Received: 16 February 2022 | Revised: 20 June 2022 | Accepted: 11 July 2022 DOI: 10.1002/hsr2.849 NARRATIVE REVIEW Current situation of shared decision making in osteoporosis: A comprehensive literature review of patient decision aids and decision drivers Xavier Nogués1 | María Cristina Carbonell2 | Laura Canals3 | Luis Lizán4,5 | Santiago Palacios6 1 Internal Medicine Department, Instituto de investigación hospital del Mar (IMIM)—Centro Abstract de Investigación Biomédica en Red de Background and Aims: Osteoporosis is a systemic skeletal disease characterized by Fragilidad y Envejecimiento Saludable (CIBERFES), Universitat Autonòma de low bone mass and microstructural deterioration of bone tissues, resulting in bone Barcelona, Barcelona, Spain fragility and increased fracture risk. It is the most common bone‐related disease in 2 Department of Medicine, Atenció Primària Barcelona—Institut Català de la Salut (ICS), the population. However, the proportion of patients who start treatment but Grupo GREMPAL, Universidad de Barcelona, discontinue it during the first year is very high (around 50%). Endeavors are made to Barcelona, Spain promote patient participation in treatment by implementing patient decision aids 3 Department of Medicine, Amgen Europe, Risch‐Rotkreuz, Switzerland (PDA), whose function is to help the patient make disease‐related decisions. We aim 4 Department of Outcomes Research, to summarize the characteristics of the currently available PDA for osteoporosis, as Outcomes'10, Castellón de la Plana, Spain well as deciding factors. 5 Department of Medicine, Universitat Jaume I, Methods: Comprehensive review of the literature. Castellón de la Plana, Spain 6 Results: Currently, eleven PDAs can be found for osteoporosis. These PDA have Instituto Palacios Salud de la Mujer, Madrid, Spain different characteristics or options such as information about treatments tailored to patient needs, graphic information of the results (to facilitate understanding), Correspondence Luis Lizán, Universitat Jaume I. Edificio personal histories (learning), tests to check the knowledge acquired, provision of ESPAITEC 2, Campus del Rius Sec, Avda. evidence, clinical practice guidelines or a final summary to share with their doctor. Sos Baynat s/n, 12071 Castellón de la plana, Spain. Only five of these PDAs can be considered complete since they provide relevant Email: lizan@outcomes10.com disease information and therapeutic options to the patient, promote patient's Funding information reflection and foment patient‐physician discussion. Amgen Conclusions: This study provides an update on the current state of decision making on osteoporosis and available PDA, which can help engage the patient through shared decision‐making by considering, among other things, patient preferences. Physicians should consider PDA, as it may promote adherence and effectiveness of treatment. KEYWORDS osteoporosis, patient decision aids, review, share decision‐making Patient or Public Contribution: Since this was a narrative review, patients, service users, carers, or members of the public were not involved in the study. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2022 The Authors. Health Science Reports published by Wiley Periodicals LLC. Health Sci. Rep. 2022;5:e849. wileyonlinelibrary.com/journal/hsr2 | 1 of 10 https://doi.org/10.1002/hsr2.849 2 of 10 | NOGUÉS ET AL. 1 | BACKGROUND AND AIMS These low rates of treatment compliance and persistence fail to reduce the risk of osteoporotic fractures, which in turn can increase Osteoporosis is a systemic skeletal disorder characterized by low healthcare costs and greatly decrease patients' quality of life21 and bone mass and microarchitectural deterioration of bone tissue that life expectancy.8,22 1,2 leads to bone fragility and increased fracture risk. It is the most Previous studies have shown that patient preferences play a key common bone disease affecting predominantly women.1,3 About 27 role in accepting or rejecting osteoporosis treatment.23 Accordingly, million people are affected by the disease in the European Union in addition to choosing the treatment based on the patient's (EU)4 and, moreover, its prevalence is expected to rise in the coming characteristics and their risk of fractures,7 it is fundamental to align 5 years. treatment choice with patients' preferences and engage them in Since osteoporosis is a silent disease without any pathognomonic treatment decisions. 6 clinical signs, it usually remains undiagnosed until a low‐trauma fracture occurs.1 Osteoporotic fracture, commonly involving the hip and spine, may affect an individual's ability to function independently, 1.2 | Patient‐centered care and patient 7 leading to chronic pain and prolonged rehabilitation. It is widely decision aids recognized that osteoporosis‐related fractures are associated with increased mortality, with the exception of forearm fractures.8 Thus, In broad terms, there are three models of doctor‐patient between 20% and 40% of individuals suffering hip fractures die interaction regarding clinical decisions: (1) paternalism, where 9 within a year. the physician has all the relevant information and is the sole The economic burden of osteoporosis is also high. In the EU it is decision maker; (2) informed model, where the physician presents estimated that the cost of osteoporotic fractures in 2010, including “the facts” and the patient makes all decisions; and (3) shared pharmacological and long‐term disability, reached 37,000 million decision‐making (SDM), where the physician and patient share euros.10,11 information, discuss options using the best evidence and reach a collaborative decision that takes into account the patient's context, values, and preferences.24–27 1.1 | Strategies to prevent osteoporosis fractures The SDM is a key component of patient‐centered care. In this model, the physician offers a recommendation and shares informa- To prevent fractures in osteoporotic patients, both nonpharmacolo- tion about the benefits, drawbacks, and burdens of the therapeutic gical and pharmacological interventions are recommended. Non- options available. At the same time, patients are encouraged to pharmacological strategies include a healthy lifestyle, such as a become involved in the decision and to express their feelings and balanced diet, regular physical exercise, no smoking, limited alcohol treatment expectations.25,26,28 This process encompasses five steps: 1,12 consumption, and implementation of fall prevention measures. (1) understanding the patient's experience, preferences, and expecta- Pharmacological treatments, such as antiresorptive and ana- tions; (2) building partnerships; (3) providing treatment evidence, bolic drugs, target patients with high or very high fracture risk. including uncertainties; (4) giving recommendations, and (5) checking 2,13 Both therapies have been shown to increase bone strength. for understanding and agreement.25 SDM does not advise the patient However, their mechanisms of action differ, as antiresorptive to choose one option over another, it provides structured guidance in therapies inhibit bone resorption by suppressing osteoclastic‐ the decision‐making steps and helps patients to make informed mediated bone breakdown and bone turnover, whereas anabolic value‐based decisions together with their physician.29,30 The final agents restore bone mineral content.2,14,15 Main pharmacological choice depends on how a patient evaluates the drawbacks and agents currently available for osteoporosis are: bisphosphonates, benefits of the different treatment options.31 In 1989 a paper was anti‐RANKL antibodies (denosumab), selective estrogen receptor published describing clinical strategies when a patient has decisional modulators, estrogen replacement, monoclonal antisclerostin needs.32 Subsequently, in 1995 the Patient Decision Aids Research antibodies (romosozumab), strontium ranelate and parathyroid Group developed the Decisional Conflict Scale, the first scale to 16,17 hormone analogs. The latest updates in clinical practice measure changes in decisional requirements following counseling.33 guidelines recommend teriparatide, abaloparatide, or romosozu- In the following years, different guidelines for developing PDAs were mab for patients with a very high risk of osteoporosis fracture.17,18 published. Also, in 2003 the International Patient Decision Aid Despite the wide range of pharmacological options available, Standards (IPDAS) was founded. It aimed to improve the quality and there is a large gap between the number of women receiving effectiveness of patient decision aids by establishing a shared treatment and those that could be considered eligible for treatment evidence‐based framework with a set of criteria to improve their based on their fracture risk.19 Several studies reveal that less than content, development, implementation, and evaluation. In this sense, 20% of patients suffering from a fragility fracture receive therapy to IPDAS established a set of quality criteria for PDA that works as a reduce future fractures within the following year.19 Moreover, many checklist for developers and users29,30 women at high risk of fractures choose not to initiate therapy, and, of On the other hand, the European League Against Rheumatism and those who do, up to 50% discontinue treatment in less than 1 year.20 the European Federation of National Associations of Orthopaedics NOGUÉS ET AL. | 3 of 10 and Traumatology recommend the inclusion of patient education OR “willingness to pay” OR “WTP” OR “willingness to accept”). National programs to prevent fractures.20 database search strategies: “Osteoporosis” AND “preferencias” AND In this respect, PDAs play a key role in providing evidence‐based (“tratamiento” OR “manejo” OR “farmacoterapia” OR “medicación”). The information about conditions, treatment options, outcomes, proba- search to identify available PDA was conducted as follows: (“Osteo- bilities, and an opportunity for patients to ponder their preferences.20 porosis”[Mesh] OR “Osteoporosis” [All Fields]) AND (“Decision Support PDA facilitate SDM by improving the patient's knowledge of the Techniques” [Mesh] OR “Decision Support Techniques” [All Fields] OR disease and encouraging reflection, generating more realistic ex- “Decision Aids” [All Fields] OR (“Decision” [All Fields] AND “support” pectations about options, reducing decisional conflict, and helping [All Fields] AND “Techniques” [All Fields]) OR (“Decision” [All Fields] patients to clarify their preferences.26,27,34 PDA also help patient to AND “Aids” [All Fields])). share information with the physician, allowing a consensus to be reached on the best treatment option.24 Although further research is required to determine the effect of 2.2 | Eligibility criteria adherence, involving patients in decision‐making could lead to improved disease management.35,36 This becomes particularly rele- Clinical trials, observational studies, and narrative or systematic vant when there is more than one therapeutic option, each with its reviews assessing the preferences for osteoporosis treatment benefits and drawbacks, as is the case for osteoporosis. Previous attributes of patients with Osteoporosis and/or the healthcare studies have shown that the use of PDA contributes to reducing professionals responsible for their management were included in decisional conflict (i.e., uncertainty about the choice, ignorance about the systematic search. They needed to be conducted in Europe or the pros and cons of each option, pressure to make a particular North America and published in English or Spanish between choice, and effectiveness of the decision).37–41 In addition, the use of 1 January 2008 and 18 December 2018. The second search included a PDA can also contribute to reducing the variation of the clinical original articles and reviews providing data on AID for osteoporosis practice in preference‐sensitive options, and improve care more published in English or Spanish before 20 December 2018. 27,28,30,34 broadly. This study aims to summarize the characteristics of the currently available PDA for osteoporosis and decision factors. 3 | RESULTS AND DISCUSS I ON We identified 619 records which resulted in the inclusion of 2 | M E TH O D S 32 studies. A total of 26 of them were related to physician and patient preferences on osteoporosis treatments and 12 PDA for Two literature reviews were conducted: (1) a review of studies on patients with osteoporosis. physician and patient preferences for osteoporosis treatments; and (2) an ordered review of the literature on PDA for patients with Osteoporosis. 3.1 | PDA Eleven PDAs are currently available worldwide for osteoporosis. 2.1 | Data sources and search strategies IPDAS establish a set of quality criteria for PDA that works as a checklist for developers and users The IPDAS criteria provided by The international databases PubMed/Medline and Cochrane library, each PDA are detailed in Table 1. On the other hand, considering that and the national Medicina en Español (MEDES) and the Índice a complete PDA explains the decision; provides information on Bibliográfico Español en Ciencias de la Salud (IBECS) databases, were options, benefits, and harms; and helps patients clarify which benefits searched to identify relevant publications on treatment preferences. and harms matter most, only five of the identified tools can be PubMed/Medline and manual sources (e.g., google, google scholar, considered as complete PDA, since they are the only ones that Ottawa Hospital) were searched to identify available PDAs for provide information, explore patients' preferences and facilitate Osteoporosis. physician‐patient discussion (Table 1).41–45 Databases were searched using both MeSH (Medical Subject Concerning the treatment options, some of the PDA support Headings) and free‐text terms, combined with the Boolean connectors patients in the decision to choose a specific drug.36–39,41–47 Most “OR” and “AND.” The treatment preferences search was conducted in tools are focused on bisphosphonate treatment while only three English (international database) and Spanish (national database). display most of the available therapies. In relation to the format, four International database search strategies: (“osteoporosis”) AND (“treat- of the PDA are on paper,37,43–45 four on online platforms36,39,41,47,48 ment” OR “management” OR “drug therapy” OR “medication” OR and three are in both formats.38,42,46 These PDAs have different “patient‐centered” OR “shared decision making”) AND (“conjoint target users according to gender, age, osteoporosis or osteopenia analysis” OR “DCE” OR “discrete choice” OR “decision aid” OR diagnosis, menopausal status, and/or history of fractures. All of them “decisional conflict” OR “preference” OR “trade‐off” OR “risk‐benefit” target the English‐speaking population (Table 2). 4 of 10 | NOGUÉS ET AL. TABLE 1 IPDAS criteria Patient decision aids Indicadores IPDAS No. 3 No. 6 No. 7 No. 8 No. 9 No. 10 No. 11 Content 1 Describe the health condition X X X X X X 2 List the options X X X X X X X 3 List the options of doing nothing X X X X X X 4 Describe the natural course without options X X X X X X X 5 Describe procedures X X X X X 6 Describe positive features [benefits] X X X X X X X 7 Describe negative features of options [harms/side X X X X X X X effects/disadvantages] 8 Include chances of positive/negative outcomes X X X X 9 Use event rates specifying the population and time period X X X X X 10 Compare outcome proabilities using the same denominator, X X X X X X time period, scale 11 Describe uncertainty around probabilities X X X X 12 Use visual diagrams X X X X X X 13 Use multiple methods to view probabilities X 14 Allows the patient to select a way of viewing probabilities [words, numbers, diagrams] 15 Allow patient to view probabilities based on their own situation X 16 Place probabilities in context of other events 17 Use both positive and negative frames X X X X x x x 18 Describe the procedures and outcomes to help patients imagine what X X X X X X X it is like to experience their physical, emotional, social effects 19 Ask patients to consider which positive and negative features X X X X matter most 20 Suggest ways for patients to share what matters most with others 21 Provide steps to make a decision X X 22 Suggest ways to talk about the decision with a health professional X X X X X X 23 Include tools to discuss options with others X X X X X Development 1 Able to compare positive/negative features of options X X X X X X X 2 Shows negative/positive features with equal detail X X X X X X 3 Includes developers' credentials/qualifications X X X 4 Finds out what users [patients/practitioners] need to discuss options. X X X 5 Has peer review by patient/professional experts not involved in X X X development and field testing 6 Is field tested with users X X X X X 7 The field tested with users [patients, practitioners] show the patient X X decision aid is: acceptable 8 The field tested with users [patients, practitioners] show the patient X X decision aid is: balanced for undecide patients 9 The field tested with users [patients, practitioners] show the patient decision aid is: understood by those with limited reading skills 10 Provides references to evidence used X X X X X X X NOGUÉS ET AL. | 5 of 10 TABLE 1 (Continued) Patient decision aids Indicadores IPDAS No. 3 No. 6 No. 7 No. 8 No. 9 No. 10 No. 11 11 Report steps to find, appraise, summarize evidence 12 Report date of last update X X X X X X X 13 Report how often patient decision aid is updated 14 Describe quality of Scientific evidence [including lack of evidence] 15 Use evidence from studies of patients similar to those of target audience 16 Report source of funding to develop and distribute the patient X X X X decision aid 17 Report weather authors or their affiliations stand to gain or lose X X X X X X by choices patient make after using the PDA 18 Is written at a level that can be understood by the majority of X X X X patients in the target group 19 Is written at a grade 8 equivalent level or les according to readability score [SMOG o FRY] 20 Provides ways to help patients understand information other X tan reading [audio, video, in‐person discussion] 21 Provide a step‐by‐setp way to move through the web pages) X 22 Allow patients to search for key words 23 Provide feedback on personal health information that is entered into the patient decision aid 24 Provides security for personal health information entered into the decision aid 25 Make it easy for patients to return to the decision aid after lining to other web pages 26 Permit printing as a single document X 27 Use stories that represent a range of positive and negative experiences 28 Reports if there was a financial or other reason why patients decided to share their story 29 State in an accessible document that the patient gave informed consent to use their stories Efectividad 1 Recognize a decision needs to be made X 2 Know options and their features X X X 3 Understand that values affect decision 4 Be clear about option features that matter most 5 Discuss values with their practitioner 6 Become involved in preferred ways X 7 Improves the match between the chosen option and the features that X matter most to the informed patient Note: 3. Osteoporosis Choice; 6. Bisphosphonates for treating osteoporosis; 7. Osteoporosis Decision Support Tool; 8. Osteoporosis: Should I Take Bisphosphonate Medicines?; 9. Should I take alendronate (Fosamax®) for osteoporosis?; 10. Should I take Etidronate (Didronel®) for osteoporosis?; 11. Should I take risedronate (Actonel®) for osteoporosis? Abbreviation: IPDAS, International Patient Decision Aid Standards. 6 of 10 | TABLE 2 Available PDA for osteoporosis Decision‐making support tool Country Target population Treatment options α‐Test β‐Test Format Complete toola Smallwood et al. (2017)39 USA Postmenopausal women with Different options (Alendronate, Yes Yes Web Yes osteoporosis Risedronate, Ibandronate, Zoledronic acid, Denosumab, Raloxifene, Teriparatide) Hiligsmann et al. (2016)36 Netherlands Postmenopausal women with Different options (Alendronate, Yes No Web and paper No osteoporosis Risedronate, Ibandronate, Zoledronic acid, Denosumab, Raloxifene, Ranelate) Osteoporosis Choice34,37 USA Patients >45 years old with One option (Bisphosphonates vs none) Yes Yes Web No osteopenia or osteoporosis Chess‐Mab46 USA Peri‐ and postmenopausal women No treatment options Yes Yes Web No Cranney et al. (2002)35 Canada Postmenopausal women with Different options (Alendronate, Yes Yes Paper No osteoporosis Etidronate, Hormonal, Raloxifene, Vitamin D/Calcium, Lifestyle) Bisphosphonates for treating osteoporosis45 (https:// UK Osteoporosis patients Bisphosphonates vs. none NA NA Web and paper No www.nice.org.uk/guidance/ta464/resources) Osteoporosis Decision Support Tool44 (https://www. USA Osteoporosis patients Bisphosphonates vs. none NA NA Web No healthdecision.org/tool.html#/tool/osteoporosis) Osteoporosis: Should I take Bisphosphonate USA Postmenopausal women with Bisphosphonates vs. healthy lifestyle NA NA Web and paper Yes medicines?40 (https://healthlinkbc.ca/health- osteoporosis topics/te7592) Should I take alendronate (Fosamax®) for Canada Postmenopausal women with Alendronate vs. none NA NA Paper Yes osteoporosis?41(https://musculoskeletal. osteoporosis and recent cochrane.org/decision-aids) previous fracture Should I take etidronate (Didronel®) for Canada Postmenopausal women with Etidronate vs. none NA NA Paper Yes osteoporosis42(https://musculoskeletal.cochrane. osteoporosis and recent org/decision-aids) previous fracture Should I take risedronate (Actonel®) for Canada Postmenopausal women with Risedronate vs. none NA NA Paper Yes osteoporosis43(https://musculoskeletal.cochrane. osteoporosis and recent org/decision-aids) previous fracture Abbreviations: NA, not available; PDA, patient decision aids; UK, United Kingdom; USA, United Sates of America. a Complete Decision‐making support tool, which must provide relevant disease information and therapeutic options to the patient, promote patient's reflection and foment patient‐physician discussion. NOGUÉS ET AL. NOGUÉS ET AL. | 7 of 10 During its development, a PDA should be validated by conducting PDA includes a test that evaluates the knowledge acquired by an alpha and/or beta test. An alpha test is an acceptability test that patients.42–45,48 aims to identify all possible issues before launching a product to users, The level of evidence provided for the information presented in while a beta test is a user utility test in which a sample of the intended the PDA demonstrates the validity and integrity of that information. audience tries the product out.49,50 Only some of the identified PDA Four PDAs include an acceptable level of evidence for the have undergone alpha37–39,41,48 and/or beta tests37,39,41,48 (Table 2). information provided.43–45,47 Identified PDA have different characteristics regarding their Clinical practice guidelines provide evidence‐based recommen- adaptability to patient profiles, graphic design, inclusion of personal dations founded on rigorous systematic reviews and synthesis of stories, availability of patient knowledge tests, level of evidence of published research in academic, governmental, and private sectors.27 the available information in the PDA, explicit information about Knowing the recommendations of the clinical practice guidelines can recommendations of clinical practice guidelines, and a final summary help patients to increase their knowledge about the treatment of the to share with the physician (Table 3). disease and, through SDM, individualize these recommendations to Since patient profile in osteoporosis is variable, adaptability is a the preferences and characteristics of each patient. Two PDA include 36,38,39,41,46,47 valued characteristic in PDA. Five of the eleven PDA clinical practice guidelines.46,47 identified are adaptable to patient profile by, i.e., calculating fracture Last, the final summary, a synopsis to share preference risk within 10 years using FRAX®.51 information with the physician, is an essential part of the PDA since Patients appreciate graphic information about their risk of it may facilitate communication with the physician and improve the developing a certain disease or the risk/benefits of a therapeutic SDM process. Two PDAs include a brief final summary to share with option.52 Moreover, the use of pictographs may improve the the physician.42,47 comprehensibility and desirability of the information presented. Seven It is very important for osteoporosis patients to adopt healthy of the PDAs identified include graphic information.36,38,39,43–47 lifestyles, including a varied and balanced diet, which guarantees the Personal stories about health experiences are used as an supply of essential nutrients for bone health and the amelioration of established resource in education as a way for patients to learn osteoporosis.54 One of the best ways to build and maintain healthy about diseases and treatments and, are included in some PDA. bones is through exercise. Exercise improves disequilibrium and reduces Although there is insufficient evidence examining whether or not the risk of falls.55 None of the PDA available includes adaptations to the personal stories contribute to the effectiveness of PDA, they were patient's exercise program, which should address flexibility, strength, identified as having four functions: (1) to provide factual information core stability, cardiovascular fitness, and equilibrium. to help patients understand the option and their outcomes; (2) to Patients expressed a positive attitude towards the use of these demonstrate how patients value decisions differently; (3) to share a PDAs as they improved their preparation for decision‐making and range of options and (4) to exemplify the steps others have taken to decreased decisional conflict. These PDAs improved knowledge reach a decision.53 Only one of the PDAs includes patient stories.42 transfer and patient involvement in decision‐making with adequate The option of performing a patient knowledge test helps patient and physician satisfaction, but with a weak or null effect on evaluate whether the patient has understood the information medication adherence.36,39 Interestingly the effectiveness of four provided in the PDA related to the disease and its treatment. Five PDAs has been evaluated. In three studies,36,39,41 decisional conflict TABLE 3 PDA characteristics Tools Tools strengths No. 1 No. 2 No. 3 No. 4 No. 5 No. 6 No. 7 No. 8 No. 9 No. 10 No. 11 Adaptable × × × × × Graphic design × × × × × × × Level evidence information × × × × Personal stories × Knowledge test × × × × × Patient preferences × × × × × × Guides recommendation × × Final summary × × Note: 1. Smallwood et al. (2016) ; 2. Hiligsmann et al. (2016) ; 3. Osteoporosis Choice; 4. Chess‐Mab; 5. Cranney et al. (2002)35; 6. Bisphosphonates for 39 36 treating osteoporosis; 7. Osteoporosis Decision Support Tool; 8. Osteoporosis: Should I Take Bisphosphonate Medicines?; 9. Should I take alendronate (Fosamax®) for osteoporosis?; 10. Should I take Etidronate (Didronel®) for osteoporosis?; 11. Should I take risedronate (Actonel®) for osteoporosis? Abbreviation: PDA, patient decision aids. 8 of 10 | NOGUÉS ET AL. scores were found in the PDA arms compared to the conventional considered by physicians since they can impact adherence to the decision, and one reported a statistically significant difference.41 treatment and its efficacy. Currently, available PDAs can help to Moreover, two studies exploring PDAs found a significant difference engage patients through shared decision‐making. Since the purpose in the percentage of patients correctly identifying their risk category of a PDA is to help patients in the decision‐making process there is postintervention36,39 and a significant difference when measuring the certain information that must necessarily be included in the PDA. The specific knowledge. Finally, the impact of PDA on adherence was also information gathered in this review regarding the decision drivers observed in one study, where more patients‐initiated treatment in may help to define which content should be included in a PDA. the intervention arm compared with controls. A UT H O R C O N T R I B U TI O NS Conceptualization: Xavier Nogués, María Cristina Carbonell, Laura 4 | DECISION DRIVERS Canals, Luis Lizán, and Santiago Palacios. Writing: Luis Lizán. Review and editing: Xavier Nogués, María Cristina Carbonell, Laura Canals, PDA brings various important patient‐centered issues (i.e., mode of and Santiago Palacios. Luis Lizán had full access to all of the data in administration, side effects, cost) to the foreground, serving as an this study and takes complete responsibility for the integrity of the invitation for the patient and physician to address these together. This data and the accuracy of the data analysis. All authors have read and means the main decision drivers in PDA are mandatory to ensure efficacy. approved the final version of the manuscript. Several treatment characteristics that could influence the decision‐making process have been described in the ACKNOWLEDGME NT S literature: (1) route and frequency of administration52,56–72 ; (2) The study has been supported by Amgen Spain. efficacy52,57,58,60,61,65,67,69,71,73; (3) cost of treatment (for the patient and for society) 52,58,62,65,67,71; (4) adverse events or DATA AVAILABILITY STATEMENT side effects52,57,58,60,61,63–65,67,69,71–75; (5) total duration of the Data sharing is not applicable to this article as no datasets were 60 treatment ; (6) convenience (i.e., number of pills, independency, generated or analyzed during the current study. dosing facility, body position) 57,63,64,74–77 ; (7) food interac- tions71,72 ; (8) period of treatment availability in the market 58,71 ; TR A N S P A R E N C Y S T A T E M E N T (9) sequential therapy 58 ; (10) drug‐site administration58,62; Luis Lizán affirms that this manuscript is an honest, accurate, and 58 (11) generic or trademark treatment ; (12) monotherapy or transparent account of the study being reported; that no important combination therapy 58 ; (13) action mode of the treatment 58; and aspects of the study have been omitted; and that any discrepancies (14) general satisfaction. 63 from the study as planned (and, if relevant, registered) have been From the patients' point of view, route and frequency of explained. treatment administration are one of the most important treatment characteristics. In general, patients prefer less frequent administra- ORC I D tion, even if subcutaneous administration is required since simpler Luis Lizán http://orcid.org/0000-0001-6039-2454 57,67–69,73 dosage regimens improve lifestyle. In this respect, numer- ous studies have reported that patients prefer a 6‐month sub- RE F ER EN CES cutaneous injection to a weekly or monthly oral tablet.58,59,62,74 1. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician's guide to Similarly, a monthly oral tablet is preferred over a weekly oral prevention and treatment of osteoporosis. Osteoporos Int. 2014;25: 50,52,56,57,60,63–65,67–69,73 2359‐2381. tablet. 2. Lou S, Lv H, Yin P, Li Z, Tang P, Wang Y. 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