Background <p>People with non-traumatic fractures typically qualify for antifracture medications to prevent recurrent fractures.</p> Objective <p>To quantify the current osteoporosis care gap and determine factors that predict prescribing of antifracture medications following hospitalization for non-traumatic fracture.</p> Design <p>Retrospective cohort study.</p> Setting <p>Twenty hospitals from a large US health system.</p> Patients <p>Patients aged 50&#xa0;years and older presenting to the emergency department with a non-traumatic hip, pelvic, or vertebral fracture between 2017 and 2023.</p> Measurements <p>In-hospital administration or outpatient prescription fill of antifracture medications within 180&#xa0;days following hospital discharge. We estimated incident rate ratios (IRRs) using modified Poisson regression with robust standard errors to in order to determine factors associated with antifracture medication initiation.</p> Results <p>The cohort included 9849 patients (median (IQR) age, 80 [70–87] years; 68% female) of which 9008 (91.4%) were antifracture medication naïve prior to hospital presentation. Of medication-naïve patients, 510 (5.7%) were prescribed antifracture medications, with 279 (3.1%) initiating treatment as an inpatient and 119 (1.3%) in the 180&#xa0;days following discharge. Medication classes included bisphosphonate (<i>N</i> = 431, 85%), RANK ligand inhibitors and selective estrogen receptor modulators (<i>N</i> = 56, 11%), and anabolic therapies (<i>N</i> = 21, 4%). Female sex (IRR 1.93; 95% CI 1.41–2.64) and a pre-existing diagnosis of osteoporosis (IRR 1.76, 95% CI 1.47–2.11) were positively associated with medication receipt.</p> Limitations <p>Inability to measure reasons for treatment non-initiation.</p> Conclusions <p>This study found very few adults with a non-traumatic fracture received medical treatment for secondary osteoporosis fracture prevention. Expanded quality improvement efforts are needed to close the osteoporosis care gap.</p>