Less prescription, more value decision: a patient decision aid for fragility fracture prevention

Background

Shared decision-making (SDM) is increasingly endorsed in clinical practice guidelines as a care standard, particularly if preference-sensitive. This applies to fragility fracture pharmacological primary prevention, where clinical decisions remain complex due to heterogeneous recommendations and treatment thresholds. The DaSH-Osteo project aimed to develop, evaluate, and implement a web-based decision aid for postmenopausal women in primary care.

Methods

Mixed-methods project with three components: (1) iterative patient decision aid (PtDA) development and user testing (10 semi-structured interviews, UX Honeycomb model; System Usability Scale); (2) multicentre three-arm randomised trial across 14 Spanish primary care centres (PtDA, PtDA with personalised decision analysis model, usual care) to assess decision quality and value-based decision; (3) a quanti-qualitative evaluation nested within the RCT (MRC framework; sequential explanatory design; implementation, mechanisms of impact, and context).

Results

User testing showed iterative improvements in risk comprehension, navigability, and values clarification. Trial enrolled 111 postmenopausal women (median age 67; mean 10-year major osteoporotic fracture FRAX 6.21%). Both interventions reduced decisional conflict (median score: 18.75) vs. usual care (31.25)(p < 0.001); high conflict fell from 49.0% (UC) to 21.0% (PtDA) and 3.2% (PtDA_DAM), and improved decision satisfaction (p = 0.020); post-encounter indecision dropped from 40.0% to 4.20%-12.90% (OR 11.33, 95% CI 3.73-38.93). Further quanti-qualitative evaluation is still ongoing.

Conclusions

DaSH-Osteo is the first Spanish-language, IPDAS-quality PtDA for fragility fracture prevention, showing clear gains in decision quality. Findings support the use of SDM tools in primary care, wider PtDA uptake, and inclusion of patient values in guidelines. The multicomponent design offers a replicable framework for SDM implementation in preference-sensitive areas.

Key messages

• DaSH-Osteo PtDA significantly reduced decisional conflict and post-encounter indecision in postmenopausal women facing fragility fracture pharmacological prevention decisions.

• This first Spanish-language, IPDAS-quality PtDA offers a replicable shared decision-making framework for preference-sensitive decisions in primary care.