Osteoporosis and post-fracture management in the primary care setting: a systematic review

To synthesize evidence on osteoporosis and fragility fracture management within the primary care setting. A systematic review was conducted using Ovid Medline, Embase, Scopus, and PsycINFO to identify studies published between 2005 and 2025. Eligible studies included qualitative, quantitative, or mixed-methods designs that examined any stage of osteoporosis and fragility fracture care (risk assessment, diagnosis, treatment, prevention) in adults ≥ 50 years within primary care. Two reviewers independently screened studies, extracted data, and appraised methodological quality using the Mixed Methods Appraisal Tool. Outcomes were categorised into four domains: (1) health provider and patient knowledge, perceptions, and experiences; (2) osteoporosis diagnosis and treatment patterns; (3) interventions to improve care; and (4) barriers and facilitators to optimal care. Eighty studies were included, comprising cross-sectional surveys, cohort studies, randomized controlled trials, and qualitative studies. Clinician knowledge was moderate, with gaps in guideline familiarity, fracture risk assessment, and pharmacotherapy. Osteoporosis and fragility fractures were widely under-identified and undertreated, with minimal screening, minimal diagnostic testing, and substantial undertreatment of guideline-eligible patients. Interventions such as electronic decision-support and fracture liaison services consistently increased BMD testing and appropriate prescribing. System-level barriers to osteoporosis and post-fracture care included limited consultation time, unclear responsibility allocation, and fragmented communication between care settings, while patient-level barriers involved limited understanding of osteoporosis and concerns about medications.Osteoporosis management in primary care remains inadequate. System-integrated, coordinator-driven approaches combined with targeted patient education effectively increase diagnosis and treatment rates, highlighting known strategies to reduce subsequent fractures and improve patient outcomes.