Abstract
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. INTRODUCTION: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.