Introduction
Methods
Co-design of the Delphi survey
Delphi participants and recruitment
Statement generation
Consultation stage/clinician task | Example statement |
---|---|
1. Greeting/introduction | The clinician should ask what the patient is expecting from the appointment (consultation) |
2. Gathering information | The clinician should ask the patient how their fracture affected them |
3. Considering therapeutic options | The clinician should, if drug treatment (medicine) is needed, offer a tablet bisphosphonate first |
4. Eliciting patient perceptions | The clinician should ask the patient what they know about osteoporosis and fractures |
5. Establishing shared decision-making preferences | The clinician should establish what involvement in decision-making the patient would like |
6. Sharing information about condition | The clinician should show and explain the bone density scan results |
7. Sharing information about treatment—lifestyle and drugs | The clinician should explain common or severe side effects |
8. Checking understanding and summarise | The clinician should check whether the patient knows the benefits and risks |
9. Signposting next steps | The clinician should give the patient information about local support groups and services |
Data collection and analysis
Results
Patient/carer | |||
Round 1 | Round 2 | Round 3 | |
Total n | 45 | 39 | 37 |
Gender female n (%) | 41 (91) | 35 (90) | 33 (89) |
Age | |||
21–30 | 0 (0) | 0 (0) | 0 (0) |
31–40 | 1 (2) | 1 (3) | 1 (3) |
41–50 | 0 (0) | 0 (0) | 0 (0) |
51–60 | 2 (4) | 3 (8)* | 1 (3) |
61–70 | 16 (36) | 14 (36) | 15 (41) |
71–80 | 21 (47) | 15 (39) | 16 (43) |
81–90 | 5 (11) | 6 (15) | 4 (11) |
Clinician | |||
Round 1 | Round 2 | Round 3 | |
Total n | 27 | 10 | 15 |
Gender female n (%) | 27 (100) | 10 (100) | 15 (100) |
Age | |||
21–30 | 1 (4) | 0 (0) | 1 (7) |
31–40 | 4 (15) | 1 (10) | 2 (13) |
41–50 | 8 (30) | 4 (40) | 3 (20) |
51–60 | 9 (33) | 2 (20) | 4 (27) |
61–70 | 4 (15) | 2 (20) | 3 (20) |
71–80 | 0 (0) | 0 (0) | 1 (7)* |
81–90 | 1 (4) | 1 (10) | 1 (7) |
Occupation | |||
Allied health professional | 1 (4) | 0 (0) | 1 (7) |
FLS nurse | 10 (37) | 4 (40) | 5 (33) |
Metabolic bone specialist | 1 (4) | 1 (10) | 1 (7) |
OP specialist nurse | 10 (37) | 3 (30) | 3 (20) |
Rheumatologist | 1 (4) | 0 (0) | 1 (7) |
Other | 4 (15) | 2 (20) | 4 (27) |
Statement | Round 3 | ||
---|---|---|---|
% of participants agreeing that each statement was ‘essential in a time-limited consultation’ ≤7 5% italics NA = not applicable | |||
Patient/carer agreement | Clinician agreement | Combined agreement | |
Stage 1: Greeting/introduction | |||
The clinician should... | |||
find out what the patient is expecting from the appointment (consultation) | 51% | 80% | 60%† |
explain to their patient that the aim of the appointment is to think about what steps they could take to improve bone health and try and prevent further broken bones | 97% | 100% | 98% |
explain that the aim is also to investigate whether the patient has osteoporosis, or weaker bones, that may be more likely to break after a minor trip or fall | 92% | 100% | 94% |
explain that the patient’s risk of breaking bones (fracture risk) in the future can be estimated | 76% | 87% | 79% |
tell the patient the limitations of estimating her risk of breaking a bone (fracture risk)* | 54% | 80% | 62% |
Stage 2: Gathering information | |||
The clinician should ask the patient… | |||
about their general health | 92% | 94% | 92% |
how the fracture impacted on their life | 95% | 67% | 87% |
about their risk factors for breaking a bone (fracture) which may include smoking, family history, previous fractures, alcohol, medical conditions, medications, etc. | 97% | 100% | 98% |
how their broken wrist happened | 76% | 100% | 83% |
questions to find out if the patient is at risk of falls | 81% | 100% | 87% |
about their other health conditions to identify causes of osteoporosis | 87% | 100% | 90% |
about their other health conditions to find out which medicines might be unsuitable | 97% | 93% | 96% |
if they have had back pain, or got shorter (height loss) (signs that they may have had fractures in their spine) | 87% | 87% | 87% |
questions about their diet and calcium intake | 92% | 100% | 94% |
The clinician should… | |||
observes the patient’s spine to look for signs of fractures (broken bones) or curvature* | 76% | 60% | 71% |
if appropriate, recommend and arrange a scan to assess the patient's bone density (strength), which will diagnose osteoporosis, if it is present | 100% | 100% | 100% |
tell the patient why the scan is being recommended, what the scan involves and how it will affect them | 87% | 100% | 90% |
arrange further imaging (such as x-rays and other tests) of the spine to look for broken bones, if appropriate | 84% | 73% | 81% |
use a website based scoring system (e.g. FRAX) to estimate the patient’s individual risk of breaking a bone (fracture)* | 68% | 87% | 73% |
if appropriate, recommend and arrange blood tests to rule out conditions that can make broken bones and/or osteoporosis more likely | 81% | 100% | 87% |
Stage 3: Considering therapeutic options | |||
The clinician should… | |||
use national guidelines (recommendations and guidance based on evidence) to decide which patients should be offered drug treatment (medicine) to prevent further fractures (broken bones) | N/A | N/A | N/A |
be aware, and take into account, the circumstances in which the estimated fracture risk may be less accurate (e.g. for patients on high-dose steroids) | N/A | N/A | N/A |
not offer tablet bisphosphonate medicines to patients who have existing problems swallowing, have severe indigestion or can’t take tablets | N/A | N/A | N/A |
not offer tablet bisphosphonate medicines to patients who have memory problems (e.g. dementia), unless they have support with taking medicines | N/A | N/A | N/A |
Stage 4: Eliciting patient perceptions | |||
The clinician should ask the patient... | |||
what they know about osteoporosis and fractures | 84% | 93% | 87% |
about their views on the strength of their bones* | 16% | 73% | 33% |
their views of prescription medicine generally* | 35% | 53% | 40% |
if they have any concerns generally, or if anything is on their mind | 81% | 80% | 81% |
their knowledge, views and preferences about osteoporosis medicines (drug treatments) | 84% | 80% | 83% |
how important maintaining independence is to them | 81% | 67% | 77% |
Stage 5: Establishing shared decision-making preferences | |||
The clinician should... | |||
establish what involvement the patient would like to have in making decisions about medicines | 68% | 87% | 73%† |
ask if the patient would like to discuss medicine or lifestyle approaches first* | 62% | 53% | 60% |
Stage 6: Sharing information about the condition | |||
The clinician should explain to the patient... | |||
that osteoporosis means bones are weaker and may be likely to break (fracture) after a minor bump or fall | 100% | 100% | 100% |
that osteoporosis does not give you physical symptoms (e.g. pain) unless you have broken a bone | 81% | 93% | 85% |
that keeping up a healthy lifestyle (not smoking, regular exercise) is important in maintaining bone strength and health | 97% | 100% | 98% |
that if osteoporosis medication is taken regularly it will lower the risk of breaking bones in the future | 97% | 100% | 98% |
that their bone density scan results are only part of a picture of their bone strength | 87% | 93% | 89% |
that they are at increased risk of breaking bones, using simple numbers (e.g. they have a 30 in 100 chance of breaking a bone over the next 10 years) | 84% | 100% | 89% |
that finding osteoporosis is a good thing because we can do something about it | 89% | 100% | 92% |
what risk factors they may have for weaker bones | 81% | 100% | 87% |
that people with osteoporosis are more likely to break bones such as their wrist, hip or bones in the spine | 95% | 100% | 96% |
that spinal fractures happen when the bone squashes down and may cause pain and curving of the spine | 81% | 80% | 81% |
The clinician should... | |||
ask the patient what they already know about how future broken bones could affect their life* | 35% | 67% | 44% |
use pictures or models to show how the condition affects the bone* | 57% | 60% | 58% |
show and explain the bone density scan results | 95% | 100% | 96% |
Stage 7: Sharing information about treatment—lifestyle and drugs | |||
The clinician should explain… | |||
how much the risk of broken bones is lowered with medicine, using simple numbers and pictures | 73% | 80% | 75%† |
that tablet medicine is usually recommended first, e.g. oral bisphosphonates | 89% | 93% | 90% |
that this medicine is recommended for osteoporosis or people with high fracture risk | 100% | 87% | 96% |
the aims and benefits of medicine, i.e. to strengthen bones and lower the chance of future broken bones | 81% | 100% | 87% |
that osteoporosis medicine does not make you feel better, and it is not possible to ‘feel’ stronger bones | 62% | 87% | 69%† |
what is involved in taking the medicine, including how long it will be taken for | 100% | 100% | 100% |
common or severe side effects | 92% | 100% | 94% |
that diet and physical activity are important in strengthening bone and have a complementary effect to medicines | 100% | 100% | 100% |
that diet, physical activity and supplements cannot be viewed as a substitute for medicines as we do not know that they work well enough to lower the risk of broken bones | 76% | 100% | 83% |
that medicines maintain bone strength and stop it from getting worse | 81% | 100% | 87% |
that osteoporosis medicines play an important role in maintaining independence and protecting your spine | 78% | 100% | 85% |
The clinician should… | |||
before discussing medicines, ask the patient if they have any concerns about their dental health* | 68% | 87% | 73% |
ask the patient what they knows about how lifestyle affects bone health* | 43% | 67% | 50% |
recommend calcium and/or vitamin D supplements as appropriate | 100% | 100% | 100% |
give general advice about avoiding falls if appropriate | 78% | 100% | 85% |
be able to discuss the benefits and risks of oral and intravenous bisphosphonates and denosumab injection | N/A | N/A | N/A |
discuss the choice of medicines with the patient in this appointment | 84% | 87% | 85% |
outline the risks and benefits of injectable medicines in this appointment, so that the patient can make an informed decision about how they want to proceed | 100% | 100% | 100% |
give advice about stopping smoking and lowering alcohol intake (if appropriate) | 81% | 100% | 87% |
General | |||
The first discussion about the benefits and risks of osteoporosis medicines is best undertaken in the Fracture Liaison Service appointment | N/A | N/A | N/A |
The discussion about the benefits and risks of osteoporosis medicines is best undertaken face-to-face | N/A | N/A | N/A |
Stage 8: Checking understanding and summarise | |||
The clinician should check whether the patient… | |||
understands what the medicine will achieve | 89% | 93% | 90% |
feels sure about the best choice of drug treatment (medicine) | 78% | 93% | 83% |
knows the benefits and risks | 70% | 93% | 77% |
is clear about which benefits and risks matter most to them | 70% | 93% | 77% |
has enough support to make an informed decision about osteoporosis drug treatment (medicine) | 81% | 87% | 83% |
is happy to take the recommended option, prefers not to take it or if they are still unsure | 97% | 100% | 98% |
feels that the recommended medicine is relevant to them to meet their goals | 46% | 73% | 54%† |
The clinician should… | |||
accept the patient may have different views on risks and benefits of medicines | 87% | 100% | 90% |
check the patient’s knowledge of osteoporosis* | 76% | 73% | 75% |
check whether the patient has any concerns about the recommended medicine | 92% | 93% | 92% |
Stage 9: Discussing next steps | |||
The clinician should… | |||
explain what to do if the patient misses a dose of their medication | 89% | 100% | 92% |
explain how medication effectiveness is measured/monitored | 81% | 93% | 85% |
outline what will happen next in terms of follow-up (i.e. the patient will receive a telephone call follow-up to find out how they are getting on with the medicine, and when this will be | 100% | 100% | 100% |
if appropriate, refer the patient on to other services, e.g. falls prevention clinic | 89% | 100% | 92% |
ask the patient what questions they have | 89% | 93% | 90% |
offer advice/onward referral if the patient has concerns about fracture symptoms, such as pain | 87% | 93% | 89% |
give the patient written information about osteoporosis | 87% | 100% | 90% |
give the patient a written copy of their individualised fracture risk, and risks and benefits of drug treatment | 84% | 67% | 79% |
send the patient's GP a written copy of their individualised fracture risk, and risks and benefits of drug treatment | 95% | 93% | 94% |
offer a further additional telephone consultation to review in 1–2 weeks time | 78% | 80% | 79% |
arrange a standard follow-up call (in 1–2 months time)* | 76% | 73% | 75% |
give the patient information to show their dentist if prescribed bisphosphonates | 76% | 87% | 79% |
suggest that the patient considers the information and then rings a patient helpline (e.g. the Royal Osteoporosis Society helpline/a local helpline) to discuss further | 95% | 73% | 89% |
give contact details for where the patient can get hold of high quality information and support (e.g. the Royal Osteoporosis Society) | 100% | 100% | 100% |
explain what information the GP will receive and when* | 65% | 80% | 69% |
ask the patient how they would like to receive further information (e.g. paper, by text, website)* | 76% | 73% | 75% |
explain who to contact in case of questions | 87% | 100% | 90% |
respect the patient's decision, and continue with providing written information, further contact details in case of questions and explain about the communications the GP will receive. | 100% | 100% | 100% |
give the patient information about local support groups and services | 89% | 67% | 83% |
Consultation stage | FLS clinician should: | Additional information |
---|---|---|
Greeting/introduction | 1. Explain the aim of the appointment* and find out what the patient is expecting from the appointment | *Aim includes investigating for osteoporosis, estimating risk of fracture and considering steps to improve bone health/ reduce chance of further fractures |
Gathering information | 2. Take a history, including information about the fracture*, medical history**, fracture risk factors***, falls and lifestyle behaviours**** | *Including how the fracture happened and impact on life **To identify causes of osteoporosis and contraindications to medicines ***Such as smoking, family history, previous fractures, alcohol, medical conditions, medications etc., back pain and height loss (signs of vertebral fracture) ****General health and diet and calcium intake |
3. Recommend, arrange and explain DXA*, spinal imaging and blood tests if appropriate | *Including why DXA is recommended, what it involves and how it will affect them | |
Considering therapeutic options | 4. Use national guidelines to decide which patients should be offered drug treatment* | *While being aware of circumstances where fracture risk may be underestimated. Do not offer oral bisphosphonates to those with severe indigestion, problems swallowing or memory problems unless they have support with taking medicines |
Eliciting patient perceptions | 5. Ask the patient what they already know and think about osteoporosis, osteoporosis medicines and their concerns and how important maintaining independence is | |
Establishing SDM preferences | 6. Establish what involvement the patient would like to have in making decisions about medicines | |
Sharing information about the condition | 7. Show and explain bone density results* | *In people who do not meet the densitometry definition for osteoporosis, but are recommended treatment, explain that bone density results are only part of a picture of their bone strength, but that they are at increased risk of breaking bones. Use simple numbers (e.g. they have a 30 in 100 chance of breaking a bone over the next 10 years) |
8. Explain what osteoporosis is*, the causes**, the consequences*** and how it can be controlled**** | *Osteoporosis means bones are weaker and may be likely to break (fracture) after a minor bump or fall; does not give you physical symptoms (e.g. pain) unless you break a bone **Risk factors the patient has ***Mean that the patient may be more likely to break bones such as wrist, hip or bones in the spine; spinal fractures happen when the bone squashes down and may cause pain and curving of the spine ****Explain finding osteoporosis is a good thing because we can do something about it; keeping up a healthy lifestyle (not smoking, regular exercise) is important in maintaining bone strength and health; osteoporosis medication, if taken regularly will lower the risk of breaking bones in the future) | |
Sharing information about treatment | 9. Discuss drug treatment* in a face-to-face FLS appointment, if possible, including explanation of why the treatment is recommended**, aims and benefits***, common or severe side effects, what is involved in taking the medicine and how long it will be taken for | *Oral or intravenous bisphosphonates, or denosumab **Medicine is recommended for osteoporosis or people with high fracture risk, tablet medicine is recommended first ***To strengthen bones, lower the chance of future broken bones, prevent worsening, to play an important role in maintaining independence and protecting the spine. Explain how much the risk of broken bones is lowered with medicine, using simple numbers and pictures. Explain that osteoporosis medicine does not make you feel better, and it is not possible to ‘feel’ stronger bones |
10. Discuss the role of lifestyle management*, including diet and supplements, physical activity, avoiding falls, smoking cessation and alcohol reduction if appropriate | *Explain diet and physical activity are important in strengthening bone and have a complementary effect to medicines; explain diet, physical activity and supplements cannot be viewed as a substitute for medicines as we do not know that they work well enough to lower the risk of broken bones | |
Checking understanding and summarise | 11. Check patient understanding* and ask about any concerns | *About the benefits and risks, whether they are clear about what matters to them and how the benefits are relevant to their goals |
12. Ask* if the patient is happy to take the recommended option, prefers not to take it or if they are still unsure** | *Check they have enough support to make a decision about medicine and if they are sure about the best choice **Accept the patient may have different views on risk and benefits and respect their decision | |
Signposting next steps | 13. Explain for patients starting treatment, how medication effectiveness is measured and monitored, what to do if a dose of medication is missed and about follow-up* | *Explain that the patient will receive a telephone call follow-up to find out how they are getting on with the medicine, and when this will be |
14. Arrange follow-up for patients who are unsure about treatment and offer helpline to discuss further | ||
15. Offer advice and onward referral for fracture management and/or falls prevention if appropriate | ||
16. Give the patient contact details and written information* | *About osteoporosis, individualised fracture risk, risks and benefits of treatment, information to give their dentist, advice on local and national support groups | |
17. Ask what questions the patient has | ||
18. Send GP a written copy of the patient’s individualised fracture risk, and of risks and benefits of drug treatment |