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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
  1. Teppo LN Järvinen, professor1,
  2. Karl Michaëlsson, professor2,
  3. Jarkko Jokihaara, registrar3,
  4. Gary S Collins, associate professor4,
  5. Thomas L Perry, clinical assistant professor5,
  6. Barbara Mintzes, senior lecturer6,
  7. Vijaya Musini, assistant professor5,
  8. Juan Erviti, head7,
  9. Javier Gorricho, senior evaluation officer8,
  10. James M Wright, professor5,
  11. Harri Sievänen, research director9
  1. 1Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
  2. 2Department of Surgical Sciences, Section of Orthopaedics, Uppsala University, Uppsala, Sweden
  3. 3Department of Hand Surgery, Tampere University Hospital, Tampere, Finland
  4. 4Centre for Statistics in Medicine, Botnar Research Centre, University of Oxford, Oxford, UK
  5. 5Departments of Anesthesiology, Pharmacology, and Therapeutics and Medicine, University of British Columbia, Vancouver, British Columbia, Canada
  6. 6Faculty of Pharmacy and Charles Perkins Centre, University of Sydney, Sydney, Australia
  7. 7Drug Information Unit, Navarre Regional Health Service, Pamplona, Navarre, Spain
  8. 8Department of Health, Government of Navarre, Pamplona, Navarre, Spain
  9. 9UKK Institute for Health Promotion Research, Tampere, Finland
  1. Correspondence to: Teppo Jarvinen teppo.jarvinen{at}helsinki.fi
  • Accepted 25 March 2015

Despite widespread endorsement, Teppo Järvinen and colleagues argue that evidence for stratifying risk of fracture and subsequent drug therapy to prevent hip fracture is insufficient to warrant our current approach

Summary box

  • Clinical context—Hip fractures cause considerable morbidity and mortality and are associated with high healthcare costs. With a growing elderly population their incidence is predicted to rise

  • Diagnostic change—Before the late 1980s, osteoporosis was diagnosed after a bone fracture. A new definition was introduced in 1994 based on low bone mineral density, expanding indications for pharmacotherapy. The introduction of fracture risk calculators exacerbated the trend

  • Rationale for change—Fractures are a function of bone fragility, which is measureable and can be improved with drugs

  • Leap of faith—Identifying and treating patients with fragile bones is a cost effective strategy to prevent fractures, particularly hip fractures

  • Impact on prevalence—Current fracture risk predictors have at least doubled the number of candidates for drug treatment. Under US guidelines about 75% of white women aged over 65 years have become candidates for drug treatment

  • Evidence of overdiagnosis—Rates of hip fracture continue to decline, and most occur in people without osteoporosis. Our meta-analysis indicates that 175 postmenopausal women with bone fragility must be treated for about three years to prevent one hip fracture

  • Harms from overdiagnosis—Being labelled as at risk of fracture imposes a psychological burden. Drug treatment is associated with adverse events, such as gastrointestinal problems, atypical femoral fractures, and osteonecrosis of the jaw

  • Limitations of evidence—Hip fractures are caused predominantly by falls in frail older adults. Few studies on preventive pharmacotherapy included adults aged ≥80, but evidence suggests no treatment benefit. Evidence is also sparse on treatment of men and optimum duration of treatment

Worldwide, about 1.5 million hip fractures occur each year.1 Incidence is expected to …

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