OBJECTIVES: Osteoporosis is a disease affecting millions of people worldwide. Fractures of the hip and spine are associated with an increased mortality, and multiple risk assessment tools have been developed to identify high risk groups. We compare performance of prediction tool for osteoporotic fractures, and cost effectiveness using clinical data and Electronic Health Records. METHODS: Design: Retrospective cohort study. Setting: Payer provider healthcare organization in Brazil. Participants: 22,745 postmenopausal women aged 50 years or older to estimate prevalence of osteoporosis using a specific tool to clinical decision support of fracture risks by FRAX, need for treatment, for validation and comparison with real world data in the population that received treatment. Main outcome: osteoporotic fracture (vertebral, hip and forearm) recorded in EHR during 4 years. Fracture rates were compared with probabilities predicted by the tool. Effectiveness rate in preventing fractures was estimated. Health care expenditures in both scenarios were compared to determine the cost avoided by the treatment and the reduction of fracture risk. For statistical significance, Chi-square tests (Mantel-Haenszel and Fisher's Exact), when p <0.005. RESULTS: Estimated prevalence of osteoporosis was 21.8% (n=4,969), and 15.4% (n=765) of women presented high risk of fractures, from these 29.9% (n=229, mean age 73.6 years) had BMD <2.5 and were treated with zoledronic acid (n = 77) and denosumab (n =152). Incidence of vertebral fracture (0.43%), hip (0.87%) and forearm (0.43%), were lower than reported by literature and considered in the tool (3.8%, 3.5%, 10.7%, respectively). Comparing with initial estimates, there were 37 less osteoporotic fractures and avoided cost was US$ 201,279.09 with treatment. CONCLUSIONS: Our results were consistent to support that predictive tools are useful to identify those at high risk for osteoporotic fractures, and make them elegibles to a disease management program. Besides that, treatment drugs used showed effectiveness.