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Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age

Appendix A. Process report

About the process

This guideline is an evidence update of Clinical guideline for the prevention and treatment of osteoporosis in postmenopausal women and older men, published in 2010 by The Royal Australian College of General Practitioners (RACGP) and approved by the National Health and Medical Research Council (NHMRC). The update process followed guideline development best practice but due to limited resourcing, some limitations were imposed.

The development of this guideline consisted of the following major phases:

  • Formation of a multidisciplinary expert Working Group
  • Working Group agreement on the scope of the guideline
  • Formulation of literature-search strategies
  • Systematic literature searches to identify primary evidence and syntheses of primary evidence
  • Appraisal and selection of evidence
  • Revision of existing or drafting of new evidence statements
  • Revision of existing or formulation of new recommendations
  • Full Working Group review of the draft guideline and agreement on recommendations
  • Endorsement of the guideline by the RACGP

Identification, appraisal and synthesis of  new evidence

The literature searches for this guideline were limited to studies published between 2006 and February 2016. However, some of the evidence used to support recommendations in the 2010 guideline has been included in this update if (in the opinion of the Working Group) these studies have retained their relevance and importance within the more recent body of evidence.

Published literature was searched systematically in three databases: Ovid Medline, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials. Additional database searches were conducted for some topics. Filters were applied in Ovid Medline to identify randomised controlled trials (RCTs), systematic reviews (SRs) and meta-analyses (MAs).1,2 Other filters applied included men and women older than 45 years of age, and studies reporting outcomes of fracture and/or bone mineral density (BMD). As far as possible, evidence used to support recommendations covering pharmacologic and other interventions for osteoporosis prevention and treatment was restricted to studies with fracture as a primary outcome. However, for some interventions, evidence meeting this criterion is sparse or of variable quality, and high-quality studies with BMD as a primary outcome have been used if, in the opinion of the Working Group, the data can be used to support recommendations.

Evidence to support the recommendations was confined to papers complying with levels I (SR of level II studies) and II (RCT or prospective cohort study) of the NHMRC evidence hierarchy (Table 5). Evidence from cohort and observational studies was used to support some recommendations concerning diagnostic investigations, monitoring, diet and lifestyle, and to update epidemiological and background information.

NHMRC evidence hierarchy

Table 5.

NHMRC evidence hierarchy3

Rating of evidence

The body of evidence supporting each recommendation was rated according to the NHMRC body of evidence matrix (Table 6). This method is designed to allow for a mixture of components, taking into account the fact that although the body of evidence in any particular area may be small (therefore attracting a low evidence base component rating), a high clinical impact and applicability to the Australian population will merit a high overall rating.

NHMRC body of evidence matrix

Table 6.

NHMRC body of evidence matrix3

Grading of recommendations

Each recommendation was given a final grading according to the NHMRC grades of recommendation (Table 7). The grading represents the overall strength of the evidence, and reflects the confidence with which clinicians can apply a recommendation in a clinical situation. The final grades are based on a summation of individual components of the body of evidence assessment shown in Table 6. A recommendation cannot be graded A or B unless the volume and consistency of evidence components are both graded either A or B.

NHMRC grades of recommendations

Table 7.

NHMRC grades of recommendations3

* The Working Group has also applied a Grade D to recommendations where there is expert consensus in the absence of a strong body of evidence.

Consultation and endorsement by the RACGP

Due to resources and time restrictions, the consultation period was focused on Osteoporosis Australia stakeholders and review by the main users of the guideline: general practitioners (GPs). The guideline was  reviewed by GP subject matter experts and the RACGP’s Expert Committee for Quality Care and endorsed by  the RACGP Council.

Ongoing feedback on the guideline is encouraged and can be submitted via the online feedback tab.


  1. White VJ, Glanville JM, Lefebvre C, Sheldon, TA. A statistical approach to designing search filters to find systematic reviews: Objectivity enhances accuracy. J Inf Sci 2001;27(6):357–70.
  2. Glanville JM, Lefebvre C, Miles JN, Camosso-Stefinovic J. How to identify randomized controlled trials in MEDLINE: Ten years on. J Med Libr Assoc 2006;94(2):130–36.
  3. National Health and Medical Research Council. NHMRC additional levels of evidence and grades for recommendations for developers of guidelines. Canberra: NHMRC, 2009. Available at www.nhmrc.gov.au/guidelines-publications/information-guidelinedevelopers/resources-guideline-developers [Accessed 1 February 2017].

Related documents

  Osteoporosis-flowchart.pdf (PDF 0.98 MB)