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Evidence-based guidelines for the prevention of osteoporosis-related fractures

The importance of an evidence-based approach to clinical practice is now widely accepted and the application of these guidelines provides a means by which best practice can be shared both within and between countries. Because some aspects of the prevention of osteoporotic fractures are country-specific (e.g. variations in diagnostic resources or in availability of different therapeutic options), development of individual evidence-based guidelines for every country is important.

Evidence-based guidelines around the world: references and links to full text

Development and appraisal of evidence-based guidelines

In order to achieve their full potential, the development of guidelines for the prevention of osteoporosis- related fractures should fulfil certain criteria. Many of the guidelines listed above have been appraised according to the AGREE Collaboration guidelines (Appraisal of Guidelines for Research and Evaluation), an instrument which provides a framework for systematic quality assessment of guidelines. For further information about AGREE and the appraisal scores, see below.

The process for developing evidence-based guidelines has been well defined by the AGREE collaboration:

  • It requires the co-operation of groups of experts from relevant professional groups together with representatives from appropriate lay organizations, and it is particularly important that patients and their carers are adequately represented.
  • Guidelines should be based on a comprehensive systematic review of the literature and recommendations should be explicitly linked to the supporting evidence.
  • In general, between four and eight meetings are required over a one- to two-year period, followed by a consultation period in which the draft guidelines are circulated for peer review.

Financial support and endorsement required

The development and dissemination of guidelines requires financial support, which should be provided by government agencies. This should be accompanied by explicit endorsement of the guidelines by these agencies in order to promote and prioritize their use in clinical practice. Unless guidelines are adequately disseminated they cannot impact significantly on standards of care.

Implications for resource allocation and health care planning

Full implementation of guidelines is usually not possible without provision of additional resources and changes in the organization of services. In this case it may involve setting up specialist osteoporosis units and explicit links between primary and secondary care, providing adequate bone densitometry resources, and ensuring appropriate reimbursement for both diagnostic and therapeutic interventions. Health-economic analyses are useful for defining the expansion of healthcare resources and financial investment required.


The ultimate aim of guidelines is to improve standards of clinical care. It is therefore essential to audit the use of guidelines and to demonstrate how their implementation results in changes in clinical practice. Guidelines should contain clearly defined audit criteria based on key recommendations. Ideally, an audit tool, which is easy to use and has clearly identified outcome measures, should be provided with the guidelines. Two audits, separated by an appropriate period of time (usually one to two years) are required to properly assess changes in clinical practice resulting from use of guidelines.

Update and appraisal of guidelines

It is important that guidelines are regularly updated to accommodate new evidence and knowledge, and the original guidelines should contain some mechanism to prompt this updating procedure. Generally, an update will be required within five years, but the introduction of new interventions may necessitate an even earlier update. It is also essential that the guidelines be appraised (see above) to ensure guideline quality.

In order to achieve their full potential, the development of guidelines for the prevention of osteoporosis- related fractures should fulfil the following criteria:

  • Be rigorous with respect to their evidence base, stakeholder involvement, objectivity and editorial independence
  • Be clearly presented so that key recommendations are unambiguous and can be easily identified
  • Should preferably include implementation tools such as a summary guide and patient information sheet
  • Be appropriately disseminated to potential users
  • Their use should be audited to define resulting changes in clinical practice
  • Be updated regularly
Visit the AGREE website for further information:

Assessment according to the AGREE Guidelines

Guidelines from many countries, and most EU member states, have recently been collated and evaluated according to the AGREE Guidelines (Appraisal of Guidelines for Research and Evaluation) There are six domains in the AGREE assessment, each of which addresses a separate aspect of guideline quality:

  • Scope and purpose
  • Stakeholder involvement
  • Rigour of development
  • Clarity of presentation
  • Applicability
  • Editorial independence

The guidelines assessed to date range from consensus statements produced by expert groups to fully evidence-based guidelines developed in accordance with the AGREE methodology (see tables below).
Please contact Dr. J.E. Compston ( for further information.

Results of AGREE appraisals for evidence-based guidelines*

Scope and purpose Stakeholder involvement Rigour of development Clarity and presentation Applicability Editorial independence
Austria 94% 46% 80% 77% 56% 58%
Canada 93% 44% 84% 81% 30% 94%
Denmark 100% 44% 63% 65% 50% 50%
France 88% 69% 87% 91% 89% 83%
Germany 97% 69% 90% 98% 64% 96%
Italy 89% 69% 78% 67% 63% 61%
Lebanon 89% 60% 82% 90% 67% 83%
Middle East and North Africa 83% 75% 77% 83% 72% 100%
Netherlands 84% 68% 75% 78% 71% 63%
Spain 96% 67% 79% 92% 64% 72%
UK/SIGN 56 76% 53% 57% 75% 48% 50%
UK/SIGN 71 81% 58% 57% 56% 76% 56%
UK/RCP 1999/2000 96% 61% 73% 64% 63% 63%
UK/RCP GIOP 87% 69% 93% 100% 56% 100%

*Each score represents the mean for 3 or 4 appraisers.

Guidelines: One of the key next steps in the European Union

In Europe, the 'Action Plan' published in November 2003 by the EU Osteoporosis Consultation Panel emphasized the importance of evidence-based guidelines for the European Union member states:

Key next steps

Action Responsibility Target date
Improvement of accessibility of current evidence-based guidelines to member and accession states to enable sharing of best practice and to ensure optimal care The EU Osteoporosis Consultation Panel June 2004
Development of national, evidence-based guidelines in all member and accession states and endorsement of existing evidence-based national guidelines by government agencies National osteoporosis related scientific societies, osteoporosis patient organisations, policy makers and the national co-ordinators for osteoporosis within government Ministries of Health December 2005
Provision of financial support from governments for the development, dissemination and implementation of national guidelines Policy makers and the national co-ordinators for osteoporosis within government Ministries of Health January 2005
Development and application of audit tools to assess clinical impact of guidelines Healthcare professionals and policy makers December 2005

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