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Our exact natural effects estimators are found to work properly in both simulations and real data example. Adults at high risk of fragility fracture should be offered pharmacological treatment when not contraindicated, however, under-treatment is common. This study aimed to investigate factors associated with bone-health medication initiation in older patients attending primary care. This was a retrospective cohort study. The study used data from forty-four general practices in Ireland from 2011-2017. The study included adults aged ≥ 65