Special Position Paper

Osteoporosis International

, Volume 19, Issue 4, pp 449-458

First online:

Implications of absolute fracture risk assessment for osteoporosis practice guidelines in the USA

  • B. Dawson-HughesAffiliated withBone Metabolism Laboratory, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University Email author 
  • , A. N. A. TostesonAffiliated withMultidisciplinary Clinical Research Center in Musculoskeletal Diseases and The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical SchoolHB7505 Clinical Research, Dartmouth Medical School, One Medical Center Drive
  • , L. J. MeltonIIIAffiliated withDivision of Epidemiology, College of Medicine, Mayo Clinic
  • , S. BaimAffiliated withThe Medical College of Wisconsin
  • , M. J. FavusAffiliated withDepartment of Medicine, University of Chicago
  • , S. KhoslaAffiliated withDivision of Endocrinology, College of Medicine, Mayo Clinic
  • , R. L. LindsayAffiliated withHelen Hayes Hospital, Regional Bone Center

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Application of the WHO fracture prediction algorithm in conjunction with an updated US economic analysis indicates that osteoporosis treatment is cost-effective in patients with fragility fractures or osteoporosis, in older individuals at average risk and in younger persons with additional clinical risk factors for fracture, supporting existing practice recommendations.


The new WHO fracture prediction algorithm was combined with an updated economic analysis to evaluate existing NOF guidance for osteoporosis prevention and treatment.


The WHO fracture prediction algorithm was calibrated to the US population using national age-, sex- and race-specific death rates and age- and sex-specific hip fracture incidence rates from the largely white population of Olmsted County, MN. Fracture incidence for other races was estimated by ratios to white women and men. The WHO algorithm estimated the probability (%) of a hip fracture (or a major osteoporotic fracture) over 10 years, given specific age, gender, race and clinical profiles. The updated economic model suggested that osteoporosis treatment was cost-effective when the 10-year probability of hip fracture reached 3%.


It is cost-effective to treat patients with a fragility fracture and those with osteoporosis by WHO criteria, as well as older individuals at average risk and osteopenic patients with additional risk factors. However, the estimated 10-year fracture probability was lower in men and nonwhite women compared to postmenopausal white women.


This analysis generally endorsed existing clinical practice recommendations, but specific treatment decisions must be individualized. An estimate of the patient’s 10-year fracture risk should facilitate shared decision-making.


Fracture prediction National Osteoporosis Foundation Osteoporosis Practice guidelines World Health Organization