hormone replacement treatment in healthy women have long-term preventive effects on bone mass and osteoporotic fractures: The PERF study. Bone. 34: 728– 735.Google Scholar
Beral V. 2003 Breast cancer and hormone-replacement therapy in the Million Women Study. Lancet. 362: 419– 427.Google Scholar
Cauley JA, Thompson DE, Ensrud KC, et al. 2000 Risk of mortality following clinical fractures. Osteoporos Int. 11: 556– 561.Google Scholar
Center JR, Nguyen TV, Schneider D, et al. 1999 Mortality after all major types of osteoporotic fracture in men and women: An observational study. Lancet. 353: 878– 882.Google Scholar
Cheung AP, Wren BG. 1992 A cost-effectiveness analysis of hormone replacement therapy in the menopause. Med J Aust. 156: 312– 316.Google Scholar
Col NF, Weber G, Stiggelbout A, et al. 2004 Short-term menopausal hormone therapy for symptom relief: An updated decision model. Arch Intern Med. 164: 1634– 1640.Google Scholar
Colditz GA, Hankinson SE, Hunter DJ, et al. 1995 The use of estrogens and progestins and the risk of breast cancer in postmenopausal women. N Engl J Med. 332: 1589– 1593.Google Scholar
Collaborative Group on Hormonal Factors in Breast Cancer. 1997 Breast cancer and hormone replacement therapy: Collaborative reanalysis of data from 51 epidemiological studies of 52 705 women with breast cancer and 108 411 women without breast cancer. Lancet. 350: 1047– 1059.
Cooper C, Atkinson EJ, Jacobsen SJ, et al. 1993 Population-based study of survival after osteoporotic fractures. Am J Epidemiol. 137: 1001– 1005.Google Scholar
Daly E, Gray A, Barlow D, et al. 1993 Measuring the impact of menopausal symptoms on quality of life. BMJ. 307: 836– 840.Google Scholar
Daly E, Roche M, Barlow D, et al. 1992 HRT: An analysis of benefits, risks and costs. Br Med Bull. 48: 368– 400.Google Scholar
Daly E, Vessey MP, Barlow D, et al. 1996 Hormone replacement therapy in a risk-benefit perspective. Maturitas. 23: 247– 259.Google Scholar
Ekman M, Zethraeus N, Dahlstrom U, et al. 2002 [Cost-effectiveness of bisoprolol in chronic heart failure]. Lakartidningen. 99: 646– 650.Google Scholar
Geelhoed E, Harris A, Prince R. 1994 Cost-effectiveness analysis of hormone replacement therapy and lifestyle intervention for hip fracture. Aust J Public Health. 18: 153– 160.Google Scholar
Glasziou PP, Bromwich S, Simes RJ. 1994 Quality of life six months after myocardial infarction treated with thrombolytic therapy. AUS-TASK Group. Australian arm of International tPA/SK Mortality Trial. Med J Aust. 161: 532– 536.Google Scholar
Hirth RA, Chernew ME, Miller E, et al. 2000 Willingness to pay for a quality-adjusted life year: In search of a standard. Med Decis Making. 20: 332– 342.Google Scholar
Hornberger JC, Redelmeier DA, Petersen J. 1992 Variability among methods to assess patients' well-being and consequent effect on a cost-effectiveness analysis. J Clin Epidemiol. 45: 505– 512.Google Scholar
Hulley S, Grady D, Bush T, et al. 1998 Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. JAMA. 280: 605– 613.Google Scholar
Jalava T, Sarna S, Pylkkanen L, et al. 2003 Association between vertebral fracture and increased mortality in osteoporotic patients. J Bone Miner Res. 18: 1254– 1260.Google Scholar
Johannesson M. 1995 The cost effectiveness of hypertension treatment in Sweden. Pharmacoeconomics. 7: 242– 250.Google Scholar
Johannesson M. 2001 At what coronary risk level is it cost-effective to initiate cholesterol lowering drug treatment in primary prevention? Eur Heart J. 22: 919– 925.Google Scholar
Johnell O, Kanis JA, Oden A, et al. 2004 Mortality after osteoporotic fractures. Osteoporos Int. 15: 38– 42.Google Scholar
Jonsson B, Christiansen C, Johnell O, et al. 1996 Cost-effectiveness of fracture prevention in established osteoporosis. Scand J Rheumatol Suppl. 103: 30– 38.Google Scholar
Kanis JA, Johnell O, Oden A, et al. 2000 Long-term risk of osteoporotic fracture in Malmö. Osteoporos Int. 11: 669– 674.Google Scholar
Kanis JA, Johnell O, Oden A, et al. 2004 The risk and burden of vertebral fractures in Sweden. Osteoporos Int. 15: 20– 26.Google Scholar
Kanis JA, Oden A, Johnell O, et al. 2004 Excess mortality after hospitalisation for vertebral fracture. Osteoporos Int. 15: 108– 112.Google Scholar
Kanis JA, Oden A, Johnell O, et al. 2003 The components of excess mortality after hip fracture. Bone. 32: 468– 473.Google Scholar
Kiefer N. 1988 Economic duration data and hazard functions. J Econ Literature. 26: 646– 679.Google Scholar
Kim C, Kwok YS. 2003 Decision analysis of hormone replacement therapy after the Women's Health Initiative. Am J Obstet Gynecol. 189: 1228– 1233.Google Scholar
Liljegren G, Karlsson G, Bergh J, et al. 1997 The cost-effectiveness of routine postoperative radiotherapy after sector resection and axillary dissection for breast cancer stage I. Results from a randomized trial. Ann Oncol. 8: 757– 763.Google Scholar
Lundberg L, Johannesson M, Isacson DG, et al. 1999 Health-state utilities in a general population in relation to age, gender and socioeconomic factors. Eur J Public Health. 19: 128– 140.Google Scholar
Meltzer D. 1997 Accounting for future costs in medical cost-effectiveness analysis. J Health Econ. 16: 33– 64.Google Scholar
Oden A, Dawson A, Dere W, et al. 1998 Lifetime risk of hip fractures is underestimated. Osteoporos Int. 8: 599– 603.Google Scholar
Oleksik A, Lips P, Dawson A, 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.Google Scholar
Parker MJ, Anand JK. 1991 What is the true mortality of hip fractures? Public Health. 105: 443– 446.Google Scholar
Read JL, Quinn RJ, Berwick DM, et al. 1984 Preferences for health outcomes. Comparison of assessment methods. Med Decis Making. 4: 315– 329.Google Scholar
Rossouw JE, Anderson GL, Prentice RL, et al. 2002 Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women's Health Initiative randomized controlled trial. JAMA. 288: 321– 333.Google Scholar
SBU [The Swedish Council on Technology Assessment in Health Care]. 1996. Behandling med östrogen. SBU report No 131. Stockholm: SBU;
SBU [The Swedish Council on Technology Assessment in Health Care]. 2002. Behandling med östrogen—En evidensbaserad kunskapssammanställning. SBU report No 159. Stockholm: SBU;
Stanford JL, Weiss NS, Voigt LF, et al. 1995 Combined estrogen and progestin hormone replacement therapy in relation to risk of breast cancer in middle-aged women. JAMA. 274: 137– 142.Google Scholar
Statistics Sweden. Sweden's statistical databases. Available at: http://www.scb.se/eng/databaser/ssd.asp.
Statistics Sweden. Sweden's statistical databases. Available at: http://www.scb.se.
Stockholms stads budgetavräkning. Stadsledningskontorets redovisningsstab. 2003. Available at: www.stockholm.se.
Tosteson AN, Rosenthal DI, Melton LJ, et al. 1990 Cost effectiveness of screening perimenopausal white women for osteoporosis: Bone densitometry and hormone replacement therapy. Ann Intern Med. 113: 594– 603.Google Scholar
Tosteson AN, Weinstein MC. 1991 Cost-effectiveness of hormone replacement therapy after the menopause. Baillieres Clin Obstet Gynaecol. 5: 943– 959.Google Scholar
Tosteson AN. 1994 Hormone replacement therapy: Benefit, risk and cost considerations. J Clin Pharmacol. 34: 719– 722.Google Scholar
Tsevat J, Goldman L, Soukup JR, et al. 1993 Stability of time-trade off utilities in survivors of myocardial infarction. Med Decis Making. 13: 161– 165.Google Scholar
US Congress, Office of Technology Assessment. 1995. Effectiveness and costs of osteoporosis screening and hormone replacement therapy: Vol. I: Cost-effectiveness Analysis, Vol. II: Evidence on benefits, risks and costs. Washington DC: US Government printing Office;
Weinstein MC. 1980 Estrogen use in postmenopausal women–costs, risks, and benefits. N Engl J Med. 303: 308– 316.Google Scholar
Weinstein MC, Schiff I. 1983 Cost-effectiveness of hormone replacement therapy in the menopause. Obstet Gynecol Surv. 38: 445– 455.Google Scholar
Weinstein MC, Tosteson AN. 1990 Cost-effectiveness of hormone replacement. Ann NY Acad Sci. 592: 162– 172.Google Scholar
Zethraeus N, Ben Sedrine W, Caulin F, et al. 2002 Models for assessing the cost-effectiveness of the treatment and prevention of osteoporosis. Osteoporos Int. 13: 841– 857.Google Scholar
Zethraeus N, Borgström F, Johnell O, et al. Costs and quality of life associated with osteoporosis related fractures—Results from a Swedish survey. Working Paper Series in Economics and Finance at the Stockholm School of Economics, No 512. 2002.
Zethraeus N, Borgström F, Jönsson B et al. A reassessment of the cost-effectiveness of hormone replacement therapy in Sweden—results based on the Women's Health Initiative randomised controlled trial. Working Paper Series in Economics and Finance at the Stockholm School of Economics, No 571. 2004.
Zethraeus N, Johannesson M, Henriksson P, et al. 1997 The impact of hormone replacement therapy on quality of life and willingness to pay. Br J Obstet Gynaecol. 104: 1191– 1195.Google Scholar
Zethraeus N, Johannesson M, Jönsson B. 1999 A computer model to analyze the cost-effectiveness of hormone replacement therapy. Int J Technol Assess Health Care. 15: 352– 365.Google Scholar
Zethraeus N, Johanneson M, Jönsson B. A computer model to analyse the cost effectiveness of hormone replacement therapy. EFI Research Paper No 6578; January 1998.
Zethraeus N, Lindgren P, Johnell O, et al. A computer model to analyse the cost effectiveness of hormone replacement therapy—a revised version. SSI/EFI Working Paper Series in Economics and Finance at the Stockholm School of Economics, No 368; 2000.
Zethraeus N, Stromberg L, Jonsson B, et al. 1997 The cost of a hip fracture. Estimates for 1,709 patients in Sweden. Acta Orthop Scand. 68: 13– 17.Google Scholar