The evidence reviewed in Sects. 2 and 3 reveals three critical gaps in how fracture risk is currently communicated to patients.

The Consequence Gap

Current fracture risk assessment tools communicate the probability of fracture, but offer no insight into what that fracture would actually mean for the patient. This is a significant omission, the consequences of fracture are precisely the information patients value most, as the RICO study clearly demonstrated [38].

Hip fracture is associated with a 1-year mortality rate of approximately 20–22%, with recent systematic reviews documenting excess mortality (above age-matched controls) ranging from 8.4% to 36% in the first year [39,40,41]. A meta-analysis found that women had a 5-fold increase and men an 8-fold increase in relative likelihood of death within the first 3 months following hip fracture [41]. This excess mortality persists for years: mortality remains elevated for at least 5–10 years after hip fracture in both sexes [39].

Vertebral fracture dramatically increases the risk of subsequent fracture. Among 377,561 female Medicare beneficiaries who sustained a fracture, 10% had another fracture within 1 year, 18% within 2 years, and 31% within 5 years [42]. The risk of subsequent fracture is highest in the immediate post-fracture period, a concept described as “imminent risk” [43, 44]. Research has demonstrated that following a first fragility fracture, the risk of a subsequent fracture within the first year is five times greater than in women with no prior fracture history [45]. Evidence shows that following an initial fracture, the risk of a major osteoporotic fracture is 2.7 times higher than the population baseline at one year, gradually declining to 1.4 times the population risk at ten years [43].

Beyond mortality and refracture, hip fracture is associated with loss of independence, institutionalization, chronic pain, depression, and reduced quality of life. More than half of hip fracture patients do not regain pre-fracture mobility in the first year [46]. Yet none of this information is communicated by current risk assessment tools. A patient told that their fracture risk is 15% has no information about what that fracture would mean for their survival, their independence, or their likelihood of further fractures. This has been likened to informing a patient of their heart attack risk without disclosing that heart attacks can be fatal — it strips the risk estimate of both its clinical significance and its emotional weight [8].

The Controllability Gap

Current fracture risk assessment tools present risk in a vacuum. They tell patients what their risk is, but not what can be done about it. A 20% fracture probability over 10 years without information on how treatment would change that probability leaves patients with a number but no actionable path forward.

This matters because risk information without efficacy information may paradoxically increase fatalism rather than motivate treatment. Evidence from health psychology demonstrates that perceived risk alone is a weak predictor of health behaviour; the combination of perceived risk and perceived efficacy (the belief that effective action is available) is far more predictive [37]. In the osteoporosis context, a patient who understands both that their risk is high and that bisphosphonates can reduce that risk by 40–70% has a reason to act and a pathway to action. A patient who understands only that their risk is high may simply feel helpless.

Effective anti-osteoporosis medications exist, including bisphosphonates (alendronate, risedronate, zoledronic acid), denosumab, and anabolic agents (teriparatide, romosozumab), which have been shown in randomized clinical trials to reduce fracture risk by 30–70% [47,48,49,50]. Contextualization of fracture risk within treatment options, showing patients how their risk profile would change with treatment, is essential for shared decision-making but is absent from all widely used fracture risk tools.

The Format Gap

Despite decades of research establishing that numerical probabilities are poorly understood by many patients, fracture risk tools have continued to prioritise statistical accuracy over communication effectiveness. Natural frequencies such as “18 out of 100 women like you will fracture in the next 10 years,” icon arrays, and age-based frames have all been shown to enhance comprehension and personal relevance, yet as reviewed in Sects. 2 and 3, none of these formats are incorporated into any existing risk calculator. The result is a persistent format gap between the evidence on effective risk communication and the tools available to clinicians in everyday practice.

BONEcheck™: Addressing the Three Gaps

BONEcheck™ (bonecheck.org) is a digital tool for personalized bone health assessment developed using data from the Dubbo Osteoporosis Epidemiology Study (Australia) and the Danish Nationwide Registry [9, 31]. Unlike conventional fracture risk tools that report a single fracture probability, BONEcheck was designed to address the three communication gaps identified in this paper. It comprises three modules: data input, risk estimation, and risk contextualization (controllability gap). Users are asked to optionally create an account to allow their responses and risk estimates to be saved and retrieved for future use. The osteogenomic profile field is optional and is not required for risk estimation; most users do not provide this information. Information entered by users is handled according to the BONEcheck privacy policy and is not used by funders or external commercial parties in the development or interpretation of individual risk estimates.

Communicating Consequences: Mortality and Refracture Risk

Using the Garvan Fracture Risk Calculator, BONEcheck estimates the 5-year probability of any fragility fracture and hip fracture, together with subsequent fracture risk and mortality risk. Mortality was incorporated in the underlying Markov transition model rather than competing risk adjustment. The model allows transitions between health states, including death, to be represented directly. We recognise that communicating mortality risk may be distressing or counterproductive for some patients. The skeletal age concept was developed partly to provide an alternative way of communicating the health burden associated with fracture risk in a more interpretable and patient-centred format.

We thought that a 5-year horizon, in older adults, it is more practical and clinically meaningful than a 10-year time frame. Mortality risk is communicated through skeletal age, defined as chronological age plus the estimated years of life lost attributable to fracture or risk factors associated with excess mortality [9, 31]. A skeletal age greater than chronological age indicates that the individual has a risk profile comparable to that of an older person with fewer adverse risk factors.

This approach addresses the consequence gap by extending risk communication beyond fracture probability alone. Rather than reporting only the likelihood of fracture, BONEcheck also quantifies the risk of subsequent fracture and communicates the associated increase in mortality risk. Thus, the emphasis shifts from the possibility of fracture to its broader implications for health and survival. This approach is consistent with findings from the RICO study, in which most participants expressed a desire to be informed about the serious consequences of fracture, including loss of mobility, independence, and quality of life [17].

For example, in a 68-year-old woman with no prior fracture, a femoral neck T-score of − 2.2, two falls in the previous year, and no major comorbidities, a conventional tool might estimate a 5-year fracture risk of approximately 13%. BONEcheck would additionally estimate her skeletal age (e.g., 71.7 years), quantify her 5-year refracture risk if fracture were to occur (17%), and place these estimates in a mortality context (Fig. 1A and B). In this way, the patient is informed not only of her risk, but also of its clinical significance.

Fig. 1

A Fracture risk assessment in a 68-year-old woman performed with BONEcheck, presented in pictograph form with contextual information. B  Fracture risk assessment in a 68-year-old woman using skeletal age as a metric of risk and the estimated interval for repeat bone mineral density measurement

Risk Contextualization: Treatment Benefit Within the Tool

BONEcheck also contextualizes fracture risk by linking it to treatment and management options. The contextualization module presents the potential reduction in fracture risk and survival benefit associated with anti-osteoporosis treatment, based on current Australian guidelines [9]. For example, the tool may indicate: “Your current 5-year fracture risk is 13%. With treatment, this could decrease to approximately 8%.” These estimates are derived from published efficacy data from randomized clinical trials of anti-osteoporosis therapies [47,48,49,50].

This approach addresses the context gap by transforming fracture probability from an abstract estimate into clinically actionable information. Presenting baseline risk alongside treatment benefit allows patients to visualize the potential gain from intervention. This is in keeping with evidence from health psychology showing that risk perception is more likely to prompt behaviour change when accompanied by perceived efficacy [37].

BONEcheck further strengthens this contextualization by linking fracture prevention to survival. By showing that treatment may reduce mortality as well as fracture risk, the tool helps patients recognize fracture as a serious health event rather than an isolated outcome.

Multi-Format Presentation: Probability, Icon Arrays, and Skeletal Age

BONEcheck presents fracture risk in both numerical and icon-array formats (Fig. 1A) [9]. The icon array displays risk within a 100-person grid, making probabilities more tangible and reducing biases associated with percentage-only presentations, such as denominator neglect and ratio bias [28, 29]. The tool also provides skeletal age, offering an age-based representation that may be easier to interpret for individuals with limited numeracy.

This approach addresses the format gap by presenting the same information in three complementary ways: numerical probability for precision, icon arrays for visual comprehension, and skeletal age for personal relevance. These design choices are consistent with the RICO study, which found that patients prefer visual presentation of fracture risk [17], with Trevena and IPDAS recommendations that no single format is universally optimal [51]. They also align with recent guidance supporting the incorporation of visual aids in to fracture risk communication [52]. Furthermore, BONEcheck uses language adapted for individuals with reading proficiency at level 8 or above, thereby helping to reduce health literacy barriers [9].