Re: Overdiagnosis of bone fragility in the quest to prevent hip fracture
I disagree with Jarvinen and colleagues on their rather nihilistic conclusion of pharmacotherapy for osteoporosis being an “intellectual fallacy”. As an orthogeriatrician in a tertiary hospital we routinely deliver integrated falls and osteoporosis services to elderly with fragility fractures which is in line with the commitment provided by the NSF for older people 2004 [1] to provide integrated falls and osteoporosis services.
Hip fracture is associated with considerable morbidity and mortality with the median cost of an uncomplicated hip fracture care being in excess of £12000 excluding social care cost which is substantial as up to one third are permanently institutionalised to care homes. In fact according to one large survey conducted on elderly community dwelling women, eighty per cent of women surveyed would rather be dead than experience the loss of independence and quality of life that results from a bad hip fracture and subsequent admission to a nursing home [2].
Furthermore we do have evidence on the effectiveness of both oral and intravenous bisphosphonates in reducing mortality post hip fracture [3]. As regards complete lack of evidence of the cost effectiveness of pharmacological fracture prevention treatment, one could question along similar lines, the efficacy of secondary preventative cardiovascular medications, the effectiveness of newer anticoagulants, etc, in the very elderly who are mostly excluded from these studies. I do believe that assessment of falls and bone health including other geriatric conditions should take precedence over most of the other pharmacotherapy in the elderly who remain at high absolute risk of these common “geriatric giants” associated with significant healthcare costs.
1. APPAG Executive summary- Falling short: Delivering integrated falls and osteoporosis services in England- A report on the implementation of Standard Six of the National Services Framework for older people December 2004
2. Quality of life related to fear of falling and hip fracture in older women: a time trade off study. Commentary: Older people's perspectives on life after hip fractures. BMJ 2000; 320 doi: http://dx.doi.org/10.1136/bmj.320.7231.341 (Published 05 February 2000) Cite this as: BMJ 2000;320:341
3. Oral bisphosphonates are associated with reduced mortality after hip fracture. Beaupre LA1, Morrish DW, Hanley DA, Maksymowych WP, Bell NR, Juby AG, Majumdar SR. Osteoporos Int. 2011 Mar;22(3):983-91. doi: 10.1007/s00198-010-1411-2. Epub 2010 Nov 4
Competing interests:
No competing interests
01 June 2015
Rajesh Dwivedi
Consultant Orthogeriatrician
Queens Medical Centre, Nottingham Universtiy Hospitals, Derby Road, Nottingham
Rapid Response:
Re: Overdiagnosis of bone fragility in the quest to prevent hip fracture
I disagree with Jarvinen and colleagues on their rather nihilistic conclusion of pharmacotherapy for osteoporosis being an “intellectual fallacy”. As an orthogeriatrician in a tertiary hospital we routinely deliver integrated falls and osteoporosis services to elderly with fragility fractures which is in line with the commitment provided by the NSF for older people 2004 [1] to provide integrated falls and osteoporosis services.
Hip fracture is associated with considerable morbidity and mortality with the median cost of an uncomplicated hip fracture care being in excess of £12000 excluding social care cost which is substantial as up to one third are permanently institutionalised to care homes. In fact according to one large survey conducted on elderly community dwelling women, eighty per cent of women surveyed would rather be dead than experience the loss of independence and quality of life that results from a bad hip fracture and subsequent admission to a nursing home [2].
Furthermore we do have evidence on the effectiveness of both oral and intravenous bisphosphonates in reducing mortality post hip fracture [3]. As regards complete lack of evidence of the cost effectiveness of pharmacological fracture prevention treatment, one could question along similar lines, the efficacy of secondary preventative cardiovascular medications, the effectiveness of newer anticoagulants, etc, in the very elderly who are mostly excluded from these studies. I do believe that assessment of falls and bone health including other geriatric conditions should take precedence over most of the other pharmacotherapy in the elderly who remain at high absolute risk of these common “geriatric giants” associated with significant healthcare costs.
1. APPAG Executive summary- Falling short: Delivering integrated falls and osteoporosis services in England- A report on the implementation of Standard Six of the National Services Framework for older people December 2004
2. Quality of life related to fear of falling and hip fracture in older women: a time trade off study. Commentary: Older people's perspectives on life after hip fractures. BMJ 2000; 320 doi: http://dx.doi.org/10.1136/bmj.320.7231.341 (Published 05 February 2000) Cite this as: BMJ 2000;320:341
3. Oral bisphosphonates are associated with reduced mortality after hip fracture. Beaupre LA1, Morrish DW, Hanley DA, Maksymowych WP, Bell NR, Juby AG, Majumdar SR. Osteoporos Int. 2011 Mar;22(3):983-91. doi: 10.1007/s00198-010-1411-2. Epub 2010 Nov 4
Competing interests: No competing interests