Shifting the focus in fracture prevention from osteoporosis to falls

Journal Club Summary

27 May 2015

Facilitated by Dr Ray Moynihan

1.  Background

  • Historically osteoporosis defined by fracture
  • 1994 new drug company supported definition decides bone mineral density of 30 year old woman is “normal” – automatically defines many healthy women as “diseased” – causing potential overdiagnosis and overtreatment
  • 2011 new models to estimate “absolute risk” of fracture – eg FRAX – controversially lowers treatment thresholds
  • Important to understand controversy over osteoporosis – e.g. this 2008 BMJ paper – if attempting to inform people about the risk of overdiagnosis
  • Ray Moynihan and others at CREBP are planning focus groups to discuss non-cancer overdiagnosis with the community, and osteoporosis may be the subject matter for these focus groups.
  • The Journal Club discussion was designed to inform development of the focus group structure and content

2.  Paper presented

The paper is an Analysis article in The BMJ, and here are the key arguments:

  • Falling, not osteoporosis, is the strongest single risk factor for fractures in elderly
  • Bone mineral density is poor predictor of fracture risk
  • Drug treatment expensive and won’t prevent fractures in most elderly
  • GPs should shift focus to falls prevention

3.  Discussion/Journal Club commentary

General enthusiasm to use osteoporosis as the subject matter for focus groups on non-cancer overdiagnosis. May reach saturation of themes, so may need to use other content as well. (eg high cholesterol).

Results of discussion about possible structure of focus groups: keep it very simple; try and elicit women’s perceptions about nature of “disease”, importance of BMD as risk factor, benefits and harms of treatments, whether overdiagnosis is an issue in osteoporosis, offer positive information about preventing fractures; open with unprompted discussion, present information, discuss information.

Strong interest in subject matter of article. Debate about whether falls or fractures should be chief focus of attention, and whether GPs are best placed to do prevention – perhaps it’s more a case where a suite of community based interventions might be more appropriate.

4.  Reference(s)

Jarvinen T, et al Shifting the focus in fracture prevention from osteoporosis to falls. BMJ 2008;336:124-6

Jarvinen T, et al Overdiagnosis of bone fragility in the quest to prevent hip fracture. BMJ 2015;350:h2088