Improving uptake of Fracture Prevention drug treatments: a protocol for Development of a consultation intervention (iFraP-D).

Funder: Wellcome TrustINTRODUCTION: Prevention of fragility fractures, a source of significant economic and personal burden, is hindered by poor uptake of fracture prevention medicines. Enhancing communication of scientific evidence and elicitation of patient medication-related beliefs has the potential to increase patient commitment to treatment. The Improving uptake of Fracture Prevention drug treatments (iFraP) programme aims to develop and evaluate a theoretically informed, complex intervention consisting of a computerised web-based decision support tool, training package and information resources, to facilitate informed decision-making about fracture prevention treatment, with a long-term aim of improving informed treatment adherence. This protocol focuses on the iFraP Development (iFraP-D) work. METHODS AND ANALYSIS: The approach to iFraP-D is informed by the Medical Research Council complex intervention development and evaluation framework and the three-step implementation of change model. The context for the study is UK fracture liaison services (FLS), which enact secondary fracture prevention. An evidence synthesis of clinical guidelines and Delphi exercise will be conducted to identify content for the intervention. Focus groups with patients, FLS clinicians and general practitioners and a usual care survey will facilitate understanding of current practice, and investigate barriers and facilitators to change. Design of the iFraP intervention will be informed by decision aid development standards and theories of implementation, behaviour change, acceptability and medicines adherence. The principles of co-design will underpin all elements of the study through a dedicated iFraP community of practice including key stakeholders and patient advisory groups. In-practice testing of the prototype intervention will inform revisions ready for further testing in a subsequent pilot and feasibility randomised trial. ETHICS AND DISSEMINATION: Ethical approval was obtained from North West-Greater Manchester West Research Ethics Committee (19/NW/0559). Dissemination and knowledge mobilisation will be facilitated through national bodies and networks, publications and presentations. TRIAL REGISTRATION NUMBER: researchregistry5041

Developing a model Fracture Liaison Service consultation with patients, carers and clinicians: a Delphi survey to inform content of the iFraP complex consultation intervention

Summary Fracture Liaison Services are recommended to deliver best practice in secondary fracture prevention. This modified Delphi survey, as part of the iFraP (Improving uptake of Fracture Prevention drug Treatments) study, provides consensus regarding tasks for clinicians in a model Fracture Liaison Service consultation. Purpose The clinical consultation is of pivotal importance in addressing barriers to treatment adherence. The aim of this study was to agree to the content of the ‘model Fracture Liaison Service (FLS) consultation’ within the iFraP (Improving uptake of Fracture Prevention drug Treatments) study. Methods A Delphi survey was co-designed with patients and clinical stakeholders using an evidence synthesis of current guidelines and content from frameworks and theories of shared decision-making, communication and medicine adherence. Patients with osteoporosis and/or fragility fractures, their carers, FLS clinicians and osteoporosis specialists were sent three rounds of the Delphi survey. Participants were presented with potential consultation content and asked to rate their perception of the importance of each statement on a 5-point Likert scale and to suggest new statements (Round 1). Lowest rated statements were removed or amended after Rounds 1 and 2. In Round 3, participants were asked whether each statement was ‘essential’ and percentage agreement calculated; the study team subsequently determined the threshold for essential content. Results Seventy-two, 49 and 52 patients, carers and clinicians responded to Rounds 1, 2 and 3 respectively. One hundred twenty-two statements were considered. By Round 3, consensus was reached, with 81 statements deemed essential within FLS consultations, relating to greeting/introductions; gathering information; considering therapeutic options; eliciting patient perceptions; establishing shared decision-making preferences; sharing information about osteoporosis and treatments; checking understanding/summarising; and signposting next steps. Conclusions This Delphi consensus exercise has summarised for the first time patient/carer and clinician consensus regarding clearly defined tasks for clinicians in a model FLS consultation

Improving uptake of Fracture Prevention drug treatments: a protocol for Development of a consultation intervention (iFraP-D)

Introduction Prevention of fragility fractures, a source of significant economic and personal burden, is hindered by poor uptake of fracture prevention medicines. Enhancing communication of scientific evidence and elicitation of patient medication-related beliefs has the potential to increase patient commitment to treatment. The Improving uptake of Fracture Prevention drug treatments (iFraP) programme aims to develop and evaluate a theoretically informed, complex intervention consisting of a computerised web-based decision support tool, training package and information resources, to facilitate informed decision-making about fracture prevention treatment, with a long-term aim of improving informed treatment adherence. This protocol focuses on the iFraP Development (iFraP-D) work. Methods and analysis The approach to iFraP-D is informed by the Medical Research Council complex intervention development and evaluation framework and the three-step implementation of change model. The context for the study is UK fracture liaison services (FLS), which enact secondary fracture prevention. An evidence synthesis of clinical guidelines and Delphi exercise will be conducted to identify content for the intervention. Focus groups with patients, FLS clinicians and general practitioners and a usual care survey will facilitate understanding of current practice, and investigate barriers and facilitators to change. Design of the iFraP intervention will be informed by decision aid development standards and theories of implementation, behaviour change, acceptability and medicines adherence. The principles of co-design will underpin all elements of the study through a dedicated iFraP community of practice including key stakeholders and patient advisory groups. In-practice testing of the prototype intervention will inform revisions ready for further testing in a subsequent pilot and feasibility randomised trial

Statistics of multi‐year droughts from the method for object‐based diagnostic evaluation

This study uses the Method for Object-based Diagnostic Evaluation (MODE) technique to examine and compare the statistics of drought attributes over the upper Colorado River basin (UCRB). The drought objects are based on the standardized precipitation index (SPI) and the standardized precipitation evapotranspiration index (SPEI) on a 36-month timescale (SPI36 and SPEI36, respectively). The drought indicators are calculated using monthly precipitation as well as minimum and maximum temperatures from the Precipitation- Elevation Regression on Independent Slopes Model datasets from 1948 to 2012. MODE uses paired object attributes such as centroid distance, orientation angle, area ratio, and intersection area and a combination of parameter thresholds to determine the number of objects identified and retained in the merging and matching process in the two fields. Using MODE run with convolution radius of 0 (no smoothing) and an area threshold of 4 grid points, this study computes and analyzes object statistics including centroid locations, areas and intensity percentiles. Results of the analysis show that SPI36 produces more drought objects than SPEI36. Although the spatial patterns are roughly similar leading up to almost similar statistics of object attributes, such as locations of the object centroids, the SPI36 produces higher percentile intensity of drought objects than does SPEI36, which is clearly obvious in the 90th percentile intensity of drought objects. The largest difference between SPEI36 and SPI36 occurs in the area of drought objects during the early 2000s when the region experienced multi-year drought resulting from increased warming of the atmosphere. This study demonstrates the use of MODE as a tool to evaluate and monitor drought event over the UCRB.This is the peer reviewed version of the following article: Abatan, Abayomi A., William J. Gutowski Jr, Caspar M. Ammann, Laurna Kaatz, Barbara G. Brown, Lawrence Buja, Randy Bullock, Tressa Fowler, Eric Gilleland, and John Halley Gotway. "Statistics of multi‐year droughts from the method for object‐based diagnostic evaluation." International Journal of Climatology 38, no. 8 (2018): 3405-3420, which has been published in final form at doi: 10.1002/joc.5512. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions.</p

Multiyear Droughts and Pluvials over the Upper Colorado River Basin and Associated Circulations

This study analyzes spatial and temporal characteristics of multiyear droughts and pluvials over the southwestern United States with a focus on the upper Colorado River basin. The study uses two multiscalar moisture indices: standardized precipitation evapotranspiration index (SPEI) and standardized precipitation index (SPI) on a 36-month scale (SPEI36 and SPI36, respectively). The indices are calculated from monthly average precipitation and maximum and minimum temperatures from the Parameter-Elevation Regressions on Independent Slopes Model dataset for the period 1950–2012. The study examines the relationship between individual climate variables as well as large-scale atmospheric circulation features found in reanalysis output during drought and pluvial periods. The results indicate that SPEI36 and SPI36 show similar temporal and spatial patterns, but that the inclusion of temperatures in SPEI36 leads to more extreme magnitudes in SPEI36 than in SPI36. Analysis of large-scale atmospheric fields indicates an interplay between different fields that yields extremes over the study region. Widespread drought (pluvial) events are associated with enhanced positive (negative) 500-hPa geopotential height anomaly linked to subsidence (ascent) and negative (positive) moisture convergence and precipitable water anomalies. Considering the broader context of the conditions responsible for the occurrence of prolonged hydrologic anomalies provides water resource managers and other decision-makers with valuable understanding of these events. This perspective also offers evaluation opportunities for climate models.This article is published as Abatan, Abayomi A., William J. Gutowski Jr, Caspar M. Ammann, Laurna Kaatz, Barbara G. Brown, Lawrence Buja, Randy Bullock, Tressa Fowler, Eric Gilleland, and John Halley Gotway. "Multiyear Droughts and Pluvials over the Upper Colorado River Basin and Associated Circulations." Journal of Hydrometeorology 18, no. 3 (2017): 799-818. doi: 10.1175/JHM-D-16-0125.1. Posted with permission.</p

Variation in UK fracture liaison service consultation conduct and content before and during the COVID pandemic: results from the iFraP-D UK survey.

Acknowledgements: We would like to acknowledge the Keele Osteoporosis Research User Group, the NIHR Clinician Scientist Award Steering Committee, and the members of the study Community of Practice for support with design and interpretation, the Royal Osteoporosis Society for support with recruitment, and the healthcare participants themselves.Funder: Haywood FoundationUNLABELLED: We conducted a survey of FLSs' consultation conduct and content which identified marked variation in whether FLS HCPs discussed osteoporosis medicine with patients. A review of service pro formas showed more content related to 'investigating' and 'intervening' than to 'informing'. We propose an expanded FLS typology and model FLS pro forma. PURPOSE: To investigate the nature of direct patient contact in fracture liaison service (FLS) delivery, examine the use and content of pro formas to guide information eliciting and sharing in FLS consultations, and determine service changes which were implemented as a result of the COVID-19 pandemic. METHODS: An electronic survey of UK FLS healthcare practitioners (HCPs) was distributed through clinical networks, social media, and other professional networks. Participants were asked to upload service pro formas used to guide consultation content. Documentary analysis findings were mapped to UK FLS clinical standards. RESULTS: Forty-seven HCPs responded, providing data on 39 UK FLSs, over half of all 74 FLSs reporting to FLS-database. Results showed variation in which HCP made clinical decisions, whether medicines were discussed with patients or not, and in prescribing practice. Services were variably affected by COVID, with most reporting a move to more remote consulting. The documentary analysis of eight service pro formas showed that these contained more content related to 'investigating' and 'intervening', with fewer pro formas prompting the clinician to offer information and support (e.g., about coping with pain). Based on our findings we propose an expanded FLS typology and have developed a model FLS pro forma. CONCLUSION: There is marked variation in the delivery of services and content of consultations in UK FLSs including discussion about osteoporosis medications. Clinical standards for FLSs should clarify the roles of primary and secondary HCPs and the importance of holistic approaches to patient care

Developing a model Fracture Liaison Service consultation with patients, carers and clinicians: a Delphi survey to inform content of the iFraP complex consultation intervention.

UNLABELLED: Fracture Liaison Services are recommended to deliver best practice in secondary fracture prevention. This modified Delphi survey, as part of the iFraP (Improving uptake of Fracture Prevention drug Treatments) study, provides consensus regarding tasks for clinicians in a model Fracture Liaison Service consultation. PURPOSE: The clinical consultation is of pivotal importance in addressing barriers to treatment adherence. The aim of this study was to agree to the content of the 'model Fracture Liaison Service (FLS) consultation' within the iFraP (Improving uptake of Fracture Prevention drug Treatments) study. METHODS: A Delphi survey was co-designed with patients and clinical stakeholders using an evidence synthesis of current guidelines and content from frameworks and theories of shared decision-making, communication and medicine adherence. Patients with osteoporosis and/or fragility fractures, their carers, FLS clinicians and osteoporosis specialists were sent three rounds of the Delphi survey. Participants were presented with potential consultation content and asked to rate their perception of the importance of each statement on a 5-point Likert scale and to suggest new statements (Round 1). Lowest rated statements were removed or amended after Rounds 1 and 2. In Round 3, participants were asked whether each statement was 'essential' and percentage agreement calculated; the study team subsequently determined the threshold for essential content. RESULTS: Seventy-two, 49 and 52 patients, carers and clinicians responded to Rounds 1, 2 and 3 respectively. One hundred twenty-two statements were considered. By Round 3, consensus was reached, with 81 statements deemed essential within FLS consultations, relating to greeting/introductions; gathering information; considering therapeutic options; eliciting patient perceptions; establishing shared decision-making preferences; sharing information about osteoporosis and treatments; checking understanding/summarising; and signposting next steps. CONCLUSIONS: This Delphi consensus exercise has summarised for the first time patient/carer and clinician consensus regarding clearly defined tasks for clinicians in a model FLS consultation