Table 2

Overarching principles and EULAR points to consider for the prevention and management of fragility fracture by non-physician HPs

No	Overarching principles			Level of Agreement (Mean (SD))
1	The management of patients at risk of a fragility fracture should be based on shared decision making between patients and non-physician HPs.			9 (1.8)
2	Non-physician HPs should be involved in the management of patients at risk of fragility fractures.			8.4 (2.2)
No	Point to consider	Level of evidence	Strength of recommendation	Level of Agreement (Mean (SD))
No	Prevention of Fragility Fractures	Level of evidence	Strength of recommendation	Median (Range)
1	Identification of patients at risk of fracture
	Non-physician HPs should identify patients at risk of fragility fracture, ensure that the patients are offered opportunities for adequate treatment and address bone fragility in patient education.			9.06 (1.16)
		2	B	9.06 (1.16)
				9.5 (7–10)
2	Fall risk evaluation
	Non-physician HPs should start with fall risk evaluation of patients at risk of fragility fracture. Patients at high-risk of falls should be assessed by non-physician HPs using an individualised approach to multi-component screening or referred to one or more non-physician HPs competent in multi-component screening.	4	C	9.61 (0.70)
				10 (8 to 10)
3	Preventive multicomponent interventions
	Tailored multicomponent interventions, including for example:
	Exercise	1 to 3	A	9.33 (0.91)
	Environmental adaptations	2	D	9.33 (0.91)
	Nutrition	1 to 2	D	10 (8 to 10)
	Education	2	D
	should be offered to patients at high-risk of primary osteoporotic fracture and/or high-risk of falls
4	Avoidance of smoking and overuse of alcohol
	Smoking and overuse of alcohol should be discouraged.	1	A	9.22 (1.31)
	Smoking and overuse of alcohol should be discouraged.	1	A	10 (5 to 10)
No	Point to consider	Level of evidence	Strength of recommendation	Level of Agreement (Mean (SD))
No	Management of Fragility Fractures	Level of evidence	Strength of recommendation	Median (Range)
5	Exercise and nutritional interventions for patients who have experienced a fragility fracture
	Non-physician HPs should ensure that patients who have experienced a fragility fracture are given opportunities for:
	adequate exercise	1 to 2	A	9.22 (0.88)
	adequate nutritional intake	2	D	9.22 (0.88)
	Calcium and vitamin D intake should be discussed with the patient focussing on actual and recommended daily calcium intake, calcium and vitamin D rich foods, and the individual’s risk/benefit profile for vitamin D supplementation.	1 to 2	D	9.5 (8 to 10)
6	Organisation and coordination of multidisciplinary services
	Non-physician HPs should be included in orthogeriatric services, FLS and/or a coordinated, multidisciplinary post-fracture prevention programme. Patients with fragility fractures should be referred to a FLS or an adequate, coordinated, multidisciplinary post-fracture prevention programme	1 to 2		9.50 (1.10)
		1 to 2		10 (6 to 10)
7	Adherence to anti-osteoporosis medicines
	Non-physician HPs should address, monitor and support medication adherence in a structured follow-up.	2 to 3	B	8.83 (1.25)
		2 to 3	B	9 (6 to 10)

EULAR, European League Against Rheumatism; FLS, fracture liaison services; HPs, health professionals.