Fractional flow reserve (FFR) and non-hyperemic pressure ratios (NHPR) are established physiologic indices that can help inform the need for percutaneous coronary intervention (PCI), however, their use in patients undergoing bifurcation PCI is uncertain. The PROGRESS-BIFURCATION study is an ongoing multi-center, international registry conducted across six centers. Among 2494 bifurcation lesions treated (2271 patients), only 158 (6.3 %) had pressure-wire based physiology assessment. Pre-PCI, 127 (5.1 %) lesions had assessments of the main vessel (MV), 32 (1.3 %) of the side branches (SB), and 18 (0.7 %) had assessments of both MV and SB. Post-PCI, 23 (0.9 %) had assessments of the MV, and 9 (0.4 %) of the SB. NHPR were used in 55 % and FFR in 45 % of cases. Technical and procedural success rates, as well as complication rates, were comparable between bifurcation PCIs performed with and without physiology assessments. However, the use of physiology assessment was associated with a lower incidence of in-hospital major adverse cardiac events (MACE) (0.0 % vs. 3.8 %; p = 0.02). Despite randomized controlled trials showing benefits of coronary physiology to inform the need for PCI and improve clinical outcomes, real-world adoption of physiology-based assessment in bifurcation PCI remains low.