In a single, large integrated US healthcare system, bisphosphonate treatment initiation for fracture prevention among older adults shifted towards higher-risk populations over a 25-year time period (1998–2022). The temporal trends among women and men who initiated treatment reflected changing practice patterns and both primary and secondary fracture prevention efforts.

While bisphosphonate (BP) drugs remain first-line for fracture prevention, treatment has changed over time. This study examines trends over 25 years among adults initiating BP in a single healthcare system.

Among adults aged 50–89 years who initiated alendronate, risedronate, ibandronate, or zoledronate in Kaiser Permanente Northern California during 1998–2022, age, sex, race and ethnicity, and fracture history were examined. Findings across 5-year periods were evaluated.

A total of 212,289 adults (86.0% women) initiated BP during 1998–2022. After 2008, a much lower proportion of adults who initiated BP were age < 65 years. Across successive 5-year periods, the percentages of women who were age < 65 years were 35.1%, 35.2%, 24.1%, 18.8%, and 17.8%. Among men, these percentages were 26.9%, 25.4%, 17.6%, 12.6%, and 4.7%. In later years, sustained or increasing numbers of adults initiating BP coincided with electronic health record targets for BMD screening (since 2016 for women, 2017–2019 for men), an impact greater for men. The proportions with prior fracture among women initiating BP increased from 21–24% (1998–2007) to 35–38% (2008–2022) after implementing a secondary fracture prevention program for women in 2008. Among men, this proportion increased from 28 to 37%, 40%, and 47% during successive 5-year periods in 1998–2017 (the secondary fracture prevention program for men began in 2015) but fell to 26% in 2018–2022 after BMD screening targeted older men.

In a large primary care population of adults initiating BP, greater treatment of older adults and those with prior fracture highlights the key role of targeted fracture prevention initiatives, sustaining treatment efforts.