Physicians’ Knowledge, Attitudes and Practices on the Diagnosis and Management of Osteoporosis in a Tertiary Hospital in Manila

Introduction

Osteoporosis is the most common bone disease in humans[1]  and is secondary to an imbalance between bone formation and bone resorption, leading to low bone mass and microarchitectural deterioration of bone tissue. This causes enhanced bone fragility and a consequent increase in fracture risk.[2] 

It is a major public health concern, as osteoporotic-related fractures are a major cause of chronic pain, disability and death. Hip fractures are associated with a 15% to 20% increased mortality rate within one year and increased requirement for long-term nursing homecare, decreased quality of life, social isolation, depression and loss of self-esteem.[1] 

Almost 20% of the global population suffers from osteoporosis, including 23.1% of women and 11.7% of men.[3]  In a local study in an urban community in Davao, Philippines, the prevalence of osteoporosis was 19.8% in postmenopausal women.[4] 

Major risk factors for the development of osteoporosis include non-modifiable risk factors such as gender and age, and modifiable risk factors such as cigarette smoking, poor nutrition and alcohol consumption. Secondary osteoporosis can also be caused by other disease conditions such as hyperparathyroidism, diabetes and the intake of medications such as corticosteroids.[5] 

The gold standard for the diagnosis of osteoporosis and prediction of fracture risk is the Dual Energy X-Ray Absorptiometry Scan.[6]  Screening instruments such as the Fracture Risk Assessment Tool are also being used. In the local setting, the Osteoporosis Screening Tool for Asians can be used to identify the risk of osteoporosis among postmenopausal women based on their age and body weight. 

In spite of significant morbidity in these patients, osteoporosis is underdiagnosed. In a study published in the American Journal of Public Health involving 2314 postmenopausal women, only 5% were told that they had osteoporosis by their primary care physicians. Appropriate drug treatment, including antiresorptive agents, calcium and vitamin D, was offered to only 36% of the diagnosed patients.[7] 

A recent study in Malaysia looked at the knowledge, skills and attitudes of primary care physicians on the screening and management of osteoporosis. Of the 350 primary care doctors included in the study, only 110 (31.4%) achieved satisfactory overall knowledge scores of >60% and only 97 (27.7%) routinely practiced osteoporosis screening. The study also identified perceived barriers to osteoporosis screening and management with the inaccessibility of bone mineral density as the most commonly cited reason. Other barriers include inadequate knowledge, coexisting medical conditions that are of a higher priority and inaccessibility of pharmacotherapy at primary care clinics.[8]  Similar results were seen in a similar study done in Israel, with only 19% of participants correctly answering questions for treatment initiation in osteoporosis and only 8% being able to answer questions on diagnostic tests and clinical risk factors for osteoporosis.[9] 

As of now, no studies of this nature have been done in the Philippines. Hence, this study aims to identify the knowledge, skills and attitudes of physicians who encounter patients with and are at risk for osteoporosis in their practice. In doing so, this study aims to identify gaps which could be addressed to improve patient care. This study will include residents, fellows and consultants from the Sections of Internal Medicine, Family Medicine, Orthopedics and Obstetrics and Gynecology in the University of Santo Tomas Hospital using an online-based questionnaire.

Methodology

Research Design

This study utilized an observational cross-sectional design. Quantitative data collected through a survey questionnaire will be used to determine the respondents’ KAP on osteoporosis screening and management.

Subjects

The research made use of purposive sampling and 109 eligible respondents participated in the study. This yielded 80% power and 5% level of significance calculated using Open Epi software (See Figure 1)

FIGURE 1: Sample Size Calculation

The criteria for inclusion were residents, fellows and consultants from the departments of Internal Medicine, Family Medicine, Orthopedic Surgery, and Obstetrics and Gynecology. These departments were chosen because they include physicians who frequently encounter patients with and who are at risk for osteoporosis in their practice. Those who did not fall within these criteria were excluded from the study.

Data Measure/Instrumentation

This study was conducted at the University of Santo Tomas Hospital, a tertiary hospital in Manila, Philippines. The researchers utilized a self-administered online questionnaire in Google Forms that was adapted with permission from the study of Chai Li Tay, et al., titled “Screening and Management of Osteoporosis: A Survey of Knowledge, Attitudes, and Practices among Primary Care Physicians in Malaysia” published in the Archives of Osteoporosis in 2022[10]  which was, in turn, adapted from a similar study done in Israel.[11] 

The questionnaire underwent face and content validation as well as pilot testing in the original study and consisted of four sections: demographic information, osteoporosis knowledge, attitude towards osteoporosis as a health issue and practices on osteoporosis screening and management. 

Data Gathering Procedure

The flowchart for the data gathering procedure is presented in Figure 2. The principal investigator corresponded with the Medical Director to allow the investigator to distribute the questionnaires to different Section Heads of the population to be included in the study. The researcher also collaborated with the different Section Heads to obtain the e-mail addresses of participants. Thereafter, the Google form link for the informed consent form and online questionnaire was sent to the participants. The test questionnaire can be found in the appendix section (see Appendix A). The collated data was tabulated, processed and subjected to statistical analysis.

FIGURE 2: Flowchart of the Study

Ethical Considerations

Ethics approval was obtained from the Research Ethics Committee of the University of Santo Tomas Hospital. All procedures were done in observance of the 2017 National Ethical Guidelines for Health and Health-Related Research and informed consent was sought from all participants.

Data Analysis

Statistical analyses were conducted using the STATA Statistical Software, Version 13, College Station, TX: StataCorp LP. A p value of 0.05 was considered statistically significant. Descriptive statistics included mean and standard deviation for continuous-level data, median and interquartile range for ordinal data, and frequency and proportion for nominal data.[12]  The knowledge scores were categorized as unsatisfactory (correct responses <60%) and satisfactory (correct responses ≥60%).[8]  In contrast, attitude score was computed by initially summating the responses in all items and categorizing the scores using the quartile and tercile scores.[13,14]  Scores below the 33^rd percentile of the dataset were classified as negative attitude, scores between the 33^rd and 67^th percentile were considered neutral attitude and those greater than the 67^th percentile were categorized as positive attitude. Comparative analyses of KAP according to designation (trainee versus consultant) were conducted using the Chi-Square Test of Homogeneity or Fisher’s Exact test for categorical variables and independent t-test for continuous-level variables.[15]  The association of overall mean knowledge, represented by the mean percentage correct responses, with attitude score was estimated using Pearson’s Correlation, while the association of the proportion of attitude level (negative, neutral and positive attitude) and knowledge level (satisfactory and unsatisfactory) were analyzed using the Chi-Square Test of Independence.[15] 

Results

A total of 107 respondents participated in the study.

Table 1 illustrates the demographic characteristics of participants. Results showed that the median age of the participants was 32 years old (IQR = 30 to 36), and majority were female (53.21%) and trainees (70.64%).

Knowledge on Osteoporosis

The descriptive statistics and comparative analyses of the knowledge items and percentage correct responses according to designation are presented in Table 2. It can be noted that the overall knowledge score, in terms of percentage correct responses, was 57.98% (SD=12.98), which were not statistically significant (p = 0.068) between trainees (x̅=59.43, SD=12.11) and consultants (x̅=54.49, SD=14.18). It can also be noted that more than half of the participants had satisfactory knowledge (58.72%) and 41.28% had unsatisfactory knowledge. Comparative analyses of the proportion of satisfactory and unsatisfactory knowledge were not statistically different between trainees and consultants (p = 0.233). 

Item analyses showed that among the different items of knowledge, the items commonly answered correct were treatment failure of osteoporosis (x̅=69.36%, SD=32.84), laboratory tests for osteoporosis (x̅=68.04%, SD=15.45), risk factors of osteoporosis (x̅=65.21%, SD=11.94) and patients requiring treatment without confirmatory tests (x̅=65.14%, SD=27.85). The least correctly answered item was the maximum duration of oral biphosphate treatment (x̅=19.27%, SD=39.62). Comparative analyses of the mean percentage correct responses according to designation, as illustrated in Table 2 and Figure 1, showed that none of the items were significantly different between trainees and consultants (p>0.05), except for item 7 (complications of osteoporosis treatment). In particular, results showed that the mean percentage correct scores of trainees (x̅=53.06%, SD=27.01) were significantly higher (p = 0.033) than the consultants (x̅=41.07%, SD=24.81). Item analyses for each sub-item can be found in Appendix C.

Attitudes on Osteoporosis

Table 3 depicts the descriptive statistics and comparative analyses of the attitudes on osteoporosis according to designation among the participants. By and large, the mean overall attitude score of the participants was 29.23 (SD=4.15) and were not statistically different (p = 0.305) between trainees (x̅=29.49, SD=4.10) and consultants (x̅=28.59, SD=4.26). It can also be noted that most participants had neutral attitude (38.53%) and the proportions of negative, neutral and positive attitude were not statistically different between trainees and consultants (p = 0.351).

Among the different attitude items, the item with the highest mean attitude score was item 1 (osteoporosis is an important health issue; x̅=4.94, SD=0.25), followed by item 2 (osteoporosis screening is beneficial for patients ≥65 years old; x̅=4.87, SD=0.41) and item 3 (BMD assessment should be made easily accessible to primary care doctors; x̅=4.85, SD=0.38). In a similar vein, majority of the participants had positive attitudes towards item 1 (100.00%), item 2 (99.08%), item 3 (99.08%) and item 5 (77.06%). Comparative analyses according to designation also indicated that the mean attitude scores and proportions of positive, neutral and negative attitudes among participants were not statistically different (p>0.05).

Practices on Osteoporosis

Descriptive statistics of the practices of screening osteoporosis among the participants is presented in Table 4. It can be noted that only 28.44% screen patients ≥65 years old who are at risk of osteoporosis. Among these participants, 83.87% used bone mineral densitometry (DXA) as the screening tool, while only 41.94% and 12.90% used fracture risk assessment tool (FRAX) and osteoporosis self-assessment tool for Asians (OSTA), respectively. None of the participants used quantitative ultrasound as a screening tool for osteoporosis.

Table 5 illustrates the descriptive statistics and comparative analyses of non-pharmacologic management of osteoporosis among participants according to designation. In general, the non-pharmacologic managements which were practiced by participants were item 2 (“I advise patients on fall prevention”; 85.32%), item 3 (“I advise patients on adequate calcium intake”; 74.31%), item 6 (“I prescribe calcium with Vitamin D supplements”; 68.81%), and item 7 (“I refer to medical or orthopedic specialist for anti-osteoporotic medications”; 65.14%). Among the consultants, the most practiced non-pharmacologic managements were item 1 (“I advise patients for weight-bearing exercise”; 71.88%) and item 2 (“I advise patients on fall prevention”; 87.50%). On the other hand, the most practiced non-pharmacologic management among trainees were item 2 (“I advise patients on fall prevention”; 84.42%), and item 3 (“I advise patients on adequate calcium intake”; 70.13%) Comparative analyses also showed that none of the items of non-pharmacologic management were not statistically significant (p>0.05).

Table 6 presents the descriptive statistics and comparative analyses of perceived barriers to osteoporosis screening and management according to designation. It can be noted that the most commonly perceived barriers were the patient’s coexisting multiple medical conditions (93.58%), patient’s low socio-economic status (92.66%), inadequate knowledge (83.49%), patient’s refusal for screening (80.73%) and inaccessibility of bone density scan (77.06%). Among consultants, the three most perceived barriers were the patient’s low socio-economic status (90.63%), patient’s multiple medical conditions (87.50%) and patient’s refusal for screening. In contrast, the three most perceived barriers among trainees were patient’s multiple medical conditions (96.10%), patient’s low socio-economic status (93.51%) and inadequate knowledge (88.31%). Comparative analyses of the perceived barriers according to designation showed that most barriers were not statistically significant (p>0.05). 

However, results indicated that proportions of participants who perceived inadequate knowledge (88.31% vs. 71.88%, p = 0.048) and inaccessibility of bone density scan (85.71% vs. 56.25%, p = 0.002) were barriers significantly higher among trainees than consultants.

Association of Knowledge and Attitude Scores

Table 7 presents the analysis of the association between knowledge and attitude scores of participants. After categorizing the knowledge and attitude scores, results showed that knowledge and attitude were significantly associated (Χ²=7.67, p = 0.022). In particular, negative attitudes were high among those with unsatisfactory knowledge while neutral attitude was seen higher among those with satisfactory knowledge. Analyses of different items of attitude also showed that most items were not significantly associated with the level of knowledge on osteoporosis (p>0.05). However, it can be noted that the attitude item, I am confident in providing non-pharmacotherapy to prevent osteoporosis, was significantly associated with knowledge (Χ²=7.23, p = 0.027). In particular, negative attitudes were higher among those with unsatisfactory knowledge than those with satisfactory knowledge.

Discussion

The overall mean knowledge of participants included in the study was 58.72% and 41.28% demonstrated low knowledge. This is consistent with findings of similar studies done among primary care physicians in Malaysia with a mean knowledge score of 50.46%[8]  and in Israel with mean knowledge scores on calcium and vitamin D of 50% and 51% on therapeutic purpose of osteoporotic pharmacotherapy.[9]  A study done in Canada that involved healthcare professionals working in fracture clinics, orthopedics, rehabilitation and the nuclear medicine department also echoed this knowledge deficit, especially with regards to health promotion and pharmacotherapy, and also looked at the most common sources of osteoporosis knowledge, which are mostly from journal articles and case presentations at work.[16]  On osteoporosis guidelines, a Germany-based study looking at primary care physicians’ awareness of osteoporosis and knowledge of national guidelines showed that only half 51.7% of participants reported good knowledge of their national guidelines.[17]  Several of these guidelines are available on the management and treatment of osteoporosis such as those by the American Academy of Clinical Endocrinologists[18]  and the Endocrine Society. [19]  In our local setting, Li-Yu, et al., together with the Osteoporosis Society of the Philippines Foundation, Inc, the Philippine Orthopedic Association Clinical Practice Guidelines Task Force Committee on Osteoporosis published a consensus statement on osteoporosis diagnosis, prevention and management in the Philippines last 2011.[20] 

Only 32.11% of patients correctly answered the question on the definition of osteoporosis, the question with the second lowest percentage of correct answers overall. The lack of knowledge in the definition of osteoporosis found in this study is similar to the findings in the original paper utilizing this questionnaire,[8]  with only 31.1% of their participants having satisfactory knowledge on the definition of osteoporosis and with other quantitative studies of this nature.[9,16,17]  A qualitative study done among primary care physicians showed one of the major findings was the presence of gaps in knowledge and insufficient awareness of osteoporosis among healthcare workers.[21] 

On the question regarding risk factors for osteoporosis, 65.21% answered correctly. More than 90% of the participants were able to identify that women aged >65 years, smokers and those with primary hyperparathyroidism needed to be screened for osteoporosis. The most frequent incorrect answer was a parental history of spine fractures, but a parental history of hip fractures and previous history of low impact wrist fractures was correctly identified as a risk factor by 90% and 80% of participants, respectively; but 79.82% of participants also incorrectly identified hypothyroidism as a risk factor for osteoporosis. The Royal Osteoporosis Society mentions that hypothyroidism itself is not a risk factor for osteoporosis, but excessive thyroid hormone supplementation to treat the condition is.[22]  A study in the American Journal of Bone and Mineral Research stated that elevated baseline TSH itself is not associated with an increased risk of fractures, but subsequent 6-month periods with low TSH, which suggests excessive thyroxine dosing was associated with increased risk of major osteoporotic fractures. Other incorrectly identified risk factors include ischemic heart disease and steroid intake (Prednisolone 40 mg) with gradual reduction over a week.[23]  Although 65.21% of participants had satisfactory knowledge when it comes to risk factors for osteoporosis, significantly higher compared to other items in the questionnaire, additional education on the risk factors is still important as screening, and therefore, correctly identifying who needs screening for this disease is of paramount value.

The next domain explored the participants’ knowledge on laboratory tests that needed to be requested prior to initiating pharmacotherapy for patients with osteoporosis and was correctly answered by 57.98% of study subjects. Most frequent incorrectly answered diagnostic tests include x-ray of thoracic and lumbar vertebrae (73.39%), x-ray of hip joints (74.31%) and quantitative ultrasound (53.21%). Most participants (97.25%) correctly identified serum creatinine as an important test. However, only 46.18% of participants scored correctly when asked which anti-osteoporotic drugs were safe for patients with an eGFR of <30 mL/min/1.73 m² implying a lack of knowledge in the application of serum creatinine results. It is important to emphasize which diagnostic tests are required for patients with osteoporosis as requesting for tests that may not be necessary increase healthcare costs for an already cost-intensive disease.

Seven of the questions of knowledge looked at pharmacotherapy for osteoporosis: recommended daily requirement of calcium and vitamin D, anti-osteoporotic medications that can be given to patients with chronic kidney disease, medications that reduce the risk of osteoporotic hip fractures, complications of osteoporosis treatment, patients requiring treatment without confirmatory tests, maximum duration of bisphosphonate treatment and treatment failure of osteoporosis. Of these items, the questions on treatment failure in osteoporosis had the most correct answers and the lowest scores were on questions regarding the maximum duration of oral bisphosphonate treatment. 

Only 43.12% of participants answered correctly about the correct daily requirement for calcium and vitamin D. This is particularly important in Filipinos as seen in the 2003 Food and Nutrition Research Institute of the Philippines Survey where the daily calcium intake of Filipinos averaged only about 440 mg/day.[24]  More recent versions of the National Nutrition Survey have not looked at calcium intake, but the 2020 version showed that of the different micronutrient and macronutrient deficiencies in the Philippines, calcium is one of the most common with a prevalence of 95% to 98%.[25]  However, calcium and vitamin D supplementation is relatively underutilized with 31.2% of participants in this study saying that they seldom to even never prescribe either calcium or calcium plus vitamin D to patients with risk factors for developing osteoporosis. A study done in Saudi Arabia involving elderly female patients with DXA scan results consistent with osteoporosis showed this as well, with only 54.3% of patients receiving vitamin D supplementation, only 53.4% receiving calcium supplementation and 26.9% of patients receiving no pharmacotherapy at all.[26]  This apparent underutilization of calcium and vitamin D supplementation in the Philippines is in contrast to the study by Chan in 2010 involving 237 physicians and 1463 patients with osteoporosis looking at the Asian viewpoint on calcium and vitamin D supplementation in osteoporosis. Among the countries included, the Philippines had the highest proportion of physicians who rated calcium and vitamin D treatment as extremely important (72% for calcium and 73% for vitamin D), with the lowest proportion for physicians in Taiwan (30% for calcium and 12% for vitamin D). Moreover, only patients from the Philippines that were included in this study had regular discussions with their physicians about calcium and vitamin D.[10]  As calcium and vitamin D supplementation is important not only for osteoporotic patients but for bone health in general, this is an area that must be addressed.

The mean attitude score of participants across all the questions was 29.23 (SD =1.45, range: 7-35) implying a neutral to somewhat positive attitude. All participants agreed that osteoporosis was an important health issue and that osteoporosis screening was beneficial for patients who were more than 65 years old. However, this does not necessarily translate to practice as seen in the section on Practices on Osteoporosis Screening and Management, where only 28.44% of patients screened were >65 years old for osteoporosis risk. Majority of them also agree that Bone Mineral Density (BMD) should be made more available. However, only 54.13% have generally positive attitudes when asked if they are confident in its interpretation. Similar studies of this nature reveal that most physicians admit to a lack of confidence in DXA interpretation.[8,9,21]  True enough, having less knowledge on osteoporosis was correlated with having less confidence in BMD interpretation (p value = 0.027). 

Almost all participants agree that BMD should be made more available and more than a third of participants see the inaccessibility of DXA scanning as a barrier in osteoporosis screening. Among those who screen elderly patients for osteoporosis, DXA is the most frequently reported screening tool used (83.87% of those who screen elderly patients for osteoporosis risk). However, underuse of DXA scans for the screening of patients with osteoporosis still exists. A study in the United States illustrates this, showing a cumulative incidence of DXA screening of 58.8% in women aged 60-64 years with ≥1 risk factor, 57.8% for women aged 65-74 years, and 42.7% for women aged ≥75 years old.[11]  Also, 77.06% of participants said that a barrier to osteoporosis screening was the inaccessibility of DXA scan. The Asian Audit, a collection of articles on the epidemiology, costs and burden of osteoporosis in Asia done in 2009 by the International Osteoporosis Foundation showed that in the Philippines, there are only 21 DXA machines all confined to urban centers, which translates to only one DXA machine per 500,000 adults 50 years old and above.[12]  Since then, more centers have also made bone densitometry available, but no studies have been done to accurately measure this statistic. However, while bone densitometry is definitely a valuable tool for the diagnosis of osteoporosis, various screening aids that do not require bone mineral densitometry measurement are validated and easily available such as the FRAX score and OSTA score. However, only a minority of the participants utilized this scoring system with only 41.94% using the FRAX score and 12.90% using the OSTA score in those who screened elderly patients for osteoporosis in their practice. Only 65.14% of participants answered correctly when given scenarios where they are asked to initiate pharmacotherapy for osteoporosis without the benefit of a bone densitometry. In another study,[21]  some physicians chose not to use the FRAX score because it took valuable time from the patient encounter and was seen as being an extra burden with uncertain value, comparable with the result of this study where a lack of doctor-patient time was also seen as an important barrier to osteoporosis screening and management. 

More than half (77.06%) of the participants agreed that patients with osteoporosis should be started on pharmacotherapy. However, only about half of participants are confident in its initiation, and 65% would rather refer to a specialist for anti-osteoporotic medications. This treatment inertia is not ubiquitous in the Philippines as reflected by a study done in France, which showed that in elderly female nursing home residents who had a history of proximal femoral fracture, only 10.3% received bisphosphonates and only 66.4% received vitamin D supplementation.[27]  Another study involving 3942 elderly women diagnosed with a fracture of the hip, vertebra, or wrist showed that only 24% of these women received pharmacotherapy for osteoporosis in the year following a fracture.[28] 

Overall, this study has demonstrated that a lack of knowledge on osteoporosis was statistically significantly correlated with negative attitudes on osteoporosis screening and management (p value = 0.022).

Equally important in the management of osteoporosis is non-pharmacologic treatment. However, only 54.13% of participants were confident in prescribing non-pharmacologic treatment in their patients. Looking at the questions on practice, the most common non-pharmacologic management prescribed includes health teachings on weight-bearing exercises, fall prevention and dietary modification such as increasing calcium and limiting caffeine intake. 

Some of the barriers to osteoporosis screening and management seen in this study are also patient-related factors. The patients’ coexisting medical conditions that need more priority are deemed the most important barrier. In the aforementioned qualitative study, osteoporosis was considered a low priority issue when compared to other diseases such as heart disease, diabetes and cancer.[21]  Patients’ refusal for screening and low socioeconomic status were also seen as major barriers. 

Although this was the first study looking at the KAP of physicians in the Philippines with regards to osteoporosis screening and management, there are still several limitations in this paper. This was a self-reported study with a possibility of recall bias. There were also a limited number of participants who answered this survey and it was recommended to involve a bigger number of participants involving multiple centers so that the results can be more applicable to the general population.

Conclusion

Similar to multiple studies exploring the KAP on osteoporosis screening and management, this study has shown that in spite of awareness of osteoporosis as an important health issue, knowledge gaps still exist that translates into a lack of confidence, particularly in initiating treatment for osteoporosis. Therefore, efforts must be made to address these knowledge gaps, improve screening practices and combat treatment inertia in osteoporosis.