Translation of best practice osteoporosis re-fracture prevention: stopping fragility fractures to keep Australians out of hospital

The trial is designed to improve the implementation of ideal Osteoporosis Re-fracture Prevention (ORP) services into three different hospital settings across three local health districts in New South Wales, Australia and will have two elements: improvement cycles and implementation stages. Different research methodologies will be used for this trial, including qualitative data collection from focus group discussions (FGD) and semi-structured interviews (formative and summative evaluation), routine quantitative data extraction (% bone mineral density (BMD)), linkage data analysis (refracture and mortality) and costing data. Formative evaluation and creation of an implementation strategy will occur based on data from Focus group discussions (FGDs) and interviews with: (1) patients and their caregivers, (2) key ORP staff, and (3) other stakeholders (e.g. geriatricians, orthopaedics, radiologists, pharmacists). FGDs and interviews will use semi-structured questions. The purpose of the FGDs and interviews will be to describe the context in which each ORP service innovation will be implemented, identify barriers and facilitators to implementation, and develop an ORP service adapted for the setting that takes into account the unique features of the context. FGDs and interviews will be conducted face-to-face or by telephone. They will include demographic information, be audio-recorded and transcribed verbatim, taking <30 minutes. Content analysis will be applied by the two Project Managers working independently for research rigor, using NVivo software. Formative evaluation data will inform the development of localised implementation strategies; planning communication and marketing, resourcing, any training and preparation required for implementation. FGDs and interviews will also be conducted at the comparator site, to illustrate barriers, facilitators and experiences of implementation in this context. Cycle 1: Initial implementation (6 months at each site): Led by each site Chief Investigator (CI); each site will identify key initial components of their ideal ORP to implement in this cycle. Two months allocated for practical preparation, four months for initial implementation. Post cycle evaluation and Cycle 2 planning (2 months at each site): After each cycle, FGDs with patients and key ORP staff will evaluate how each cycle worked, how the service functioned and any barriers and facilitators to the optimum ORP (3 weeks). This formative evaluation will feed into problem solving discussions (1 week), followed by practical preparation for Cycle 2 (1 month). Data collection will repeat formative evaluation methods with staff and patients. Project Managers will analyse site-specific data and present brief formative evaluation (lessons learnt) at Site Steering Group planning meetings. Cycle 2: Full implementation (5 months at each site): Cycle 2 will proceed as Cycle 1, with 1 month preparation for 4 months full implementation of the optimal ORP model at each site. Summative evaluation (Post implementation, 1 month at each site) will consist of a final round of qualitative data collection and analysis. Recruitment and sampling will repeat formative evaluation methods, capturing the final evaluation of the ORP service delivery and implementation of the service. Each study site will also submit 3 months’ of service process data pre-implementation and post-implementation to benchmark their services against the optimal ORP service, to demonstrate the fidelity of site services. Cost-effectiveness data will also be collected pre and 3 years post-ORP service implementation.