UK clinical guideline for the prevention and treatment of osteoporosis Managing behavioural and psychological symptoms in community dwelling older people with dementia: 1. A systematic review of the effectiveness of interventions [Optimization of calcium intake for the prevention of osteoporosis and osteoporotic fractures: a review of the evidence]. Structuring communication relationships for interprofessional teamwork (SCRIPT): a cluster randomized controlled trial Pharmacologic Treatment of Low Bone Density or Osteoporosis to Prevent Fractures: A Clinical Practice Guideline from the American College of Physicians Effects of a three party healthcare network on the incidence levels of drug related problems AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both Effects of workplace-based dietary and/or physical activity interventions for weight management targeting healthcare professionals: a systematic review of randomised controlled trials Behavioural interventions for urinary incontinence in community-dwelling seniors: an evidence-based analysis. North of England evidence based guidelines development project: methods of developing guidelines for efficient drug use in primary care Low acceptance of treatment in the elderly for the secondary prevention of osteoporotic fracture in the acute rehabilitation setting Systematic review of exercise effects on health outcomes in women with breast cancer. Discontinuing Inappropriate Medication Use in Nursing Home Residents Characterisation of Patients with Postmenopausal Osteoporosis in French Primary Healthcare Systematic review of the effectiveness of integrated care pathways: what works, for whom, in which circumstances? Effectiveness of interventions to improve the public’s antimicrobial resistance awareness and behaviours associated with prudent use of antimicrobials: a systematic review Non-randomized studies as a source of complementary, sequential or replacement evidence for randomized controlled trials in systematic reviews on the effects of interventions. Helping patients help themselves: A systematic review of self-management support strategies in primary health care practice Critical appraisal skills training for health care professionals: a randomized controlled trial [ISRCTN46272378] Ten-year risk of osteoporotic fractures in postmenopausal Chinese women according to clinical risk factors and BMD T-scores: a prospective study. Vitamin D and calcium supplementation prevents osteoporotic fractures in elderly community dwelling residents: a pragmatic population-based 3-year intervention study. Systematic reviews of the effectiveness of quality improvement strategies and programmes How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect?
Introduction In 2008 , the UK National Osteoporosis Guideline Group ( NOGG ) produced a guideline on the prevention and treatment of osteoporosis , with an up date in 2013 . This paper presents a major up date of the guideline , the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women and men age 50 years or over . Methods Where available , systematic review s , meta-analyses and r and omised controlled trials were used to provide the evidence base . Conclusions and recommendations were systematic ally grade d according to the strength of the available evidence . Results Review of the evidence and recommendations are provided for the diagnosis of osteoporosis , fracture-risk assessment , lifestyle measures and pharmacological interventions , duration and monitoring of bisphosphonate therapy , glucocorticoid-induced osteoporosis , osteoporosis in men , postfracture care and intervention thresholds . Conclusion The guideline , which has received accreditation from the National Institute of Health and Care Excellence ( NICE ) , provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals who are involved in its management Background Two-thirds of people living with dementia live at home in the UK and many experience distressing behavioural and psychological symptoms . This systematic review evaluates the effectiveness of non-pharmacological interventions for behavioural and psychological symptoms among community-dwelling people living with dementia . Methods This two-stage review undertook an initial mapping of the literature followed by a systematic review of relevant r and omised controlled trials . We search ed electronic data bases for pertinent studies reporting outcomes from interventions from January 2000 to March 2015 and up date d search es in October 2016 . We included studies that considered behavioural and psychological symptom management for older people living with dementia who live at home and excluded studies conducted in long-term care setting s. This paper presents findings from a narrative synthesis of 48 r and omised controlled trials evaluating interventions for people living with dementia alone , family carers alone and patient-carer dyads . Results We retrieved 17,871 de-duplicated records and screened them for potential inclusion . Evidence from 48 r and omised controlled trials suggests that family carer training and educational programmes that target problem behaviours and potential triggers can improve outcomes . Nurses and occupational therapists appear to help people with dementia with behavioural and psychological symptoms , but professional comparisons are lacking and there is no shared language about or underst and ing of behavioural and psychological symptoms amongst professionals , or between professionals and family carers . Conclusions Future research should focus on the effectiveness of components of multi-faceted programmes and their cost effectiveness and include qualitative data to better target interventions for behavioural and psychological symptoms . It is important to consider family carer readiness to use non-pharmacological strategies and to develop a shared language about the inherent needs and communications of behavioural and psychological symptoms One of the main focuses of lifestyle modification for the prevention of osteoporosis and osteoporotic fractures  in Japan is improvement in dietary calcium intake . However , virtually no r and omized controlled trial to assess the preventive effects of administration of calcium on the risk of fractures has been conducted in Japan . In this study , we review ed all the scientific papers currently available from medical literature data bases to propose evidence -based recommendations on the preventive procedures for osteoporosis . The result of the present systematic review gives the evidence showing that calcium supplementation or optimal dietary calcium intake increases bone density in childhood and adolescence and reduces the risk of fracture due to osteoporosis in the elderly people regardless of the gender . The evidence also supports the current health policy guiding the elderly to increase their dietary calcium intake in daily life Background Despite a burgeoning interest in using interprofessional approaches to promote effective collaboration in health care , systematic review s find scant evidence of benefit . This protocol describes the first cluster r and omized controlled trial ( RCT ) to design and evaluate an intervention intended to improve interprofessional collaborative communication and patient-centred care . Objectives The objective is to evaluate the effects of a four-component , hospital-based staff communication protocol design ed to promote collaborative communication between healthcare professionals and enhance patient-centred care . Methods The study is a multi-centre mixed- methods cluster r and omized controlled trial involving twenty clinical teaching teams ( CTTs ) in general internal medicine ( GIM ) divisions of five Toronto tertiary-care hospitals . CTTs will be r and omly assigned either to receive an intervention design ed to improve interprofessional collaborative communication , or to continue usual communication practice s . Non-participant naturalistic observation , shadowing , and semi-structured , qualitative interviews were conducted to explore existing patterns of interprofessional collaboration in the CTTs , and to support intervention development . Interviews and shadowing will continue during intervention delivery in order to document interactions between the intervention setting s and adopters , and changes in interprofessional communication . The primary outcome is the rate of unplanned hospital readmission . Secondary outcomes are length of stay ( LOS ) ; adherence to evidence -based prescription drug therapy ; patients ' satisfaction with care ; self-report surveys of CTT staff perceptions of interprofessional collaboration ; and frequency of calls to paging devices . Outcomes will be compared on an intention-to-treat basis using adjustment methods appropriate for data from a cluster r and omized design . Discussion Pre-intervention qualitative analysis revealed that a substantial amount of interprofessional interaction lacks key core elements of collaborative communication such as self- introduction , description of professional role , and solicitation of other professional perspectives . Incorporating these findings , a four-component intervention was design ed with a goal of creating a culture of communication in which the fundamentals of collaboration become a routine part of interprofessional interactions during unstructured work periods on GIM wards . Trial registration Registered with National Institutes of Health as NCT00466297 The National Institutes of Health 's consensus conference ( 1 ) defined osteoporosis as a skeletal disorder characterized by compromised bone strength predisposing to an increased risk for fracture . Bone strength reflects the integration of two main features : bone density and bone quality .Bone quality refers to architecture , turnover , damage accumulation ( e.g. , microfractures ) , and mineralization . Although osteoporosis can affect any bone , the hip , spine , and wrist are most likely to be affected . Osteoporosis affects an estimated 44 million Americans or 55 % of people 50 years of age or older . Another 34 million Americans are estimated to have low bone mass , meaning that they are at an increased risk for osteoporosis . Osteoporosis can be diagnosed by the occurrence of fragility fracture . In patients without fragility fracture , osteoporosis is often diagnosed by low bone density .  Dual x-ray absorptiometry ( DXA ) is the current gold st and ard test for diagnosing osteoporosis in people without an osteoporotic fracture .  Dual x-ray absorptiometry results are scored as st and ard deviations ( SDs ) from a young healthy norm ( usually female ) and reported as T-scores . For example , a T-score of 2 indicates a bone mineral density that is 2 SDs below the comparative norm . The international reference st and ard for the description of osteoporosis in postmenopausal women and in men age 50 years or older is a femoral neck bone mineral density of 2.5 SD or more below the young female adult mean ( 2 ) . Low bone density , as measured by DXA , is an imperfect predictor of fracture risk , identifying fewer than half the people who go on to have an osteoporotic fracture . Screening guidelines for women are well established ( 3 ) , and the American College of Physicians ( ACP ) recently published guidelines on screening for men ( 4 ) . This guideline presents the available evidence on various pharmacologic treatments to prevent fractures in men and women with low bone density or osteoporosis . Medications used to treat osteoporosis may affect different parts of the skeletal system differently , and efficacy for vertebral fractures does not necessarily imply efficacy for nonvertebral fractures . The target audience for this guideline is all clinicians and the target patient population is all adult men and women with low bone density or osteoporosis . These recommendations are based on the systematic evidence review by MacLean and colleagues ( 5 ) and the Agency for Healthcare Research and Quality sponsored Southern California Evidence -Based Practice Center evidence report ( 6 ) . The drugs currently approved for prevention of osteoporosis include alendronate , ib and ronate , risedronate , zoledronic acid , estrogen , and raloxifene . The drugs currently approved for treatment of osteoporosis include alendronate , ib and ronate , risedronate , calcitonin , teriparatide , zoledronic acid ( in postmenopausal women ) , and raloxifene . Testosterone , pamidronate , and etidronate are not approved by the U.S. Food and Drug Administration for the treatment or prevention of osteoporosis . Methods The literature search done by MacLean and colleagues for the systematic review ( 5 ) included studies from MEDLINE ( 1966 to December 2006 ) , the ACP Journal Club data base , the Cochrane Central Register of Controlled Trials ( no date limits ) , the Cochrane Data base of Systematic Review s ( no date limits ) , Web sites of the United Kingdom National Institute of Health and Clinical Excellence ( no date limits ) , and the United Kingdom Health Technology Assessment Program ( January 1998 to December 2006 ) . The review ers limited their search to English- language publications and human studies . They derived evidence for comparative benefits of various treatments exclusively from r and omized , controlled trials , whereas they included evidence from other types of studies for short- and long-term harms . Two physicians independently abstract ed data about study population s , interventions , follow-up , and outcome ascertainment by using a structured form . For each group within a r and omized trial , a statistician extracted the sample size and number of persons reporting fractures . Two review ers , under the supervision of the statistician , independently abstract ed information about adverse events . The statistician or the principal investigator resolved disagreements . This guideline is based on an evaluation of 76 r and omized , controlled trials , 4 of which were identified in the up date d search , and 24 meta-analyses that were included in the efficacy analyses . The analyses of adverse events included 491 articles , representing 417 r and omized trials , 25 other controlled clinical trials , 11 open-label trials , 31 large observational studies , and 9 case reports of osteonecrosis among bisphosphonate users . MacLean and colleagues ' background article ( 5 ) includes details about the methods used for the systematic evidence review . The ACP rates the evidence and recommendations by using the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) system with minor modifications ( Table 1 ) . In addition , the evidence review ers used predefined criteria to assess the quality of systematic review s and r and omized trials , based on internal and external validity assessment s detailed in the Quality of Reporting of Meta-Analyses ( QUOROM ) statement ( 7 ) . Table 1 . The American College of Physicians ' Guideline Grading System The objective of this guideline is to synthesize the evidence for the following questions : What are the comparative benefits in fracture reduction among and also within the following treatments for low bone density :  bisphosphonates , specifically alendronate , risedronate , etidronate , ib and ronate , pamidronate , and zoledronic acid ; calcitonin ; estrogen for women ; teriparatide ; selective estrogen receptor modulators ( SERMs ) , specifically raloxifene and tamoxifen ; testosterone for men ; vitamins and minerals , specifically vitamin D and calcium ; and the combination of calcium plus vitamin D ? How does fracture reduction result ing from treatments vary among individuals with different risks for fracture as determined by bone mineral density ( borderline , low , or severe ) , previous fractures ( prevention vs. treatment ) , age , sex , glucocorticoid use , and other factors ( such as community-dwelling vs. institutionalized or vitamin Ddeficient vs. not ) ? What are the short- and long-term harms ( adverse effects ) of these therapies , and do these vary by specific sub population s ? Comparative Benefits of Drugs versus Placebo in Fracture Reduction Evidence from 24 meta-analyses ( 830 ) and 35 additional r and omized trials published after the meta-analyses ( 3165 ) described the effect of 9 of the 14 agents ( alendronate , etidronate , risedronate , calcitonin , estrogen , teriparatide , raloxifene , calcium , and vitamin D ) on fracture incidence . For 4 agents ( ib and ronate , pamidronate , zoledronic acid , and tamoxifen ) , the review ers found no meta-analyses and instead gathered the evidence from 14 r and omized trials ( 6679 ) . No studies were found that reported fracture rates for testosterone . Three r and omized trials ( 35 , 80 , 81 ) and 1 meta- analysis ( 82 ) evaluated the combination of calcium plus vitamin D  on fractures .  Bisphosphonates Good- quality evidence showed that alendronate , etidronate , ib and ronate , and risedronate prevent vertebral fractures . In addition , evidence from good- quality studies demonstrated that both alendronate and risedronate prevent nonvertebral and hip fractures . Two large r and omized trials showed that zoledronic acid prevents vertebral and nonvertebral fractures in high-risk population s and reduces the risk for hip fracture ( 67 , 74 ) . Ib and ronate has not been shown to reduce nonvertebral fractures ( 68 ) . Of the 6 fairly small trials that looked at vertebral fractures , 1 demonstrated a statistically significant reduction in fractures with pamidronate relative to placebo ( 0.14 [ 95 % CI , 0.03 to 0.72 ] ) ( 73 ) . However , after these data were pooled , the pooled risk estimate for fractures for pamidronate relative to placebo was not significant ( 0.52 [ CI , 0.21 to 1.24 ] ) ( 6 ) . Calcitonin Fair- quality evidence shows that calcitonin reduces vertebral fractures ( 83 , 84 ) . Good- quality evidence indicates that calcitonin does not reduce nonvertebral fractures ( 13 , 16 ) . Estrogen Good- quality evidence shows that estrogen reduces the incidence of vertebral ( 29 , 85 ) , nonvertebral ( 86 ) , and hip fractures ( 85 ) . Teriparatide Good- quality evidence shows that teriparatide prevents vertebral fractures . The evidence related to teriparatide preventing nonvertebral fractures is mixed ; 1 large r and omized trial showed a reduction in nonvertebral fractures ( 34 ) but 2 small trials did not ( 87 , 88 ) . SERMs Good- quality evidence shows that raloxifene prevents vertebral fractures , but that tamoxifen has no effect on vertebral fractures ( 8991 ) . In addition , both raloxifene and tamoxifen had no effect on hip fractures ( 91 ) . Tamoxifen is not approved by the U.S. Food and Drug Administration for the treatment or prevention of osteoporosis . Testosterone No studies reported fracture rates for testosterone . Calcium and Vitamin D In the studies evaluated by MacLean and colleagues ( 5 ) , the evidence for the effect of calcium alone on reduction of fractures is complex . Most studies of pharmacologic agents for osteoporosis include calcium and vitamin D as part of the treatment regimen . Evidence from 1 meta- analysis ( 27 ) and several r and omized trials ( 35 , 48 , 51 , 92 ) showed no significant difference between calcium and placebo in preventing vertebral , nonvertebral , and hip fractures in postmenopausal women . However , nonadherence to therapy may influence this result , and 1 trial with a prespecified analysis of adherent patients found a reduction in fracture risk ( 48 ) . A recent meta- analysis ( 82 ) concluded that the relative risk ( RR ) for fracture with calcium alone was 0.90 ( CI , 0.80 to 1.00 ) , but it did not include a modestly large trial with negative results ( 35 ) . MacLean and colleagues ( 5 ) Background Drug related problems ( DRPs ) are impairing patients ’ health and cause high costs . Neither delegation of home medication review nor regular pharmaceutical care are common in Germany . Objective We aim ed to reduce several DRP by the implementation of a three party healthcare team [ AGnES- practice assistant , pharmacist , general practitioner ( GP ) ] and adherence supporting strategies ( using a medication reminder chart , medication compliance aid ) . Setting The setting was ambulatory primary healthcare in German rural areas with a cohort of home-dwelling , elderly , mostly multimorbid patients with limited mobility ( study period : 06/2006–12/2008 ) . Methods We conducted a prospect i ve non-r and omized implementation cohort study with home medication review ( home medication review module ; mean participation time : 9 months ) . Data collection was delegated to additionally qualified AGnES- practice assistants ( AGnES : GP-supporting , community-based , e-health-assisted systemic intervention ) . The intervention comprised pharmaceutical care by the local pharmacy in addition to medical interventions by the GP .  408 patients ( mean age : women : 80.7 years ; men : 75.3 years ) received both pharmaceutical care and at least one follow-up visit . Main outcome measurement Outcome measurements comprised self-reported DRPs , objective ly evaluated DRP , and prevalence of adherence supporting strategies . Results The three party healthcare team approach reduced self-reported forgetfulness ( 7.7–3.2 % ; p = 0.001 ) , the proportion of patients with intermittent drug intake ( 5.3–1.3 % ; p < 0.001 ) , and the proportion of patients with potentially clinical relevant drug – drug interaction ( 61.6–51.2 % ; p < 0.001 ) . Self-reported adverse drug reactions decreased non-significantly ( 5.4–4.6 % ; p = 0.564 ; all tests χ2-McNemar ) . The median number of active substances taken was reduced from 8 to 7 ( p < 0.001 ; Wilcoxon signed rank test ) . The proportions of patients using medication charts and compliance aids increased significantly ( 75.2–90.3 % ; p < 0.001 ) and ( 70.0–80.1 % ; p > 0.001 ) , respectively . Conclusion This is the first study evaluating effects of a three party team on DRPs in a primary healthcare setting in Germany . This approach led to reduction in the occurrence of several DRPs and improved adherence supporting strategies . However , the study is a pre-post analysis , and had no control group The number of published systematic review s of studies of healthcare interventions has increased rapidly and these are used extensively for clinical and policy decisions . Systematic review s are subject to a range of biases and increasingly include non-r and omised studies of interventions . It is important that users can distinguish high quality review s. Many instruments have been design ed to evaluate different aspects of review s , but there are few comprehensive critical appraisal instruments . AMSTAR was developed to evaluate systematic review s of r and omised trials . In this paper , we report on the updating of AMSTAR and its adaptation to enable more detailed assessment of systematic review s that include r and omised or non-r and omised studies of healthcare interventions , or both . With moves to base more decisions on real world observational evidence we believe that AMSTAR 2 will assist decision makers in the identification of high quality systematic review s , including those based on non-r and omised studies of healthcare interventions Background The prevalence of overweight and obesity is high amongst healthcare professionals and there is growing interest in delivering weight loss interventions in the workplace . We conducted a systematic review to ( i ) examine the effectiveness of workplace-based diet and /or physical activity interventions aim ed at healthcare professionals and to ( ii ) identify and describe key components of effective interventions . Seven electronic data bases were systematic ally search ed . Results Thirteen r and omised controlled trials met the inclusion criteria , of which seven had data available for meta- analysis . Where meta- analysis was possible , studies were grouped according to length of follow-up ( < 12 months and ≥12 months ) and behavioural target ( diet only , physical activity only or diet and physical activity ) , with outcome data pooled using a weighted r and om effects model . Nine studies reported statistically significant ( between-group ) differences . Four studies reported being informed by a behaviour change theory . Meta- analysis of all trials reporting weight data demonstrated healthcare professionals allocated to dietary and physical activity interventions lost significantly more body weight ( −3.95 Kg , [ 95 % CI −4.96 to- 2.95 Kg ] ) than controls up to 12 months follow up . Conclusions Workplace diet and /or physical activity interventions targeting healthcare professionals are limited in number and are heterogeneous . To improve the evidence base , we recommend additional evaluations of theory-based interventions and adequate reporting of intervention content UNLABELLED In early August 2007 , the Medical Advisory Secretariat began work on the Aging in the Community project , an evidence -based review of the literature surrounding healthy aging in the community . The Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the ministry 's newly released Aging at Home Strategy .After a broad literature review and consultation with experts , the secretariat identified 4 key areas that strongly predict an elderly person 's transition from independent community living to a long-term care home . Evidence -based analyses have been prepared for each of these 4 areas : falls and fall-related injuries , urinary incontinence , dementia , and social isolation . For the first area , falls and fall-related injuries , an economic model is described in a separate report . Please visit the Medical Advisory Secretariat Web site , http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html , to review these titles within the Aging in the Community series . AGING IN THE COMMUNITY : Summary of Evidence -Based AnalysesPrevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors : An Evidence -Based Analysis Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors : An Evidence -Based Analysis Caregiver- and Patient-Directed Interventions for Dementia : An Evidence -Based Analysis Social Isolation in Community-Dwelling Seniors : An Evidence -Based Analysis The Falls/Fractures Economic Model in Ontario Residents Aged 65 Years and Over ( FEMOR ) OBJECTIVE : To assess the effectiveness of behavioural interventions for the treatment and management of urinary incontinence ( UI ) in community-dwelling seniors . CLINICAL NEED TARGET POPULATION AND CONDITION Urinary incontinence defined as " the complaint of any involuntary leakage of urine " was identified as 1 of the key predictors in a senior 's transition from independent community living to admission to a long-term care ( LTC ) home . Urinary incontinence is a health problem that affects a substantial proportion of Ontario 's community-dwelling seniors ( and indirectly affects caregivers ) , impacting their health , functioning , well-being and quality of life . Based on Canadian studies , prevalence estimates range from 9 % to 30 % for senior men and nearly double from 19 % to 55 % for senior women . The direct and indirect costs associated with UI are substantial . It is estimated that the total annual costs in Canada are $ 1.5 billion ( Cdn ) , and that each year a senior living at home will spend $ 1,000 to $ 1,500 on incontinence supplies . Interventions to treat and manage UI can be classified into broad categories which include lifestyle modification , behavioural techniques , medications , devices ( e.g. , continence pessaries ) , surgical interventions and adjunctive measures ( e.g. , absorbent products ) . The focus of this review is behavioural interventions , since they are commonly the first line of treatment considered in seniors given that they are the least invasive options with no reported side effects , do not limit future treatment options , and can be applied in combination with other therapies . In addition , many seniors would not be ideal c and i date s for other types of interventions involving more risk , such as surgical measures . NOTE It is recognized that the terms " senior " and " elderly " carry a range of meanings for different audiences ; this report generally uses the former , but the terms are treated here as essentially interchangeable . DESCRIPTION OF TECHNOLOGY/THERAPY Behavioural interventions can be divided into 2 categories according to the target population :  caregiver-dependent techniques and patient-directed techniques . Caregiver-dependent techniques ( also known as toileting assistance ) are targeted at medically complex , frail individuals living at home with the assistance of a caregiver , who tends to be a family member . These seniors may also have cognitive deficits and /or motor deficits . A health care professional trains the senior 's caregiver to deliver an intervention such as prompted voiding , habit retraining , or timed  voiding . The health care professional who trains the caregiver is commonly a nurse or a nurse with advanced training in the management of UI , such as a nurse continence advisor ( NCA ) or a clinical nurse specialist ( CNS ) . The second category of behavioural interventions consists of patient-directed techniques targeted towards mobile , motivated seniors . Seniors in this population are cognitively able , free from any major physical deficits , and motivated to regain and /or improve their continence . A nurse or a nurse with advanced training in UI management , such as an NCA or CNS , delivers the patient-directed techniques . These are often provided as multicomponent interventions including a combination of bladder training techniques , pelvic floor muscle training ( PFMT ) , education on bladder control strategies , and self-monitoring . Pelvic floor muscle training , defined as a program of repeated pelvic floor muscle contractions taught and supervised by a health care professional , may be employed as part of a multicomponent intervention or in isolation . Education is a large component of both caregiver-dependent and patient-directed behavioural interventions , and patient and /or caregiver involvement as well as continued practice strongly affect the success of treatment . Incontinence products , which include a large variety of pads and devices for effective containment of urine , may be used in conjunction with behavioural techniques at any point in the patient 's management . EVIDENCE -BASED ANALYSIS METHODS A comprehensive search strategy was used to identify systematic review s and r and omized controlled trials that examined the effectiveness , safety , and cost-effectiveness of  caregiver-dependent and patient-directed behavioural interventions for the treatment of UI in community-dwelling seniors ( see Appendix 1 ) . RESEARCH QUESTIONS Are caregiver-dependent behavioural interventions effective in improving UI in medically complex , frail community-dwelling seniors with/without cognitive deficits and /or motor deficits?Are  patient-directed behavioural interventions effective in improving UI in mobile , motivated community-dwelling seniors?Are behavioural interventions delivered by NCAs or CNSs in a clinic setting effective in improving incontinence outcomes in community-dwelling seniors ? ASSESSMENT OF QUALITY OF EVIDENCE The quality of the evidence was assessed as high , moderate , low , or very low according to the GRADE methodology and GRADE Working Group . As per GRADE the following definitions apply : HighFurther research is very unlikely to change confidence in the estimate of effect . ModerateFurther research is likely to have an important impact on confidence in the estimate of effect and may change the estimate . LowFurther research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate . Very LowAny estimate of effect is very uncertain SUMMARY OF FINDINGS Executive Summary Table 1 summarizes the results of the analysis . The available evidence was limited by considerable variation in study population s and in the type and severity of UI for studies examining both caregiver-directed and patient-directed interventions . The UI literature frequently is limited to reporting subjective outcome measures such as patient observations and symptoms . The primary outcome of interest , admission to a LTC home , was not reported in the UI literature . The number of eligible studies was low , and there were limited data on long-term follow-up . Executive Summary Table 1 : Summary of Evidence on Behavioural Interventions for the Treatment of Urinary Incontinence in Community-Dwelling SeniorsInterventionTarget Population Interventions Conclusions GRADE quality of the evidence 1 . Caregiver-dependent techniques ( toileting assistance)Medically complex , frail individuals at home with/without cognitive deficits and /or motor deficitsDelivered by informal caregivers who are trained by a nurse or a nurse with specialized UI training (NCA/CNS)Prompted voidingHabit retrainingTimed voidingThere is no evidence of effectiveness for habit retraining ( n=1 study ) and timed voiding ( n=1 study ) .Prompted voiding may be effective , but effectiveness is difficult to substantiate because of an inadequately powered study ( n=1 study ) .Re source implication s and caregiver burden ( usually on an informal caregiver ) should be considered . Low2 . Patient-directed techniquesMobile , motivated seniorsDelivered by a nurse or a nurse with specialized UI training (NCA/CNS)Multicomponent  behavioural interventions Include a combination ofBladder trainingPFMT ( with or without biofeedback)Bladder control strategiesEducationSelf-monitoringSignificant  reduction in the mean number of incontinent episodes per week ( n=5 studies , WMD 3.63 , 95 % CI , 2.07 - 5.19)Significant improvement in patient 's perception of UI ( n=3 studies , OR 4.15 , 95 % CI , 2.70 - 6.37)Suggestive beneficial impact on patient 's health-related quality of lifeModerate PFMT aloneSignificant reduction in the mean number of incontinent episodes per week ( n=1 study , WMD 10.50 , 95 % CI , 4.30 - 16.70)Moderate3 . Behavioural interventions led by an NCA/CNS in a clinic setting Community-dwelling seniorsBehavioural interventions led by NCA/CNSOverall , effective in improving incontinence outcomes ( n=3 RCTs + 1 Ontario-based before/after study ) Moderate*CI refers to confidence interval ; CNS , clinical nurse specialist ; NCA , nurse continence advisor ; PFMT , pelvic floor muscle training ; RCT , r and omized controlled trial ; WMD , weighted mean difference ; UI , urinary incontinence . ECONOMIC ANALYSIS A budget impact analysis was conducted to forecast costs for caregiver-dependent and patient-directed multicomponent behavioural techniques delivered by NCAs , and PFMT alone delivered by physiotherapists . ( ABSTRACT TRUNCATED Practice guidelines are valid if “ they lead to the health gains and costs predicted for them.”1 When implemented , valid guidelines lead to changes in clinical practice and improvements in outcomes for patients .2 - 5 Invalid guidelines , however , may lead to the use of ineffective interventions that waste re sources , or even to harm . Guidelines must offer recommendations for both effective and efficient care , and these have not previously been available in the United Kingdom . We have reported the development and content of guidelines for primary care in the United Kingdom based explicitly on evidence of effectiveness.6 - 9 Here , we present the methods used to develop evidence based guidelines on the use in primary care of four important groups of drugs — angiotensin converting enzyme inhibitors in patients with heart failure , choice of antidepressants , non-steroidal anti-inflammatory drugs in patients with osteoarthritis , and aspirin as an antithrombotic agent.10 - 13 Abridged versions of the guidelines on angiotensin converting enzyme inhibitors , aspirin , and non-steroidal anti-inflammatory drugs will be published in subsequent articles.14 - 16 # # # # Summary points Guideline development groups defined important clinical questions , produced search criteria , and drew up protocol s for systematic review and , where appropriate , meta- analysis Medline and Embase were search ed for systematic review s and meta-analyses , r and omised trials , quality of life studies , and economic studies Meta- analysis was used extensively by the group to answer specific clinical questions Statements on evidence were categorised in relation to study design , reflecting their susceptibility to bias Strength of recommendations was grade d according to the category of evidence and its applicability , economic issues , values of the guideline group and society , and the groups ' awareness of practical issues Recommendations cease to apply in December 1999 , by which time relevant results that may affect recommendations may be known Guideline development groups comprised three broad classes of members — relevant healthcare professionals ( up to five general practitioners ( all with Background and aims : Given the high risk of subsequent fracture among elderly persons with fracture , it is important to initiate secondary treatment for osteoporosis . Acute rehabilitation centers may offer a unique opportunity to introduce treatment . Therefore , we evaluated willingness-to-participate and compliance with evidence -based interventions for the secondary prevention of  osteoporotic fracture in a non-r and omized study conducted in the acute rehabilitation setting . We also described differences in baseline characteristics between study participants and non- participants . Methods : All consecutive , community-dwelling admissions to an acute rehabilitation unit ( Boston , MA ) with the diagnosis of fracture were screened for enrollment . Eligible subjects were offered a free , 6-month supply of alendronate/cholecalciferol ( 70 mg/2800 IU weekly ) , calcium and vitamin D supplements , and fall prevention strategies . Six-month compliance ( ≥75 % consumption of medication or supplement ) with the interventions was determined at a home visit . Results : Among 62 eligible subjects , 25 agreed to participate . Non- participants were older than participants ( 86 vs 80 yrs , p<0.01 ) . There was no significant difference between other characteristics of participants and non- participants including sex , weight , type of fracture , cognitive status , and functional status . The most common reason for non-participation was reluctance to take another medication . Among participants , only 52 % were compliant with alendronate and 58 % were compliant with calcium and vitamin D supplementation at 6 months . Conclusions : Willingness-to-participate and compliance with secondary prevention strategies for osteoporosis was low in the acute rehabilitation setting , even when medications were provided free of cost . Educating individuals with fracture and their families on the consequences and treatment of osteoporosis may help to decrease the risk of sustaining a second fracture by accepting secondary preventive measures PURPOSE Exercise is commonly recommended to women after breast cancer surgery , yet it is difficult for patients and health professionals to adopt safe and beneficial types and modes of exercise . Thus studies on exercise interventions targeting women with breast cancer treatment were systematic ally review ed . METHODS The review process and quality assessment of the studies followed the guideline of the National Evidence -based Healthcare Collaborating Agency . Relevant studies were obtained from electronic data bases , and two trained review ers independently analyzed the studies . Of the 902 articles sorted , 11 were selected . Then , quality assessment for each study was carried out with the Scottish Intercollegiate Guideline Network ( SIGN ) checklist . RESULTS Seven different types of  exercise interventions were identified from 3 quasi-experimental and 8 r and omized controlled trial studies . The interventions varied in duration from several days to 13 weeks , and tended to show significant effects on psychological outcomes and upper body functions within a short-term period and were effective in alleviating lymphedema at a longer 1-year point . Supervised , professional intervention had significant effects on health indicators and a higher adherence rate . CONCLUSION Well- design ed exercises are effective and beneficial for improving women 's physical , physiological , and psychological health outcomes after breast cancer treatment as well as to facilitate changes in exercise behaviors . The feasibility of applying intervention protocol s , efficiency of interventions , and strengths of exercise protocol s should be further examined Polypharmacy , often defined as coincident prescribing of at least 5 long-term medications , is associated with an increased risk for inappropriate prescribing . As many as 40 % of nursing home residents may receive 1 or more inappropriate drugs ( 1 ) , a rate similar to that among community-dwelling older persons ( 2 ) . In nursing home residents , inappropriate prescribing has been shown to be associated with adverse events ( 3 ) and hospitalizations ( 4 ) . Inappropriate prescribing of antihypertensives , benzodiazepines , and the atypical antipsychotic quetiapine has been associated with increased fall risk in community-dwelling older persons ( 5 ) , loss of physical function in community-dwelling older women ( 6 ) , and an increase in cognitive decline in nursing home residents ( 7 ) , respectively . In addition to overprescribing , inappropriate prescribing may also manifest as underprescribing ( the omission of appropriate medication ) . Underprescribing of oral anticoagulants among nursing home residents has been reported ( 8) . Deprescribing has been defined as the process of withdrawal of an inappropriate medication , supervised by a health care professional with the goal of managing polypharmacy and improving outcomes ( 9 ) . Studies targeting discontinuation of use of specific medications have shown mixed results . Bergh and colleagues ( 10 ) found a worsening of depressive symptoms after discontinuation of antidepressant use but concluded that this worsening was in the sub clinical range . A systematic review showed that many patients remained normotensive after withdrawal of antihypertensives , although proportions ranged from 20 % to 85 % across studies ( 11 ) . Furthermore , conflicting results were found for discontinuation of antipsychotic use and risk for relapse of neuropsychiatric symptoms ( 12 , 13 ) . Multidisciplinary systematic medication review s done by physicians and pharmacists working together are aim ed at improving prescribing in patients with polypharmacy , but findings about their effectiveness have been equivocal ( 1418 ) . Negative findings may have been due to inclusion of inappropriate outcomes ( 17 ) and heterogeneity of interventions . Medication review s were performed by a multidisciplinary team of physicians and pharmacists in some studies but were done by a single health professional in others ( 19 ) . More extensive intervention studies using well-defined pharmacologic outcome measures and proximal outcomes indicative of patients ' well-being are needed ( 18 ) . Moreover , evidence on the effectiveness of multidisciplinary systematic medication review s is limited for nursing home residents , a particularly vulnerable population . Accordingly , the aim of this study was to assess whether multidisciplinary systematic medication review s increase successful discontinuation of inappropriate medication use , improve prescribing in other respects , and improve clinical outcomes in nursing home residents . Methods Design Overview We conducted the DIM-NHR ( Discontinuing Inappropriate Medication in Nursing Home Residents ) study , a pragmatic cluster r and omized controlled trial . Clusters of elder care physicians and their wards with residents from the 3 northern provinces of the Netherl and s were r and omly allocated to the intervention or control group in a 1:1 ratio . Participants were recruited between June 2014 and December 2015 , and follow-up was completed in April 2016 . The Medical Ethical Committee of the University Medical Center Groningen approved the study ( protocol number NL48091.042.14 ) . Written informed consent was requested from residents in wards for disabling conditions if they were deemed capable by the nursing staff . Informed consent from a legal representative was requested for residents who were not capable of providing informed consent and for those from dementia special care units . The study 's methods have been published ( 20 ) . The original trial protocol and a summary of changes to it are provided in the Supplement . Supplement . Study Protocol Changes and Original Protocol Setting and Participants We screened nursing home wards , elder care physicians , and nursing home residents for eligibility . Nursing home wards were eligible if they were dementia special care units or if they provided care for residents with disabling conditions . We included long-term care wards to reduce loss of participants to follow-up . Nursing home wards were excluded if they primarily cared for atypical patients ( for example , those with lifelong psychiatric disorder or intellectual disability ) , if they participated in other research aim ed at improving drug prescribing within the previous 12 months , or if medication review s had been done within 6 months before the beginning of recruitment . Unlike in many other countries , where different nursing home residents have different primary care physicians , in the Netherl and s , specialized elder care physicians are based in the nursing home . We recruited pharmacists and elder care physicians who were committed to performing the medication review s. Elder care physicians were ineligible if they previously received or were about to receive recertification for systematic medication review s. Nursing home residents were included if they had a life expectancy greater than 4 weeks and were deemed ineligible if they declined treatment with medication or at the discretion of nursing staff ( for example , because of a difficult relationship between nursing home staff and family members ) . R and omization and Intervention Cluster r and omization was performed at the level of the elder care physicians and the wards they were responsible for in order to minimize contamination that might occur if individual nursing home residents who shared the same elder care physician were r and omly assigned to different groups . Elder care physicians and their wards were first matched on relevant characteristics , including supplying pharmacy , health care organization , and ward type ( for example , wards for residents with dementia vs. residents with disabling conditions and number of residents in the ward ) . For each matched pair of physicians , one was r and omly assigned to the intervention group and the other to the control group . The r and om assignment was generated using the r and om variable function in SPSS software and was done by a research er who was not involved in data collection . Because physicians and pharmacists implemented the intervention , they were not blinded to the allocation of wards to the intervention or control group . Other nursing home staff , nursing home residents , and assessors of outcomes were not informed about the treatment allocation . The intervention consisted of a single Multidisciplinary Multistep Medication Review ( 3MR ) ( Table 1 ) that was done by the treating elder care physicians in collaboration with hospital pharmacists or pharmacists appointed to conduct medication review s in nursing homes . Participating elder care physicians and pharmacists received brief training about the 3MR before performing it . Adherence to the 3MR was checked by confirming with the pharmacists whether steps 1 to 3 had been completed and confirming with the physicians whether step 4 had been completed . The control condition consisted of usual care , including medication safety monitoring and ad hoc medication review s for individual residents when clinical ly indicated . These review s differed in quality and frequency from the st and ardized 3MRs performed in the intervention group . Table 1 . Overview of 3MR Steps Outcomes and Follow-up Primary and secondary outcome measures were collected at baseline and after 4 months . This follow-up was chosen because it allowed for consolidation of medication changes while also preventing excessive loss to follow-up owing to substantial mortality risk among these frail patients . The primary outcome was the proportion of residents who successfully discontinued use of at least 1 inappropriate medication ( that is , without relapse symptoms or severe withdrawal effects ) after 4 months of follow-up . Pharmacy and medical interns review ed all physician notes in each resident 's medical chart between baseline and follow-up to detect potential withdrawal or relapse symptoms . Medications that had to be tapered gradually ( such as narcotics or steroids ) because of the potential for severe withdrawal effects were not excluded from the intervention and were included in the count of successful discontinuations . A switch of an inappropriate medication to another medication in the same Anatomical Therapeutic Chemical ( ATC ) group was not considered a successful discontinuation . Medications were excluded if they were prescribed temporarily ( for example , antibiotics , dermatologic agents , or as-needed medications ) . Secondary pharmacologic outcomes were the number of residents for whom at least 1 underprescribed medication ( according to the START [ Screening Tool to Alert doctors to Right Treatment ] criteria [ 21 ] ) was initiated between baseline and follow-up , at least 1 dose was adjusted , and at least 1 potentially hazardous drug was replaced by a safer alternative . We also assessed cumulative exposure to anticholinergic and sedative drugs as measured with the Drug Burden Index ( DBI ) ( 23 ) at follow-up . Assessment of the primary and secondary pharmacologic outcomes was based on data from computerized pharmacy dispensing records . Data included the generic drug names , ATC codes , dosages , and start and stop date s for all prescribed medications between baseline and follow-up . All pharmacologic outcomes were review ed and adjudicated by a panel consisting of the interns , an elder care physician who was not involved in conducting the 3MRs , and a professor of clinical pharmacy . Secondary clinical outcome measures included the number of falls , visits to outpatient clinics , visits by elder care physicians , and consultations by other health care professionals ( for example , physiotherapists ) , as documented in residents ' medical charts . Cognitive function was Background The public health burden of osteoporosis is high , principally because of increased risk of fractures and associated morbidity , h and icap and mortality . Osteoporotic fracture prevention is therefore an important public health goal . General practitioners ( GPs ) play a key role in the management of osteoporosis , both in ensuring timely diagnosis and in providing treatment . Little information is available on st and ards of care for postmenopausal women with osteoporosis in general practice . Objectives The primary objective of this study was to describe risk factors and treatment in postmenopausal women with osteoporosis . Secondary objectives were to evaluate treatment compliance and to assess the impact of osteoporosis on quality of life . Methods This observational , cross-sectional , pharmacoepidemiological study was performed in a primary -care setting in France . A r and om sample of GPs recruited postmenopausal women with a diagnosis of osteoporosis who had been followed by the investigator for at least 2 years . At inclusion , investigators completed a question naire providing information on patient age , osteoporosis duration , risk factors and treatment history . The first three patients recruited by each investigator completed a question naire providing information on sociodemographic features , osteoporosis treatments and quality of life . Treatment compliance was quantified using the Test d’Evaluation de l’Observance and quality of life evaluated using the 12-item Short Form Health Survey ( SF-12 ) . Results Overall , 389 physicians included 3097 patients , of whom 1053 completed the patient question naire . Risk factors for osteoporotic fracture were identified in 2148 patients ( 69.4 % ) , most frequently personal or maternal antecedents of osteoporotic fracture and a low body mass index . Of these , 946 ( 44.0 % ) presented more than one risk factor . At the time of diagnosis , 629 patients ( 59.7 % ) presented fractures , which involved the vertebrae in 51.7 % of cases , the wrist in 40.5 % and the hip in 5.4 % . Older patients were more likely to have fractures at the time of diagnosis and to have multiple fractures . After diagnosis , at least one new fracture occurred in 201 patients ( 19.2 % ) . Multivariate logistic regression analysis identified age > 70 years , diagnosis at least 10 years previously , diagnosis based on the presence of a fracture , biochemical and haematological evaluation at the time of diagnosis , and a change in osteoporosis treatment in the previous 2 years as being significantly associated with incident fracture risk . At inclusion , 1019 patients ( 97.4 % ) were receiving treatment for osteoporosis , most frequently weekly bisphosphonates ( 71.6 % of treatments ) . Most patients ( 81.0 % ) had been treated for at least 1 year . Treatment compliance was high in 61 % of patients and low in < 5 % . Patient variables associated with high compliance were being retired , prescription of bisphosphonates and , among the bisphosphonate users , prescription of weekly formulations . SF-12 quality -of-life scores were low , ranging from 38.6 ( energy/vitality ) to 65.1 ( social functioning ) out of a possible maximum score of 100 . Baseline variables associated with SF-12 physical component summary scores included age , height loss since menopause , diagnosis following a fracture , fracture incidence since diagnosis , time since diagnosis and treatment with bisphosphonates . Conclusions In this study of postmenopausal osteoporosis in the French primary healthcare setting , many women with osteoporosis were diagnosed following a fracture . Although most were treated with bone-consolidating drugs , compliance was suboptimal in a significant minority . Osteoporotic fracture was associated with reduced quality of life UNLABELLED Aim Integrated care pathways ( ICP ) are management technologies which formalise multidisciplinary team-working and enable professionals to examine their roles and responsibilities . ICPs are now being implemented across international healthcare arena , but evidence to support their use is equivocal . The aim of this study was to identify the circumstances in which ICPs are effective , for whom and in what context s. Methods A systematic review of high- quality r and omised controlled trials published between 1980 and 2008 ( March ) evaluating  ICP use in child and adult population s in the full range of healthcare setting s. RESULTS 1 For relatively predictable trajectories of care ICPs can be effective in supporting proactive care management and ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner . This can lead to improvements in service quality and service efficiency without adverse consequences for patients . 2 ICPs are an effective mechanism for promoting adherence to guidelines or treatment protocol s thereby reducing variation in practice . 3 ICPs can be effective in improving documentation of treatment goals , documentation of communication with patients , carers and health professionals . 4 ICPs can be effective in improving physician agreement about treatment options . 5 ICPs can be effective in supporting decision-making when they incorporate a decision-aide . 6 The evidence considered in this review indicates that ICPs may be particularly effective in changing professional behaviours in the desired direction , where there is scope for improvement or where roles are new . 7 Even in context s in which health professionals are already experienced with a particular pathway , ICP use brings additional beneficial effects in directing professional practice in the desired direction . 8 ICPs may be less effective in bringing about service quality and efficiency gains in variable patient trajectories . 9 ICPs may be less effective in bringing about quality improvements in circumstances in which services are already based on best evidence and multidisciplinary working is well established . 10 Depending on their purpose , the benefits of ICPs may be greater for certain patient subgroups than others . 11 We do not know whether the costs of ICP development and implementation are justified by any of their reported benefits . 12 ICPs may need supporting mechanisms to underpin their implementation and ensure their adoption in practice , particularly in circumstances in which ICP use is a significant change in organisational culture . 13 ICP documentation can introduce scope for new kinds of error . Conclusions ICPs are most effective in context s where patient care trajectories are predictable . Their value in setting s in which recovery pathways are more variable is less clear . ICPs are most effective in bringing about behavioural changes where there are identified deficiencies in services ; their value in context s where inter-professional working is well established is less certain . None of the studies review ed included an economic evaluation and thus it is not known whether their benefits justify the costs of their implementation Background A global antimicrobial resistance ( AMR ) awareness intervention targeting the general public has been prioritized . Objectives To evaluate the effectiveness of interventions that aim to change AMR awareness and subsequent stewardship behaviours amongst the public . Methods Five data bases were search ed between 2000 and 2016 for interventions to change the public 's AMR awareness and /or antimicrobial stewardship behaviours . Study design s meeting the Cochrane Effective Practice and Organization of Care ( EPOC ) criteria , non-controlled before- and -after studies and prospect i ve cohort studies were considered eligible . Participants recruited from healthcare setting s and studies measuring stewardship behaviours of healthcare professionals were excluded .  Quality of studies was assessed using EPOC risk of bias criteria . Data were extracted and synthesized narratively . Registration : PROSPERO international prospect i ve register of systematic review s ( PROSPERO 2016 : CRD42016050343 ) . Results Twenty studies were included in the review with nine meeting the EPOC criteria . The overall risk of bias was high . Nineteen studies were conducted in high-income countries .  Mass media interventions were most common ( n = 7 ) , followed by school-based ( n = 6 ) and printed material interventions ( n = 6 ) . Seventeen studies demonstrated a significant effect on changing knowledge , attitudes or the public 's antimicrobial stewardship behaviours . Analysis showed that interventions targeting schoolchildren and parents have notable potential , but for the general public the picture is less clear . Conclusions Our work provides an in-depth examination of the effectiveness of AMR interventions for the public . However , the studies were heterogeneous and the quality of evidence was poor . Well- design ed , experimental studies on behavioural outcomes of such interventions are required The terms applicability , generalizability , external validity and transferability are related , sometimes used interchangeably and have in common that they lack a clear and consistent definition in the classic epidemiological literature . However , all of these terms generally describe one overarching theme : whether or not available research evidence can be directly utilized to answer the healthcare questions at h and , ideally supported by a judgment about the degree of confidence for this utilization . This concept has been called directness . The objectives of this paper were to delineate how non-r and omized studies ( NRS ) inform judgments in relation to directness and the concepts that it encompasses in the context of systematic review s. We will briefly review what is known and describe the theoretical and practical issues as well as offer guidance to those tackling the challenges of judging directness and using research evidence to answer healthcare questions with evidence from NRS . In particular , we suggest a framework in which authors can use NRS as a complement , sequence or replacement for r and omized controlled trials ( RCTs ) by focusing on judgments about the population , intervention , comparison and outcomes . Authors of systematic review s will use NRS to complement judgments about the inconsistencies , the rationale and credibility of subgroup analysis , the baseline risk estimates for the determination of absolute benefits and downsides , and the directness of surrogate outcomes . This evidence includes context ual or supplementary evidence . Authors of systematic review and other summaries of the evidence use NRS as sequential evidence to provide evidence when insufficient evidence is available for an outcome from RCTs , but NRS evidence is available ( e.g. , long-term harms ) . Use of evidence from NRS may also serve to replace RCT evidence when NRS provide equivalent ( or potentially higher ) confidence in the evidence ( i.e. quality ) compared to indirect evidence from RCTs . These judgments will be made in the context of other domains that influence the overall quality of the body of evidence , including the risk of bias , publication bias ( i.e. limitations in the detailed study design and execution ) , inconsistency , imprecision and factors that increase our confidence in effects . This article will support systematic review ers in their interaction with decision makers , that is , those who use the systematic review to develop guidelines , address health policy makers , and make clinical decisions , by making these judgments transparent . Copyright © 2013 John Wiley & Sons , Background Primary health professionals are well positioned to support the delivery of patient self-management in an evidence -based , structured capacity . A need exists to better underst and the active components required for effective self-management support , how these might be delivered within primary care , and the training and system changes that would subsequently be needed . Objectives ( 1 ) To examine self-management support interventions in primary care on health outcomes for a wide range of diseases compared to usual st and ard of care ; and ( 2 ) To identify the effective strategies that facilitate positive clinical and humanistic outcomes in this setting . Method A systematic review of r and omized controlled trials evaluating self-management support interventions was conducted following the Cochrane h and book & PRISMA guidelines . Published literature was systematic ally search ed from inception to June 2019 in PubMed , Scopus and Web of Science . Eligible studies assessed the effectiveness of individualized interventions with follow-up , delivered face-to-face to adult patients with any condition in primary care , compared with usual st and ard of care . Matrices were developed that mapped the evidence and components for each intervention . The method ological quality of included studies were appraised . Results 6,510 records were retrieved . 58 studies were included in the final qualitative synthesis . Findings reveal a structured patient-provider exchange is required in primary care ( including a one-on-one patient-provider consultation , ongoing follow up and provision of self-help material s ) . Interventions should be tailored to patient needs and may include combinations of strategies to improve a patient ’s disease or treatment knowledge ; independent monitoring of symptoms , encouraging self-treatment through a personalized action plan in response worsening symptoms or exacerbations , psychological coping and stress management strategies , and enhancing responsibility in medication adherence and lifestyle choices . Follow-up may include tailored feedback , monitoring of progress with respect to patient set healthcare goals , or honing problem-solving and decision-making skills . Theoretical models provided a strong base for effective SMS interventions . Positive outcomes for effective SMS included improvements in clinical indicators , health-related quality of life , self-efficacy ( confidence to self-manage ) , disease knowledge or control . An SMS model has been developed which sets the foundation for the design and evaluation of practical strategies for the construct of self-management support interventions in primary healthcare practice . Conclusions These findings provide primary care professionals with evidence -based strategies and structure to deliver SMS in practice . For this collaborative partnership approach to be more widely applied , future research should build on these findings for optimal SMS service design and upskilling healthcare providers to effectively support patients in this collaborative process Introduction Critical appraisal skills are believed to play a central role in an evidence -based approach to health practice . The aim of this study was to evaluate the effectiveness and costs of a critical appraisal skills educational intervention aim ed at health care professionals . Methods This prospect i ve controlled trial r and omized 145 self-selected general practitioners , hospital physicians , professions allied to medicine , and healthcare managers/administrators from the South West of Engl and to a half-day critical appraisal skills training workshop  ( based on the model of problem-based small group learning ) or waiting list control . The following outcomes were assessed at 6-months follow up : knowledge of the principles necessary for appraising evidence ; attitudes towards the use of evidence about healthcare ; evidence seeking behaviour ; perceived confidence in appraising evidence ; and ability to critically appraise a systematic review article . Results At follow up overall knowledge score [ mean difference : 2.6 ( 95 % CI : 0.6 to 4.6 ) ] and ability to appraise the results of a systematic review [ mean difference : 1.2 ( 95 % CI : 0.01 to 2.4 ) ] were higher in the critical skills training group compared to control . No statistical significant differences in overall attitude towards evidence , evidence seeking behaviour , perceived confidence , and other areas of critical appraisal skills ability ( methodology or generalizability ) were observed between groups . Taking into account the workshop provision costs and costs of participants time and expenses of participants , the average cost of providing the critical appraisal workshops was approximately £ 250 per person . Conclusions The findings of this study challenge the policy of funding ' one-off ' educational interventions aim ed at enhancing the evidence -based practice of health care professionals . Future evaluations of evidence -based practice interventions need to take in account this trial 's negative findings and method ological difficulties UNLABELLED Independent risk factors for osteoporotic fracture were identified for a Southern Chinese postmenopausal population .  Clinical risk factor assessment with or without BMD measurement was shown to be an effective predictor of 10-yr risk of osteoporotic fracture and provides a more accessible tool for patient evaluation . INTRODUCTION Asian-specific data on risk factors for osteoporosis remain sparse . However , risk factor assessment , in addition to BMD measurement , is increasingly recognized as a reliable predictor of absolute osteoporotic fracture risk . The purpose of this prospect i ve study was to determine the specific independent risk factors for osteoporotic fracture and to predict the 10-yr risk of osteoporotic fracture in the postmenopausal Southern Chinese population . MATERIAL S AND METHODS A total of 1435 community-dwelling , postmenopausal , treatment-naive women were recruited . Baseline demographic characteristics and clinical risk factors were obtained , and  BMD at the spine and  hip  was measured . Subjects were followed for outcomes of incident low trauma fracture . Ten-year risk of osteoporotic fracture was predicted from the risk factor assessment and BMD measurement by Cox proportional hazards models . RESULTS The mean age of subjects was 63.4 + /- 8.3 yr . After 5.0 + /- 2.3 yr ( range , 1.0 - 11.0 yr ) of follow-up , 80 nontraumatic new fractures were reported during follow-up . Eight independent clinical risk factors identified at baseline were found to be significant predictors of osteoporotic fracture , with the most important being use of walking aids ( RR , 4.2 ; 95 % CI , 2.7 - 6.7 ; p < 0.001 ) and a history of fall ( RR , 4.0 ; 95 % CI , 2.5 - 6.2 ; p < 0.001 ) . Other predictive factors included being homebound , calcium intake < 400 mg/d , age > 65 yr , history of fracture , and BMI < 19 kg/cm(2 ) . Subjects with three to eight clinical risk factors had a predicted 10-year risk of osteoporotic fracture of 25 % , which increased to 30 % if they also had total hip BMD T-score < or= -2.5 . CONCLUSIONS Clinical risk factor assessment , with or without BMD measurement  , is a reliable predictor of 10-year risk of osteoporotic fracture and may be particularly useful in regions or primary care clinics without access to bone densitometry equipment UNLABELLED This study of 9605 community-dwelling residents supports that vitamin D and calcium supplementation may prevent  osteoporotic fractures in elderly in a northern European region known to be deficient in vitamin D , especially during winter periods . INTRODUCTION We evaluated the effect of two programs for the prevention of osteoporotic fractures leading to acute hospital admission in a population of elderly community-dwelling residents . MATERIAL S AND METHODS This was a factorial , cluster-r and omized , pragmatic , intervention study . We included 9605 community-dwelling residents aged 66 + years . We offered a prevention program of a daily supplement of 1000 mg of elemental calcium as calcium carbonate and 400 IU ( 10 microg ) of vitamin D3 to a total of 4957 participants . Another program with evaluation and suggestions for the improvement of the domestic environment was offered to a total of 5063 participants . Both programs included revision of the resident 's current pharmaceutical treatment . We achieved information on osteoporotic fractures in the study population from the Danish Hospital Registration Data base . We defined osteoporotic fractures as low energy fractures of the proximal humerus , distal forearm , vertebral column , pelvis , cervical femur , and intertrochanteric femur . RESULTS Active participation was 50.3 % in the Calcium and Vitamin D Program and 46.4 % in the Environmental and Health Program . We observed a 16 % reduction in fracture incidence rate ( relative risk [ RR ] , 0.84 ; CI , 0.72 - 0.98 ; p < 0.025 ) among male and female residents offered the Calcium and Vitamin D Program ( intention-to-prevent analysis ) . CONCLUSIONS This study supports that vitamin D and calcium supplementation may prevent osteoporotic fractures in community-dwelling elderly people in a northern European region known to be deficient in vitamin D , especially during winter periods Systematic review s provide the best evidence on the effectiveness of healthcare interventions including quality improvement strategies . The methods of systematic review of individual patient r and omised trials of healthcare interventions are well developed . We discuss method ological and practice issues that need to be considered when undertaking systematic review s of quality improvement strategies including developing a review protocol , identifying and screening evidence sources , quality assessment and data abstract ion , analytical methods , reporting systematic review s , and appraising systematic review s. This paper builds on our experiences within the Cochrane Effective Practice and Organisation of Care ( EPOC ) review group UNLABELLED EXECUTIVE SUMMARY : BACKGROUND Across the developed world , we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision . Integrated care pathways ( ICPs ) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration . ICPs map out a patient 's journey , providing coordination of services for users . They aim to have : ' the right people , doing the right things , in the right order , at the right time , in the right place , with the right outcome ' . The value for ICPs in supporting the delivery of care across organisational boundaries , providing greater consistency in practice , improving service continuity and increasing collaboration has been advocated by many . However , there is little evidence to support their use , and the need for systematic evaluations in order to measure their effectiveness has been widely identified . A recent Cochrane review assessed the effects of ICPs on functional outcome , process of care , quality of life and hospitalisation costs of in patients with acute stroke , but did not specifically focus on service integration or its derivatives . To the best of our knowledge , no such systematic review of the literature exists . OBJECTIVES • To systematic ally review all high- quality studies which have evaluated the impact of care pathway technologies on ' service integration ' and its derivatives in stroke care • To examine how elements of service integration are defined in such studies • To examine the type of evidence utilised to measure service integration • To analyse the weight of evidence used to support cl aims about the effectiveness of ICPs on improving service integration • To produce recommendations for ICP developers , users and evaluators . INCLUSION CRITERIA Types of participants The review focused on the care of adult patients who had suffered a stroke . It included the full spectrum of services - acute care , rehabilitation and long-term support - in hospital and community setting s. Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest , defined for the purpose of this review as ' a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and st and ardise the outcome orientated care ' Here ' multidisciplinary ' is taken to refer to the involvement of two or more disciplines . Types of outcomes ' Service integration ' was the outcome of interest however , this was defined and measured in the selected studies . Types of studies This review was concerned with how ' service integration ' was defined in evaluations of ICPs ; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on ' service integration ' . Studies that made an explicit link between ICPs and service integration were included in the review . Evidence generated from r and omised controlled trials , quasi-experimental , qualitative and health economics research was sought . The search was limited to publications after 1980 , coinciding with the emergence of ICPs in the healthcare context . Assessment for inclusion of foreign papers was based on the English- language abstract , where available . These were included only if an English translation was available . EXCLUSION CRITERIA This review excluded studies that : • focused only on a single aspect of stroke care ( e.g. dysphasia ) • evaluated ICPs as part of a wider program of service development • did not make an explicit link between ICPs and service integration • did not meet the definition of ICP utilised for the purpose s of the review • focused exclusively on the outcomes of variance analysis SEARCH STRATEGY In order to avoid replication , the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Data base and the Cochrane Library were search ed to establish that no systematic review s existed and none were in progress . A three-stage search strategy was then used to identify both published and unpublished studies ( see Appendix III ) . DATA COLLECTION Our search strategy located 2123 papers , of which 39 were retrieved for further evaluation . We critically appraised seven papers , representing five studies . These were all evaluation studies and , as is typical in this field , comprised a range of study design s and data collection methods . Owing to the diversity of the study types included in the review , we developed a single- appraisal checklist and data - extraction tool which could be applied to all research design s.(32 ) The tool drew on the Joanna Briggs Institute ( JBI ) appraisal checklists for experimental studies and interpretive and critical research , and also incorporated specific information and issues which were relevant for our purpose s ( see Appendix VI ) . This extends the thinking outlined in Lyne et al.(31 ) in which , drawing on Campbell and Stanley 's classic paper , the case is made for developing an appraisal tool which is applicable to all types of evaluation , irrespective of study design . In assessing the quality of the papers , we were sympathetic to the method ological challenges of evaluating complex interventions such as ICPs . We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare context s. In accordance with the aims of this particular review , we have included studies , which are method ologically weaker than is typical of many systematic review s because , in our view , in the absence of stronger evidence , they yield useful information . DATA SYNTHESIS Given the heterogeneity of the included studies , meta- analysis and /or qualitative synthesis was not possible . A narrative summary of the study findings is presented . RESULTS 1 ICPs can be effective in ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner , although these improvements may reflect better documentation rather than actual changes in practice . 2 ICPs can be effective in improving the documentation of rehabilitation goals , documentation of communication with patients , carers ( diagnosis , prognosis and follow-up arrangements ) and documentation of notification of primary care physicians of discharge . However , this can create additional burdens of work for staff . 3 Early studies of ICP-managed care in the acute stroke context have demonstrated reduced length of stay without any associated adverse effects on discharge destination , morbidity or mortality . These effects do not reach statistical significance , however , and may reflect wider changes in service provision and a general trend towards reduced length of hospital stay . While later studies in the acute and rehabilitation context s do not reveal any significant reduction in length of stay , they do report greater documented use of certain clinical interventions and assessment s , suggesting that ICPs can be effective in mobilising hospital re sources around the patient . 4 ICPs implemented in the context of acute stroke care can be effective in reducing the occurrence of urinary tract infections , although we do not know whether this can be attributed to improved service integration . 5 ICP management in stroke rehabilitation may not be flexible enough to meet diverse patient needs and can result in insufficient attention to higher-level functioning and carer needs influencing perceptions of quality of life . 6 ICP management may assist in clarifying role boundaries and a shared underst and ing of the work , but this can result in some members of the disciplinary team perceiving that their contribution is not appropriately reflected in the documentation . 7 There is some evidence that ICPs may be effective in changing professional behaviours in the desired direction where there is scope for improvement , but in situations in which multidisciplinary working is effective , their positive effects may be limited . Furthermore , it is far from clear what the active ingredients of ICPs actually are . Kwan et al. suggest that it was the process of ICP development that had most impact on behaviours rather than the use of the artefact per se.(20 ) 8 None of the studies assessed the balance of costs and benefits of ICP  use . Therefore , we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits . CONCLUSIONS Implication s for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care . This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of re sources around the patient without incurring additional increases in length of stay .  ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable . Their value in the context of rehabilitation setting s in which recovery pathways are more variable is less clear . There is some evidence that ICPs may be effective in bringing about behavioural changes in context s where deficiencies in service provision have been identified . Their value in context s where inter-professional working is well established is less clear . While earlier before and after studies show a reduction in length of stay in ICP-managed care , this may reflect wider healthcare trends , and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced . There is some evidence to suggest that ICPs bring about improvements in documentation , but we do not know how far documented practice reflects actual practice . It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use . ( ABSTRACT TRUNCATED
Collectively , these studies provided some evidence to show that interventions by healthcare professionals improved the QOL medication compliance and calcium intake of patients but its effects on BMD , medication persistence , knowledge , and other lifestyle modifications were less conclusive .
Summary A systematic review was conducted to evaluate evidence concerning the effect of non-drug interventions by healthcare professionals on community-dwelling postmenopausal osteoporotic women .
Evidence available indicates that such interventions are effective in improving the quality of life , medication compliance , and calcium intake , but effect on other outcomes is less conclusive .
Introduction The purpose of this study is to conduct a systematic review to evaluate evidence concerning the effect of non-drug interventions by healthcare professionals on community-dwelling postmenopausal osteoporotic women .