Aim: To examine the performance of the disease risk score (DRS) in a cohort study with evidence of policy-induced selection bias. Methods: We examined two cohorts of new users of bisphosphonates. Estimates for 1-year hip fracture rates between agents using DRS, exposure propensity scores and traditional multivariable analysis were compared. Results: The results for the cohort with no evidence of policy-induced selection bias showed little variation across analyses (-4.1–2.0%). Analysis of the cohort with evidence of policy-induced selection bias showed greater variation (-13.5–8.1%), with the greatest difference seen with DRS analyses. Conclusion: Our findings suggest that caution may be warranted when using DRS methods in cohort studies with policy-induced selection bias, further research is needed.