Log in
Rheumatology

2019 EULAR points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older

EULAR2021Full text
Full text · CC BYAdams J, Wilson N, Hurkmans E, Bakkers M, Balážová P, Baxter M et al.. 2019 EULAR points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older. Ann Rheum Dis, 2021. Licensed under CC BY. Changes: reformatted for the web. Original: https://doi.org/10.1136/annrheumdis-2020-216931

Summary

Objective

To establish European League Against Rheumatism (EULAR) points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older.

Methods

Points to consider were developed in accordance with EULAR standard operating procedures for EULAR-endorsed recommendations, led by an international multidisciplinary task force, including patient research partners and different health professionals from 10 European countries. Level of evidence and strength of recommendation were determined for each point to consider, and the mean level of agreement among the task force members was calculated.

Results

Two overarching principles and seven points to consider were formulated based on scientific evidence and the expert opinion of the task force. The two overarching principles focus on shared decisions between patients and non-physician health professionals and involvement of different non-physician health professionals in prevention and management of fragility fractures. Four points to consider relate to prevention: identification of patients at risk of fracture, fall risk evaluation, multicomponent interventions to prevent primary fracture and discouragement of smoking and overuse of alcohol. The remaining three focus on management of fragility fractures: exercise and nutritional interventions, the organisation and coordination of multidisciplinary services for post-fracture models of care and adherence to anti-osteoporosis medicines. The mean level of agreement among the task force for the overarching principles and the points to consider ranged between 8.4 and 9.6.

Conclusion

These first EULAR points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older serve to guide healthcare practice and education.

Keywords: osteoporosis, multidisciplinary team-care, health services research

Introduction

Countries across the world are facing a fragility fracture crisis.1 Estimates suggest that by 2040 over 300 million adults age 50 years or more worldwide will be at high-risk of fragility fracture.2 In 2017, across France, Germany, Italy, Spain, Sweden and the UK alone, there were 2.68 million new fragility fractures, costing an estimated €37.5 billion.3 These numbers are projected to rise, such that in 2030 over 3.3 million new fractures are anticipated across the same six countries, with accompanying total fracture-related costs approximating €47.4 billion.3

Many fragility fractures require immediate acute fracture care and typically lead to physical disability, persistent pain, impaired quality of life and increased mortality.4 Among those who sustain a fragility fracture, the risk of imminent subsequent fracture is substantial,5 6 highlighting the importance of primary and secondary fracture prevention.

Interventions delivered by non-physician health professionals (HPs), such as dietitians, nurses, occupational therapists, pharmacists and physiotherapists, in close collaboration with rheumatologists, orthopaedic surgeons, rehabilitation specialists and general practitioners, are important in the management of patients at high-risk of fragility fractures. Interventions by non-physician HPs include exercise and functional training, prescription of assistive devices, fall prevention programmes, nutritional supplements and education. Drug therapy is important in the prevention and management of fractures, and in some countries non-physician HPs can prescribe anti-osteoporosis medicines.7

The European League Against Rheumatism (EULAR) Standing Committees recognise the importance of optimising healthcare delivered by non-physician HPs to people at high-risk of fragility fractures. The EULAR/EFORT (European Federation of National Associations of Orthopaedics and Traumatology) recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fracture,8 focussed primarily on physician-based interventions. Interventions delivered by non-physician HPs were not comprehensively covered. Therefore, this study aimed to establish EULAR points to consider for the prevention and management of fragility fractures by non-physician HPs to complement and extend the EULAR/EFORT recommendations. As there is considerable variation across European countries in the roles and tasks of HPs, we focussed on interventions that could potentially be delivered by non-physician HPs independent of whether specific HPs do certain interventions in a country or not.

Methods

Points to consider were developed in accordance with up-to-date EULAR standard operating procedures for EULAR-endorsed recommendations.9 An international multidisciplinary task force was established, comprising two patient research partners, one dietitian, one geriatrician and one nurse, three occupational therapists, two orthopaedic surgeons, four physiotherapists, one specialist in physical medicine and rehabilitation and five rheumatologists, with expertise in the management of osteoporosis and/or fragility fractures. A Delphi survey, conducted by email, was undertaken to set up and prioritise the clinical questions on a 9-point Likert-scale (scores 1 to 3 ‘not relevant’, scores 4 to 6 ‘potentially relevant’, scores 7 to 9 ‘(highly) relevant’). Thirteen questions were reduced to eight via two rounds of voting by the task force (questions scoring <4 were excluded, questions scoring >6 were included and questions scoring 4 to 6 were discussed and revised). This was followed by a systematic literature review (SLR) based on the eight clinical questions (online supplementary file 1, table 1) formulated around two linked concepts: (i) adults ≥50 years of age at high-risk of primary or secondary osteoporotic fracture and (ii) interventions delivered by non-physician HPs to prevent and manage osteoporotic fractures. High-risk of osteoporotic fracture was categorised based on bone mineral density (BMD) values for osteoporosis and osteopenia10 and/or short-term probability of fracture (table 1). Key outcomes were fractures and falls, although BMD and risk of falling were included as surrogate endpoints.

Table 1

Categorisation of individuals at high-risk of fragility fracture

OsteopeniaT score =<-1.0 to −2.5 SD
OsteoporosisT score =≤−2.5 SD
FRAX 10-year probability of a major* osteoporotic fracture≥20% (age independent)
FRAX 10-year probability of hip fracture≥3% (age independent)
FRAX NOGG threshold40 to 90 years (age dependent)

Note: T score, unit of SD from the mean for bone mineral density compared with a healthy young adult; FRAX, Fracture Risk Assessment Tool; NOGG, National Osteoporosis Guideline Group.

FRAX intervention thresholds vary between countries.

*A clinical spine, hip, forearm or humerus fracture.

Evidence was appraised using a domain-based assessment of risk of bias for primary studies,11 and A MeaSurement Tool to Assess systematic Reviews (AMSTAR 2)12 and classified using the Oxford 2011 Levels of Evidence Table13 (online supplementary file 1, tables 2-5). Evidence was rated as: sufficient, some, insufficient and insufficient evidence to determine14 (online supplementary file 1, table 6). The research fellow (NW), and one convenor (EH), extracted data for the SLR in close collaboration with the methodologist (TAS). This SLR has been published.15

The task force met for one face-to-face meeting to review the results of the SLR and formulated the points to consider; these were finalised over subsequent weeks by online discussions and circulated to all task force members for voting via email. The level of agreement for the overarching principles and each point to consider was assessed using a numerical rating scale from 0 (complete disagreement) to 10 (complete agreement). In parallel with this, research and education agendas for the non-physician HP workforce to prevent and optimally manage fragility fractures were proposed and developed via a single round of iterative online discussion among the task force.

Results

Two overarching principles to underpin high quality care were supported by the task force; shared decision-making16 and multi-professional working. Shared decision-making is an essential component of personalised care17 and may reduce unwarranted variation in healthcare practice,18 while involving non-physician HPs in the treatment and management of patients at high-risk of fragility fracture widens opportunities to prevent and optimally manage fragility fractures. Currently, non-physician HPs are only sometimes involved in the organisation and delivery of care for patients at high-risk of fracture.

Seven points to consider, describing non-pharmacological interventions, were developed and are summarised in table 2, along with underpinning levels of evidence, strength of recommendations and level of agreement among task force members.

Table 2

Overarching principles and EULAR points to consider for the prevention and management of fragility fracture by non-physician HPs

No Overarching principles Level of Agreement (Mean (SD))
1 The management of patients at risk of a fragility fracture should be based on shared decision making between patients and non-physician HPs.9 (1.8)
2 Non-physician HPs should be involved in the management of patients at risk of fragility fractures.8.4 (2.2)
No Point to consider Level of evidence Strength of recommendation Level of Agreement (Mean (SD))
Prevention of Fragility Fractures Median (Range)
1 Identification of patients at risk of fracture
Non-physician HPs should identify patients at risk of fragility fracture, ensure that the patients are offered opportunities for adequate treatment and address bone fragility in patient education.9.06 (1.16)
2B
9.5 (7–10)
2 Fall risk evaluation
Non-physician HPs should start with fall risk evaluation of patients at risk of fragility fracture. Patients at high-risk of falls should be assessed by non-physician HPs using an individualised approach to multi-component screening or referred to one or more non-physician HPs competent in multi-component screening.4C9.61 (0.70)
10 (8 to 10)
3 Preventive multicomponent interventions
Tailored multicomponent interventions, including for example:
  • Exercise
1 to 3A9.33 (0.91)
  • Environmental adaptations
2D
  • Nutrition
1 to 2D10 (8 to 10)
  • Education
2D
should be offered to patients at high-risk of primary osteoporotic fracture and/or high-risk of falls
4 Avoidance of smoking and overuse of alcohol
Smoking and overuse of alcohol should be discouraged.1A9.22 (1.31)
10 (5 to 10)
No Point to consider Level of evidence Strength of recommendation Level of Agreement (Mean (SD))
Management of Fragility Fractures Median (Range)
5 Exercise and nutritional interventions for patients who have experienced a fragility fracture
Non-physician HPs should ensure that patients who have experienced a fragility fracture are given opportunities for:
  • adequate exercise
1 to 2A9.22 (0.88)
  • adequate nutritional intake
2D
Calcium and vitamin D intake should be discussed with the patient focussing on actual and recommended daily calcium intake, calcium and vitamin D rich foods, and the individual’s risk/benefit profile for vitamin D supplementation.1 to 2D9.5 (8 to 10)
6 Organisation and coordination of multidisciplinary services
Non-physician HPs should be included in orthogeriatric services, FLS and/or a coordinated, multidisciplinary post-fracture prevention programme. Patients with fragility fractures should be referred to a FLS or an adequate, coordinated, multidisciplinary post-fracture prevention programme1 to 29.50 (1.10)
10 (6 to 10)
7 Adherence to anti-osteoporosis medicines
Non-physician HPs should address, monitor and support medication adherence in a structured follow-up.2 to 3B8.83 (1.25)
9 (6 to 10)

EULAR, European League Against Rheumatism; FLS, fracture liaison services; HPs, health professionals.

Point to consider 1: identification of patients at risk of fracture

No studies evaluating the effect of fracture risk detection by non-physician HPs were included in the SLR. Case finding people at risk of fracture can be undertaken in the first instance through identification of clinical factors (for example age, low body mass index, smoking, family fracture history, height loss ≥4 cm or a thoracic kyphosis).19 20 Simple online assessment tools incorporating various clinical risk factors (with or without a measure of BMD) into a fracture risk algorithm (such as the Fracture Risk Assessment Tool (FRAX),21 Garvan22 and QFracture23) are freely available in many countries24 and recent evidence suggests that FRAX-based screening and guided management of community-dwelling older women, may reduce incident hip fractures, but not overall fractures.25 Given the centrality of risk assessment to fracture prevention, the task force agreed that non-physician HPs should identify patients at risk of fragility fracture.

Risk identification and stratification can facilitate appropriate management, and workforce developments over recent decades have widened opportunities for non-physician HPs to manage individuals at risk of fragility fracture.26 27 National and local practice policies and pathways can be established to support requests for laboratory testing and diagnostic investigations (such as dual-energy X-ray absorptiometry scans) by non-physician HPs, and implementation of non-medical prescribing could increase patient access to effective osteoporosis treatment.7 27 As an example, Bowers et al 28 reported higher anti-fracture medicine prescription rates for women at high-risk of fragility fracture with implementation of a collaborative pharmacist-physician model of management compared with physician-only management.

Point to consider 2: fall risk evaluation

Initial assessment of risk of falls in adults at high-risk of fragility fracture should focus on key questions relating to: any history of falls within the past 12 months, fear of falling and/or feeling unsteady while walking or standing.29 A positive response in any of these areas should be followed up with a multifactorial falls-risk assessment incorporating evaluation of gait and mobility (measured for example by the Timed Up and Go test30) and other relevant factors, such as balance, lower limb strength, medication, postural dizziness/hypotension, vision, mental health and cognitive capacity, footwear and environmental factors.29 Although the evidence identified in the SLR was insufficient to determine benefit of fall risk evaluation in adults at high-risk of fragility fracture, the task force agreed that a multifactorial falls risk assessment should be done (by one appropriately skilled HP or a number of different HPs31) as, when followed by multifactorial fall prevention interventions, multifactorial falls risk assessment involving non-physician HPs may reduce rate of falls in older people when compared with other approaches.32 33

Point to consider 3: preventative multicomponent interventions

Multicomponent interventions, including for example exercise, fall-prevention strategies and education about bone health are important in primary fragility fracture prevention. Such multicomponent interventions may reduce fall rate and positively influence bone health in older people at high-risk of fragility fracture and/or at high-risk of falls.34–36

Regular long-term exercise is essential for bone health.37 38 Weight-bearing impact exercise and/or resistance training promotes strong bones and improves physical performance,38 while exercise interventions incorporating balance and functional training reduce rate of falls and number of fallers in older people at high-risk of falls living in the community.39

In people with bone fragility, we found sufficient evidence that multicomponent exercise incorporating dynamic weight-bearing, strength and balance training undertaken 2 to 3 days a week for at least 10 weeks, reduces risk of falling,40 and some evidence that multicomponent exercise undertaken for >1 year positively influences BMD.35 41 Evidence about whole body vibration or low impact exercise is limited and insufficient to determine effect on bone health-related outcomes in people with bone fragility.42 43

Customised multifactorial interventions, targeting individualised fall-risk factors, may reduce the incidence in falls rate in community-dwelling older people at high-risk of falling.32 33 One randomised controlled trial (RCT),36 reported a reduced falls rate in participants attending fall prevention clinics in Finland who received, on average, five fall and injury prevention interventions, commonly including home hazard modification, nutrition and lifestyle advice, medicines review and strength and balance training delivered by different HPs, including nurses and physiotherapists. The incidence rate of falls per 100 person years over a 12-month period were 95 in the intervention group and 131 in the control group (incidence rate ratio 0.72, 95% CI 0.61 to 0.86; p<0.001). The number needed to treat to prevent one fall was three.36

Data about the effect of nutrition on bone health-related outcomes in people with osteoporosis or osteopenia are limited. The evidence identified in our SLR was insufficient to determine the effect of vitamin D analogues, non-soy protein or daily vitamin K on BMD or fractures in older women with T scores between −1 and ≥−2.5.44–46 Nonetheless, maintenance of a healthy weight, increased consumption of fresh fruit and vegetables, lowering sodium intake and ensuring country-specific recommended intake levels of dietary calcium, may favourably impact bone health.47 Adequate serum levels of vitamin D are important for good musculoskeletal health, although the effect of supplementation on bone health-related outcomes remains contested.48–50 Analysis of pooled data from RCTs showed vitamin D supplementation had no effect on falls (n=34 144, relative risk (RR) 0.97, 95% CI 0.93 to 1.02) or total fractures (n=44 790, RR 1.00, 95% CI 0.93 to 1.07).51

The effect of face-to-face patient education on bone health-related outcomes in people with bone fragility is uncertain.52 In a systematic review including 13 RCTs of mostly high or moderate risk of bias, outcomes, including knowledge about osteoporosis, initiation and adherence to osteoporosis medication and fractures, were mixed;52 less than half of the studies reported a statistically significant difference favouring the intervention.

Despite insufficient evidence to determine the effect of some interventions, the task force agreed that non-physician HPs should offer multicomponent interventions including nutrition, multifactorial fall prevention initiatives and education, along with exercise (in particular supervised progressive weight-bearing, strength and balance training), to patients at high-risk of falls and or primary fragility fracture.

Point to consider 4: avoidance of smoking and overuse of alcohol

The negative impact of tobacco smoking on bone and bone-health related outcomes are widely recognised.53 Smoking adversely affects bone mass in some populations,54 55 and results from meta-analyses consistently demonstrate increased risk of osteoporotic fractures in people who currently smoke compared with never or non-smokers.56–59

High intakes of alcohol (more than two units/day or ≥50 g/day) also increase fracture risk.60 61 The effects of alcohol on bone are complex and dose-dependent, and influenced by both direct and indirect mechanisms, such as alterations in activity and numbers of osteoblast and osteoclasts, hormonal changes and impaired nutrition.62 For some, the consequences of skeletal fragility are exacerbated by increased risk of falling63 mediated by intoxication and/or neuropathy.

Point to consider 5: exercise and nutritional interventions for patients who have experienced a fragility fracture

Following hip fracture surgery, structured exercise interventions, in particular interventions that incorporate progressive resistance exercise training, result in small but significant improvements in mobility and physical function.64 65 Multicomponent exercise, incorporating strength and balance training, reduces risk of falls in people who have experienced an osteoporotic fracture,40 while regular long-term resistance and weight-bearing exercise may favourably affect BMD.41 Evidence about the optimal frequency, intensity and duration of exercise for people with osteoporotic fracture is limited. However, several country-specific recommendations drawing on expert consensus, in combination with evidence, are available to guide practice.66 67

Concerning the effect of nutrition on bone health, insufficient evidence was found to determine the effect of oral protein supplementation on functional outcomes in people following hip fracture68 while vitamin D (800 IU) and calcium (1000 mg) supplementation in older people with a history of osteoporotic fracture appeared generally ineffective in preventing future hip or any new fracture.69 One RCT, at low risk of bias, investigated the effect of a single loading dose of vitamin D3 compared with a placebo injection administered to older people within 7 days of hip fracture surgery.70 At 4 weeks there was no statistically significant between-group difference in fracture incidence, but the falls rate of participants in the active group was 250 (number of falls/days x 1000) compared with 821.4 in the placebo group (absolute risk reduction 57.1%).

The task force considered these findings and agreed that non-physician HPs should encourage adequate nutrition for patients with a history of osteoporotic fracture and discuss vitamin D and calcium intake with them, focussing on actual and recommended daily calcium intake, calcium and vitamin D rich foods and the individual’s risk/benefit profile for vitamin D supplementation.

Point to consider 6: organisation and coordination of multidisciplinary services

The clinical and cost-effectiveness of coordinated multidisciplinary post-fracture models of care was confirmed in our SLR.71–73 Orthogeriatric services, delivering collaborative multidisciplinary inpatient care to older people admitted with hip fracture, reduce relative risk of in-hospital and long-term mortality compared with standard care. Functional recovery and factors associated with risk of falling may also be positively impacted by early multidisciplinary HP team care approaches.74 75

Alongside, multidisciplinary fracture liaison services (FLS), in which non-physician HPs such as nurses, pharmacists and physiotherapists effectively coordinate case finding, risk stratification and secondary fracture prevention,76 reduce re-fracture rates. In a meta-analysis of 19 519 participants who had experienced an osteoporotic fracture, a FLS compared with no FLS or usual care reduced absolute risk of re-fracture rate by approximately 30%.72 Irrespective of the care model or country, FLS when compared with usual care or no treatment are cost-effective.73

Many countries in Europe have now implemented coordinated post-fracture multidisciplinary models of care based on best practice standards,77 and the task force recommended that non-physician HPs should be included in these services.

Point to consider 7: adherence to anti-osteoporosis medicines

Despite the efficacy of anti-fracture pharmaceuticals,78 79 rates of non-adherence to anti-osteoporosis medicines are high80 81 and adversely affect outcomes.82 Non-adherence to medicines can be characterised by non-initiation of a prescription, suboptimal implementation and premature discontinuation of treatment.83 Interventions to improve adherence commonly target drug regimens, systems, providers and patients, although effects are inconsistent in people with chronic health problems.84 There is some evidence that interventions delivered by HPs (education, less frequent dosing regimens, electronic prescription and pharmacist-delivered osteoporosis management services) may improve adherence to anti-osteoporosis medications.85–87 Consequently, the task force agreed that non-physician HPs should evaluate medication adherence in patients prescribed anti-osteoporosis medicines, and explore ways to improve adherence.

Research and education agenda

The research and education agendas (boxes 1 and 2), support the development of capability and capacity within the non-physician workforce to prevent and optimally manage fragility fractures in adults 50 years or older. We recommend that consensus-derived core competencies are identified and embedded in HP education and training.

Discussion

These EULAR points to consider, underpinned by shared decision-making and multi-professional working complement the previous EULAR/EFORT recommendations.8 They provide a template for the organisation and delivery of healthcare by non-physician HPs to prevent and manage fragility fractures and contribute to holistic patient management.88 In addition to fall risk evaluation and interventions delivered by non-physician HPs, the task force developed a separate point to consider, focussed on adherence to medicines. While some non-physician HPs prescribe medicines, all non-physician HPs should address, monitor and support adherence to prescribed anti-osteoporosis medicines in patients at risk of fragility fracture.

We acknowledge that patient management and HP roles and responsibilities differ across countries. However, these points can be tailored and used jointly by stakeholders as a focus for contextualised formative evaluations about implementation of interventions delivered by non-physician HPs, underpinned by country-specific patient level data from audit databases and registries.89–91 The generation of this knowledge, in conjunction with the identification of contextual barriers and facilitators to optimal management and implementation strategies,92 93 could enhance the role and impact of non-physician HPs working alongside medical colleagues to deliver services for this patient population.

We recommend that education about osteoporosis, fall and fracture risk assessment, and interventions to prevent and optimally manage fragility fractures, should be a core component of non-physician HP undergraduate training. An interdisciplinary focus through generic competencies for non-physician HPs in fragility fracture prevention and management, may lead to more consistent and effective care, and tackle the personal, societal and economic burden associated with fracture events.

The low levels of evidence for some points to consider call for well-designed research studies that include specific non-physician HP interventions. Such studies should consider using behavioural change techniques to enhance adherence to interventions delivered by non-physician HPs and optimise service delivery to prevent and manage fragility fractures.

Our study has some limitations. First, over half of our points to consider were formulated wholly or in part based on the expert opinion of the task force, due to insufficient published research evidence. Our definition of high-risk populations probably excluded evidence from other studies examining commonly used interventions, such as multifactorial falls prevention strategies for other older adult populations. Second, our SLR preferentially selected systematic reviews and large RCTs and may have excluded some studies. Third, while data extraction and risk of bias judgements were conducted systematically, duplicate independent assessments would have added further value. Lastly, the addition of a general practitioner on the task force would have been beneficial.

Conclusion

The personal, societal and economic burdens associated with fragility fractures are enormous. These EULAR points to consider, based on robust development processes and agreed by an international task force, can guide non-physician HPs in the prevention and management of fragility fractures in adults 50 years or older.

Acknowledgments

We thank EULAR for supporting the development of these points to consider.

Footnotes

Handling editor: Désirée van der Heijde

Twitter: @Stiddyo, @JennydelaTorr16

JA and NW contributed equally.

Contributors: NW, JA, EH, MB, PB, MB, A-BB, KB, CCh, CCo, RGD, GG, WL, EM, SP, CS, PS, ST, JdlT-A and TAS discussed and formulated the clinical questions and interpreted the results. NW, JA, EH and TAS collected the data, performed the analysis and wrote the manuscript. All authors read and critically reviewed the manuscript prior to submission. JA and NW contributed equally to this paper.

Funding: This study was funded by the European League Against Rheumatism (EULAR). Grant reference HPR 032.

Competing interests: None declared.

Patient and public involvement: Patients and/or the public were involved in the design, or conduct, or reporting or dissemination plans of this research. Refer to the Methods section for further details.

Patient consent for publication: Not required.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement: All data relevant to the study are included in the article or uploaded as supplementary information.

References

1. Dreinhöfer KE, Mitchell PJ, Bégué T, et al. A global call to action to improve the care of people with fragility fractures. Injury 2018;49:1393–7. 10.1016/j.injury.2018.06.032 2. Odén A, McCloskey EV, Kanis JA, et al. Burden of high fracture probability worldwide: secular increases 2010-2040. Osteoporos Int 2015;26:2243–8. 10.1007/s00198-015-3154-6 3. International Osteoporosis Foundation Broken bones, broken lives: A roadmap to solve the fragility fracture crisis in Europe, 2018. Available: http://share.iofbonehealth.org/EU-6-Material/Reports/IOF%20Report_EU.pdf [Accessed 4 Apr 2019].4. Sànchez-Riera L, Wilson N. Fragility Fractures & Their Impact on Older People. Best Pract Res Clin Rheumatol 2017;31:169–91. 10.1016/j.berh.2017.10.001 5. Kanis JA, Johansson H, Odén A, et al. Characteristics of recurrent fractures. Osteoporos Int 2018;29:1747–57. 10.1007/s00198-018-4502-0 6. Balasubramanian A, Zhang J, Chen L, et al. Risk of subsequent fracture after prior fracture among older women. Osteoporos Int 2019;30:79–92. 10.1007/s00198-018-4732-1 7. Cope LC, Abuzour AS, Tully MP. Nonmedical prescribing: where are we now? Ther Adv Drug Saf 2016;7:165–72. 10.1177/2042098616646726 8. Lems WF, Dreinhöfer KE, Bischoff-Ferrari H, et al. EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures. Ann Rheum Dis 2017;76:802–10. 10.1136/annrheumdis-2016-210289 9. van der Heijde D, Aletaha D, Carmona L, et al. 2014 update of the EULAR standardised operating procedures for EULAR-endorsed recommendations. Ann Rheum Dis 2015;74:8–13. 10.1136/annrheumdis-2014-206350 10. World Health Organisation Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: Report of a WHO Study Group. Geneva: World Health Organisation, 1994.11. Higgins JPT, Altman DG, Sterne JAC. Chapter 8: Assessing risk of bias in included studies In: Higgins JPT, Churchill R, Chandler J, et al., eds Cochrane Handbook for Systematic Reviews of Interventions Version 5.2.0, 2017.12. Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 2017;358:j4008. 10.1136/bmj.j4008 13. OCEBM Levels of Evidence Working Group “The Oxford 2011 Levels of Evidence”. Oxford Centre for Evidence-Based Medicine. Available: http://www.cebm.net/index.aspx?o=5653 [Accessed 4 Apr 2019].14. Ryan R, Santesso N, Lowe D, et al. Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database Syst Rev 2014:CD007768. 10.1002/14651858.CD007768.pub3 15. Wilson N, Hurkmans E, Adams J, et al. Prevention and management of osteoporotic fractures by non-physician health professionals: a systematic literature review to inform EULAR points to consider. RMD Open 2020;6:e001143. 10.1136/rmdopen-2019-001143 16. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med 2012;27:1361–7.17. NHS England Universal personalised care: implementing the comprehensive model, 2019. Available: https://www.england.nhs.uk/wp-content/uploads/2019/01/universal-personalised-care.pdf [Accessed 21 Mar 2020].18. Wennberg JE. Practice variation: implications for our health care system. Manag Care 2004;13:3–7. 19. Kanis JA, Cooper C, Rizzoli R, et al. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 2019;30:3–44. 10.1007/s00198-018-4704-5 20. Compston J, Cooper A, Cooper C, et al. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos 2017;12:43. 10.1007/s11657-017-0324-5 21. University of Sheffield Fracture risk assessment tool. Available: https://www.sheffield.ac.uk/FRAX/ [Accessed 3 Mar 2019].22. Garvan Institute Bone fracture risk calculator. Available: https://www.garvan.org.au/bone-fracture-risk [Accessed 3 Mar 2019].23. ClinRisk Welcome to the QFracture-2016 risk calculator. Available: https://qfracture.org/ [Accessed 3 Mar 2019].24. Curtis EM, Moon RJ, Harvey NC, et al. Reprint of: The impact of fragility fracture and approaches to osteoporosis risk assessment worldwide. Int J Orthop Trauma Nurs 2017;26:7–17. 10.1016/j.ijotn.2017.04.004 25. Shepstone L, Lenaghan E, Cooper C, et al. Screening in the community to reduce fractures in older women (SCOOP): a randomised controlled trial. Lancet 2018;391:741–7. 10.1016/S0140-6736(17)32640-5 26. World Health Organisation Mid-level health workers: a review of the evidence, 2017. Available: https://apps.who.int/iris/bitstream/handle/10665/259878/UHC-health_workers.pdf;jsessionid=70E8F78561A1C5E41DAE91A96EC4DD5C?sequence=1 [Accessed 3 Mar 2019].27. Weeks G, George J, Maclure K, et al. Non-Medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care. Cochrane Database Syst Rev 2016;11:CD011227. 10.1002/14651858.CD011227.pub2 28. Bowers BL, Drew AM, Verry C. Impact of pharmacist-physician collaboration on osteoporosis treatment rates. Ann Pharmacother 2018;52:876–83. 10.1177/1060028018770622 29. Ambrose AF, Cruz L, Paul G, Falls PG. Falls and fractures: a systematic approach to screening and prevention. Maturitas 2015;82:85–93. 10.1016/j.maturitas.2015.06.035 30. Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142–8. 10.1111/j.1532-5415.1991.tb01616.x 31. National Institute for Health and Care Excellence Falls in older people: assessing risk and prevention, 2013. Available: http://www.nice.org.uk/guidance/cg161 [Accessed 30 Mar 2019].32. Guirguis-Blake JM, Michael YL, Perdue LA, et al. Interventions to prevent falls in older adults: updated evidence report and systematic review for the US preventive services Task force. JAMA 2018;319:1705–16. 10.1001/jama.2017.21962 33. Hopewell S, Adedire O, Copsey BJ, et al. Multifactorial and multiple component interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2018;7:CD012221. 10.1002/14651858.CD012221.pub2 34. Smulders E, Weerdesteyn V, Groen BE, et al. Efficacy of a short multidisciplinary falls prevention program for elderly persons with osteoporosis and a fall history: a randomized controlled trial. Arch Phys Med Rehabil 2010;91:1705–11. 10.1016/j.apmr.2010.08.004 35. Gianoudis J, Bailey CA, Ebeling PR, et al. Effects of a targeted multimodal exercise program incorporating high-speed power training on falls and fracture risk factors in older adults: a community-based randomized controlled trial. J Bone Miner Res 2014;29:182–91.36. Palvanen M, Kannus P, Piirtola M, et al. Effectiveness of the chaos falls clinic in preventing falls and injuries of home-dwelling older adults: a randomised controlled trial. Injury 2014;45:265–71. 10.1016/j.injury.2013.03.010 37. Behringer M, Gruetzner S, McCourt M, et al. Effects of weight-bearing activities on bone mineral content and density in children and adolescents: a meta-analysis. J Bone Miner Res 2014;29:467–78. 10.1002/jbmr.2036 38. Xu J, Lombardi G, Jiao W, et al. Effects of exercise on bone status in female subjects, from young girls to postmenopausal women: an overview of systematic reviews and meta-analyses. Sports Med 2016;46:1165–82. 10.1007/s40279-016-0494-0 39. Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev 2019;1:CD012424. 10.1002/14651858.CD012424.pub2 40. Varahra A, Rodrigues IB, MacDermid JC, et al. Exercise to improve functional outcomes in persons with osteoporosis: a systematic review and meta-analysis. Osteoporos Int 2018;29:265–86. 10.1007/s00198-017-4339-y 41. de Kam D, Smulders E, Weerdesteyn V, et al. Exercise interventions to reduce fall-related fractures and their risk factors in individuals with low bone density: a systematic review of randomized controlled trials. Osteoporos Int 2009;20:2111–25. 10.1007/s00198-009-0938-6 42. Luo X, Zhang J, Zhang C, et al. The effect of whole-body vibration therapy on bone metabolism, motor function, and anthropometric parameters in women with postmenopausal osteoporosis. Disabil Rehabil 2017;39:2315–23. 10.1080/09638288.2016.1226417 43. Wei X, Xu A, Yin Y, et al. The potential effect of Wuqinxi exercise for primary osteoporosis: a systematic review and meta-analysis. Maturitas 2015;82:346–54. 10.1016/j.maturitas.2015.08.013 44. Porter J, Adderley M, Bonham M, et al. The effect of dietary interventions and nutritional supplementation on bone mineral density in otherwise healthy adults with osteopenia: A systematic review. Nutr Bull 2016;41:108–21. 10.1111/nbu.12199 45. Koutsofta I, Mamais I, Chrysostomou S. The effect of protein diets in postmenopausal women with osteoporosis: systematic review of randomized controlled trials. J Women Aging 2019;31:117–39. 10.1080/08952841.2018.1418822 46. Cheung AM, Tile L, Lee Y, et al. Vitamin K supplementation in postmenopausal women with osteopenia (ECKO trial): a randomized controlled trial. PLoS Med 2008;5:e196. 10.1371/journal.pmed.0050196 47. Prentice A, Diet PA. Diet, nutrition and the prevention of osteoporosis. Public Health Nutr 2004;7:227–43. 10.1079/phn2003590 48. Bischoff-Ferrari HA, Orav EJ, Abderhalden L, et al. Vitamin D supplementation and musculoskeletal health. Lancet Diabetes Endocrinol 2019;7:85. 10.1016/S2213-8587(18)30347-4 49. Bouillon R, Lips P, Bilezikian JP. Vitamin D supplementation and musculoskeletal health. Lancet Diabetes Endocrinol 2019;7:85–6. 10.1016/S2213-8587(18)30348-6 50. Bolland MJ, Grey A, Avenell A. Vitamin D supplementation and musculoskeletal health. Authors’ reply. Lancet Diabetes Endocrinol 2019;7:88–9.51. Bolland MJ, Grey A, Avenell A. Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis. Lancet Diabetes Endocrinol 2018;6:847–58. 10.1016/S2213-8587(18)30265-1 52. Morfeld J-C, Vennedey V, Müller D, et al. Patient education in osteoporosis prevention: a systematic review focusing on methodological quality of randomised controlled trials. Osteoporos Int 2017;28:1779–803. 10.1007/s00198-017-3946-y 53. Al-Bashaireh AM, Haddad LG, Weaver M, et al. The effect of tobacco smoking on musculoskeletal health: a systematic review. J Environ Public Health 2018;2018:1–106. 10.1155/2018/4184190 54. Ward KD, Klesges RC. A meta-analysis of the effects of cigarette smoking on bone mineral density. Calcif Tissue Int 2001;68:259–70. 10.1007/BF02390832 55. Strozyk D, Gress TM, Breitling LP. Smoking and bone mineral density: comprehensive analyses of the third National health and nutrition examination survey (NHANES III). Arch Osteoporos 2018;13:16. 10.1007/s11657-018-0426-8 56. Law MR, Hackshaw AK. A meta-analysis of cigarette smoking, bone mineral density and risk of hip fracture: recognition of a major effect. BMJ 1997;315:841–6. 10.1136/bmj.315.7112.841 57. Shen GS, Li Y, Zhao G, et al. Cigarette smoking and risk of hip fracture in women: a meta-analysis of prospective cohort studies. Injury 2015;46:1333–40. 10.1016/j.injury.2015.04.008 58. Wu Z-J, Zhao P, Liu B, et al. Effect of cigarette smoking on risk of hip fracture in men: a meta-analysis of 14 prospective cohort studies. PLoS One 2016;11:e0168990. 10.1371/journal.pone.0168990 59. Kanis JA, Johnell O, Oden A, et al. Smoking and fracture risk: a meta-analysis. Osteoporos Int 2005;16:155–62. 10.1007/s00198-004-1640-3 60. Kanis JA, Johansson H, Johnell O, et al. Alcohol intake as a risk factor for fracture. Osteoporos Int 2005;16:737–42. 10.1007/s00198-004-1734-y 61. Zhang X, Yu Z, Yu M, et al. Alcohol consumption and hip fracture risk. Osteoporos Int 2015;26:531–42. 10.1007/s00198-014-2879-y 62. Maurel DB, Boisseau N, Benhamou CL, et al. Alcohol and bone: review of dose effects and mechanisms. Osteoporos Int 2012;23:1–16. 10.1007/s00198-011-1787-7 63. Cawthon PM, Harrison SL, Barrett-Connor E, et al. Alcohol intake and its relationship with bone mineral density, falls, and fracture risk in older men. J Am Geriatr Soc 2006;54:1649–57. 10.1111/j.1532-5415.2006.00912.x 64. Diong J, Allen N, Sherrington C. Structured exercise improves mobility after hip fracture: a meta-analysis with meta-regression. Br J Sports Med 2016;50:346–55. 10.1136/bjsports-2014-094465 65. Lee SY, Yoon B-H, Beom J, et al. Effect of lower-limb progressive resistance exercise after hip fracture surgery: a systematic review and meta-analysis of randomized controlled studies. J Am Med Dir Assoc 2017;18:1096.e19–1096.e26. 10.1016/j.jamda.2017.08.021 66. Beck BR, Daly RM, Singh MAF, et al. Exercise and sports science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis. J Sci Med Sport 2017;20:438–45. 10.1016/j.jsams.2016.10.001 67. National Osteoporosis Society Strong, Steady and Straight: An expert consensus statement on physical activity and exercise for osteoporosis. Bath, National Osteoporosis Society, 2018.68. Myint MWW, Wu J, Wong E, et al. Clinical benefits of oral nutritional supplementation for elderly hip fracture patients: a single blind randomised controlled trial. Age Ageing 2013;42:39–45. 10.1093/ageing/afs078 69. Avenell A, Mak JCS, O'Connell D. Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men. Cochrane Database Syst Rev 2014:CD000227. 10.1002/14651858.CD000227.pub4 70. Mak JC, Mason RS, Klein L, et al. An initial loading-dose vitamin D versus placebo after hip fracture surgery: randomized trial. BMC Musculoskelet Disord 2016;17:336. 10.1186/s12891-016-1174-9 71. Grigoryan KV, Javedan H, Rudolph JL. Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis. J Orthop Trauma 2014;28:e49–55. 10.1097/BOT.0b013e3182a5a045 72. Wu C-H, Tu S-T, Chang Y-F, et al. Fracture liaison services improve outcomes of patients with osteoporosis-related fractures: a systematic literature review and meta-analysis. Bone 2018;111:92–100. 10.1016/j.bone.2018.03.018 73. Wu C-H, Kao I-J, Hung W-C, et al. Economic impact and cost-effectiveness of fracture liaison services: a systematic review of the literature. Osteoporos Int 2018;29:1227–42. 10.1007/s00198-018-4411-2 74. Leigheb F, Vanhaecht K, Sermeus W, et al. The effect of care pathways for hip fractures: a systematic overview of secondary studies. Eur J Orthop Surg Traumatol 2013;23:737–45. 10.1007/s00590-012-1085-x 75. Prestmo A, Hagen G, Sletvold O, et al. Comprehensive geriatric care for patients with hip fractures: a prospective, randomised, controlled trial. Lancet 2015;385:1623–33. 10.1016/S0140-6736(14)62409-0 76. Wu C-H, Chen C-H, Chen P-H, et al. Identifying characteristics of an effective fracture liaison service: systematic literature review. Osteoporos Int 2018;29:1023–47. 10.1007/s00198-017-4370-z 77. Akesson K, Marsh D, Mitchell PJ, et al. Capture the fracture: a best practice framework and global campaign to break the fragility fracture cycle. Osteoporos Int 2013;24:2135–52. 10.1007/s00198-013-2348-z 78. Crandall CJ, Newberry SJ, Diamant A, et al. Comparative effectiveness of pharmacologic treatments to prevent fractures: an updated systematic review. Ann Intern Med 2014;161:711–23. 10.7326/M14-0317 79. Yusuf AA, Cummings SR, Watts NB, et al. Real-World effectiveness of osteoporosis therapies for fracture reduction in post-menopausal women. Arch Osteoporos 2018;13:33. 10.1007/s11657-018-0439-3 80. Kothawala P, Badamgarav E, Ryu S, et al. Systematic review and meta-analysis of real-world adherence to drug therapy for osteoporosis. Mayo Clin Proc 2007;82:1493–501. 10.1016/S0025-6196(11)61093-8 81. Karlsson L, Lundkvist J, Psachoulia E, et al. Persistence with denosumab and persistence with oral bisphosphonates for the treatment of postmenopausal osteoporosis: a retrospective, observational study, and a meta-analysis. Osteoporos Int 2015;26:2401–11. 10.1007/s00198-015-3253-4 82. Liu J, Guo H, Rai P, et al. Medication persistence and risk of fracture among female Medicare beneficiaries diagnosed with osteoporosis. Osteoporos Int 2018;29:2409–17. 10.1007/s00198-018-4630-6 83. Vrijens B, De Geest S, Hughes DA, et al. A new taxonomy for describing and defining adherence to medications. Br J Clin Pharmacol 2012;73:691–705. 10.1111/j.1365-2125.2012.04167.x 84. Nieuwlaat R, Wilczynski N, Navarro T, et al. Interventions for enhancing medication adherence. Cochrane Database Syst Rev 2014:CD000011. 10.1002/14651858.CD000011.pub4 85. Hiligsmann M, Salas M, Hughes DA, et al. Interventions to improve osteoporosis medication adherence and persistence: a systematic review and literature appraisal by the ISPOR Medication Adherence & Persistence Special Interest Group. Osteoporos Int 2013;24:2907–18. 10.1007/s00198-013-2364-z 86. Stuurman-Bieze AGG, Hiddink EG, van Boven JFM, et al. Proactive pharmaceutical care interventions decrease patients' nonadherence to osteoporosis medication. Osteoporos Int 2014;25:1807–12. 10.1007/s00198-014-2659-8 87. Kooij MJ, Heerdink ER, van Dijk L, et al. Effects of telephone counseling intervention by pharmacists (TelCIP) on medication adherence; results of a cluster randomized trial. Front Pharmacol 2016;7:269. 10.3389/fphar.2016.00269 88. Health Education England, NHS England and Skills for Health. Musculoskeletal core capabilities framework for first point of contact practitioners, 2018. Available: https://www.skillsforhealth.org.uk/images/projects/msk/Musculoskeletal%20framework.pdf?s=form [Accessed 15 Mar 2020].89. Royal College of Physicians Secondary fracture prevention in the NHS: achieving effective service delivery by FLSs. London: Royal College of Physicians, 2018.90. Royal College of Physicians National hip fracture database, 2007. Available: www.nhfd.co.uk [Accessed 5 Jun 2019].91. Norwegian National Advisory unit on arthroplasty and hip fractures. The Norwegian hip fracture register, 2005. Available: http://nrlweb.ihelse.net/eng/ [Accessed 5 Jun 2019].92. Damschroder LJ, Aron DC, Keith RE, et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009;4:50. 10.1186/1748-5908-4-50 93. Powell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: results from the expert recommendations for implementing change (ERIC) project. Implement Sci 2015;10:21. 10.1186/s13012-015-0209-1

Associated Data

Supplementary Materials

References

  1. Dreinhöfer KE, Mitchell PJ, Bégué T, et al. A global call to action to improve the care of people with fragility fractures. Injury 2018;49:1393–7. 10.1016/j.injury.2018.06.032
  2. Odén A, McCloskey EV, Kanis JA, et al. Burden of high fracture probability worldwide: secular increases 2010-2040. Osteoporos Int 2015;26:2243–8. 10.1007/s00198-015-3154-6
  3. International Osteoporosis Foundation Broken bones, broken lives: A roadmap to solve the fragility fracture crisis in Europe, 2018. Available: http://share.iofbonehealth.org/EU-6-Material/Reports/IOF%20Report_EU.pdf [Accessed 4 Apr 2019].
  4. Sànchez-Riera L, Wilson N. Fragility Fractures & Their Impact on Older People. Best Pract Res Clin Rheumatol 2017;31:169–91. 10.1016/j.berh.2017.10.001
  5. Kanis JA, Johansson H, Odén A, et al. Characteristics of recurrent fractures. Osteoporos Int 2018;29:1747–57. 10.1007/s00198-018-4502-0
  6. Balasubramanian A, Zhang J, Chen L, et al. Risk of subsequent fracture after prior fracture among older women. Osteoporos Int 2019;30:79–92. 10.1007/s00198-018-4732-1
  7. Cope LC, Abuzour AS, Tully MP. Nonmedical prescribing: where are we now? Ther Adv Drug Saf 2016;7:165–72. 10.1177/2042098616646726
  8. Lems WF, Dreinhöfer KE, Bischoff-Ferrari H, et al. EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures. Ann Rheum Dis 2017;76:802–10. 10.1136/annrheumdis-2016-210289
  9. van der Heijde D, Aletaha D, Carmona L, et al. 2014 update of the EULAR standardised operating procedures for EULAR-endorsed recommendations. Ann Rheum Dis 2015;74:8–13. 10.1136/annrheumdis-2014-206350
  10. World Health Organisation Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: Report of a WHO Study Group. Geneva: World Health Organisation, 1994.
  11. Higgins JPT, Altman DG, Sterne JAC. Chapter 8: Assessing risk of bias in included studies In: Higgins JPT, Churchill R, Chandler J, et al., eds Cochrane Handbook for Systematic Reviews of Interventions Version 5.2.0, 2017.
  12. Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 2017;358:j4008. 10.1136/bmj.j4008
  13. OCEBM Levels of Evidence Working Group “The Oxford 2011 Levels of Evidence”. Oxford Centre for Evidence-Based Medicine. Available: http://www.cebm.net/index.aspx?o=5653 [Accessed 4 Apr 2019].
  14. Ryan R, Santesso N, Lowe D, et al. Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database Syst Rev 2014:CD007768. 10.1002/14651858.CD007768.pub3
  15. Wilson N, Hurkmans E, Adams J, et al. Prevention and management of osteoporotic fractures by non-physician health professionals: a systematic literature review to inform EULAR points to consider. RMD Open 2020;6:e001143. 10.1136/rmdopen-2019-001143
  16. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med 2012;27:1361–7.
  17. NHS England Universal personalised care: implementing the comprehensive model, 2019. Available: https://www.england.nhs.uk/wp-content/uploads/2019/01/universal-personalised-care.pdf [Accessed 21 Mar 2020].
  18. Wennberg JE. Practice variation: implications for our health care system. Manag Care 2004;13:3–7.
  19. Kanis JA, Cooper C, Rizzoli R, et al. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 2019;30:3–44. 10.1007/s00198-018-4704-5
  20. Compston J, Cooper A, Cooper C, et al. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos 2017;12:43. 10.1007/s11657-017-0324-5
  21. University of Sheffield Fracture risk assessment tool. Available: https://www.sheffield.ac.uk/FRAX/ [Accessed 3 Mar 2019].
  22. Garvan Institute Bone fracture risk calculator. Available: https://www.garvan.org.au/bone-fracture-risk [Accessed 3 Mar 2019].
  23. ClinRisk Welcome to the QFracture-2016 risk calculator. Available: https://qfracture.org/ [Accessed 3 Mar 2019].
  24. Curtis EM, Moon RJ, Harvey NC, et al. Reprint of: The impact of fragility fracture and approaches to osteoporosis risk assessment worldwide. Int J Orthop Trauma Nurs 2017;26:7–17. 10.1016/j.ijotn.2017.04.004
  25. Shepstone L, Lenaghan E, Cooper C, et al. Screening in the community to reduce fractures in older women (SCOOP): a randomised controlled trial. Lancet 2018;391:741–7. 10.1016/S0140-6736(17)32640-5
  26. World Health Organisation Mid-level health workers: a review of the evidence, 2017. Available: https://apps.who.int/iris/bitstream/handle/10665/259878/UHC-health_workers.pdf;jsessionid=70E8F78561A1C5E41DAE91A96EC4DD5C?sequence=1 [Accessed 3 Mar 2019].
  27. Weeks G, George J, Maclure K, et al. Non-Medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care. Cochrane Database Syst Rev 2016;11:CD011227. 10.1002/14651858.CD011227.pub2
  28. Bowers BL, Drew AM, Verry C. Impact of pharmacist-physician collaboration on osteoporosis treatment rates. Ann Pharmacother 2018;52:876–83. 10.1177/1060028018770622
  29. Ambrose AF, Cruz L, Paul G, Falls PG. Falls and fractures: a systematic approach to screening and prevention. Maturitas 2015;82:85–93. 10.1016/j.maturitas.2015.06.035
  30. Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142–8. 10.1111/j.1532-5415.1991.tb01616.x
  31. National Institute for Health and Care Excellence Falls in older people: assessing risk and prevention, 2013. Available: http://www.nice.org.uk/guidance/cg161 [Accessed 30 Mar 2019].
  32. Guirguis-Blake JM, Michael YL, Perdue LA, et al. Interventions to prevent falls in older adults: updated evidence report and systematic review for the US preventive services Task force. JAMA 2018;319:1705–16. 10.1001/jama.2017.21962
  33. Hopewell S, Adedire O, Copsey BJ, et al. Multifactorial and multiple component interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2018;7:CD012221. 10.1002/14651858.CD012221.pub2
  34. Smulders E, Weerdesteyn V, Groen BE, et al. Efficacy of a short multidisciplinary falls prevention program for elderly persons with osteoporosis and a fall history: a randomized controlled trial. Arch Phys Med Rehabil 2010;91:1705–11. 10.1016/j.apmr.2010.08.004
  35. Gianoudis J, Bailey CA, Ebeling PR, et al. Effects of a targeted multimodal exercise program incorporating high-speed power training on falls and fracture risk factors in older adults: a community-based randomized controlled trial. J Bone Miner Res 2014;29:182–91.
  36. Palvanen M, Kannus P, Piirtola M, et al. Effectiveness of the chaos falls clinic in preventing falls and injuries of home-dwelling older adults: a randomised controlled trial. Injury 2014;45:265–71. 10.1016/j.injury.2013.03.010
  37. Behringer M, Gruetzner S, McCourt M, et al. Effects of weight-bearing activities on bone mineral content and density in children and adolescents: a meta-analysis. J Bone Miner Res 2014;29:467–78. 10.1002/jbmr.2036
  38. Xu J, Lombardi G, Jiao W, et al. Effects of exercise on bone status in female subjects, from young girls to postmenopausal women: an overview of systematic reviews and meta-analyses. Sports Med 2016;46:1165–82. 10.1007/s40279-016-0494-0
  39. Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev 2019;1:CD012424. 10.1002/14651858.CD012424.pub2
  40. Varahra A, Rodrigues IB, MacDermid JC, et al. Exercise to improve functional outcomes in persons with osteoporosis: a systematic review and meta-analysis. Osteoporos Int 2018;29:265–86. 10.1007/s00198-017-4339-y
  41. de Kam D, Smulders E, Weerdesteyn V, et al. Exercise interventions to reduce fall-related fractures and their risk factors in individuals with low bone density: a systematic review of randomized controlled trials. Osteoporos Int 2009;20:2111–25. 10.1007/s00198-009-0938-6
  42. Luo X, Zhang J, Zhang C, et al. The effect of whole-body vibration therapy on bone metabolism, motor function, and anthropometric parameters in women with postmenopausal osteoporosis. Disabil Rehabil 2017;39:2315–23. 10.1080/09638288.2016.1226417
  43. Wei X, Xu A, Yin Y, et al. The potential effect of Wuqinxi exercise for primary osteoporosis: a systematic review and meta-analysis. Maturitas 2015;82:346–54. 10.1016/j.maturitas.2015.08.013
  44. Porter J, Adderley M, Bonham M, et al. The effect of dietary interventions and nutritional supplementation on bone mineral density in otherwise healthy adults with osteopenia: A systematic review. Nutr Bull 2016;41:108–21. 10.1111/nbu.12199
  45. Koutsofta I, Mamais I, Chrysostomou S. The effect of protein diets in postmenopausal women with osteoporosis: systematic review of randomized controlled trials. J Women Aging 2019;31:117–39. 10.1080/08952841.2018.1418822
  46. Cheung AM, Tile L, Lee Y, et al. Vitamin K supplementation in postmenopausal women with osteopenia (ECKO trial): a randomized controlled trial. PLoS Med 2008;5:e196. 10.1371/journal.pmed.0050196
  47. Prentice A, Diet PA. Diet, nutrition and the prevention of osteoporosis. Public Health Nutr 2004;7:227–43. 10.1079/phn2003590
  48. Bischoff-Ferrari HA, Orav EJ, Abderhalden L, et al. Vitamin D supplementation and musculoskeletal health. Lancet Diabetes Endocrinol 2019;7:85. 10.1016/S2213-8587(18)30347-4
  49. Bouillon R, Lips P, Bilezikian JP. Vitamin D supplementation and musculoskeletal health. Lancet Diabetes Endocrinol 2019;7:85–6. 10.1016/S2213-8587(18)30348-6
  50. Bolland MJ, Grey A, Avenell A. Vitamin D supplementation and musculoskeletal health. Authors’ reply. Lancet Diabetes Endocrinol 2019;7:88–9.
  51. Bolland MJ, Grey A, Avenell A. Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis. Lancet Diabetes Endocrinol 2018;6:847–58. 10.1016/S2213-8587(18)30265-1
  52. Morfeld J-C, Vennedey V, Müller D, et al. Patient education in osteoporosis prevention: a systematic review focusing on methodological quality of randomised controlled trials. Osteoporos Int 2017;28:1779–803. 10.1007/s00198-017-3946-y
  53. Al-Bashaireh AM, Haddad LG, Weaver M, et al. The effect of tobacco smoking on musculoskeletal health: a systematic review. J Environ Public Health 2018;2018:1–106. 10.1155/2018/4184190
  54. Ward KD, Klesges RC. A meta-analysis of the effects of cigarette smoking on bone mineral density. Calcif Tissue Int 2001;68:259–70. 10.1007/BF02390832
  55. Strozyk D, Gress TM, Breitling LP. Smoking and bone mineral density: comprehensive analyses of the third National health and nutrition examination survey (NHANES III). Arch Osteoporos 2018;13:16. 10.1007/s11657-018-0426-8
  56. Law MR, Hackshaw AK. A meta-analysis of cigarette smoking, bone mineral density and risk of hip fracture: recognition of a major effect. BMJ 1997;315:841–6. 10.1136/bmj.315.7112.841
  57. Shen GS, Li Y, Zhao G, et al. Cigarette smoking and risk of hip fracture in women: a meta-analysis of prospective cohort studies. Injury 2015;46:1333–40. 10.1016/j.injury.2015.04.008
  58. Wu Z-J, Zhao P, Liu B, et al. Effect of cigarette smoking on risk of hip fracture in men: a meta-analysis of 14 prospective cohort studies. PLoS One 2016;11:e0168990. 10.1371/journal.pone.0168990
  59. Kanis JA, Johnell O, Oden A, et al. Smoking and fracture risk: a meta-analysis. Osteoporos Int 2005;16:155–62. 10.1007/s00198-004-1640-3
  60. Kanis JA, Johansson H, Johnell O, et al. Alcohol intake as a risk factor for fracture. Osteoporos Int 2005;16:737–42. 10.1007/s00198-004-1734-y
  61. Zhang X, Yu Z, Yu M, et al. Alcohol consumption and hip fracture risk. Osteoporos Int 2015;26:531–42. 10.1007/s00198-014-2879-y
  62. Maurel DB, Boisseau N, Benhamou CL, et al. Alcohol and bone: review of dose effects and mechanisms. Osteoporos Int 2012;23:1–16. 10.1007/s00198-011-1787-7
  63. Cawthon PM, Harrison SL, Barrett-Connor E, et al. Alcohol intake and its relationship with bone mineral density, falls, and fracture risk in older men. J Am Geriatr Soc 2006;54:1649–57. 10.1111/j.1532-5415.2006.00912.x
  64. Diong J, Allen N, Sherrington C. Structured exercise improves mobility after hip fracture: a meta-analysis with meta-regression. Br J Sports Med 2016;50:346–55. 10.1136/bjsports-2014-094465
  65. Lee SY, Yoon B-H, Beom J, et al. Effect of lower-limb progressive resistance exercise after hip fracture surgery: a systematic review and meta-analysis of randomized controlled studies. J Am Med Dir Assoc 2017;18:1096.e19–1096.e26. 10.1016/j.jamda.2017.08.021
  66. Beck BR, Daly RM, Singh MAF, et al. Exercise and sports science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis. J Sci Med Sport 2017;20:438–45. 10.1016/j.jsams.2016.10.001
  67. National Osteoporosis Society Strong, Steady and Straight: An expert consensus statement on physical activity and exercise for osteoporosis. Bath, National Osteoporosis Society, 2018.
  68. Myint MWW, Wu J, Wong E, et al. Clinical benefits of oral nutritional supplementation for elderly hip fracture patients: a single blind randomised controlled trial. Age Ageing 2013;42:39–45. 10.1093/ageing/afs078
  69. Avenell A, Mak JCS, O'Connell D. Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men. Cochrane Database Syst Rev 2014:CD000227. 10.1002/14651858.CD000227.pub4
  70. Mak JC, Mason RS, Klein L, et al. An initial loading-dose vitamin D versus placebo after hip fracture surgery: randomized trial. BMC Musculoskelet Disord 2016;17:336. 10.1186/s12891-016-1174-9
  71. Grigoryan KV, Javedan H, Rudolph JL. Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis. J Orthop Trauma 2014;28:e49–55. 10.1097/BOT.0b013e3182a5a045
  72. Wu C-H, Tu S-T, Chang Y-F, et al. Fracture liaison services improve outcomes of patients with osteoporosis-related fractures: a systematic literature review and meta-analysis. Bone 2018;111:92–100. 10.1016/j.bone.2018.03.018
  73. Wu C-H, Kao I-J, Hung W-C, et al. Economic impact and cost-effectiveness of fracture liaison services: a systematic review of the literature. Osteoporos Int 2018;29:1227–42. 10.1007/s00198-018-4411-2
  74. Leigheb F, Vanhaecht K, Sermeus W, et al. The effect of care pathways for hip fractures: a systematic overview of secondary studies. Eur J Orthop Surg Traumatol 2013;23:737–45. 10.1007/s00590-012-1085-x
  75. Prestmo A, Hagen G, Sletvold O, et al. Comprehensive geriatric care for patients with hip fractures: a prospective, randomised, controlled trial. Lancet 2015;385:1623–33. 10.1016/S0140-6736(14)62409-0
  76. Wu C-H, Chen C-H, Chen P-H, et al. Identifying characteristics of an effective fracture liaison service: systematic literature review. Osteoporos Int 2018;29:1023–47. 10.1007/s00198-017-4370-z
  77. Akesson K, Marsh D, Mitchell PJ, et al. Capture the fracture: a best practice framework and global campaign to break the fragility fracture cycle. Osteoporos Int 2013;24:2135–52. 10.1007/s00198-013-2348-z
  78. Crandall CJ, Newberry SJ, Diamant A, et al. Comparative effectiveness of pharmacologic treatments to prevent fractures: an updated systematic review. Ann Intern Med 2014;161:711–23. 10.7326/M14-0317
  79. Yusuf AA, Cummings SR, Watts NB, et al. Real-World effectiveness of osteoporosis therapies for fracture reduction in post-menopausal women. Arch Osteoporos 2018;13:33. 10.1007/s11657-018-0439-3
  80. Kothawala P, Badamgarav E, Ryu S, et al. Systematic review and meta-analysis of real-world adherence to drug therapy for osteoporosis. Mayo Clin Proc 2007;82:1493–501. 10.1016/S0025-6196(11)61093-8
  81. Karlsson L, Lundkvist J, Psachoulia E, et al. Persistence with denosumab and persistence with oral bisphosphonates for the treatment of postmenopausal osteoporosis: a retrospective, observational study, and a meta-analysis. Osteoporos Int 2015;26:2401–11. 10.1007/s00198-015-3253-4
  82. Liu J, Guo H, Rai P, et al. Medication persistence and risk of fracture among female Medicare beneficiaries diagnosed with osteoporosis. Osteoporos Int 2018;29:2409–17. 10.1007/s00198-018-4630-6
  83. Vrijens B, De Geest S, Hughes DA, et al. A new taxonomy for describing and defining adherence to medications. Br J Clin Pharmacol 2012;73:691–705. 10.1111/j.1365-2125.2012.04167.x
  84. Nieuwlaat R, Wilczynski N, Navarro T, et al. Interventions for enhancing medication adherence. Cochrane Database Syst Rev 2014:CD000011. 10.1002/14651858.CD000011.pub4
  85. Hiligsmann M, Salas M, Hughes DA, et al. Interventions to improve osteoporosis medication adherence and persistence: a systematic review and literature appraisal by the ISPOR Medication Adherence & Persistence Special Interest Group. Osteoporos Int 2013;24:2907–18. 10.1007/s00198-013-2364-z
  86. Stuurman-Bieze AGG, Hiddink EG, van Boven JFM, et al. Proactive pharmaceutical care interventions decrease patients' nonadherence to osteoporosis medication. Osteoporos Int 2014;25:1807–12. 10.1007/s00198-014-2659-8
  87. Kooij MJ, Heerdink ER, van Dijk L, et al. Effects of telephone counseling intervention by pharmacists (TelCIP) on medication adherence; results of a cluster randomized trial. Front Pharmacol 2016;7:269. 10.3389/fphar.2016.00269
  88. Health Education England, NHS England and Skills for Health. Musculoskeletal core capabilities framework for first point of contact practitioners, 2018. Available: https://www.skillsforhealth.org.uk/images/projects/msk/Musculoskeletal%20framework.pdf?s=form [Accessed 15 Mar 2020].
  89. Royal College of Physicians Secondary fracture prevention in the NHS: achieving effective service delivery by FLSs. London: Royal College of Physicians, 2018.
  90. Royal College of Physicians National hip fracture database, 2007. Available: www.nhfd.co.uk [Accessed 5 Jun 2019].
  91. Norwegian National Advisory unit on arthroplasty and hip fractures. The Norwegian hip fracture register, 2005. Available: http://nrlweb.ihelse.net/eng/ [Accessed 5 Jun 2019].
  92. Damschroder LJ, Aron DC, Keith RE, et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009;4:50. 10.1186/1748-5908-4-50
  93. Powell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: results from the expert recommendations for implementing change (ERIC) project. Implement Sci 2015;10:21. 10.1186/s13012-015-0209-1

Conditions covered

Fragility fracturesOsteoporosisBone fracture prevention

Other guidelines on this topic

Reproduced for free educational use under the licence shown above. WhiteCoat Pro is not affiliated with or endorsed by the authors, the publisher or the issuing organisation. Always check the original document for the current version.