Health Care Costs in a Cohort of HIV-Infected U.S. Veterans Receiving Regimens Containing Tenofovir Disoproxil Fumarate/Emtricitabine.

BACKGROUND: Tenofovir disoproxil fumarate (TDF), a key component in many human immunodeficiency virus (HIV) treatment regimens, is associated with increased renal and bone toxicities. The contributions of such toxicities to treatment costs, as well as the relative differences in treatment costs for various TDF/emtricitabine (FTC) regimens, remains unexplored. OBJECTIVE: To estimate and compare mean overall and renal- and bone-specific costs, including total, inpatient, outpatient, and pharmacy costs in patients treated with TDF/FTC+efavirenz (EFV) compared with several non-EFV-containing TDF/FTC regimens. METHODS: We conducted a national cohort study of treatment-naive HIV-infected U.S. veterans who initiated treatment from 2003 to 2015 with TDF/FTC in combination with EFV, elvitegravir/cobicistat, rilpivirine, or ritonavir-boosted protease inhibitors (atazanavir, darunavir, or lopinavir). Outcomes of interest were quarterly total, inpatient, outpatient, and pharmacy costs using data from the Veterans Health Administration (VHA) electronic medical record and Managerial Cost Accounting System (an activity-based accounting system that allocates VHA expenditures to patient encounters). We controlled for measured confounders using inverse probability of treatment (IPT) weights and assessed differences using standardized mean differences (SMDs). For comparisons where SMDs exceeded 0.1 after IPT weighting, we used the more conservative matching weights in sensitivity analyses. For hypothesis testing, we compared IPT-adjusted differences in quarterly costs between treatment groups using Mann-Whitney U-tests and generalized estimating equation (GEE) regression models. RESULTS: Of 33,048 HIV-positive veterans, 7,222 met eligibility criteria, including 4,172 TDF/FTC + EFV recipients; mean (SD) age of the cohort was 50.0 (10.0) years; 96.7% were male; 60.1% were black; and 30.1% were white. Quarterly periods of exposure to EFV-containing regimens were 22,499 and of exposure to non-EFV-containing regimens were 11,633. After IPT weighting, absolute SMDs were < 0.1 except for a few covariates in the rilpivirine comparison. The per-patient adjusted mean total quarterly costs were $7,145 for EFV versus $8,726 for non-EFV (P < 0.001; Mann-Whitney U-test) and the per-patient adjusted mean difference in total quarterly costs was $1,419 lower for EFV versus all non-EFV combined (P < 0.001; GEE model). Corresponding values for outpatient costs ($2,656 vs. $2,942; P < 0.001; difference, -$254; P = 0.001), inpatient costs ($2,009 vs. $2,614; P < 0.001), radiology costs ($213 vs. $276; P < 0.001), and pharmacy costs ($2,480 vs. $3,170; P < 0.001; difference, -$600; P < 0.001) were all lower for EFV versus all non-EFV combined. Findings based on matching weights were qualitatively similar. Contributions of renal and bone costs to the total costs of treatment were very small, ranging between $52 and $94 per patient per quarter for renal outcomes and between $6 and $114 for bone outcomes. CONCLUSIONS: Among 7,222 HIV-treated veterans over an average follow-up of 1.2 years per patient, those patients receiving TDF/FTC + EFV had lower overall health care costs compared with those receiving non-EFV regimens. DISCLOSURES: This study was funded by Bristol-Myers Squibb. Nelson, Ma, Crook, Knippenberg, Nyman, and LaFleur are employees of the University of Utah, which received a grant from Bristol-Myers Squibb to conduct this study. Nyman also discloses honoraria for consulting from Otsuka and for writing a book chapter from Fresenius. La Fleur reports advisory board and consulting fees from Bristol-Myers Squibb outside of this study. Paul and Esker are employees of, and own stock in, Bristol-Myers Squibb.

18F-Sodium Fluoride PET/CT and PET/MR Imaging of Bone and Joint Disorders.

18F-sodium fluoride (18F-NaF) PET/CT provides high sensitivity and specificity for the assessment of bone and joint diseases. It is able to accurately differentiate malignant from benign bone lesions, especially when using dynamic quantitative approaches. Its high-quality, clinical accuracy, and high feasibility for patient management and greater availability of PET/CT scanners as well as decreasing trend of the cost of radiotracer all indicate the need to consider the use of 18F-NaF PET/CT as standard bone imaging, particularly in malignant diseases of the skeleton.

Economic burden of skeletal-related events in patients with multiple myeloma: analysis of US commercial claims database.

AIMS: To estimate incremental healthcare resource utilization (HRU) and costs associated with skeletal-related events (SREs) secondary to multiple myeloma (MM), and HRU and cost differences in patients with one vs multiple SREs. METHODS: Adults with MM diagnosis between January 1, 2010-December 31, 2014, with benefits coverage ≥12 months pre- and ≥6 months post-diagnosis were followed to last coverage date or December 31, 2015, excluding patients with prior anti-myeloma treatment or cancers. SREs were identified by diagnosis or procedure codes (pathological fracture, spinal cord compression, radiation, or surgery to the bone). SRE patients (index = first post-diagnosis SRE) were propensity score matched 1:1 to patients without SRE (assigned pseudo-index) using baseline characteristics, and ≥1 month of continuous enrollment after index/pseudo-index date was required. Per-patient-per year (PPPY) HRU and costs (2016 US$) were determined for inpatient, outpatient, emergency department (ED), and outpatient pharmacy services during follow-up. Wilcoxon signed rank for means and McNemar's tests for proportions were used to assess differences. Negative binomial regression and generalized linear regression analyses estimated differences in HRU and costs, respectively, for the comparison of single vs multiple SREs. RESULTS: Each cohort included 848 patients (mean age = 61 - 62 years, 57% male) with no significant differences in pre-index demographic or clinical characteristics between matched cohorts. Versus non-SRE patients, SRE patients had significantly higher PPPY use (p < .0001) of inpatient hospitalizations, ED visits, outpatient pharmacy, and higher direct medical costs ($188,723 vs $108,160, p < .0001). Adjusted PPPY total costs were $209,820 in patients with multiple SREs; $159,797 in patients with one SRE. LIMITATIONS: SRE misclassification and residual confounding are possible. CONCLUSIONS: Among patients with MM, average annual costs were substantially higher in patients with SRE compared with matched non-SRE patients. The economic burden of SRE increased further with multiple events.

Phosphorus and other aspects of CKD-MBD in the conservative management of chronic kidney disease.

As the prevalence of chronic kidney disease (CKD) increases and the population ages, there is an imperative to offer cost effective and patient specific therapeutic options for the management of advanced CKD. In cases where there is a desire to avoid or delay renal replacement therapy, conservative options need to be defined and strategies for delaying the need for renal replacement therapy should be offered. CKD-mineral bone disorders (MBD) refers to the constellation of disturbances in abnormal bone and soft tissue calcification along with abnormalities, in phosphorus, calcium, parathyroid hormone, vitamin D, and FGF-23. CKD-MBD is associated with morbidity and mortality in dialysis patients. Addressing CKD-MBD necessitated understanding phosphorus handling in the intestine and kidney and the ordered process of vascular calcification and uremic osteodystrophy. Decreasing dietary phosphorus intake and absorption is the mainstay of conservative management of CKD-MBD; pharmacologic therapy with binders, vitamin D analogues, and niacin may also be indicated. FGF-23 levels, parathyroid hormone levels, tubular reabsorption of phosphorus, and 24 hour urinary phosphorus can be tracked to trigger and evaluate these interventions. Further research is required to generate an ordered multifaceted approach to CKD-MBD.

Short-term disability in solid tumor patients with bone metastases and skeletal-related events.

OBJECTIVE: The skeleton is a common site of metastasis in patients with solid tumors. These patients often experience pain and reduced quality-of-life. This analysis evaluated the time and costs associated with short-term disability use among solid tumor patients with bone metastases (BM) and skeletal-related events (SREs). METHODS: Data from patients 18-64 years old with solid tumors and BM, eligible for short-term disability benefits between January 1, 2002 and December 31, 2010, were extracted from MarketScan Research Databases. Short-term disability hours and costs associated with BM and SREs were evaluated. RESULTS: Overall, 1098 patients met the criteria. For all patients with BM, the monthly mean short-term disability hours were 17.7 h pre-BM diagnosis and increased to 60.2 h post-BM diagnosis (p < 0.001). The corresponding mean monthly short-term disability costs were $277 and $963 in the pre- and post-BM diagnosis periods, respectively (p < 0.001). Monthly mean short-term disability hours were higher for the cohort of patients with SREs (21.2 h pre-SRE diagnosis and 67.4 h post-SRE diagnosis) than for those without an SRE (8.6 h pre-SRE diagnosis and 14.4 h post-SRE diagnosis) (p < 0.001). Similarly, the corresponding monthly mean short-term disability costs were higher for patients with SREs ($625 and $1259 pre- and post-SRE diagnosis, respectively) than for patients without an SRE ($452 and $612 pre- and post-SRE diagnosis, respectively) (p < 0.001). RESULTS of a multivariate analysis indicated that SREs were associated with an additional 39.4 short-term disability hours and $613 in short-term disability costs per month (p < 0.001). CONCLUSION: Short-term disability hours and costs increased significantly when patients with solid tumors developed BM and SRE.

Utilization and costs of medications associated with CKD mineral and bone disorder in dialysis patients enrolled in Medicare Part D.

BACKGROUND: Information is limited regarding utilization patterns and costs for chronic kidney disease-mineral and bone disorder (CKD-MBD) medications in Medicare Part D-enrolled dialysis patients. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Annual cohorts of dialysis patients, 2007-2010. PREDICTORS: Cohort year, low-income subsidy status, and dialysis provider. OUTCOMES: Utilization and costs of prescription phosphate binders, oral and intravenous vitamin D analogues, and cinacalcet. MEASUREMENTS: Using logistic regression, we calculated adjusted odds of medication use for low-income subsidy versus non-low-income subsidy patients and for patients from various dialysis organizations, and we report per-member-per-month and average out-of-pocket costs. RESULTS: Phosphate binders (∼83%) and intravenous vitamin D (77.5%-79.3%) were the most commonly used CKD-MBD medications in 2007 through 2010. The adjusted odds of prescription phosphate-binder, intravenous vitamin D, and cinacalcet use were significantly higher for low-income subsidy than for non-low-income subsidy patients. Total Part D versus CKD-MBD Part D medication costs increased 22% versus 36% from 2007 to 2010. For Part D-enrolled dialysis patients, CKD-MBD medications represented ∼50% of overall net Part D costs in 2010. LIMITATIONS: Inability to describe utilization and costs of calcium carbonate, an over-the-counter agent not covered under Medicare Part D; inability to reliably identify prescriptions filled through a non-Part D reimbursement or payment mechanism; findings may not apply to dialysis patients without Medicare Part D benefits or with Medicare Advantage plans, or to pediatric dialysis patients; could identify only prescription drugs dispensed in the outpatient setting; inability to adjust for MBD laboratory values. CONCLUSIONS: Part D net costs for CKD-MBD medications increased at a faster rate than costs for all Part D medications in dialysis patients despite relatively stable use within medication classes. In a bundled environment, there may be incentives to shift to generic phosphate binders and reduce cinacalcet use.

Healthcare costs associated with skeletal-related events in breast cancer patients with bone metastases.

BACKGROUND: Patients with bone metastases secondary to breast cancer are pre-disposed to skeletal-related events (SREs), including spinal cord compression (SCC), pathologic fracture (PF), surgery to bone (SB), and radiotherapy to bone (RT). OBJECTIVE: To document current patterns of healthcare utilization and costs of SREs in patients with breast cancer and bone metastases. METHODS: This was a retrospective, observational study using the Thomson MedStat MarketScan Commercial Claims and Encounters database from 9/2002 to 6/2011. Study subjects included all persons with claims for breast cancer and for bone metastases, and ≥1 claims for an SRE. Unique SRE episodes were identified based on a gap of at least 90 days without an SRE claim, and classified by treatment setting (inpatient or outpatient) and SRE type (SCC, PF, SB, or RT). RESULTS: Of 17,266 patients with breast cancer and bone metastases, 9142 (53%) had one or more SRE episodes. Among 5809 patients who met all other criteria, there were 7617 SRE episodes over mean (SD) follow-up of 17.2 (15.2) months. The percentage of episodes that required inpatient treatment ranged from 11% (RT) to 76% (SB). On average, inpatient SCC episodes (n=83 episodes) were most costly; while outpatient PF episodes (n=552 episodes) were least costly. Of the total SRE costs (mean [SE] $21,072 [$36,462]/episode), 36% were attributable to outpatient RT (n=5265 episodes) and 31% to inpatient PF (n=838 episodes). LIMITATIONS: The administrative claims data used in this study may lack sensitivity and specificity for identification of clinical events and may not be generalizable to other populations. Also, for some SRE episode categories, the number of events was small and cost estimates may lack precision. CONCLUSION: In patients with breast cancer and bone metastases, SREs are associated with high costs and hospitalizations.

Health state utilities for skeletal-related events secondary to bone metastases.

INTRODUCTION: Patients with bone metastases often experience skeletal-related events (SREs). Although cost-utility models are used to examine treatments for metastatic cancer, limited information is available on utilities of SREs. The purpose of this study was to estimate the disutility of four SREs: spinal cord compression, pathological fracture, radiation to bone, and surgery performed to stabilize a bone. METHODS: General population participants from the UK and Canada completed time trade-off (TTO) interviews to assess the utility of health states drafted based on literature review, clinician interviews, and patient interviews. Respondents first rated a health state describing cancer with bone metastases. Then, the SREs were added to this health state. RESULTS: Interviews were completed with 187 participants (50.8 % male, 80.2 % white). Cancer with bone metastases without an SRE had a mean utility of 0.47 (SD = 0.43) on a standard utility scale (1 = full health, 0 = death). Of the SREs, spinal cord compression was associated with the greatest disutility (i.e., the utility decrease): -0.32 with paralysis and -0.22 without paralysis. Surgery had a disutility of -0.07. Leg, arm, and rib fractures had disutilities of -0.06, -0.04, and -0.03. Two weeks of daily radiation treatment had a disutility of -0.06, while two radiation appointments had the smallest impact on utility (-0.02). CONCLUSION: All SREs were associated with statistically significant utility decreases, suggesting a perceived impact on quality of life beyond the impact of cancer with bone metastases. The resulting disutilities may be used in cost-utility models examining treatments to prevent SREs secondary to bone metastases.

Routine perinatal and paediatric post-mortem radiography: detection rates and implications for practice.

BACKGROUND: Routine perinatal and paediatric post-mortem plain radiography allows for the diagnosis and assessment of skeletal dysplasias, fractures and other bony abnormalities. OBJECTIVE: The aim of this study was to review the diagnostic yield of this practice. MATERIALS AND METHODS: We identified 1,027 cases performed in a single institution over a 2½-year period, including babygrams (whole-body examinations) and full skeletal surveys. Images were reported prior to autopsy in all cases. Radiology findings were cross-referenced with the autopsy findings using an autopsy database. We scored each case from 0 to 4 according to the level of diagnostic usefulness. RESULTS: The overall abnormality rate was 126/1,027 (12.3%). There was a significantly higher rate of abnormality when a skeletal survey was performed (18%) rather than a babygram (10%; P < 0.01); 90% (665/739) of babygrams were normal. Of the 74 abnormal babygrams, we found 33 incidental non-contributory cases, 19 contributory, 20 diagnostic, and 2 false-positive cases. There were only 2 cases out of 739 (0.27%) in whom routine post-mortem imaging identified potentially significant abnormalities that would not have been detected if only selected imaging had been performed. A policy of performing selected, rather than routine, foetal post-mortem radiography could result in a significant cost saving. CONCLUSION: Routine post-mortem paediatric radiography in foetuses and neonates is neither diagnostically useful nor cost-effective. A more evidence-based, selective protocol should yield significant cost savings.

The EOS 2D/3D X-ray imaging system: a cost-effectiveness analysis quantifying the health benefits from reduced radiation exposure.

OBJECTIVES: To evaluate the cost-effectiveness of the EOS(®) 2D/3D X-ray imaging system compared with standard X-ray for the diagnosis and monitoring of orthopaedic conditions. MATERIALS AND METHODS: A decision analytic model was developed to quantify the long-term costs and health outcomes, expressed as quality-adjusted life years (QALYs) from the UK health service perspective. Input parameters were obtained from medical literature, previously developed cancer models and expert advice. Threshold analysis was used to quantify the additional health benefits required, over and above those associated with radiation-induced cancers, for EOS(®) to be considered cost-effective. RESULTS: Standard X-ray is associated with a maximum health loss of 0.001 QALYs, approximately 0.4 of a day in full health, while the loss with EOS(®) is a maximum of 0.00015 QALYs, or 0.05 of a day in full health. On a per patient basis, EOS(®) is more expensive than standard X-ray by between £10.66 and £224.74 depending on the assumptions employed. The results suggest that EOS(®) is not cost-effective for any indication. Health benefits over and above those obtained from lower radiation would need to double for EOS to be considered cost-effective. CONCLUSION: No evidence currently exists on whether there are health benefits associated with imaging improvements from the use of EOS(®). The health benefits from radiation dose reductions are very small. Unless EOS(®) can generate additional health benefits as a consequence of the nature and quality of the image, comparative patient throughput with X-ray will be the major determinant of cost-effectiveness.

The economic burden associated with skeletal-related events in patients with bone metastases secondary to solid tumors in Belgium.

OBJECTIVES: More than 1.5 million patients worldwide are affected by bone metastases. Patients with bone metastases frequently develop skeletal-related events (SREs, including radiation to bone, non-vertebral fracture, vertebral fracture, surgery to bone, and spinal cord compression) that are associated with high healthcare costs. This study aims to provide an estimate of the cost per SRE in both the inpatient and outpatient settings in Belgian patients with bone metastases secondary to solid tumors (breast, prostate, and lung cancers). METHODS: Patients were retrieved from the IMS Hospital Disease database from 2005-2007. Inclusion was based on the International Classification of Diseases and Related Health Problems Version 9 (ICD-9) diagnosis and/or procedure codes covering patients with breast, prostate, or lung cancer with bone metastases who were hospitalized for one or more SREs. All costs were extrapolated to 2010 using progression in hospitalization costs since 2001. Additional outpatient costs resulting from radiation to bone and diagnostic tests performed in ambulatory settings were estimated by combining published unit costs with resource use data obtained from a Delphi panel. RESULTS: The average cost per SRE across solid tumor types based on the weighted average of inpatient and outpatient costs was €2653 for radiation to bone, €5015 for a vertebral fracture, and €7087 for a non-vertebral fracture. Costs were €12,885 and €15,267 for surgery to bone and spinal cord compression, respectively. LIMITATIONS: No patient follow-up across calendar years could be done. Also, details regarding the exact anatomic sites of SREs were not always available. CONCLUSIONS: SREs add a substantial cost to the management of patients with bone metastases. Avoiding SREs can lead to important cost-savings for the healthcare payer.

Pharmacoeconomics of bisphosphonates for skeletal-related event prevention in metastatic non-breast solid tumours.

Bisphosphonates reduce the risk of skeletal-related events (SREs; i.e. spinal cord compression, pathological fracture, radiation or surgery to the bone, and hypercalcaemia) in patients with metastatic cancer. A number of analyses have been conducted to assess the cost effectiveness of bisphosphonates in patients with bone metastases secondary to breast cancer, but few in other solid tumours. This is a review of cost-effectiveness analyses in patients with non-breast solid tumours and bone metastases. A literature search was conducted to identify cost-effectiveness analyses reporting the cost per QALY gained of bisphosphonates in patients with metastatic bone disease secondary to non-breast solid tumours. Four analyses met inclusion criteria. These included two in prostate cancer (one of which used a global perspective but expressed results in $US, and the other reported from a multiple country perspective: France, Germany, Portugal and the Netherlands). The remaining analyses were in lung cancer (in the UK, France, Germany, Portugal and the Netherlands), and renal cell carcinoma (in the UK, France and Germany). In each analysis, the cost effectiveness of zoledronic acid versus placebo was analysed. Zoledronic acid was found to be cost effective in all European countries across all three indications but not in the sole global prostate cancer analysis. Across countries and indications, assumptions regarding patient survival, drug cost and baseline utility (i.e. patient utility with metastatic disease but without an SRE) were the most robust drivers of modelled estimates. Assumptions of SRE-related costs were most often the second strongest cost driver. Further review indicated that particular attention should be paid to the inclusion or exclusion of nonsignificant survival benefits, whether health state utilities were elicited from community or patient samples or author assumptions, delineation between symptomatic and asymptomatic SREs, and the methods with which SRE disutility was modelled over time. While the field of cost-effectiveness analysis in solid tumours other than breast cancer is still evolving, outcomes will likely continue to be driven by drug cost and assumptions regarding treatment benefits. Although considerations such as adverse events and administration costs are important, they were not found to influence cost-effectiveness estimates greatly. As zoledronic acid will lose patent protection in 2013 and subsequently be greatly reduced in price, it is likely that the field of cost effectiveness will change with regard to SRE-limiting agents. Meanwhile, research should be conducted to improve our understanding of the impact on quality of life and medical costs of preventing SREs.

Trends in parathyroidectomy rates in US hemodialysis patients from 1992 to 2007.

BACKGROUND: Parathyroidectomy rates in hemodialysis patients increased from 1992 to 2002, when medication choices to manage secondary hyperparathyroidism expanded. STUDY DESIGN: Retrospective follow-up registry study. SETTING & PARTICIPANTS: We evaluated annual cohorts of point-prevalent US hemodialysis patients with Medicare as primary payer for 1992-2007 (n = 1,063,258 for 1992-1999; 757,207 for 2000-2003; 902,119 for 2004-2007). PREDICTOR: Comorbid conditions, vitamin D use, previous kidney transplant, and parathyroid hormone testing were assessed in the previous year. Available bone and mineral disorder treatment patterns were evaluated. OUTCOMES: We examined incidence rate trends and patient characteristics through 2007 to estimate the association between parathyroidectomy and patient factors. Follow-up was from January 1 of each study year to the earliest in the same year of parathyroidectomy, death, or December 31. MEASUREMENTS: We used χ(2) analysis to compare patient characteristics in 3 time frames. Unadjusted and adjusted parathyroidectomy rates were calculated. Cox regression was used to test the association of parathyroidectomy and covariates. RESULTS: Adjusted parathyroidectomy rates increased from 1998 (7.0/1,000 patient-years; 1,045 events), peaked in 2002 (12.8/1,000 patient-years; 2,229 events), decreased through 2005 (5.4/1,000 patient-years; 1,078 events), and increased in 2006 (8.6/1,000 patient-years; 1,743 events) and 2007 (8.8/1,000 patient-years; 1,832 events). Vitamin D use, virtually undetectable in 1991, subsequently steadily increased; >80% of patients received vitamin D in 2006. LIMITATIONS: The study was not designed to provide causal explanations for observed changes; oral medication use trend data were limited to one large dialysis provider and may not reflect use patterns in all dialysis facilities; because Medicare is not the primary payer for all US hemodialysis patients, results do not describe the entire US hemodialysis population; parathyroid hormone values are lacking in the database. CONCLUSIONS: Adjusted parathyroidectomy rates varied substantially from 1992 through 2007. Rates were highest in 1994 and 2002 and lowest in 1998 and 2005, likely influenced by changing medication use patterns and guideline publication.

Health care utilization for musculoskeletal back disorders, Washington State union carpenters, 1989-2003.

OBJECTIVE: Private health care utilization rates for musculoskeletal back disorders were contrasted to rates of work-related injuries or disorders for a large cohort of union carpenters over a 15-year period. METHODS: Yearly utilization rates were compared with rates of work-related back injuries or disorders. Negative binomial regression with generalized estimating equations was used to assess utilization rates based on age, gender, union tenure, type of work, and previous work-related back injuries. RESULTS: Private utilization rates were over twice as high in 2003 as in 1989 whereas compensation rates declined substantially. Utilization was higher among carpenters with less union tenure and increased with the number of work-related injuries. CONCLUSIONS: Patterns of utilization across private and workers' compensation delivery systems are not independent; we need to look broadly at sources of health care coverage to better understand the health of working populations.

Cost effectiveness of bisphosphonates in the management of breast cancer patients with bone metastases.

BACKGROUND: Bisphosphonates are recommended to prevent skeletal related events (SREs) in patients with breast cancer and bone metastases (BCBM). However, their clinical and economic profiles vary from one agent to the other. MATERIALS AND METHODS: Using modeling techniques, we simulated from the perspective of the UK's National Health Service (NHS) the cost and quality adjusted survival (QALY) associated with five commonly-used bisphosphonates or no therapy in this patient population. The simulation followed patients into several health states (i.e. alive or dead, experiencing an SRE or no SRE, and receiving first or second line therapy). Drugs costs, infusion costs, SREs costs, and utility values were estimated from published sources. Utilities were applied to time with and without SREs to capture the impact on quality of life. RESULTS: Compared to no therapy, all bisphosphonates are either cost saving or highly cost-effective (with a cost per QALY < or = 6126 pounds sterlings). Within this evaluation, zoledronic acid was more effective and less expensive than all other options. CONCLUSIONS: Based on our model, the use of bisphosphonates in breast cancer patients with bone metastases should lead to improved patient outcomes and cost savings to the NHS and possibly other similar entities.