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

Rayan A Siraj,1 Aminah Mengash,1 Maryam M Almulhem,1 Mushabbab A Alahmari,2,3 Abdulelah M Aldhahir,4 Abdullah A Alqarni,5,6 Jaber S Alqahtani,7,8 Nowaf Y Alobaidi,9,10 Saleh S Algarni,11,12 Abdulrhman S Alghamdi,13 Malak A Alowaisi,13 Hussam S Alghamdi,14 Ghadeer S Alshammari,15 Abdulelah Alsulami,15 Mohammed M Alyami161Department of Respiratory Therapy, College of Applied Medical Sciences, King Faisal University, Al-Ahsa, Saudi Arabia; 2Department of Respiratory Therapy, Faculty of Applied Medical Sciences, University of Bisha, Bisha, Saudi Arabia; 3Health and Humanities Research Centre, University of Bisha, Bisha, Saudi Arabia; 4Respiratory Therapy Program, Department of Nursing, College of Nursing and Health Sciences, Jazan University, Jazan, Saudi Arabia; 5Department of Respiratory Therapy, Faculty of Medical Rehabilitation Sciences, King Abdulaziz University, Jeddah, Saudi Arabia; 6Respiratory Therapy Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia; 7Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam, Saudi Arabia; 8Research and Innovation Institute, Ministry of Defense Health Services, Riyadh, Saudi Arabia; 9Department of Respiratory Therapy, King Saud bin Abdulaziz University for Health Sciences, Al Ahsa, Saudi Arabia; 10King Abdullah International Medical Research Centre, Al Ahsa, Saudi Arabia; 11Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; 12King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia; 13Department of Rehabilitation Health Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia; 14Family Medicine Department, King Fahd Military Medical Complex, Dhahran, Saudi Arabia; 15Department of Respiratory Care Services, King Abdullah Specialized Children Hospital, King Abdulaziz Medical City, Ministry of National Guard, Jeddah, Saudi Arabia; 16Respiratory Therapy Department, Batterjee Medical College, Khamis Mushait, Saudi ArabiaCorrespondence: Rayan A Siraj, Department of Respiratory Therapy, College of Applied Medical Sciences, King Faisal University, Al-Ahsa, 31982, Saudi Arabia, Email [email protected]: 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.Methods: 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.Results: 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.Conclusion: 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.Keywords: bone health, chronic obstructive pulmonary disease, osteoporosis, physicians, risk assessment