The article on it here:
Everyone over 60 is suffering this disease – we just don’t know it
The editorial in BMJ:http://bjsm.bmj.com/content/early/2015/10/01/bjsports-2015-095286.full?sid=728f278a-d27b-4691-b590-ecd3de4ecfdf
- Correspondence to Professor Teppo LN Järvinen, Clinical Medicine/Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Central Hospital, Töölö Hospital/Topeliuksenkatu 5, Helsinki 00014, Finland; teppo.jarvinen@helsinki.fi
- Accepted 1 September 2015
- Published Online First 16 November 2015
Whenever a doctor cannot do good, he must be kept from doing harm.
Hippocrates
Nowadays, being at ‘high risk’ of
having a disease has become a disease in and of itself. Sweeping
educational programmes
at all levels of healthcare now turn an
otherwise healthy person's ‘high’ blood pressure, elevated serum lipids
or low bone
density into chronic conditions having
increased risk of a potentially bad event.1
But what represents ‘high risk’? This question lies at the heart of
modern medicine, particularly with respect to pharmacological
primary prevention.
Advocates of this evolution argue
simply that primary prevention saves lives. However, permissive
labelling of conditions
as diseases may not be entirely harmless.
On an individual patient level, possible disadvantages include making
relatively
healthy individuals perceive themselves as
‘sick’, and almost every treatment has inherent risks.2
On a societal level, we probably all still remember the discouraging
effect of the new European guidelines on cardiovascular
disease classified most adult
Norwegians—among the healthiest populations in the world—to be at ‘high
risk’ of cardiovascular
disease.3 If these guidelines were applied to the Norwegian healthcare system, the focus on hypertension would drain the entire primary
healthcare budget.
‘High risk': How low can we go?
Current debate on ‘High Risk
as a Disease’ twirls around the ‘appropriate’ threshold for defining
something as a disease.
The recently introduced osteoporosis
guideline put out by medical experts of the National Osteoporosis
Foundation (NOF, USA)
recommends osteoporosis medications if a
person's 10-year probability of sustaining a hip fracture is 3% or
over. Applying
these NOF recommendations to a large
prospective cohort study, at least 72% of Caucasian women >65 years
of age and 93% of
those >75 years of age, in the USA,
would be recommended for drug therapy.4 The new cholesterol guideline similarly colonises virtually the entire elderly population into the realm of ‘sick’.
Understanding risk: are the blind leading the blind?
But who are the right people to determine the threshold for ‘high risk’? Advocates of the hegemony of medical experts argue
that doctors—as content experts—should define diseases.5
If we assume doctors are truly more competent in making value
judgements about the lives of their patients than the patients
sitting in front of them, should we not
have proof that doctors can do the job? Sadly, despite medical
education and clinical
experience, doctors do not seem to
possess the required skill.6
Even more discouragingly, patients might not fully agree with our perceptions. For example, the above noted NOF threshold
is more than 15 times lower than what patients would consider a 10-year fracture risk justifying initiation of bone-targeted pharmacotherapy (50%).7
Similarly, there is a huge gap on what the two stakeholders consider ‘effective treatment’. Patients generally expect >20%
absolute risk reduction (in heart attacks) for preventive pharmacotherapy to opt for treatment.8
In contrast, doctors world-wide began prescribing enthusiastically when
an osteoporosis drug was shown to increase the probability
of avoiding a hip fracture from 97.9%
to 98.9%. Indeed, this 1% absolute risk advantage convinced our peers; mind you, after being framed as a 50% relative risk reduction.
Does the Hippocratic Oath oblige us to intervene?
One may wonder why we still
intervene when not only our patients disagree with our views on what
constitutes a plausible risk
to be treated or an effective treatment
but also when the preventive efforts are 10 times more resource
consuming than the
treatment for the event to be
prevented? Most doctors argue that, in matters of life and death, we
have no other option. However,
in other disciplines affecting the
health and well-being of humans, we easily make decisions based on cost.
For example, teachers
in primary school are well aware of the
fact that there are numerous children in each class with learning
disabilities who
might come from troubled families and
who would be naturally at ‘high risk’ of becoming illiterate. But does
the increased
risk of consequent social deprivation
drive us to fund and execute large-scale special needs teaching for all
‘at-risk kids’?
Treating ‘high risk’—a mockery of shared decision-making?
Let us get back to the
pivotal question: Is treating ‘High Risk’ a viable concept? A strategy
of obtaining a single estimate
of a patient's risk and reducing this
risk effectively is appealing. However, evidence from behavioural
sciences suggests
that we are generally poor in making
probability decisions.9
And, despite laudable efforts to improve the communication and
comprehension of both the concept of risk and the anticipated
treatment benefit, risk-illiteracy of
the gravest magnitude still affects both doctors and patients (figure 1).6 But without accurate and common comprehension of these key aspects, there is no basis for shared decisions.10 And without shared decision-making, pharmacological primary prevention becomes a tyranny of eminence.
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