Cumulative network meta-analyses, practice guidelines, and actual prescriptions for post-menopausal osteoporosis: a meta-epidemiological study

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Kataoka Y1, Luo Y2, Chaimani A3, Onishi A4, Kimachi M5, Tsujimoto Y6, Murad MH7, Li T8, Cipriani A9, Furukawa TA2
1Hospital Care Research Unit, Hyogo Prefectural Amagasaki General Medical Center, 2Department of Health Promotion and Human Behavior, School of Public Health in the Graduate School of Medicine, Kyoto University, 3Paris Descartes University; Inserm, UMR1153 Epidemiology and Statistics, Sorbonne Paris Cité Research Center (CRESS), METHODS Team; Cochrane France, 4Department of Rheumatology and Clinical Immunology, Kobe University Graduate School of Medicine, 5Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, 6Department of Nephrology and Dialysis, Kyoritsu Hospital, 7Mayo Clinic–Preventive Medicine, 8Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 9Department of Psychiatry, University of Oxford


Evidence practice gap, or the delay in incorporating research results into practices, is receiving increasing attention of clinicians and consumers alike. One of its many possible causes is a time delay between the publication of individual study results and the recommendations provided in clinical practice guidelines. Another cause may be a time delay between evidence, either as individual studies or as guideline recommendations, and the real-work prescriptions by the clinicians.


To compare the results of cumulative network meta-analyses (NMAs) with the recommendations in post-menopausal osteoporosis practice guidelines and actual prescribing practices in the US.


MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus were searched to retrieve randomized controlled trials (RCTs) on July 2017. The Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and associated society websites were searched to retrieve guidelines on June 2018. We used the Medical Expenditure Panel Survey (MEPS) to analyze prescription data from 1996 to 2015. Two independent investigators selected eligible RCTs. One investigator selected potential eligible guidelines, which were confirmed by another investigator. Two independent investigators extracted data from included RCTs. One investigator extracted recommendations from guidelines, which were confirmed by another investigator. (Registration: UMIN000031894)


We analyzed data from 1995, 2000, 2005, 2010, and 2015. We chose hip fracture as the primary outcome of cumulative NMAs. We included 51 trials, 17 guidelines, and 5099 post-menopausal osteoporosis patients from the MEPS. Bisphosphonate, including alendronate, and combination of vitamin D and calcium (vDCa) were consistently recommendable from an efficacy viewpoint in NMAs and recommended in guidelines. Alendronate was the most prescribed drug (more than 30% over the observation period); however, vDCa was seldom prescribed. The maximum proportion was 5.3% from 2011 to 2015.


In postmenopausal osteoporosis, there was no apparent discrepancy between guideline recommendations and drug prescribing rankings, with the exception of vDCa, when we used cumulative NMAs as references.

Patient or healthcare consumer involvement:no