Background People with intellectual disabilities (ID) suffer higher rates of major osteoporotic fracture (MOF), including hip fracture (HF), at younger ages than the general population. We compared the cost-effectiveness of alternative fracture risk assessment strategies for people with ID aged ≥40 years from a UK National Health Services perspective over a lifetime horizon.

Methods Three strategies were assessed: (S1) Risk assessment using the standard (QFracture) score at current policy thresholds; (S2) Use of a novel, tailored IDFracture risk score for all; and (S3) Conducting a one-time dual-energy X-ray absorptiometry (DXA) scan in all. S1 and S2 were followed by DXA scan for those at risk. At-risk individuals received recommended interventions. A decision-analytical model incorporated data from literature and national databases to calculate discounted direct healthcare costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). Sensitivity and subgroup analyses were conducted.

Results In the base-case, S2 (ICER: −£2,568/QALY) was dominant (i.e. less costly and more effective) and S3 (ICER: £1,678/QALY) was cost-effective relative to S1 for MOF. For HF, S2 (ICER: £32,116/QALY) and S3 (ICER: £49,536/QALY) were not cost-effective relative to S1 under the NICE-recommended cost-effectiveness thresholds. Findings from the sensitivity analyses were predominantly consistent with the base-case results. Subgroup analyses showed that age- and gender-specific strategies could be used.

Conclusions For people with ID aged ≥40 years, a proactive approach to risk assessment for MOF is not only clinically beneficial, but also cost-effective.

PLAIN ENGLISH SUMMARY People with intellectual disabilities (ID) are at higher risk of fracture, particularly hip fracture, due at least partly to thinning of the bones (osteoporosis). These fractures carry huge costs in human terms, and to the NHS. Finding better ways of preventing them is essential. In this study, we aimed to determine which of three risk assessment strategies is the most cost-effective at preventing fractures in these individuals.

The first strategy was the currently recommended approach, involving risk assessment in all women from age 65 and men from 75 years, or younger in those with a risk factor for osteoporosis. ID itself is not recognised as a risk factor in current guidelines. The second involved using IDFracture in people with ID at or above 40 years, followed by a bone density (DXA) scan for those found to be at risk. The third strategy involved a single DXA in those aged 40 years or over. In each strategy, preventive treatment would be offered if needed, based on the DXA result.

We found that the most cost-effective way of identifying people with risk above the intervention threshold of 10% over ten years for major osteoporotic fracture at age 40-79 years is to perform a DXA. The most cost-effective way of identifying people with risk above the intervention thresholds of 3% over ten years for hip fracture at age 40-79 years is to use QFracture and perform a DXA in those at risk. However, different strategies may be needed for different age and gender subgroups.

VF, MS, GSC, and TAH report other grants from the National Institute for Health and Care Research (NIHR) during the conduct of this study. VF, MS and TAH also report grants from The Baily Thomas Charitable Fund. JR is the mother of an individual with intellectual disability.

This study was funded by the National Institute for Health Research Translating Research into Policy (NIHR TRiP, reference number: NIHR202094). The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

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The Clinical Practice Research Datalink (CPRD) has broad National Research Ethics Service approval to cover observational research using anonymised primary care data and established linkages. The study obtained ethics approval through CPRD Research Data Governance process (Protocol Number 21_000433 _).

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Electronic health records are, by definition, considered “sensitive” data in the UK by the Data Protection Act and cannot be shared via public deposition because of information governance restrictions in place to protect patient confidentiality. Access to data is possible only once approval has been obtained through the individual constituent entities controlling access to the data. The primary care data can be requested via application to the Clinical Practice Research Datalink (www.cprd.com/researcher), secondary care data can be requested via application to the hospital episode statistics from the UK Health and Social Care Information Centre (www.hscic.gov.uk/hesdata). The HES data used in this analysis are re-used with permission from NHS Digital who retain the copyright for that data.