The Recognition-to-Practice Gap: Physicians' Approaches to Osteoporosis Assessment and Management in COPD

Osteoporosis is a common yet frequently under-recognised comorbidity in patients with chronic obstructive pulmonary disease (COPD), yet its integration into routine COPD care remains poorly understood. This study evaluated physicians' perceptions, confidence, clinical practices, perceived barriers, and factors associated with routine osteoporosis risk assessment.

A national cross-sectional survey of general practitioners, pulmonologists, and critical care physicians practising in Saudi Arabia between October 2025 and March 2026 was conducted. The questionnaire assessed physicians' perceptions, confidence, osteoporosis-related clinical practices, and perceived barriers. Univariate and multivariate logistic regression analyses identified factors associated with routine osteoporosis risk assessment.

A total of 977 physicians participated. Most physicians recognised osteoporosis as an important comorbidity in COPD and agreed that it increases the risk of fractures, falls, and impaired lung function. Although 61.0% reported routinely assessing osteoporosis risk, several practices were inconsistently implemented, including fracture risk assessment and referral for bone health evaluation. Physicians generally reported moderate-to-high confidence in recognising and managing osteoporosis; however, gaps remained in identifying at-risk patients. The most frequently reported barriers were prioritisation of respiratory symptoms (58.9%), lack of clinical protocols (55.1%), limited consultation time (51.1%), and restricted access to diagnostic resources (51.1%). In multivariate analysis, pulmonologists (AOR=1.53, 95% CI: 1.07-2.18), physicians managing 10-30 COPD patients monthly (AOR=1.70, 95% CI: 1.20-2.40), formal training (AOR=1.45, 95% CI: 1.04-2.03), and self-reported knowledge (AOR=1.71, 95% CI: 1.22-2.39) were independently associated with routine osteoporosis assessment.

Despite favourable perceptions and moderate-to-high confidence, osteoporosis risk assessment remains inconsistently integrated into COPD care. Educational initiatives and standardised clinical pathways may help improve the recognition and management of osteoporosis in patients with COPD.