ABSTRACT
Objectives:
To assess the use of osteoporosis screening tests in average-risk individuals at primary healthcare centers affiliated with the Ministry of National Guard Health Affairs in Riyadh, Saudi Arabia, between 2016 and 2023.
Methods:
Data were presented using frequencies n (%), mean, and standard deviation. Chi-square, t-test, and ANOVA tests were used for bivariate comparisons to evaluate test completion and prevalence estimates of osteopenia and osteoporosis. Binary logistic regression models were used to identify the factors associated with high odds of bone mineral density (BMD) test ordering and completion. For all analyses, a p≤0.05 was considered statistically significant.
Results:
We retrieved and analyzed data from 5,965 unique women. Analysis showed 4,075 BMD order requests; only 1,017 (25%) orders were completed by 894 women, representing only 15% of all women included in this study. Osteoporosis was found in 274 (26.9%) tests and osteopenia in 540 tests (53.1%). Factors like patient’s age, facility, number of outpatient visits, ordering staff title, and year of order were assessed to predict high utilization and completion of BMD test.
Conclusion:
This research showed that although osteoporosis is a serious public health concern causing significant morbidity and mortality, there is still a gap in osteoporosis screening practices within primary care settings. Also, it sheds light on some factors that may predict physicians’ high utilization of BMD tests and patients’ completion rates.
Keywords: Osteoporosis, screening, primary care, family medicine, public health
Primary healthcare is the foundation on which healthcare systems are built.1,2 Primary care practitioners are critical to community health as they are the first point of contact with patients.3 They provide holistic and personalized care for patients of all ages, encompassing the management of chronic and acute illnesses, promotion of healthy behaviors, and use of preventive measures, such as targeted health screenings.
In Saudi Arabia, as part of the National Transformation Program 2020, the healthcare system’s focus has shifted to primary care to enhance the health of the population by improving care, increasing access to healthcare services, and decreasing the burden on secondary and tertiary care.1 One of the objectives of this program is to provide services for effective screening and early detection.1 According to the World Health Organization, medical screening is defined as “the presumptive identification of unrecognized disease in a healthy, asymptomatic population by means of tests, examinations or other procedures that can be applied rapidly and easily to the target population”.4,5 Various screening guidelines are available for different diseases, such as diabetes, dyslipidemia, infectious diseases, cancer, and osteoporosis. Although the use of age-appropriate screening tests has the potential to avoid a significant amount of pain and mortality, their use in Saudi Arabia remains unsatisfactory.5-7
One of the screening services provided at primary care centers is osteoporosis screening.8 Osteoporosis, a chronic metabolic bone disease, is characterized by reduced bone density and can lead to increased fragility and a high risk of fractures.9,10 It is considered the most common metabolic bone disease worldwide and is particularly prevalent in Saudi Arabia, with reported rates ranging between 34% and 52.8%.11-13 Some studies showed that Saudi Arabia had a more prevalent osteoporosis problem than Western countries.13,14 A systematic review of 24 studies conducted in 2012 reported osteoporosis prevalence rates of 34% in women and 30.7% in men aged 50–79 years.12 Risk factors for osteoporosis include advanced age, female sex, low weight, postmenopausal state, hyperparathyroidism, hyperthyroidism, low vitamin D and calcium levels, smoking, alcohol abuse, immobility, chronic kidney disease, and prolonged use of certain medications.10,15 Osteoporosis can be diagnosed clinically or through bone mineral density (BMD) measurements of the lumbar spine, femoral neck, or distal radius.16 A T-score of -2.5 or lower defined osteoporosis, while a T-score of -1 to -2.5 characterized the low bone mineral mass, also called osteopenia.16
Osteoporosis has severe complications, imposing a significant burden on the Saudi healthcare system.12 A 2017 study reported a 1-year mortality rate of nearly 27% for hip fractures in Saudi Arabia.17 The estimated number of hip fractures in Saudi Arabia was 2,949 in 2015 and is expected to reach 6,971 by 2030.18 Furthermore, Sadat-Ali et al17 have reported that by 2025, the lifetime cost of hip fractures and related complications will reach SR 35 billion. A 2020 study further highlighted the growing economic impact of osteoporotic fractures, estimating approximately 1 million frailty fractures between 2019 and 2023, with a projected cost of SR 13.5 billion.9
Despite the availability of screening tools and advancements in treatment options, most individuals with osteoporosis remain undiagnosed and untreated until complications arise.9,12 In 2015, Saudi Arabia established its first national guideline recommending routine osteoporosis screening via BMD for all women aged over 60 years, and this guideline was updated in 2023.8,16 Internationally, the US Preventive Services Task Force (USPSTF) recommends osteoporosis screening using bone measurement testing for women aged 65 years and older (Grade B recommendation). Moreover, the USPSTF recommends early screening for women under 65 years with risk factors (Grade B recommendation).19 Early detection and intervention for this debilitating condition can prevent fragility fractures, thereby reducing associated morbidity and mortality.11,20
Although osteoporosis screening has been shown to reduce morbidity and mortality rates significantly, national participation in screening programs remains poor.6 This study evaluated the quality of primary healthcare preventive services by assessing osteoporosis screening practices for average-risk individuals at primary healthcare centers affiliated with the Ministry of National Guard Health Affairs (MNGHA) in Riyadh, Saudi Arabia, between 2016 and 2023.
Primary objectives
The primary objective of this study was to measure the proportion of patients who were offered age-appropriate screening tests for osteoporosis among average-risk individuals between 2016 and 2023. In addition, the study aimed to identify the proportion of the patients who completed BMD tests during the same timeframe. Furthermore, this study indicated factors predicting the high utilization of osteoporosis screening tests among this population.
Secondary objectives
The secondary objective of this study was to measure the prevalence of osteoporosis and osteopenia in the sample during the study period (2016–2023). In addition, this study compared the osteoporosis screening practices and the prevalence of osteoporosis among the four main MNGHA-affiliated primary care centers in Riyadh (Dirab, Iskan, Khashm Alan, and UmAlhamam) during the study period.
Methods
This retrospective longitudinal study conducted in March 2024 analyzed patient records from 2016 to 2023 to evaluate osteoporosis screening practices at the 4 primary care centers affiliated with the MNGHA in Riyadh, Saudi Arabia. These centers include the Health Care Specialty Center (HCSC), also known as Khashm Alan; the National Guard Comprehensive Specialized Center (NGCSC), referred to as UmAlhamam; the King Abdulaziz City Housing (Iskan) Center; and the King Saud City Housing (Dirab) Center.
The Iskan Center and HCSC serve patients in the eastern region of Riyadh, whereas the Dirab Center caters to patients in the western and southern regions. The NGCSC provides healthcare services to patients in the northern region of Riyadh.
The sample size was determined based on the observation that only 20% of eligible patients who presented to the hospital with a history of fractures had been previously screened.6 Using 95% confidence interval (CI), 1% margin of error, and a design effect of 1, the required sample size was calculated to be 5,639. To enhance precision and increase the power of the study, we decided to increase the sample size to 6,000.
Data were extracted from the King Abdullah International Medical Research Center (KAIMRC) and the Data and Business Intelligence Management databases at the MNGHA. The sample was randomly selected using a multistage sampling technique, employing structured query language (SQL) to identify 6,000 patients—1,500 from each center—who met the inclusion and exclusion criteria. However, we finally received data for only 5,965 subjects, as only 1,465 women from the Iskan Center met the inclusion criteria.
The inclusion criteria for the study were women aged 60 years or older who were eligible for MNGHA services and had been followed at one of the 4 primary care centers between 2016 and 2023. Age was calculated as the difference between 2016 and the year of birth. Patients with known osteoporosis or those using osteoporosis medications, such as bisphosphonates, denosumab, teriparatide, calcitonin, or raloxifene, were excluded from the study.
The collected data included variables such as gender, age, BMD order dates, completion dates, result reports, facility names, titles of the ordering staff, and the number of patient visits per year. The assessment of osteoporosis screening practices was conducted according to the 2015 guidelines of the Saudi Osteoporosis Society, which recommend that all women aged 60 years and above should undergo osteoporosis screening through BMD testing.8
Statistical analysis
Data analysis was performed using SAS software (Cary, NC, USA). Categorical variables are presented as frequencies, whereas continuous variables are presented using means and standard deviations. Chi-square tests, t-tests, and ANOVA were used for bivariate comparisons to evaluate BMD test completion and prevalence estimates of osteopenia and osteoporosis.
Binary logistic regression models were used to identify factors associated with a high likelihood of BMD test ordering and completion. To account for multiple test orders per subject, mixed-effects logistic regression was used to examine the relationship between BMD test ordering and primary healthcare centers, stratified by age group. This approach was also applied to identify factors associated with BMD test completion. In addition, nominal logistic regression was used to identify factors associated with high odds of osteopenia and osteoporosis compared with normal BMD. For all analyses, a p-value of ≤0.05 was considered statistically significant.
This study was conducted after obtaining approval from the Institutional Review Board of the KAIMRC (IRB/1485/23). All data collected were confidential, contained no patient-identifying information, and used solely for research. Access to the collected data was restricted to the principal investigator, coinvestigator, and statistician.
Results
During the 8 years from 2016 to 2023, we collected and analyzed data from 5,965 women across 4 locations: Dirab (n=1,500), Iskan (n=1,465), Khashm Alan (n=1,500), and UmAlhamam (n=1,500). Notably, only 1,465 women from Iskan met the study’s inclusion criteria. The overall mean age of participants was 66.1±4.6 (range: 60–75) years.
The mean number of visits per participant throughout the follow-up period was 17.8 ± 15.0 (range: 1–104). A total of 2,342 women (39.3%) received BMD orders. Among these, 1,356 women received a single order for BMD test, whereas 986 women had multiple orders, resulting in 4,075 BMD order requests. Notably, no orders were made for 3,623 women (60.7%) included in this study. Table 1 provides the demographic characteristics of the study sample.
Table 1.
- Participants’ descriptive statistics (N=5,965).
| Variables | Number | % |
|---|---|---|
| Sample size (n) | 5,965 | 100 |
| Facility | ||
| Dirab clinic | 1,500 | 25.2 |
| Iskan clinic | 1,465 | 24.6 |
| Khashm Alan clinic | 1,500 | 25.2 |
| UmAlhamam clinic | 1.500 | 25.2 |
| Did the subject receive bone density scan (BMD)? | ||
| Yes | 2,342 | 39.3 |
| No | 3,623 | 60.7 |
| If yes, did the subject complete BMD? | ||
| No | 1,672 | 71.4 |
| Yes | 670 | 28.6 |
| Total BMD orders | 4,075 | |
| Age (60-75), mean ± standard deviation (SD) | 66.1 | 4.6 |
| Outpatient clinic visits (1-104), mean±SD | 17.8 | 15 |
Factors predicting BMD orders
There were significant differences in the likelihood of ordering a bone density test based on age group and facility (F=4.73; df = 6, 5952; p<0.0001). Table 2 outlines the factors associated with BMD test ordering among 5,965 women. The adjusted odds of ordering bone mineral density tests were significantly high in Iskan (adjusted AOR= 2.564, 95 % confidence interval [CI]: 1.839-3.576), and UmAlhamam (AOR=2.209, 95% CI (1.615-3.020) than in Khashm Alan.
Table 2.
- Factors associated with high odds of ordering bone mineral density (BMD) test on women (N=5,965).
| Variables | 95% CI for OR | P-value | 95% CI for AOR | P-value | ||||
|---|---|---|---|---|---|---|---|---|
| OR | LCL | UCL | AOR | LCL | UCL | |||
| Facility | ||||||||
| Dirab | 0.844* | 0.720* | 0.991* | 0.0380* | 1.015 | 0.728 | 1.415 | 0.9299 |
| Iskan | 2.761* | 2.374* | 3.211* | <0.0001* | 2.564* | 1.839* | 3.576* | <0.0001* |
| UmAlhamam | 2.184* | 1.879* | 2.538* | <0.0001* | 2.209* | 1.615* | 3.020* | <0.0001* |
| Khashm Alan | 1.000 | 1.000 | ||||||
| Age | ||||||||
| 66-69 | 3.955* | 3.427* | 4.566* | <0.0001* | 3.917* | 2.794* | 5.491* | <0.0001* |
| ≥70 | 4.153* | 3.644* | 4.734* | <0.0001* | 4.463* | 3.264* | 6.103* | <0.0001* |
| 60-65 | 1.000 | 1.000 | ||||||
| Total visits | 1.038* | 1.034* | 1.042* | <0.0001* | 1.049* | 1.044* | 1.053* | <0.0001* |
| Facility by age | ||||||||
| Dirab | ||||||||
| 66-69 | 0.639* | 0.410* | 0.997 | 0.0484* | 0.778 | 0.487 | 1.244 | 0.2953 |
| ≥70 | 0.614* | 0.409* | 0.922 | 0.0189* | 0.794 | 0.518 | 1.216 | 0.2879 |
| 60-65 | 1.000 | 1.000 | ||||||
| Iskan | ||||||||
| 66-69 | 1.229 | 0.794 | 1.902 | 0.3544 | 1.686* | 1.067* | 2.664* | 0.0251* |
| ≥70 | 1.283 | 0.859 | 1.915 | 0.2237 | 1.793* | 1.180* | 2.723* | 0.0062* |
| 60-65 | 1.000 | 1.000 | ||||||
| UmAlhamam | ||||||||
| 66-69 | 0.690 | 0.455 | 1.048 | 0.0816 | 0.786 | 0.506 | 1.221 | 0.2839 |
| ≥70 | 0.617* | 0.419* | 0.909* | 0.0145* | 0.671 | 0.448 | 1.007 | 0.0541 |
| 60-65 | 1.000 | 1.000 | ||||||
Statistical significance (p=0.05).
AOR: adjusted odds ratio, OR: odds ratio, CI: confidence interval, LCL: lower confidence limit,UCL: upper confidence limit
Older women were more likely to receive a BMD test order, with women aged 66–69 years showing an AOR of 3.917 (95% CI: 2.794–5.491) and those aged 70 years or older showing an AOR of 4.463 (95% CI: 3.264–6.103) compared with younger women. In addition, women who had frequent visits were more likely to receive a BMD test order (AOR=1.049, 95% CI: 1.044–1.053).
The likelihood of ordering a bone density test increased with age, varying by facility. For example, among women in Iskan, the odds of receiving a BMD test significantly increased for those aged 66–69 years (AOR=1.686, 95% CI: 1.067–2.664) and for those aged 70 years or older (AOR = 1.793, 95% CI: 1.182–2.723) compared with younger women.
Factors predicting BMD test completion
Results reveal that there was no significant difference in the odds of BMD test completion by age group and facility (F=0.53; df = 6,2329; p=0.7861). Table 3 presents factors associated with BMD test completion among 2,342 unique women for whom the BMD test was ordered. Compliance with the BMD test orders did not significantly vary by facility or age group. However, a high frequency of visits was linked to increased odds of completing the BMD test (AOR=1.008, 95% CI: 1.002–1.015). Furthermore, Dirab (AOR=0.309, 95% CI: 0.163–0.586) and UmAlhamam (AOR=0.565, 95% CI: 0.327–0.977) demonstrated lower odds of BMD test completion than Khashm Alan Clinic.
Table 3.
- Factors associated with high odds of test completion on unique subjects “no duplicates” (N=2,342).
| Variables | 95% CI for OR | P-value | 95% CI for AOR | P-value | ||||
|---|---|---|---|---|---|---|---|---|
| OR | LCL | UCL | AOR | LCL | UCL | |||
| Facility | ||||||||
| Dirab | 0.255* | 0.185* | 0.351* | <.0001 | 0.309* | 0.163* | 0.586* | 0.0003* |
| Iskan | 0.967 | 0.765 | 1.221 | 0.7768 | 1.249 | 0.693 | 2.249 | 0.4592 |
| UmAlhamam | 0.688* | 0.541* | 0.875* | 0.0023 | 0.565* | 0.327* | 0.977* | 0.0410* |
| Khashm Alan | 1.000 | 1.000 | ||||||
| Age | ||||||||
| 66-69 | 0.989 | 0.782 | 1.250 | 0.9256 | 0.880 | 0.503 | 1.541 | 0.6556 |
| ≥70 | 0.882 | 0.709 | 1.099 | 0.2631 | 0.750 | 0.442 | 1.274 | 0.2868 |
| 60-65 | 1.000 | 1.000 | ||||||
| Total visits | 1.049* | 1.044* | 1.053* | 0.5590 | 1.008* | 1.002* | 1.015* | 0.0094* |
| Facility by Age | ||||||||
| Dirab | ||||||||
| 66-69 | 0.690 | 0.287 | 1.656 | 0.4060 | 0.697 | 0.290 | 1.676 | 0.4204 |
| ≥ 70 | 0.784 | 0.351 | 1.755 | 0.5543 | 0.806 | 0.360 | 1.805 | 0.5996 |
| 60-65 | 1.000 | 1.000 | ||||||
| Iskan | ||||||||
| 66-69 | 0.852 | 0.419 | 1.731 | 0.6577 | 0.876 | 0.430 | 1.783 | 0.7147 |
| ≥70 | 0.866 | 0.445 | 1.688 | 0.6736 | 0.885 | 0.454 | 1.727 | 0.7206 |
| 60-65 | 1.000 | 1.000 | ||||||
| UmAlhamam | ||||||||
| 66-69 | 1.174 | 0.590 | 2.335 | 0.6482 | 1.190 | 0.597 | 2.371 | 0.6215 |
| ≥ 70 | 1.277 | 0.666 | 2.447 | 0.4617 | 1.298 | 0.676 | 2.491 | 0.4336 |
| 60-65 | 1.000 | 1.000 | ||||||
Statistical significance (p=0.05).
AOR: adjusted odds ratio, OR: odds ratio, CI: confidence interval, LCL: lower confidence limit,UCL: upper confidence limit
Of 4,075 requests for BMD tests, only 1,017 (25%) were completed. A total of 785 women had a single test result, whereas 109 women had multiple test results (232 test results). In total, 1,017 test results were obtained from 894 women, which constituted only 15% of the total sample of women (n=5,965).
Table 4 presents the completion rates of BMD tests categorized by sample characteristics. The overall completion rate for BMD tests was significantly higher in younger age groups: 28.6% for those under 65 years of age, 24.3% for those aged 66 to 69 years, and 24.0% for those aged 70 years and above (p=0.032). In addition, the completion rates varied by clinic location: Dirab (13.3%), Iskan (25.3%), Khashm Alan (31.7%), and UmAlhamam (25.6%), with a significant difference noted (p=0.001). Furthermore, requests placed by a consultant resulted in a high completion rate (Staff, 23.2%; Resident, 20.8%; Assistant/Associate consultant, 23.4%; and Consultant, 31.0%; p=0.001). Our findings indicated that recent years were associated with a lower percentage of BMD test completion compared with 2016 (p=0.001), as shown in Figure 1.
Table 4.
- Overall test orders and test completion (N=4,075).
| Variables | Overall | BMD Test Completion | P-value | ||||
|---|---|---|---|---|---|---|---|
| No | Yes | ||||||
| Frequency | % | Frequency | % | Frequency | % | ||
| Total number of subjects | 4,075 | 100% | 3,058 | 75% | 1,017 | 25% | |
| Age groups | |||||||
| < 65 | 772 | 18.9% | 551 | 71.4% | 221 | 28.6% | 0.032 |
| 66 -69 | 1,336 | 32.8% | 1,012 | 75.8% | 324 | 24.3% | |
| ≥ 70 | 1,967 | 48.3% | 1495 | 76.0% | 472 | 24.0% | |
| Facility | |||||||
| Dirab | 534 | 13.1% | 463 | 86.7% | 71 | 13.3% | 0.001 |
| Iskan | 1,595 | 39.1% | 1,191 | 74.7% | 404 | 25.3% | |
| Khashm Alan | 715 | 17.5% | 488 | 68.3% | 227 | 31.7% | |
| UmAlhamam clinic | 1,231 | 30.2% | 916 | 74.4% | 315 | 25.6% | |
| Years | |||||||
| 2016 | 228 | 5.6% | 144 | 63.2% | 84 | 36.8% | 0.001 |
| 2017 | 439 | 10.8% | 317 | 72.2% | 122 | 27.8% | |
| 2018 | 625 | 15.3% | 418 | 66.9% | 207 | 33.1% | |
| 2019 | 542 | 13.3% | 437 | 80.6% | 105 | 19.4% | |
| 2020 | 381 | 9.3% | 302 | 79.3% | 79 | 20.7% | |
| 2021 | 518 | 12.7% | 395 | 76.3% | 123 | 23.7% | |
| 2022 | 634 | 15.6% | 500 | 78.9% | 134 | 21.1% | |
| 2023 | 708 | 17.4% | 545 | 77.0% | 163 | 23.0% | |
| Staff title | |||||||
| Staff | 1,732 | 42.5% | 1,331 | 76.8% | 401 | 23.2% | 0.001 |
| Resident | 655 | 16.1% | 519 | 79.2% | 136 | 20.8% | |
| Assistant/Associate consultant | 572 | 14.0% | 438 | 76.6% | 134 | 23.4% | |
| Consultant | 1,116 | 27.4% | 770 | 69.0% | 346 | 31.0% | |
| Mean | SD | Mean | SD | Mean | SD | ||
| Age when ordered (60-82) | 69.8 | 4.7 | 70.0 | 4.8 | 69.5 | 4.7 | 0.009 |
Figure 1.
- Trends of bone mineral density test completion by years (N=4,075 test orders)
Factors associated with higher odds of completing the BMD tests included being related to the Khashm Alan Clinic (AOR=1.515, 95% CI: 1.227–1.870) and having tests ordered by a consultant (AOR=1.268, 95% CI: 1.030–1.559). Conversely, factors associated with lower odds of test completion included being related to the Dirab clinic (AOR=0.412, 95% CI: 0.308–0.550), year of the BMD test order (2016–2023) (AOR=0.917, 95% CI: 0.883–0.953), and having test orders placed by a resident (AOR=0.732, 95% CI: 0.578–0.928).
Osteoporosis prevalence
Analysis of 1,017 test result reports revealed that osteoporosis was present in 26.9% of the individuals (95% CI, 24.2%–29.8%), osteopenia in 53.1% (95% CI, 50%–56.2%), and normal bone density in 20% (95% CI, 17.5%–22.6%). The average age at screening was 69.5 (±SD 4.7) years.
Table 5 displays the percentage of BMD test results according to various sample characteristics. The prevalence of osteoporosis was slightly higher among older age groups: 23.1% for those under 65 years, 23.5% for those aged 66–69 years, and 31.1% for those aged 70 years and older (p=0.094). The prevalence rates of osteoporosis also varied by clinic: 25.4% at Dirab, 31.2% at Iskan, 18.5% at Khashm Alan, and 27.9% at UmAlhamam (p=0.005). In addition, the prevalence rates of osteoporosis were influenced by the personnel who ordered the BMD tests: 31.2% for staff, 28.7% for residents, 15.7% for assistant/associate consultants, and 25.7% for consultants (p=0.005).
Table 5.
- Prevalence of osteopenia and osteoporosis (N=1,017).
| Variable | Overall | Normal | Osteopenia | Osteoporosis | P-value | ||||
|---|---|---|---|---|---|---|---|---|---|
| Frequency | % | Frequency | % | Frequency | % | Frequency | % | ||
| Total number of subjects | 1,017 | 100 | 203 | 20 | 540 | 53.1 | 274 | 26.90 | |
| Age groups | |||||||||
| <65 | 221 | 21.7 | 47 | 18.7 | 123 | 55.7 | 36 | 23.1 | 0.094 |
| 66 -69 | 324 | 31.9 | 68 | 23.6 | 180 | 55.6 | 56 | 23.5 | |
| ≥70 | 472 | 46.4 | 88 | 18.7 | 237 | 50.2 | 182 | 31.1 | |
| Facility | |||||||||
| Dirab | 71 | 7.0 | 12 | 16.9 | 41 | 57.7 | 18 | 25.4 | 0.005 |
| Iskan | 404 | 39.7 | 73 | 18.1 | 205 | 50.7 | 126 | 31.2 | |
| Khashm Alan | 227 | 22.3 | 63 | 27.8 | 122 | 53.7 | 42 | 18.5 | |
| UmAlhamam | 315 | 31.0 | 55 | 17.5 | 172 | 54.6 | 88 | 27.9 | |
| Years | |||||||||
| 2016 | 70 | 6.9 | 13 | 18.6 | 36 | 51.4 | 21 | 30.0 | 0.013 |
| 2017 | 113 | 11.1 | 16 | 14.2 | 67 | 59.3 | 30 | 26.5 | |
| 2018 | 194 | 19.1 | 29 | 14.9 | 100 | 51.5 | 65 | 33.5 | |
| 2019 | 132 | 13.0 | 25 | 18.9 | 71 | 53.8 | 36 | 27.3 | |
| 2020 | 74 | 7.3 | 14 | 18.9 | 37 | 50.0 | 23 | 31.1 | |
| 2021 | 127 | 12.5 | 21 | 16.5 | 66 | 52.0 | 40 | 31.5 | |
| 2022 | 130 | 12.8 | 36 | 27.7 | 65 | 50.0 | 29 | 22.3 | |
| 2023 | 177 | 17.4 | 49 | 27.7 | 98 | 55.4 | 30 | 16.9 | |
| Staff title | |||||||||
| Staff | 401 | 39.4 | 72 | 18.0 | 204 | 50.9 | 125 | 31.2 | 0.005 |
| Resident | 136 | 13.4 | 33 | 24.3 | 64 | 47.1 | 39 | 28.7 | |
| Assistant/Associate consultant | 134 | 13.2 | 37 | 27.6 | 76 | 56.7 | 21 | 15.7 | |
| Consultant | 346 | 34.0 | 61 | 17.6 | 196 | 56.6 | 89 | 25.7 | |
| Mean | SD | Mean | SD | Mean | SD | Mean | SD | ||
| Age (60-82) mean±standard deviation | 69.5 | 4.7 | 69.2 | 4.6 | 69.3 | 4.7 | 70.3 | 4.8 | 0.010 |
ANOVA revealed a significant difference in the age of participants based on their test results: those with normal results had a mean age of 69.2 years, those with osteopenia had a mean age of 69.3 years, and those with osteoporosis had a mean age of 70.3 years (p=0.001). The result demonstrates that the adjusted odds of osteoporosis increased with age (AOR=1.085, 95% CI:1.040–1.133) and decreased with the number of years (AOR=0.837, 95% CI: 0.759–0.923). The adjusted odds of osteopenia decreased with years (AOR=0.909, 95% CI: 0.834–0.990). The Khashm Alan Center had lower odds of osteoporosis than the Iskan Center (AOR=0.514, 95% CI: 0.309–0.855).
Discussion
In total, 5,965 women were examined across four primary care facilities, and the findings indicated a low order and completion rate for BMD tests. Despite multiple studies showing high levels of awareness and knowledge on osteoporosis among the general population and healthcare practitioners, our data revealed that only two-fifths of the subjects underwent a BMD test during the 8 years.21,22 Surprisingly, compliance with BMD test orders was poor, with only 38% of those who received orders completing the test, representing less than one-fifth of the total study subjects. Supporting our findings, a local study indicated that less than 20% of patients with fragility fractures had been screened for osteoporosis.23 Yet, another study by Awwad et al24 revealed a higher testing rate; 50% of patients attending orthopedics clinics were screened for osteoporosis. Internationally, a study conducted in the US revealed that less than two-thirds of surveyed individuals had been screened for osteoporosis.25 The low order and completion rates for BMD tests in our study suggest that healthcare providers are not adhering to screening guidelines and patients are not following test orders, contributing to the overall low osteoporosis screening rates. This conclusion aligns with the findings of Fouda et al,26 who demonstrated a low osteoporosis screening rate following fragility fractures.
Our results indicated that older individuals (≥70 years) at a higher risk for osteoporosis received more BMD order requests. However, they had the lowest completion rate compared with younger age groups (p<0.05). This finding was consistent with a study conducted in the US, which showed that older individuals are less likely to be screened than younger individuals.25 In addition, a survey conducted in the US evaluated factors predicting the completion of osteoporosis screening in primary care. The findings indicated that older age was inversely related to the completion rate of BMD testing.27 Numerous studies have been conducted locally and internationally to evaluate the knowledge and beliefs about osteoporosis among individuals of various age groups, revealing inconsistent results.21,28,29 According to a US study, age has a negative relationship with beliefs in osteoporosis.29 Furthermore, a local survey conducted in four cities in Saudi Arabia (Arar, Tabuk, Bahah, and Madinah) revealed similar findings.28 In contrast, A study conducted at the family medicine clinics of the Security Force Hospital in Riyadh found that younger individuals had lesser knowledge of osteoporosis than older individuals.21
Regarding facilities and catchment areas, several studies have reported that the level of education and utilization of PHC services are related to the area of residence.30,31 Our findings demonstrated that although Iskan clinic, followed by UmAlhamam clinic, had the highest BMD order rates (39.1% and 30.2%, respectively), they were behind Khashm Alan regarding the BMD test completion rate (p=0.001). These findings may be linked to the patients’ educational background, consultation time, and the complexity of patients’ health conditions in different facilities. In addition, the number of outpatient visits was significantly associated with higher adjusted odds of receiving BMD orders (AOR=1.049, 95% CI: 1.044–1.053) as well as completing BMD tests (AOR=1.008, 95% CI: 1.002–1.015). These findings suggest a significant correlation between the number of primary care visits and the effective use of preventive services, such as screenings, as reported by Hostetter et al.32
The experience level of a medical provider is significantly correlated with the high utilization of evidence-based screening tools.33-35 Staff physicians had the highest order rate, with 1732 orders (42.5%), followed by consultants (1116, 27.4%), residents (655, 16.1%), and assistant/associate consultants (572, 14%) (p=0.001). However, patients who received BMD orders from consultants had significantly higher adjusted odds of test completion than those who received orders from other staff (AOR=1.268, 95% CI: 1.030–1.559). This finding may be attributed to patients’ trust in experienced clinicians, which positively affects the test completion rate.36
Our analysis of the order trends by year revealed a significant increase in BMD orders from 2016 to 2023. The highest order rate was recorded in 2023, with 708 orders representing 17.4%. However, there was an unexpected decline in orders during 2019 and 2020, likely due to the COVID-19 pandemic. Interestingly, the completion rate for BMD tests significantly decreased over the years (p=0.001). This decline may be attributed to the reduced continuity of care following the implementation of a new appointment system at MNGHA primary care, launched in 2018. This system allows patients to book appointments one day in advance with any available doctor, thereby limiting physicians’ ability to schedule follow-up appointments. Although this new system has improved access to care and decreased the underutilization of appointment slots, it has negatively affected the continuity of care. Numerous studies have established a link between continuity of care and stronger physician–patient relationships, enhancing patient adherence to management plans.36,37
Regarding osteoporosis and osteopenia, our results revealed that they are highly prevalent in Saudi Arabia compared with Western countries.12 The majority of the samples (80%) were found to be osteopenic or osteoporotic, with 53.1% diagnosed with osteopenia and 26.9% with osteoporosis. This prevalence surpasses the global prevalence of osteoporosis reported in a recent meta-analysis by Salari et al.38 Although many studies have indicated that the prevalence of osteoporosis increases with time, our results have demonstrated the opposite.12,13 The prevalence rate of osteoporosis in our sample decreased from 30% in 2016 to 16.9% in 2023 (p=0.013). In addition, the adjusted odds of osteoporosis decreased with years (AOR=0.837, 95% CI: 0.759–0.923). These findings may be explained by the concurrent decline in the BMD completion rate from 36.8% in 2016 to 23% in 2023 (p=0.001). They may also explain the lower osteoporosis prevalence rate in our data compared with local studies published earlier.12 Our data indicated that age was a significant risk factor for osteoporosis, with adjusted odds of the condition increasing significantly with an increase in age (AOR=1.085, 95% CI: 1.040–1.133). This finding underscores the critical role of aging in the pathophysiology of osteoporosis.39,40
Study limitations
The healthcare system in Saudi Arabia allows individuals to seek care at multiple government hospitals, which may affect our results. Patients might receive BMD tests outside of the National Guard Health Affairs facilities. Moreover, some patients may have been offered BMD tests by their physician but chose to refuse them; this point could not be evaluated in this study. While we included a large sample size from various MNGHA-affiliated primary care centers in Riyadh that serve a substantial population, further studies are needed across all regions of Saudi Arabia to generalize our findings.
In conclusion, this research emphasizes that osteoporosis is a serious public health issue that leads to considerable morbidity and mortality. However, there is a substantial gap in osteoporosis screening practices within primary care settings. This study also identifies factors that may influence physicians’ high utilization of BMD testing and patient completion rates. The findings of this study aim to raise awareness among healthcare professionals about this often-overlooked condition, which has numerous adverse health and economic consequences. In addition, this study will promote further initiatives to enhance public awareness regarding the importance of preventive services to reduce osteoporosis-related morbidity and mortality.
Acknowledgment
We thank Dr. Anwar E. Ahmed for his assistance in the statistical analysis part. Also, we akcnowledge Enago (www.enago.com) for the English language editing.
Footnotes
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