Intended for healthcare professionals

Rapid response to:

Analysis Too Much Medicine

Overdiagnosis of bone fragility in the quest to prevent hip fracture

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h2088 (Published 26 May 2015) Cite this as: BMJ 2015;350:h2088

Rapid Response:

Prevention of hip fracture is difficult. No method has proven efficacy, effectiveness and cost-effectiveness

As noted in my previous rapid response (1) to the paper of Järvinen and colleagues (2), hip fracture should be the main target of the fracture prevention in older adults. Later on, prof. Sugiyama wrote that both falling and bone fragility should be the main focus of this task (3). This is easy to agree.

Concerning falls prevention, it is evidence-based that regular strength and balance training can reduce the risk of falling in community-dwelling older adults (4). However, it is not well proven that this benefit translates into fracture reduction, although a recent meta-analysis points to that direction (5). Also, without further evidence, extrapolation of these promising results to frail elderly adults at risk of hip fracture can be misleading.

Concerning prevention and treatment of bone fragility in a clinical setting, the situation is not better. As pointed out in several previous responses to Järvinen et al., Cochrane and other reviews have summarized that bisphosphonates (BIS) have very limited value in primary prevention of (hip) fractures. For this reason, the focus and hope have turned towards secondary prevention, in many of the above noted responses, via Fracture Liaison Services (FLS) (6-9). But, as noted in my previous rapid response (1), there seems to be no randomised, controlled study to show that FLS works – let alone its cost-effectiveness. Despite this major gap, patients, health officers and tax payers would be most keen to know the costs needed to prevent one hip fracture via FLS.

FLS have been developed and implemented to identify, evaluate and treat older patients with a recent fracture, the treatment clearly having the main focus in the treatment of osteoporosis by BIS, calcium and vitamin D (6-9). However, a recent analysis, again in the prestigious BMJ, showed that calcium and vitamin D supplementation have no sufficient and reasonable effect on osteoporosis, falls and fractures of older adults (10). Thus, the entire FLS system seem to rely on BIS only - an approach which has the known evidence gap in prevention of hip fractures (2).

Altogether, prevention of hip fracture is very difficult, especially if the goal is to do it cost-effectively in real life. However, this difficulty should not mean that we are allowed to advocate ineffective and often costly surrogate methods. I see that this approach is the gold standard for all preventive work in medicine.

Pekka Kannus, MD,PhD
UKK Institute, Tampere, Finland

References
1. Kannus P. Hip fracture is the main target of fracture prevention, but where is RCT-proof that Fracture Liaison Services work? BMJ 2015;350:h2088. Rapid response June 23, 2015.
2. Järvinen TL, Michaelsson K, Jokihaara J et al. Overdiagnosis of bone fragility in the quest to prevent hip fracture. BMJ 2015;350:h2088.
3. Sugiyama T. Both falling and bone fragility should be targeted: the limited effectiveness of exercise on fall prevention. BMJ 2015;350:h2088. Rapid response July 25, 2015.
4. Gillespie LD, Robertson MC, Gillespie WJ et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;9:CD007146.
5. El-Khoury F, Cassou B, Charles M-A et al. The effect of fall prevention exercise programmes on fall induced injuries in community-dwelling older adults: systematic review and meta-analysis of randomized controlled trials. BMJ 2013;347:f6234.
6. McLellan AR, Wolowacz SE, Zimovetz EA et al. Fracture liaison services for the evaluation and management of patients with osteoporotic fracture: a cost-effectiveness evaluation based on data collected over 8 years of service provision. Osteoporos Int 2011;22:2083-2098.
7. Lih A, Nandapalan H, Kim M et al. Targeted intervention reduces refracture rates in patients with incident non-vertebral osteoporotic fractures: a 4-year prospective controlled study. Osteoporos Int 2011;22:849-858.
8. Huntjens KBM, van Geel TACM, van den Bergh JPW et al. Fracture liaison service: impact on subsequent nonvertebral fracture incidence and mortality. J Bone Joint Surg (Am) 2014;96:e29(1-8).
9. Nakayama A, Major G, Bogduk N. Comparative refracture rates in hospitals with and without a fracture liaison service: a 6 month historical cohort study. Intern Med J 2015;45(Suppl.2):3.
10. Grey A, Bolland M. Analysis.Web of industry, advocacy, and academia in the management of osteoporosis. BMJ 2015;351:h3170.

Competing interests: No competing interests
6 August 2015
Pekka A Kannus
Chief Physician
Injury & Osteoporosis Research Center, UKK Institute for Health Promotion Research
P.O. Box 30, FIN-33501 Tampere, Finland

Competing interests: No competing interests

06 August 2015
Pekka A Kannus
Chief Physician
Injury & Osteoporosis Research Center, UKK Institute for Health Promotion Research
UKK Institute, P.O. Box 30, FIN-33501 Tampere, Finland