Grades of Recommendation, Assessment, Development, and Evaluation Confidence in the Evidence from Qualitative Reviews summary of qualitative findings table
| Review finding (and contributing studies) | Methodological limitations | Coherence | Adequacy | Relevance | CERQual confidence assessment |
| Concerns | |||||
| Intervention coherence Both before starting, and during treatment, patients considered the perceived need or necessity for bisphosphonates based on their views of osteoporosis, including its seriousness and controllability, symptoms and their perception of their own health. Perceived need was weighed up against concerns about medication, including suspicion of drugs in general and specific concerns about bisphosphonate safety by both patients and HCPs. HCPs sometimes used principles of ethicality to support perceptions of low necessity and their reluctance to prescribe. The decision process of balancing necessity against concerns, was influenced by the doctor–patient relationship and wider societal influences including friends, family and the general media. This process influenced whether HCPs reported recommending bisphosphonates. For patients, the decision process could be explicit or tacit, was revisited over time and influenced both whether they initiated treatment and subsequently adhered.16 23 25–30 32 33 35–44 46 | Minor 12/22 papers rated moderate value due to sample size, depth of analysis or lack of reflexivity.* | None or very minor The finding reflects the complexity and variation of the data, and these influences on sense making are well supported by details in the underlying studies. | None or very minor 22 papers contributed to this finding, and although some gave little detail, in-depth insights were reported in 10 papers and information was consistent across studies. | Minor Spread of studies from primary and secondary care and range of countries. Uncertainties remain about sense making related patients taking intravenous bisphosphonates and influence of gender. | High |
| Perceived effectiveness Both patients and HCPs expressed doubt or uncertainty about the mechanism of effectiveness of bisphosphonates and expressed a range of treatment expectations including strengthening bone—improving bone density, preventing worsening of osteoporosis—maintaining bone density and/or total fracture prevention. Patients wanted proof or evidence of effectiveness through more structured monitoring and follow-up, and were disincentivised to continue treatment in the absence of evidence of perceived effectiveness. 16 23 24 29 34 35 38–40 42 43 | Minor 7/15 papers rated moderate value, mostly (4/7) due to limited relevant content. Methodological concerns relate to depth of analysis or lack of reflexivity.* | None or very minor The finding reflects the complexity and variation of the data, and these issues are supported by details in the underlying studies. | None or very minor 15 papers contributed to this finding. Some gave little detail, but in-depth insights were reported in six papers and information was consistent. | Minor Spread of studies from primary and secondary care and range of countries. Uncertainties remain about perceived effectiveness of intravenous bisphosphonates. | High |
| Self-efficacy Measures to help patients integrate medication taking into daily routines (supporting routinisation), and the provision of information and support, enhanced their feeling of having control over their health and confidence to adhere to bisphosphonates. Clinician reported barriers to supporting adherence related to perceptions of their knowledge and attitudes, with several knowledge gaps and uncertainties reported, and the perception that osteoporosis was not a priority. Finally, service level barriers which impaired clinicians’ self-efficacy in recommending and managing patients on bisphosphonates, included uncertainty about professional roles and responsibilities, capacity, access to intravenous drugs and communication and IT systems. 16 24 26 27 30–32 37 38 45 | Minor 7/15 papers rated moderate value, mostly (4/7) due to limited relevant content. Methodological concerns relate to depth of analysis or sample size.* | None or very minor The finding reflects the complexity and variation of the data, and these issues are supported by details in the underlying studies. | None or very minor 17 papers contributed to this finding. Some gave little detail, but in-depth insights were reported in five papers and information was consistent. | Minor Spread of studies from primary and secondary care and range of countries. Uncertainties remain about self-efficacy relating to intravenous bisphosphonates. | High |
| Affective attitudes The emotions elicited by bisphosphonates were closely related to intervention coherence. Bisphosphonates were associated predominantly with negative emotions of fear (of side effects) and annoyance (with special instructions); however, positive emotions of reassurance and hope were noted in two studies, linked to the anticipated protection that bisphosphonates could incur. 16 23 26 27 35 37 38 40 | Minor 2/8 papers rated moderate value due to depth of analysis or lack of reflexivity.* | None or very minor The finding reflects the data, supported by details in the underlying studies. | Moderate Reports of affective attitude were mostly descriptive with little depth. | Moderate Uncertainties remain about affective attitudes to injectable bisphosphonates received in hospital. | Moderate |
| Burden The burden or effort of oral bisphosphonates was described mostly relating to the special instructions to take oral bisphosphonates or experienced side effects, although costs incurred were also a potential source of burden. 16 23 26 27 32 37–39 42 43 46 | Minor 4/11 papers rated moderate value due to sample size, depth of analysis.* | None or very minor The finding reflects the data, and these aspects of burden are supported by details in the underlying studies. | Moderate Reports mostly descriptive with little depth and a possible focus on presence of burden (side effects) rather than absence. | Moderate Uncertainties remain about burden of indirect costs (travel, dental checks) and burden due to intravenous bisphosphonates. | Moderate |
| Opportunity costs Circumstances where competing priorities challenged adherence or initiation of bisphosphonates were described relating to comorbid conditions. The presence of comorbid conditions were described as resulting in less time to support discussion about bisphosphonates in consultations and, result in recommendation of, and adherence to, bisphosphonates being given relative low priority.16 27 29 32 33 38 41 42 44–46 | None or very minor 4/11 papers rated moderate value, but this was mostly (n=3) due to limited relevant content rather than methodological concerns. | Moderate No discussion of the alternative explanation that having comorbid conditions may facilitate bisphosphonate acceptability. | Moderate Reports were limited, lacked depth and three papers contained little content relevant to the research question. | Moderate No information about values, benefits that have to be given up to partake in intravenous bisphosphonates, which are likely to be different and likely limited sampling of patients with complex health needs. | Low |
*Concerns considered minor because of the methodological strength of the other papers in this domain, and low likelihood that reflexivity would affect finding.
CERQual, Confidence in the Evidence from Qualitative Reviews.