The Medical journal of Australia
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Review Case Reports
7: Treatment of osteoporosis: why, whom, when and how to treat. The single most important consideration is the individual's absolute risk of fracture.
All women and men with a history of fragility fractures should be considered for treatment of osteoporosis to reduce their risk of future fracture. There is high-level evidence for the anti-fracture efficacy of treatment in women with osteoporosis, particularly if there is prevalent fracture; the evidence is less compelling for women with osteopenia, with or without a fracture, and for men. ⋯ HRT is not recommended in women for fracture risk reduction alone. Evidence for the anti-fracture efficacy of calcitonin, fluoride, anabolic steroids and active vitamin D metabolites is insufficient to justify their use; lifestyle changes, while not shown to reduce fracture risk, may have a role in maintaining bone strength throughout life.
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There are internationally agreed optimal methods for developing clinical practice guidelines. The quality of published guidelines varies. ⋯ Computerisation of guidelines can cover a range of formats, from brief prompts through to complex decision-support systems. Integrating guidelines into computerised reminder systems has been shown to be effective in improving patient care, but there is less evidence to support the effectiveness of guidelines integrated into computerised decision-support systems.
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We propose the formation of evidence-based clinical practice support units in hospitals and clinical research implementation networks. The purpose of these initiatives will be to increase the uptake of beneficial forms of care and remove harmful or ineffective practices. They will bring together clinicians and other professionals to improve clinical care across the healthcare system.
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Few studies have monitored change in professional practice over time to determine the sustainability of change. Research from other behavioural change literature shows that initial change is difficult to maintain, with reported relapse rates as high as 80%. Interventions most likely to succeed are based on a clear understanding of target behaviours and the environmental context. ⋯ The issue targeted for intervention must be clearly defined at the outset, so that antecedents, determinants and supporting mechanisms can be defined, suggesting points for intervention and strategies for initial and sustainable change. The target population's readiness to change is an important factor at both an individual and organisational level. In most cases, a combination of different interventions will be needed to achieve lasting change.