Recommendation
2019 EULAR points to consider for non-physician
health professionals to prevent and manage fragility
fractures in adults 50 years or older
Jo Adams ,1 Nicky Wilson ,1 Emalie Hurkmans,2 Margot Bakkers,3
Petra Balážová,4,5 Mark Baxter,6 Anne-Birgitte Blavnsfeldt,7 Karine Briot ,8
Catharina Chiari,9 Cyrus Cooper,10 Razvan Gabriel Dragoi,11 Gabriele Gäbler,12
Willem Lems,13 Erika Mosor,12 Sandra Pais,14 Cornelia Simon,15 Paul Studenic
Simon Tilley,6,17 Jenny de la Torre-Aboki ,18 Tanja A Stamm 12,19
ABSTRACT
Objective To establish European League Against
Rheumatism (EULAR) points to consider for non-physician
► Additional material is
health professionals to prevent and manage fragility
published online only. To view
please visit the journal online
fractures in adults 50 years or older.
(http://dx.doi.org/10.1136/
Methods Points to consider were developed in
annrheumdis-2020-216931).
accordance with EULAR standard operating procedures
for EULAR-endorsed recommendations, led by an
For numbered affiliations see
international multidisciplinary task force, including patient
end of article.
research partners and different health professionals from
Correspondence to
10 European countries. Level of evidence and strength
Professor Tanja A Stamm,
of recommendation were determined for each point to
Section for Outcomes Research,
consider, and the mean level of agreement among the task
Centre for Medical Statistics,
force members was calculated.
Informatics, and Intelligent
Results Two overarching principles and seven points to
Systems, Medical University of
Vienna, Spitalgasse 23, 1090
consider were formulated based on scientific evidence and
Vienna, Austria;
the expert opinion of the task force. The two overarching
tanja.stamm@meduniwien.ac.at
principles focus on shared decisions between patients and
JA and NW contributed equally. non-physician health professionals and involvement of
different non-physician health professionals in prevention
JA and NW are joint first
and management of fragility fractures. Four points to
authors.
consider relate to prevention: identification of patients
at risk of fracture, fall risk evaluation, multicomponent
Received 2 January 2020
interventions to prevent primary fracture and
Revised 31 March 2020
Accepted 2 April 2020
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 postfracture 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.
Handling editor Désirée van
der Heijde
© Author(s) (or their
employer(s)) 2020. Re-use
permitted under CC BY.
Published by BMJ.
To cite: Adams J, Wilson N,
Hurkmans E, et al.
Ann Rheum Dis Epub ahead
of print: [please include Day
Month Year]. doi:10.1136/
annrheumdis-2020-216931
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
,16
Key messages
What is already known about this subject?
► Interventions delivered by non-physician
health professionals to prevent and manage
fragility fractures contribute to optimal patient
outcomes. They have not been sufficiently
covered to date in existing European League
Against Rheumatism/European Federation of
National Associations of Orthopaedics and
Traumatology recommendations.
What does this study add?
► This paper will guide clinical practice in Europe
regarding interventions delivered by nonphysician health professionals to prevent and
manage fragility fractures in adults 50 years
or older. Several areas described in this paper
highlight the necessity for further research.
Future studies could build on our findings.
International and national initiatives may
find our paper useful as a common European
reference.
► Prevention of fragility fractures is essential
for good health in older age; osteoporosis
and fractures are key issues that need to be
considered. Especially vulnerable patient
groups, for example, frail older people,
and those with cognitive impairments will
benefit from European standards regarding
interventions delivered by non-physician
health professionals to prevent and manage
osteoporotic fractures.
► Implementation will be supported by national
organisations, professional and scientific
societies, including patient leagues.
3.3 million new fractures are anticipated across the
same six countries, with accompanying total fracturerelated 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
Adams J, et al. Ann Rheum Dis 2020;0:1–8. doi:10.1136/annrheumdis-2020-216931
1
Recommendation
Key messages
Table 1 Categorisation of individuals at high-risk of fragility
fracture
How might this impact on clinical practice or future
developments?
► Improved care delivered by non-physician health
professionals to prevent and manage fragility fractures offers
opportunities for better health outcomes in older people in
Europe.
Osteopenia
T score =<-1.0 to −2.5 SD
Osteoporosis
T score =≤−2.5 SD
FRAX 10-year probability of a major*
osteoporotic fracture
≥20% (age independent)
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 nonphysician 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
2
FRAX 10-year probability of hip fracture
≥3% (age independent)
FRAX NOGG threshold
40 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.
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.
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 multiprofessional 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.
Point to consider 1: identification of patients at risk of
fracture
No studies evaluating the effect of fracture risk detection by nonphysician 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
Adams J, et al. Ann Rheum Dis 2020;0:1–8. doi:10.1136/annrheumdis-2020-216931
Recommendation
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
Prevention of Fragility Fractures
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.
2
2
B
9.06 (1.16)
9.5 (7–10)
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.
3
Level of Agreement (Mean (SD))
Median (Range)
4
C
9.61 (0.70)
10 (8 to 10)
Preventive multicomponent interventions
Tailored multicomponent interventions, including for example:
► Exercise
1 to 3
A
2
D
9.33 (0.91)
► Nutrition
1 to 2
D
10 (8 to 10)
► Education
2
D
1
A
Level of evidence
Strength of recommendation
► Environmental adaptations
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.
9.22 (1.31)
10 (5 to 10)
No
Point to consider
Management of Fragility Fractures
5
Level of Agreement (Mean (SD))
Median (Range)
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
► adequate nutritional intake
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.
6
A
2
D
9.22 (0.88)
1 to 2
D
9.5 (8 to 10)
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
programme
7
1 to 2
1 to 2
9.50 (1.10)
10 (6 to 10)
Adherence to anti-osteoporosis medicines
Non-physician HPs should address, monitor and support medication adherence in a
structured follow-up.
2 to 3
B
8.83 (1.25)
9 (6 to 10)
EULAR, European League Against Rheumatism; FLS, fracture liaison services; HPs, health professionals.
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 communitydwelling 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 al28 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.
Adams J, et al. Ann Rheum Dis 2020;0:1–8. doi:10.1136/annrheumdis-2020-216931
3
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 fallsrisk 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
Recommendation
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 weightbearing, 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 healthrelated outcomes in people with bone fragility is uncertain.52 In a
4
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 weightbearing, 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 bonehealth 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 countryspecific 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 nonphysician 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
Adams J, et al. Ann Rheum Dis 2020;0:1–8. doi:10.1136/annrheumdis-2020-216931
Recommendation
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 antiosteoporosis 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.
Box 1 Research agenda to prevent and optimally manage
fragility fractures for non-physician health professionals
(HPs) including (but not limited to) dietitians, nurses,
occupational therapists, pharmacists and physiotherapists
► Randomised clinical trials on the effect of non-
►
►
►
►
►
►
►
pharmacological interventions, as well as interventions to
facilitate adherence.
Research studies need to define and qualify those at high-risk
of fragility fracture in patient sample populations.
Research studies investigating interventions to prevent falls
and fragility fractures need to clearly record fracture status at
baseline.
Validation and reliability testing of (multicomponent)
screening methods for risk of falling is needed.
Research studies need to include long-term follow-up
measures of bone health, incidence rates of falls and
fractures and functional mobility outcomes.
A consensus agreement and statement between relevant
stakeholders on the definition of high-risk of secondary
fracture is required.
Further clinical trials to evaluate the cost-effectiveness of
management of patients with osteoporosis and/or a (highrisk) of fragility fractures by non-physician HPs are needed.
Research studies to identify the clinically effective optimal
duration, intensity and frequency of interventions delivered
by non-physician HPs to patients following fragility fracture
should be conducted.
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
Box 2 Non-physician health professional (HP) education
agenda to prevent and optimally manage fragility
fractures
Non-physician HPs should be educated on:
► How to use (multicomponent) screening tools to understand
fracture risk.
► How to deliver, and what to include in a falls prevention
DISCUSSION
These EULAR points to consider, underpinned by shared decisionmaking 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
Adams J, et al. Ann Rheum Dis 2020;0:1–8. doi:10.1136/annrheumdis-2020-216931
programme.
► How to tailor education for people and patients with varying
risk of falls.
► The scope and role of non-physician HPs in fracture liaison
services.
► How to support and promote medication adherence.
► How to effectively promote bone health.
► Medication side effects that impact on bone health.
Education standards need to be agreed and underpinned by learning
principles.
5
Recommendation
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 nonphysician 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.
Twitter Paul Studenic @Stiddyo and Jenny de la Torre-Aboki @JennydelaTorr16
Acknowledgements We thank EULAR for supporting the development of these
points to consider.
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.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits
others to copy, redistribute, remix, transform and build upon this work for any
purpose, provided the original work is properly cited, a link to the licence is given,
and indication of whether changes were made. See: https://creativecommons.org/
licenses/by/4.0/.
ORCID iDs
Jo Adams http://orcid.org/0000-0003-1765-7060
Nicky Wilson http://orcid.org/0000-0001-7404-7360
Karine Briot http://orcid.org/0000-0002-6238-2601
Paul Studenic http://orcid.org/0000-0002-8895-6941
Jenny de la Torre-Aboki http://orcid.org/0000-0002-4905-2034
Tanja A Stamm http://orcid.org/0000-0003-3073-7284
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.
REFERENCES
Author affiliations
1
School of Health Sciences, University of Southampton, Southampton, UK
2
Department Care I, Musculoskeletal System & Neurology, Dutch National Health
Care Institute, Diemen, The Netherlands
3
EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE),
Zurich, Switzerland
4
EULAR Young PARE, Zurich, Switzerland
5
Slovak League Against Rheumatism, Piestany, Slovakia
6
Medicine for Older People, University Hospital Southampton NHS Foundation Trust,
Southampton, UK
7
Department of Rheumatology, Aarhus University Hospital, Arrhus, Denmark
8
INSERM U1153, Paris Descartes University, Reference Center for Genetic Bone
Diseases - Department of Rheumatology, Cochin Hospital, Paris, France
9
Department of Orthopedics and Trauma-Surgery, Medical University of Vienna,
Vienna, Austria
10
MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
11
Rehabilitation, Physical Medicine and Rheumatology, ’Victor Babes’ University of
Medicine and Pharmacy, Timisoara, Timisoara, Romania
12
Section for Outcomes Research, Centre for Medical Statistics, Informatics, and
Intelligent Systems, Medical University of Vienna, Vienna, Austria
13
Department of Rheumatology, VU University Medical Centre Amsterdam,
Amsterdam, Noord-Holland, The Netherlands
14
Centre for Biomedical Research, Department of Biomedical Sciences and Medicine,
University of Algarve, Faro, Portugal
15
Department of Balneology, Rehabilitation and Rheumatology, ’Victor Babes’
University of Medicine and Pharmacy, Timisoara, Timisoara, Romania
16
Internal Medicine 3, Division of Rheumatology, Medical University Vienna, Vienna,
Austria
17
Trauma & Orthopaedics, University Hospital Southampton NHS Foundation Trust,
Southampton, UK
18
Day Hospital, Alicante General and university Hospital, Alicante, Spain
19
Ludwig Boltzmann Institute Arthritis and Rehabilitation, Vienna, Austria
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