BMJ  2008;336 (19 January), doi:10.1136/bmj.39462.555197.47

Editor's Choice

Absolute risk please

The BMJ has a noble tradition of fighting the trend to medicalise risk factors (BMJ 2002;324:886-91; doi: 10.1136/bmj.324.7342.886). This week we hear more about whether we should be treating women who have "pre-osteoporosis," otherwise known as osteopenia—bone mineral densities that are slightly below normal. These women are at low risk of fracture but are considered by some to be "at risk of being at risk." They comprise more than half of the world’s postmenopausal women.

Pablo Alonso-Coello and colleagues examine four post hoc analyses of trials of osteoporosis drugs that claim to support drug treatment for osteopenia (p 126; doi 10.1136/bmj.39435.656250.AD). They find that the benefits of treatment in these low risk women are overstated and the harms underplayed. They urge clinicians to base treatment decisions on absolute rather than relative risk. It’s a lesson worth repeating: "impressive sounding reductions in relative risk can mask much smaller reductions in absolute risk." Critical as these authors are of the World Health Organization’s 1994 definition of "normal" bone density, produced by a working group which received funding from several drug companies, they—like many others—are doubtless awaiting with interest WHO’s new model for calculating absolute fracture risk.

The authors accept the current consensus that drug treatment is both effective and cost effective for preventing fractures in women with osteoporosis. But even in this group Teppo Jarinen and colleagues argue that the emphasis should be on preventing falls rather than treating low bone mineral density (p 124; doi: 10.1136/bmj.39428.470752.AD). Among older people, there is good evidence, they say, that the greatest risk of fracture comes from falls, not osteoporosis.

The problem then is how to prevent falls. Previous systematic reviews have been upbeat about the benefits of assessing all of a person’s risk factors and offering targeted interventions. As a result, programmes for prevention of falls were required by the UK’s national service framework for older people, and throughout the NHS there are falls clinics and slipper exchanges (from one of which we photographed the slippers on the front cover). But S Gates and colleagues have looked again at the evidence on the effectiveness of these programmes and found it to be limited and inconclusive (p 130; doi: 10.1136/bmj.39412.525243.BE). If there is any effect on the number of falls it is smaller than previously thought, they say, and most likely to follow higher intensity programmes that provide treatment for risk factors rather than those that just give information or refer patients on.

Moving to other matters: of the four main strings to the doctor’s bow (clinical practice, research, teaching, and management), teaching is perhaps the most easily neglected and undervalued. But we all have examples in our own lives of teachers who have inspired and helped us (about which, by the way, we would welcome your accounts as filler articles). This week we begin a new series aimed at supporting clinicians who teach, beginning with Yvonne Steinert’s article on how to manage the "problem" junior doctor (p 150; doi: 10.1136/bmj.39308.610081.AD). Her structured approach to diagnosis and treatment could transform both the learner and the teacher.

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Relevant Articles

Shifting the focus in fracture prevention from osteoporosis to falls

Teppo L N Järvinen, Harri Sievänen, Karim M Khan, Ari Heinonen, and Pekka Kannus
BMJ 2008 336: 124-126. [Extract] [Full Text] [PDF]

Drugs for pre-osteoporosis: prevention or disease mongering?

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The "problem" junior: whose problem is it?

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Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis

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Selling sickness: the pharmaceutical industry and disease mongering • Commentary: Medicalisation of risk factors

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