Archives of Osteoporosis

, 13:103 | Cite as

The prevalence of overtreatment of osteoporosis: results from the PAADRN trial

  • Sylvie F. HallEmail author
  • Nicole C. Wright
  • Fredric D. Wolinsky
  • Yiyue Lou
  • Stephanie Edmonds
  • Douglas Roblin
  • Michael Jones
  • Kenneth Saag
  • Peter Cram
Original Article



Overtreatment of osteoporosis increases costs and puts patients at unnecessary risk of experiencing adverse drug events. In the Patient Activation After DXA Receipt Notification (PAADRN) trial, we found that 8% of individuals with no indication for therapy were recommended a new osteoporosis medication or continuation of an existing medication.


There is a robust body of literature addressing undertreatment in osteoporosis, but limited data addressing overtreatment. Understanding overtreatment is important to minimize harm and decrease costs.


One of the pre-specified post hoc analyses of the PAADRN trial, a randomized, controlled, pragmatic clinical trial, was to quantify and identify risk factors associated with osteoporosis overtreatment. PAADRN included patients ≥ 50 years of age presenting for bone density testing between February, 2012, and August, 2014, at three US healthcare systems. We assessed 20,397 patients for eligibility and randomized 7749. Intervention patients received a tailored letter containing their dual-energy X-ray absorptiometry (DXA) results and an educational osteoporosis brochure. Control patients received usual care. Using the National Osteoporosis Foundation treatment guidelines, we defined overtreatment as the receipt of osteoporosis pharmacotherapy 12 weeks after DXA when treatment was not indicated. We evaluated the relationship between the following baseline variables—sex, race/ethnicity, educational attainment, and differences across health systems—and overtreatment using a series of multivariable logistic regression models.


Among 3602 patients with no apparent indication for osteoporosis treatment, 292 (8.1%; 95% CI, 7.22 to 9.00%) received a new prescription for osteoporosis pharmacotherapy or were instructed to continue an existing medication (presumed overtreatment). Presumed overtreatment was more common among participants with prior DXA history, those who reported a history of osteoporosis or low bone mass, and those referred for testing by family medicine providers.


In our sample of older adults, overuse of osteoporosis pharmacotherapy was only 8.1%. Nevertheless, overtreatment exposes patients to possible risk with negligible chance of benefit and should be minimized.

Trial registration identifier: NCT01507662


Osteoporosis Therapeutics Aging DXA Fracture risk assessment 



This work was supported by R01 AG033035 (Cram/Wolinsky) from the NIA at NIH. Dr. Cram is supported by a K24 AR062133 award from NIAMS at the NIH. Dr. Wright is supported by a K12 HS023009 award from AHRQ. Dr. Saag is supported by a K24 AR052361 award from the NIAMS at the NIH.

Role of the sponsor

The NIA had no role in the design and conduct of the study; collection, management, analysis, and interpretation of data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Author contributions

Study concept and design: Cram, Edmonds, Jones, Roblin, Saag, Wolinsky

Acquisition of data: Edmonds, Hall

Analysis and interpretation of data: Jones, Lou, Wolinsky

Drafting of the manuscript: Cram, Hall, Lou, Wolinsky, Wright

Critical revision of the manuscript: Cram, Edmonds, Hall, Jones, Lou, Roblin, Saag, Wolinsky, Wright

Statistical analysis: Jones, Lou

Obtained funding: Cram, Roblin, Saag

Administrative, technical, or material support: Edmonds, Hall, Wolinsky

Study supervision: Cram, Edmonds, Hall, Wolinsky

Compliance with ethical standards


Cram, Jones, Lou, and Wolinsky had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Conflicts of interest

P Cram, M Jones, F Wolinsky, S Edmonds, S Hall, Y Lou, and D. Roblin have no conflicts of interest. NC Wright has received unrestricted grant support from Amgen for work unrelated to this project, and is a consultant to Pfizer. KG Saag has received grants from Amgen, Eli Lilly, and Merck and has served as a paid consultant to Amgen, Eli Lilly, and Merck.


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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2018

Authors and Affiliations

  • Sylvie F. Hall
    • 1
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  • Nicole C. Wright
    • 2
    • 3
  • Fredric D. Wolinsky
    • 4
    • 5
    • 6
  • Yiyue Lou
    • 7
  • Stephanie Edmonds
    • 4
    • 6
  • Douglas Roblin
    • 8
    • 9
  • Michael Jones
    • 7
  • Kenneth Saag
    • 3
  • Peter Cram
    • 10
    • 11
  1. 1.Department of PharmacyCleveland ClinicClevelandUSA
  2. 2.Department of EpidemiologyUniversity of Alabama at BirminghamBirminghamUSA
  3. 3.Division of Clinical Immunology and RheumatologyUniversity of Alabama at BirminghamBirminghamUSA
  4. 4.Division of General Internal Medicine, Department of Internal Medicine, College of MedicineUniversity of Iowa CarverIowa CityUSA
  5. 5.Department of Health Management and Policy, College of Public HealthUniversity of IowaIowa CityUSA
  6. 6.College of NursingUniversity of IowaIowa CityUSA
  7. 7.Department of Biostatistics, College of Public HealthUniversity of IowaIowa CityUSA
  8. 8.Kaiser PermanenteAtlantaUSA
  9. 9.School of Public HealthGeorgia State UniversityAtlantaUSA
  10. 10.Faculty of MedicineUniversity of TorontoTorontoCanada
  11. 11.Division of General Internal Medicine and GeriatricsMt. Sinai and UHN HospitalsTorontoCanada

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