Cost-Effectiveness of the Screening for the Primary Prevention of Fragility Hip Fracture in Spain Using FRAX®

  • Mario Martin-Sanchez
  • Mercè ComasEmail author
  • Margarita Posso
  • Javier Louro
  • Laia Domingo
  • Cristian Tebé
  • Xavier Castells
  • Mireia Espallargues
Original Research


To assess the cost-effectiveness of the primary prevention of fragility hip fractures through opportunistic risk-based screening using FRAX® among women aged 70 to 89 years, and the subsequent treatment with alendronate in women at high-risk, from the Spanish national health system perspective. We performed a discrete-event simulation model. Women were categorized in low, intermediate and high-risk of fragility hip fracture through screening based on the FRAX® risk assessment tool score (Spanish version). Low-risk women received lifestyle recommendations whereas the high-risk group was assigned to alendronate treatment. For women at intermediate-risk, treatment decision was based on a recalculated score considering bone mineral density (BMD). The cost-effectiveness analysis tested six scenarios defined by different FRAX® cut-off values assessing the incremental costs per averted fracture in 20 years. Deterministic sensitivity analysis was performed. We included a random sample of 5146 women obtained from a Spanish cohort of women referred for BMD. The most cost-effective intervention had an Incremental Cost-effectiveness Ratio (ICER) of 57,390 € per averted hip fracture and consisted of using the FRAX® score without BMD and treating women with a score higher than 5%. The ICER exceeded the acceptability threshold of 25,000 € in all the scenarios. Sensitivity analysis based on time to fracture, treatment efficacy, adherence to treatment and cost of dependence resulted in ICERs ranging from 39,216 € to 254,400 €. An ICER of 24,970 € was obtained when alendronate cost was reduced to 1.13 € per month. The use of FRAX® as screening tool followed by alendronate treatment is not cost-effective in senior women in Spain. Other primary preventions strategies are advisable.


Health economics Dxa Screening Osteoporosis Fracture prevention 



Xavier Surís and Marta Larrosa from Pla Director de les Malalties Reumàtiques i de l’Aparell Locomotor, and Maria Jesús Pueyo and Josep Fusté from Direcció General de Planificació i Recerca en Salut for their participation in the validation of the model. Luis del Rio and Silvana di Gregorio from CETIR medical centre for providing data. Adolfo Díez-Pérez for the insightful comments and suggestions.

Author Contributions

MC and ME designed the study. MM and MP prepared the first draft of the paper. XC, CT and LD contributed to the analytical work. JL and MC were responsible for statistical analysis of the data. All authors revised the paper critically for intellectual content and approved the final version. All authors agree to be accountable for the work and to ensure that any questions relating to the accuracy and integrity of the paper are investigated and properly resolved.


This research has been produced under the collaboration agreement signed by the Instituto de Salud Carlos III, an autonomous body of the Ministry of Economy and Competitiveness, and the Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), under the development of activities of the Spanish Network of Health Technology and Health Services Provision Assessment Agencies of the National Health Service, funded by the Ministry of Health, Social Services and Equality in 2012.

Compliance with Ethical Standards

Conflict of interest

MM, MC, MP, JL, LD, CT, XC and ME declare that they have no conflict of interest.

Informed Consent

Research based on secondary data, informed consent was not required.

Human and Animal Rights

Research involving humans and/or animals. This article does not contain any studies with human participants performed by any of the authors.

Supplementary material

223_2019_570_MOESM1_ESM.pdf (548 kb)
Supplementary material 1 (PDF 548 kb)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Epidemiology and EvaluationIMIM (Hospital del Mar Medical Research Institute)BarcelonaSpain
  2. 2.Preventive Medicine and Public Health Training Unit PSMAR-UPF-ASPB (Parc de Salut Mar – Pompeu Fabra University-Public Health Agency of Barcelona)BarcelonaSpain
  3. 3.Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC)BarcelonaSpain
  4. 4.Bellvitge Biomedical Research Institute (IDIBELL)BarcelonaSpain
  5. 5.Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS)BarcelonaSpain

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