Prevention takes a lot of energy. But all too often, through a series of miscalculations, prevention becomes a "commercial" activity, in which we lose sight of the goal of preventive care.

For example, it is legitimate to try to prevent hip fractures, which are often very traumatic for patients. But little by little, attention has shifted towards preventing less worrisome, and even asymptomatic, fractures. And then to "risk factors" for fractures; osteoporosis in particular has been singled out. Then we went from osteoporosis to bone density. Radiological measurement of bone density has become routine in women over age 50. These measurements have become the criteria for evaluating drug treatments. Improving these values is then held up as a treatment objective. Various drugs have been authorised, sold, heavily promoted, and reimbursed by insurance. The media regularly bring the matter to the public’s attention. This is an all-too-common trend. Millions of women are followed, examined, monitored, encouraged to take drugs for years, despite the risk of adverse effects. Thousands of healthcare professionals devote time to appointments, extra tests, getting specialists' opinions, writing prescriptions, in private practice and in hospitals, in the security that comes from insurance coverage. All this business of keeping an eye on bone density and "treating" it seems self-evident. Many patients and many healthcare practitioners participate in these activities, in good faith and good conscience.

In-depth, systematic analysis of drug evaluation data gives a good reason to snap out of this "general anaesthesia". The rationale for this type of prevention is slim. The measurement of bone density has little demonstrated benefit, other than to avoid exposing too many women to the adverse effects of drugs that are only useful for a small minority of them.

The amount and cost of treatment revolving around marginally useful tests such as measurement of bone density are not in patients’ interests. By losing sight of the initial motivation, precious human and financial resources are wasted, at a time when there is so much to be done to treat real illnesses, and to provide access to needed healthcare for all.

Once again all the energy mobilised mainly serves a few special interests, but does not really serve public health. Those who want to improve healthcare need to keep a clear head and their feet on the ground, and carefully evaluate the benefits of preventive measures.

©Prescrire 2007

Source: "Chaînes" Rev Prescrire 2007; 27 (285): 481.