Initiation of anti-osteoporosis medication following hip fracture in older adults: a systematic review and thematic synthesis of qualitative studies from patient and healthcare professional perspectives

Background Pharmacological osteoporosis treatment is recommended for secondary fracture prevention in older patients following a hip fracture. However, not all eligible patients receive anti-osteoporosis medication (AOMs). Understanding the decision-making process regarding treatment initiation at patient level may help explain low prescription rates and offer novel solutions beyond organisational initiatives. Objective This systematic review aimed to synthesise data from qualitative studies on the initiation of AOMs after a hip fracture in old age, to (i) explore the experiences and preferences of patients and healthcare professionals in the decision-making process, and (ii) clarify if this explains low prescription rates. Methods A systematic search in seven medical databases identified qualitative publications on the initiation of AOMs in older hip fracture patients. Thematic synthesis was applied, with the CASP checklist and GRADE-CERQual approach enhancing review’s rigour. Results Twenty studies were included, revealing two main themes with eight subthemes. The ‘addressing’ step illustrates that addressing osteoporosis treatment is not self-evident and depends on specialty-specific responsibilities, knowledge and capability, commitment to identifying eligible patients, and the perceived importance and feasibility of treatment. The ‘discussing’ step highlights the need for patient education, patient perceptiveness, making sense, a patient-centred approach, and patient choice, indicating that discussing treatment is not a clear-cut path. Conclusions AOM initiation after hip fracture in old age is shaped by a two-step decision-making process of (i) addressing treatment and (ii) discussing treatment—which may partly explain low prescription rates. Beyond organisational strategies, promoting education and awareness may strengthen professional initiative and patient engagement.