Disparities in osteoporosis care after fragility fracture: a systematic review and meta-analysis.

OBJECTIVE: Fragility fractures are indicative of osteoporosis; evaluation with bone density testing and subsequent pharmacotherapy significantly reduces the risk of subsequent fractures. Sex- and race-based osteoporotic treatment disparities are well described; however, whether disparities persist after fragility fractures remains unclear, especially when all patients after fragility fracture should receive equivalent evaluation. METHODS: In this systematic review and meta-analysis, PubMed, CINAHL, Embase, Web of Science, and the Cochrane Library were searched from inception through June 30, 2026, for studies of adults with fragility fractures that reported sex- or race-stratified data on post-fracture osteoporosis pharmacotherapy, DXA testing, or referral. Data were independently extracted by four authors. The primary outcomes were initiation of osteoporosis pharmacotherapy, DXA testing, and referral for osteoporosis evaluation after fragility fracture, stratified by sex and race. RESULTS: Eighty studies were included, of which 47 contributed 69 estimates to at least one meta-analysis. Sex disparities were evaluated in 72 studies and racial disparities in 19 studies. Compared with women, men had lower odds of receiving osteoporosis pharmacotherapy (pooled OR 0·43 [95% CI 0·36-0·50]) or undergoing DXA testing (0·39 [0·31-0·50]). Compared with White patients, Black patients had lower odds of receiving osteoporosis pharmacotherapy (0·63 [0·56-0·70]) or undergoing DXA testing (0·56 [0·50-0·62]). CONCLUSION: Men and Black patients were significantly less likely to receive osteoporosis pharmacotherapy and bone density testing after fragility fracture. These findings demonstrate persistent inequities in secondary fracture prevention and support the implementation of systematic post-fracture care pathways designed to ensure equitable osteoporosis evaluation and treatment.