PRevention of Osteoporotic fractures Through Equitable Case finding and Treatment Support (PROTECTS)

Background Osteoporotic fractures are the fourth leading cause of disability costing the NHS £4.5billion annually, increasing health and social care demand. For fracture prevention, clinical guidelines recommend people with risk factors (e.g. corticosteroids, diabetes, smoking) have assessments, and if indicated bone-strengthening medicines and other interventions. However, less than 40% at increased risk receive appropriate treatments with specific underserved groups disproportionately affected. Aim To PRevent Osteoporotic fractures, Through Equitable Case-finding and Treatment Support (PROTECTS). We will establish and evaluate an equitable bone health model of care in general practice, incorporating automated case finding, implementation package and clinician and patient tools, training and information. Five workstreams (WS), are underpinned by research inclusion, implementation science and public partnerships. WS1 (Years 1-6) Objective: To co-develop, undertake and evaluate strategies for knowledge mobilisation and implementation. Methods: evidence synthesis of implementation barriers and enablers focus groups with primary care professionals to explore equity considerations in implementation workshops using an evidence-based implementation toolkit workshops using Community of Practice methods and systems thinking Outputs: implementation package; impact plan. WS2 (Years 1-3) Objective: To investigate optimal approach(es) for automated, inclusive case-finding and assessment. Methods: electronic healthcare records study to investigate the current assessment gap, including its impact on underserved groups, and to evaluate the performance of different fracture assessment tools for these groups economic modelling study exploring optimal thresholds for assessment. workshops and Delphi consensus exercise. Outputs: Identification of who/what proportion represent underserved groups refinements to an existing automated case-finding tool new quality indicators for osteoporosis management. WS3 (Year 1) Objective: to investigate and optimise patient engagement with PROTECTS, inclusive of underserved groups. Methods: a scoping review to describe existing interventions to optimise bone health in underserved groups focus groups and interviews to explore information needs of people about bone health assessments and treatment co-design workshops to develop patient and service-user oriented outputs. Outputs: patient resources to explain bone health assessments and treatment e.g easy-read leaflets, posters and videos in different languages. WS4 (Year 1-3) Objective: to investigate uptake, feasibility and acceptability of PROTECTS and feasibility of the proposed main trial. Methods: A feasibility study with theoretically informed mixed methods process evaluation in 12-15 general practices. Data collection will include practice profile questionnaires, primary care professional (PCP) questionnaires, medical record review to record numbers of patients offered and attending appointments, assessed, treated and referred, and patient and PCP interviews. Outputs: refined intervention components and implementation package, progression criteria (NIHR checkpoint). WS5 (Year 4-6) Objective: To determine the clinical- and cost-effectiveness, and assess implementation of the PROTECTS model of care. Methods: A pragmatic parallel cluster-randomised controlled trial, in 92 general practices. A process evaluation will explore implementation and health economic study will capture downstream quality of life impacts of preventing fracture. Outputs: Evidence of cost and clinical effectiveness, acceptability and implementation. Dissemination With clinical and patient partners: conferences, publications, policy briefings, webinars, blogs, press releases, infographics, events (national/international). Anticipated impact Reduced fractures with reductions in associated deaths, disability, costs.