Table 5

Characteristics of intervention studies and their main findings: implementation strategies to increase implementation of recommendations; multidisciplinary team (MDT) care; interventions to enhance adherence to antiosteoporosis medicines

Authors, country, setting if statedStudy designPopulation characteristics; number of participants for outcomes of interestIntervention; healthcare professional if statedMain findingsLoE
i) Implementation strategies to increase implementation of recommendations
Cox et al UK,
Care homes33		Cluster RCT

  1. Group 1 (n=3315)

  2. Group 2 (n=2322)

  1. Education+feedback

  2. No intervention

Specialist osteoporosis nurses		Significant increase in bisphosphonate prescription (IRR 1.5, 95% CI 1.00 to 2.24; p=0.05) and calcium and vitamin D prescription (IRR 1.64, 95% CI 1.23 to 2.18; p<0.01) in IG versus CG at 12 months2
Kennedy et al
Canada, Care homes63		Pilot
cluster
RCT

  1. Group 1 (n=2185)

  2. Group 2 (n=3293)

  1. Education+action planning +feedback

  2. Fracture prevention toolkits

Interdisciplinary care teams		Significant increase in vitamin D and calcium prescription from baseline to 12 months in IG versus CG; OR 1.82 (95% CI 1.12 to 2.96) and 1.33 (95% CI 1.01 to 1.74), respectively.
No significant between group difference in prescribing osteoporosis medicines		2
Ciaschini et al
Canada, community68		RCTAdults at risk of future fracture

  1. Group 1 (n=101)

  2. Group 2 (n=100)

  1. Multifaceted intervention

  2. Usual care

Nurses		29/52 participants in IG versus 16/60 participants in CG taking osteoporotic medicines at 6 months (relative risk 2.09, 95% CI 1.29 to 3.40). Treatment with calcium and vitamin D increased by 34%–17%, respectively, in IG compared with CG.2
Kilgore et al community64Cluster RCT

  1. Group 1 (n=330)

  2. Group 2 (n=337)

  1. Multicomponent

  2. Usual care

Nurse		No significant difference between IG and CG in average proportion of eligible patients receiving osteoporosis medicines (IG: 19.1% vs UC; 15.7%, difference in proportions 3.4%, 95% CI −2.6 to 9.5%, p=0.252)2
Baypinar et al69Cohort study

  1. Group 1 (n=60)

  2. Group 2 (n=47)

  1. Clinical decision support alert

  2. No alert

Pharmacists		Coprescription of vitamin D or vitamin D analogues with a bisphosphonate increased by 29% (p=0.001) in the IG compared with the CG3
ii) MDT care
Grigoryan et al inpatients32MAPatients with hip fracture
9 studies (n=3333) and 11 studies (n=6305)		Orthogeriatric compared with standard care MDTOrthogeriatric care 40% reduction in ST mortality
(relative risk 0.60, 95% CI 0.43 to 0.84) and 17% reduction in LT mortality (relative risk 0.83, 95% CI 0.74 to 0.94)		1
Prestmo et al
Norway, inpatients65		RCTPatients with hip fracture
1.Group 1 (n=198)
2.Group 2 (n=199)

  1. Orthogeriatric care

  2. Orthopaedic care

MDT		Significant between group difference in SPPB in favour of orthogeriatric care at 4 months (between group difference 0.74, 95% CI 0.18 to 1.30, p=0.010) and at 12 months (0.69, 95% CI 0.10 to 1.28, p=0.023).2
Wu et al inpatients and outpatients25MAPatients with all fracture types
11 studies (n=19 519) and 15 studies (n=16 802)		FLS versus usual care/control
MDT		FLS reduced absolute risk of refracture (ARR −0.05, 95% CI −0.08 to −0.03; NNT=20)
FLS reduced absolute risk of mortality (ARR −0.03, 95% CI −0.05 to −0.01; NNT=33)		1
Wu et al inpatients and outpatients66SRPatients with all fracture typesFLS versus usual care or no treatment
MDT		FLS implemented in HICs and MICs are cost effective across FLS model types2
Leigheb et al inpatients and community67SOPatients with hip fractureCare pathways and MCA versus usual care MDTNo significant reduction in short-term mortality
Mixed effect on functional recovery		1
iii) Interventions to enhance adherence to antiosteoporosis medicines
Hiligsman et al70SRAdults using osteoporosis medicines
20 studies (n=14 662)		Education; monitoring/supervision; drug regimens; electronic prescription; decision aid.
Nurses, pharmacists, physicians, MDT, clinical personnel and health educators		9/12 studies showed statistically significant improvement in adherence to medicines in IG versus CG
5/13 studies showed improved persistence with an intervention		2
Kooij et al, The Netherlands, community pharmacies72Cluster RCTParticipants starting bisphosphonates

  1. Group 1 (n=379)

  2. Group 2 (n=255)

  1. Single telephone counselling call

  2. Usual care

Pharmacist, trainee pharmacist, pharmacy technician		No significant between group difference in mean adherence rate. IG: 75.2% versus
UC: 73.3%. Counselling call only received by 137 participants in the IG		2
Stuurman-Bieze et al, The Netherlands, community pharmacies71Cohort studyPatients initiating osteoporosis medicines

  1. Group 1 (n=495)

  2. Group 2 (n=442)

  1. Counselling and monitoring service

  2. Usual care

Pharmacists		No statistically significant difference in non-adherence rate at 12 months.
Significantly lower discontinuation rates in counselling and monitoring group
(IG: 15.8% vs UC: 27.8%; p<0.001).		3

  • ARR, absolute risk reduction; CG, control group; FLS, fracture liaison services; HIC, high-income countries; IG, intervention group; IRR, incidence rate ratio; LoE, level of evidence; LT, long term; MA, meta-analysis; MCA, multidisciplinary care approaches; MIC, middle-income countries; NNT, numbers needed to treat; OR, Odds ratio; RCT, randomised controlled trial; RR, relative risk; RR, risk ratio; SO, systematic overview; SPPB, short physical performance battery; ST, short-term; UC, usual care.