Many pharmacological treatments are now available to prevent the occurrence of fragility fractures in patients with osteoporosis. Despite this, concerns persist that many individuals who might benefit from osteoporosis treatment do not receive it-the "osteoporosis treatment gap." The underlying reasons for this gap are diverse and include those who are not identified as being eligible for treatment as well as those who intentionally choose not to take medications because of uncertainty, unanswered questions, or an inability to understand or do what is being asked of them. In this perspective article we highlight the importance of providing information on the causes and consequences of osteoporosis during encounters when treatment is being discussed as well as what osteoporosis treatment can achieve and what it cannot. We also review the importance of communicating the benefits and risks of treatment in absolute terms so that patients can understand what taking treatment will mean for them and discuss the utility of decision aids to assist in these conversations. We suggest it is not the treatment gap that is the problem but the care gap. This language acknowledges the importance of healthcare providers identifying those likely to benefit from treatment and increasing the quality of clinical conversations to promote patient engagement and involvement while respecting that treatment is not suitable or wanted by all.

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.

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