Exploring Disparities in Post-Fracture Osteoporosis Pharmacotherapy Initiation: A Retrospective Cohort Study Utilizing the All of Us Research Database

Background/Objectives: Osteoporosis-related fragility fractures are sentinel events that should trigger timely secondary prevention, yet post-fracture care remains inconsistent. Leveraging the NIH All of Us Research Program, we quantified initiation of osteoporosis pharmacotherapy after fragility fracture and explored associations by age, sex at birth, race, and ethnicity. Methods: Retrospective cohort study using All of Us Controlled Tier data (v8) included adults aged 45 to 100 years with an index fragility fracture using prespecified OMOP concept sets intended to capture fractures commonly associated with osteoporosis. A new-user design excluded participants with any osteoporosis pharmacotherapy in the 365 days before fracture; participants required at least 180 days of follow-up. The primary outcome was initiation of osteoporosis pharmacotherapy (bisphosphonates, denosumab, or anabolic agents) within 180 days. Secondary outcomes were completion of dual-energy x-ray absorptiometry (DXA) and bone-health laboratory testing within 180 days. Multivariable logistic regression estimated adjusted odds ratios (OR) for each outcome by age at fracture, sex at birth, race, and ethnicity. Results: Among 1492 eligible participants, 87 initiated pharmacotherapy within 180 days (5.83%). After adjustment, older age was associated with higher odds of initiation (OR 1.04 per year; 95% CI 1.02 to 1.05). Male participants had markedly lower odds of pharmacotherapy initiation (OR 0.20; 95% CI 0.11 to 0.37) and DXA screening (OR 0.22; 95% CI 0.15 to 0.32) compared with female participants. In exploratory adjusted models, we did not detect an independent association between race and pharmacotherapy initiation (White vs. Black/African American OR 1.01; 95% CI 0.49 to 2.09), while White participants had higher odds of DXA screening than Black/African American participants (OR 1.79; 95% CI 1.02 to 3.28). Conclusions: In this diverse national EHR-based cohort, initiation of osteoporosis pharmacotherapy after fracture was uncommon, highlighting a substantial secondary prevention gap. In exploratory adjusted models, male sex was associated with lower odds of pharmacotherapy initiation and DXA receipt, while White participants had higher odds of DXA receipt than Black participants. System-level post-fracture pathways, including fracture liaison services and EHR-based prompts, may improve equitable identification and treatment of osteoporosis for All of Us participants and their communities.