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Review of osteoporosis clinical practice guidelines finds majority lack patient values

Review included countries such as Australia, Canada, Germany, India, Italy, Scotland, South Africa, Spain, United Kingdom and United States

Toronto, March 20, 2019

By Michael Oliveira

Dr. Joanna Sale
Dr. Joanna Sale

Patients' voices are ignored all too often in osteoporosis clinical practice guidelines, say researchers, who reviewed 70 English-language guidelines around the world and found less than 40 percent included any mention of patients' beliefs, values or preferences (BVPs).

Clinical practice guidelines are designed to help health-care professionals achieve the best possible outcomes for their patients by outlining evidence-based recommendations for care.

In this review, published by the journal Osteoporosis International, only 27 of the 70 guidelines analyzed by researchers included mention of patient BVPs. The review included guidelines from the likes of Australia, Canada, Germany, India, Italy, Scotland, South Africa, Spain, the United Kingdom and the United States.

Guidelines that did include BVPs most often referred to patient preferences for one medication over another, said lead author Dr. Joanna Sale, a clinical epidemiologist and scientist with the Li Ka Shing Knowledge Institute of St. Michael's Hospital in Toronto.

That finding could reflect the ability of pharmaceutical companies to influence these guidelines over the experiences of patients themselves.

"The choice of medication does not appear to reflect the BVPs of individuals with bone health issues. Rather, it appears to reflect the agenda of pharmaceutical companies and/or financial constraints of the individual or health-care system, rather than health," said Dr. Sale.

"If patients do not see themselves in the guidelines and their clinicians' recommendations, and when their health beliefs do not align with their understanding of what is needed to support their bone health, they are less likely to follow advice. It is only natural."

Of the guidelines that did mention BVPs, they most commonly considered patient considerations as important but these statements were typically not supported by evidence. Dr. Sale also noted that references to preferences appeared in guidelines much more frequently than values and beliefs.

"Preferences are easier to articulate than values and beliefs. It is easy to measure whether patients want to take medication once a week or once every six months, and whether they are willing to take the medication in the morning but then have to wait for a while before they eat. It is more difficult to measure directly and accurately if they value fracture prevention, for example, or if they do not believe they are at risk for future fracture," Dr. Sale said.

"Qualitative research which looks at patients' experiences and perceptions would help us to learn more about values and beliefs."

Dr. Sale ultimately hopes that BVPs become a staple of all clinical practice guidelines.

"Beliefs, values, and preferences are supposed to be a fundamental component of guidelines," said Dr. Sale.

"Over time, with the inclusion of more BVPs we might see shifts in values and beliefs to support truly informed preferences and better partnerships between patients and clinicians."


This paper is an example of how St. Michael's Hospital is making Ontario Healthier, Wealthier, Smarter.

About St. Michael's Hospital

St. Michael’s Hospital provides compassionate care to all who enter its doors. The hospital also provides outstanding medical education to future health care professionals in more than 29 academic disciplines. Critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, care of the homeless and global health are among the Hospital’s recognized areas of expertise. Through the Keenan Research Centre and the Li Ka Shing International Healthcare Education Centre, which make up the Li Ka Shing Knowledge Institute, research and education at St. Michael’s Hospital are recognized and make an impact around the world. Founded in 1892, the hospital is fully affiliated with the University of Toronto.

About Unity Health Toronto

Unity Health Toronto, comprised of Providence Healthcare, St. Joseph’s Health Centre and St. Michael’s Hospital, works to advance the health of everyone in our urban communities and beyond. Our health network serves patients, residents and clients across the full spectrum of care, spanning primary care, secondary community care, tertiary and quaternary care services to post-acute through rehabilitation, palliative care and long-term care, while investing in world-class research and education. For more information, visit www.unityhealth.to.


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