Overview of 2019 surveillance methods

NICE's surveillance team checked whether recommendations in osteoporosis: assessing the risk of fragility fracture (NICE guideline CG146) remain up to date. The 2019 surveillance followed the static list review process, consisting of:

  • Feedback from topic experts via a questionnaire.

  • A search for new or updated Cochrane reviews and national policy.

  • Consideration of evidence from previous surveillance.

  • Examining related NICE guidance and quality standards and NIHR signals.

  • A search for ongoing research.

  • Examining the NICE event tracker for relevant ongoing and published events.

For further details about the process and the possible update decisions that are available, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual.

Evidence considered in surveillance

Cochrane reviews

We searched for new Cochrane reviews related to the guideline. We found 1 relevant Cochrane review published between 1 September 2011 and 4 February 2019.

The Cochrane review evaluated the impact of the use of steroidal contraceptives on bone mineral density and risk of fracture in women. There was insufficient evidence to determine the impact. Women using steroidal contraceptives are not a target population for assessment of fracture risk in NICE guideline CG146. The findings of the Cochrane review do not have an impact on the current guideline recommendations.

NIHR signals

We checked for NIHR signals, and we found 1 relevant systematic review (Poly et al. 2019). The systematic review assessed the impact of the treatment with proton pump inhibitors on the risk of hip fracture. Twenty-four observational studies were included. PIP therapy was associated with an increased risk of hip fracture. The findings of the study support the current guideline recommendations.

Studies highlighted by topic experts

One study was highlighted by topic experts (Shepstone et al. 2018). This is a randomised controlled trial that compared a community-based screening programme of risk of fracture using FRAX with usual care. A total of 6,233 women aged 70–85 years identified from 100 GP practices in the UK were included. Participants were identified through a primary care list. The intervention reduced the incidence of hip fractures, but no differences were identified in the reduction of all osteoporosis-related fractures, all clinical fractures, mortality, quality of life or anxiety. This study is relevant because NICE guideline CG146 includes a research recommendation about using GP practice lists to identify people at high risk.

Ongoing research

We checked for relevant ongoing research; of the ongoing studies identified, 1 study was assessed as having the potential to change recommendations. This study is:

  • A back pain checklist (Vfrac) for use in primary care to identify older women with back pain due to undiagnosed broken bones in the back – ISRCTN16550671

    • One of the aims of this observational study is to develop a checklist for identifying undiagnosed osteoporotic vertebral fractures in women with back pain. The intention to publish date is 30 June 2021.

We will share the details of this study with the developers responsible for updating the guideline so that they can evaluate the impact of any published results.

Search and selection strategy

No further specific literature searching was needed in any of the sections of the guideline because the initial intelligence gathering and feedback from topic experts strongly indicated that an update of the guideline is needed.

Intelligence gathered during surveillance

Views of topic experts

We considered the views of topic experts who were recruited to the NICE Centre for Guidelines Expert Advisers Panel to represent their speciality. For this surveillance review, topic experts completed a questionnaire about developments in evidence, policy and services related to the guidelines.

We sent questionnaires to 11 topic experts and received 7 responses. Five experts indicated the guideline should be updated. Issues highlighted by topic experts included:

  • Intervention thresholds. Topic experts suggested that the scope of the guideline needs to include intervention thresholds, so all the NICE products could link more consistently.

  • Vertebral fracture diagnosis and assessment. One topic expert considered that the diagnosis and assessment of vertebral fractures should be included in NICE guideline CG146. The expert highlighted the recent publication of the National Osteoporosis Society's Clinical guidance for the effective identification of vertebral fractures. We identified an ongoing study in this area (see ongoing research).

  • Provision of information to patients at risk of fracture. A topic expert felt that a more holistic approach, including patients' priorities, is needed in the guideline. NICE is currently developing a guideline on sharing decision making (expected publication 2021) which will be relevant to this area. The topic expert also highlighted the importance of other areas not considered in NICE guidance including non-pharmacological interventions (for example diet and exercise) and patient-important outcomes (for example pain, fear of fracture or QALYs), currently not covered within the scope of CG146.

Other sources of information

None identified.

Views of stakeholders

Stakeholders are consulted on all surveillance reviews except if the whole guideline will be updated and replaced. Because this surveillance proposal was to update all of the guideline, we did not consult with stakeholders.

See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.


No equalities issues were identified during the surveillance process.

Overall decision

After considering all evidence and other intelligence and the impact on current recommendations, we decided that an update is necessary.

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