Effective prevention and management of osteoporotic fractures: a systematic literature review of non-physician health professionals' interventions for a EULAR points-to-consider project

Background Osteoporotic fractures are a global concern due to associated patient mortality, morbidity and health service expenditure. Optimal care provided by non-physician health professionals, such as dieticians, nurses, occupational therapists, pharmacists and physiotherapists, to adults at high risk of primary or secondary osteoporotic fracture, is integral in the prevention and management of minimal trauma fracture, but may not be sufficiently realised in all European countries. To address this, a commissioned task force has developed the first collaborative EULAR points to consider/recommendations for non-physician health professionals in the prevention and management of osteoporotic fractures, underpinned by a systematic literature review (SLR).Objectives To identify and review the scientific literature to inform the development of evidence-based EULAR points to consider/recommendations for non-physician health professionals in the prevention and management of osteoporotic fracture.Methods A SLR for each of eight clinical questions that were previously formulated and consensually agreed by the task force members was undertaken by a research fellow (NW), with guidance from the task force convenors and the methodologist. Four electronic databases (Medline, Embase, Cinahl and PubMed) were searched over the period 13th - 31 st October 2017. The search strategies combined MeSH terms and keywords to identify studies related to two key concepts: (i) adults≥50 years of age at high risk of primary or secondary osteoporotic fracture and (ii) interventions delivered by non-physician health professionals to prevent, treat and manage osteoporotic fractures. Exclusion criteria included articles not in English and without online access. Evidence was categorised using the Oxford Centre for Evidence-based Medicine Levels of Evidence. For critical appraisal of systematic reviews, AMSTAR 2 was used. Risk of bias was assessed by the Cochrane Collaboration’s tool.Results The eight primary searches returned a total of 15 917 citations; duplicates were removed and the remaining 11 195 citations screened for relevance by title, abstract, design and year of publication (recently published reviews and/or RCTs were prioritised). Thirty-two studies were finally selected. Overall confidence in the findings of included systematic reviews (n=13) ranged from low to high. Risk of bias also varied across other included studies. Strongest evidence of benefit was found for exercise in the management of osteoporotic fracture [level 1a].Conclusions There is a lack of high quality evidence for the role of health professionals in the prevention and management of adults at high risk of primary or secondary osteoporotic fracture. We recommend the instigation of an education and research agenda for non-physician health professionals