At Odds About the Odds: Women’s Choices to Accept Osteoporosis Medications Do Not Closely Agree with Physician-Set Treatment Thresholds



Osteoporosis guidelines recommend pharmacologic therapy based on 10-year risk of major osteoporotic fracture (MOF) and hip fracture, which may fail to account for patient-specific experiences and values.


We aimed to determine whether patient decisions to initiate osteoporosis medication agree with guideline-recommended intervention thresholds.

Design and Participants

This prospective cohort study included women aged ≥ 45 with age-associated osteoporosis who attended a group osteoporosis self-management consultation at a tertiary osteoporosis center.


A group osteoporosis self-management consultation, during which participants received osteoporosis education and then calculated1 their 10-year MOF and hip fracture risk using FRAX and2 their predicted absolute fracture risk with therapy (assuming 40% relative reduction). Participants then made autonomous decisions regarding treatment initiation.

Main Measures

We evaluated agreement between treatment decisions and physician-set intervention thresholds (10-year MOF risk ≥ 20%, hip fracture risk ≥ 3%).

Key Results

Among 85 women (median [IQR] age 62 [58–67]), 27% accepted treatment (median [IQR] MOF risk, 15.1% [9.9–22.0]; hip fracture risk, 3.3% [1.3–5.3]), 46% declined (MOF risk, 9.5% [6.5–11.6]; hip fracture risk, 1.8% [0.6–2.3]), and 27% remained undecided (MOF risk, 14.0% [9.8–20.2]; hip fracture risk, 4.4% [1.7–4.9]). There was wide overlap in fracture risk between treatment acceptors and non-acceptors. Odds of accepting treatment were higher in women with prior fragility fracture (50% accepted; OR, 5.3; 95% CI, 1.9–15.2; p = 0.0015) and with hip fracture risk ≥ 3% (32% accepted; OR, 3.6; 95% CI, 1.4–9.2; p = 0.012), but not MOF risk ≥ 20% (47% accepted; OR, 3.0; 95% CI, 1.0–8.5; p = 0.105).


Informed decisions to start osteoporosis treatment are highly personal and not easily predicted using fracture risk. Guideline-recommended intervention thresholds may not permit sufficient consideration of patient preferences.

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Author information

Correspondence to Emma O. Billington MD.

Ethics declarations

Informed consent was obtained from all participants prior to study enrollment, and the study received approval from the local Health Research Ethics Board.

Conflict of Interest

EOB reports receiving honoraria from Eli Lilly and Amgen for serving on their Scientific Advisory Boards, and has received research funding from Amgen. All remaining authors declare that they do not have a conflict of interest.

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Billington, E.O., Feasel, A.L. & Kline, G.A. At Odds About the Odds: Women’s Choices to Accept Osteoporosis Medications Do Not Closely Agree with Physician-Set Treatment Thresholds. J GEN INTERN MED 35, 276–282 (2020) doi:10.1007/s11606-019-05384-x

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  • osteoporosis
  • fracture
  • bisphosphonates
  • shared decision-making
  • patient preference
  • patient education