Commentary: Opportunities to prevent fracture are being missed

BMJ 2013; 346 doi: (Published 21 January 2013) Cite this as: BMJ 2013;346:f278
  1. M Kassim Javaid, Norman Collison lecturer in metabolic bone disease,
  2. Cyrus Cooper, professor of rheumatology
  1. 1Oxford NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
  1. kassim.javaid{at}

Improving the management of osteoporosis remains important given the high cost of fragility fracture for patients, carers, clinicians, and healthcare systems.1 The availability of a wide range of effective oral, intravenous, and subcutaneous therapies that can be administered at varying intervals (daily, weekly, monthly, six monthly to annually) should make treatment the envy of other chronic disease specialties such as diabetes or hypertension, which have more limited dosage portfolios.

Yet the care of patients at high risk of fracture remains poor, as shown by the aptly titled, recent audit of services in England, Wales, and Northern Ireland, Falling Standards, Broken Promises.2 One of the reasons is that many different professionals are involved in the care pathway and no one has clear responsibility for instituting and maintaining effective secondary prevention. Such a situation would be unthinkable after an acute myocardial infarction, raising interesting (and often awkward) discussions about why it continues to be the case for most patients with a fragility fracture.

A problem in primary prevention is to identify which patients are at sufficient risk to merit bone specific therapy. Several risk algorithms are now being used in clinical practice (FRAX, QFracture, Garvan) with varying fracture sensitivity (39-79%) and specificity (39-93%).

The analytical assumptions used in these predictive models are important, as Bolland and colleagues have elegantly shown.3 Key factors such as the time frame for estimation and inclusion of population based predictions of mortality contribute to different tools producing contradictory risk assignments for the same patient. Although FRAX identifies fewer women as high risk than Garvin, the number is still higher than the current rate of elderly women treated with bone agents.

A key clinical priority in the NHS remains the management of the 300 000 patients presenting with fragility fracture(s) every year to reduce the risk of the next fracture. Most of the fracture risk prediction tools were not primarily designed for this scenario.

Fortunately for clinicians, the strongest risk factor for fracture is a previous fracture, and the majority of people with non-vertebral fractures reach clinical attention through inpatient or outpatient attendance. This presents the NHS with a unique opportunity for a step change in care. Only 37% of trusts currently have access to a fracture prevention service2; most patients are unevaluated till the next fracture. The new Quality and Outcomes Framework indicators for osteoporosis management in primary care may help to reduce fractures, but general practitioners and secondary care specialists need to understand the shortcomings of the assessment tools they are using.

Task forces set up by the UK National Osteoporosis Society and American Society for Bone and Mineral Research aim to improve secondary prevention. The International Osteoporosis Foundation has developed a tool to benchmark services for preventing secondary fracture and guide improvement of services.

The ageing population has raised concern about a potential epidemic of fragility fractures, but better identification of patients at risk and effective drug treatment can limit this. As always, translation of research evidence to clinical practice through systematic commissioning of specialist services, whether in primary or secondary care, has been and remains the missing link and is more important than which risk assessment score is least inaccurate.


Cite this as: BMJ 2013;346:f278


  • doi:10.1136/bmj.e8669
  • Competing interests: The authors have read and understood the BMJ Group policy on declaration of interests and have declare MKJ is a member of the National Osteoporosis Society clinical scientific committee, the International Osteoporosis Foundation committee of scientific advisers for Capture the Fracture, and the Arthritis Research Metabolic Bone Disease clinical study group. CC has received honorariums and consulting fees from Amgen, ABBH, Eli Lilly, Medtronic, Merck, Novartis, and Servier.

  • Provenance and peer review: Commissioned; not externally peer reviewed.