Communicating Absolute Fracture Risk Reduction and the Acceptance of Treatment for Osteoporosis

Katherine A P Ralston,Barbara Hauser,Stuart H Ralston,Jonathan Phillips,Amrey Krause

doi:10.1007/s00223-022-00948-2

Abstract

Healthcare professionals frequently communicate the benefits of treatments as a relative risk reduction (RRR) in the likelihood of an event occurring. Here we evaluated whether presenting the benefits of osteoporosis treatment as a RRR in fractures compared with an absolute risk reduction (ARR) changed the patient’s attitudes towards accepting treatment. We surveyed 160 individuals attending a specialised osteoporosis clinic for face-to-face consultations between May 2018 and Jan 2021. They were presented with information on RRR for the treatment being considered followed by ARR and after each question were asked about how likely they would be to start treatment on a 5-point scale (1 = very likely, 5 = very unlikely). Participants were less likely to accept treatment when it was presented as ARR (mean score 2.02 vs. 2.67, p < 0.001, 95% CI for difference − 0.82 vs − 0.47) and thirty-eight participants (23.7%) declined treatment with knowledge of their ARR when they would have accepted the same treatment based on the RRR. Individuals who declined treatment had a lower 5-year risk of fracture than those who accepted treatment (9.0 vs. 12.5%, p < 0.001, 95% CI − 5.0 to − 1.6) and as fracture risk decreased, the participant was less likely to accept treatment (Spearman r − 0.32, 95% CI − 0.46 to − 0.17, p ≤ 0.001). Whilst presentation of data as ARR more accurately reflects individual benefit and helps facilitate shared decision-making, clinicians should be aware that this will lead to a proportion of patients with lower fracture risk declining treatment for osteoporosis.

Highlights

Osteoporosis is a common condition characterised by low bone mass and deterioration in bone architecture, leading to bone fragility and increased fracture risk [1]
The participants likelihood of accepting treatment was significantly lower when data on the likely benefits were presented as absolute risk reduction (ARR) versus relative risk reduction (RRR)
None of the other variables was identified as a significant predictor of the patient changing their mind about treatment. This indicates that older patients with a low absolute fracture risk were most likely to decline treatment after being presented with information on RRR followed by ARR

Summary

Introduction

Osteoporosis is a common condition characterised by low bone mass and deterioration in bone architecture, leading to bone fragility and increased fracture risk [1]. A variety of treatments are available which have been shown to reduce the risk of fractures in patients with osteoporosis and osteopenia, none can completely prevent the occurrence of fractures [2]. In the context of osteoporosis, many bisphosphonates reduce the relative risk of hip fracture by 40% compared with placebo This sounds impressive, the absolute benefit in terms of hip fractures prevented in osteopenic women with the characteristics of those treated by Reid and colleagues [6] corresponds to a reduction from 12 fractures per 1000

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Conclusion