Osteoporosis International

Management of Osteoporosis in the Middle East and North Africa: A Survey ofPhysicians’ Perceptions and Practices

--Manuscript Draft--

Manuscript Number:

Full Title: Management of Osteoporosis in the Middle East and North Africa: A Survey ofPhysicians’ Perceptions and Practices

Article Type: Original Article

Funding Information:

Abstract: Background: The 2011 IOF Middle East Osteoporosis Audit highlighted major caregaps in osteoporosis care in the Middle East and North Africa (MENA) region.Objective: investigate osteoporosis management practice patterns in this region.Materials and Methods: we mailed an electronic survey to a convenience sample ofphysicians, explaining the study rationale and methods. It gathered information onphysicians’ profiles, availability and utilization of resources, risk assessment andmanagement. 573 responses were obtained from the United Arab Emirates (UAE,36%), Saudi Arabia (KSA, 25%), Lebanon (14%), and others (25%). Endocrinologywas the single most represented specialty. Results: 60% of participants had access todensitometers, but treating physicians were not in charge of densitometry reading.Screening for vitamin D deficiency and secondary contributors to osteoporosis wasfrequently implemented. Although two thirds of professionals were aware of FRAX®only 42% used it, either because of lack of know how or of a country specific calculator.Almost all (96.0%) had access to oral and 68.9% to intravenous bisphosphonates, andover half to teriparatide (46.4%) and denosumab (45.0%). Most participants (92%)were aware of concerns regarding side effects of bisphosphonates, and this changedthe management in the majority (73%). Important barriers to osteoporosis care werelack of osteoporosis awareness among physicians, patients, and cost of treatment.Conclusions: This first look at physicians’ practice patterns on the diagnosis andtreatment of osteoporosis in the MENA region underscores the pressing need for anofficial call for action, at all levels, to address this large care gap.

Corresponding Author: Salem Arifi Beshyah, PhD FRCP FACP FACESheikh Khalifa Medical CityAbu Dhabi, Abu Dhabi UNITED ARAB EMIRATES

Corresponding Author SecondaryInformation:

Corresponding Author's Institution: Sheikh Khalifa Medical City

Corresponding Author's SecondaryInstitution:

First Author: Salem Arifi Beshyah, PhD FRCP FACP FACE

First Author Secondary Information:

Order of Authors: Salem Arifi Beshyah, PhD FRCP FACP FACE

Yousef Al-Saleh, MD FACE

Ghada El-Hajj Fuleihan, MD MPH FRCP

Order of Authors Secondary Information:

Author Comments: Dear Dr. Cosman,

We would be grateful if you consider the this submission for publication inOsteoporosis International.

Our manuscript presents the results of the first comprehensive survey on themanagement of osteoporosis through survey of the knowledge, attitudes and practicesof relevant physicians in the Middle East and North Africa and studies their views of the

Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation

barriers to optimal osteoporosis care. We also explored differences within the region bycomparing responses from the largest three countries contributing to the study andmade comparisons to results of two other regions (Asia and Korea).

Osteoporosis is an orphan condition in our region as in many other parts of the worldbeing lost between the conventional disciplinary lines of division. Hence ascertainingthe knowledge, attitudes and practices of the MENA physicians concerning thescreening, investigation, and treatment of osteoporosis is or paramount importance.

We feel the issue is important in general and the fact our survey is the first of its kind inthe MENA region, a new region where data is missing and conflicting schools ofthoughts may coexist due to training history and current affiliation of the individualphysicians.

It underscores practice patterns and care gap in osteoporosis, in a diverse targetsample, obstacles to good care, need for guidelines and better understanding ofFRAX.

We also took the opportunity of the existence of two surveys from Asia and Korea tomake a global perspective of the manuscript

We hope you find it valuable and appropriate of OI.

Kindest regards

Salem A BeshyahYousef Al-SalehGhada El-Hajj Fuleihan

Suggested Reviewers: Manju Chandran, MD, FACP, FACE, FAMS, CCDSenior Consultant, Singapore General Hospitalmchandran7@gmail.comSimilar publication and interest.

Neil BinkleyDirector, University of Wisconsin-Madisonnbinkley@wisc.eduspecial interest in this type of research

Nelson B WattsConsultant, Mercy Health Osteoporosis and Bone Health Servicesnwatts@mercy.comInterest and publication in this area

Pauline M Camacho, MD FACEProfessor and director, Osteoporosis and Metabolic Bone Disease Center at LoyolaUniversity Chicago Stritch School of Medicine.PCAMACH@lumc.eduexperience in the area of access and care gaps

Sanford Baim, MD FACEDirector, Rush University Medical Center, Chicago, IL, USA.Sanford_Baim@rush.eduinterest and experience in the area

E Michael Lewiecki, MD FACP FACEDirector, New Mexico Clinical Research & Osteoporosis Centermlewiecki@gmail.comexperience and interest and publications

Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation

Research Article

Management of Osteoporosis in the Middle East and North Africa: A

Survey of Physicians’ Perceptions and Practices.

*Salem A Beshyah, MBBCh DIC PhD FRCP FACP FACE

Consultant Endocrinologist, Center for Diabetes and Endocrinology, Sheikh Khalifa Medical

City, Abu Dhabi, UAE.

Adjunct Professor of Clinical Research and Metabolic Medicine, Dubai Medical College,

Dubai, UAE.

Tel: 00971 505662723

E-mail: beshyah@yahoo.com

Yousef Al-Saleh, MD FACE

Associate Professor

Department of Medicine, King Abdulaziz Medical City, Riyadh, Ministry of National Guard

Health Affairs, Saudi Arabia

King Abdullah International Medical Research Center, Riyadh, Saudi Arabia, King Saud bin

Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

Riyadh, Saudi Arabia·

T: +966(11)8011111 Ext.13056

F: +966(11)8011111 Ext. 14229

E-mail: alaslawi@hotmail.com

Ghada El-Hajj Fuleihan, MD MPH FRCP

Professor of Medicine

Director, Calcium Metabolism and Osteoporosis Program

WHO Collaborating Center for Metabolic Bone Disorders

Director Scholars in HeAlth Research Program (SHARP)

American University of Beirut, Beirut, Lebanon

Tel: 961-1-350,000 Ext 5362 or 7412 (SHARP)

Tel: Direct line 961-1-737868

Fax: 961-1-745321 or 961-1-744464

Corresponding author:

Dr. Salem A Beshyah

Key words: Osteoporosis, FRAX, MENA region, Bone Health, Physicians Practices, Care

Gap

Submission details:

Word Count: Exclusive of abstract and references = 4211

Tables 3

Figures 2. (Color: None)

Supplementary Material: Appendix 1, 2, 3

Manuscript Click here to access/download;Manuscript;MENAOsteoporosis Management Survey - Main-Final

Click here to view linked References

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

ABSTRACT

Background: The 2011 IOF Middle East Osteoporosis Audit highlighted major care gaps in

osteoporosis care in the Middle East and North Africa (MENA) region. Objective: investigate

osteoporosis management practice patterns in this region. Materials and Methods: we mailed

an electronic survey to a convenience sample of physicians, explaining the study rationale and

methods. It gathered information on physicians’ profiles, availability and utilization of

resources, risk assessment and management. 573 responses were obtained from the United

Arab Emirates (UAE, 36%), Saudi Arabia (KSA, 25%), Lebanon (14%), and others (25%).

Endocrinology was the single most represented specialty. Results: 60% of participants had

access to densitometers, but treating physicians were not in charge of densitometry reading.

Screening for vitamin D deficiency and secondary contributors to osteoporosis was frequently

implemented. Although two thirds of professionals were aware of FRAX® only 42% used it,

either because of lack of know how or of a country specific calculator. Almost all (96.0%) had

access to oral and 68.9% to intravenous bisphosphonates, and over half to teriparatide (46.4%)

and denosumab (45.0%). Most participants (92%) were aware of concerns regarding side

effects of bisphosphonates, and this changed the management in the majority (73%). Important

barriers to osteoporosis care were lack of osteoporosis awareness among physicians, patients,

and cost of treatment. Conclusions: This first look at physicians’ practice patterns on the

diagnosis and treatment of osteoporosis in the MENA region underscores the pressing need for

an official call for action, at all levels, to address this large care gap.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

INTRODUCTION:

With improved health care, urbanization, sedentary lifestyle, and increased longevity,

osteoporosis (OP) disease burden will constitute a large proportion of the growing list of non-

communicable diseases (NCDs) in the Middle East and North Africa (MENA) region [1]. In

2011 the Middle East Osteoporosis Africa IOF audit provided a comprehensive assessment of

the status of osteoporosis in the region. It underscored the lack of national databases, registries,

and cohorts, and identified gaps in resources, knowledge and care [2]. Osteoporosis is an

orphan condition being claimed by different specialties in different countries, and despite the

large incurred disease burden, it is not on the classic list of NCDs. It therefore remains un-

recognized as a national health care priority in many countries globally, and in the region [2,3],

and puts affected patients at even greater risk of late recognition, suboptimal management, and

poorer outcomes [4,5].

The diagnosis of osteoporosis, fracture risk assessment and management, rely primarily on

presence of fragility fractures, bone mineral density (BMD) measurements and personal risk

factors [6]. However, this diagnostic process is hindered in many Middle East and North Africa

(MENA) countries in light of the scarcity of BMD devices, and costs [2]. Only 2 countries, the

United Arab Emirates (UAE) and Lebanon, met the IOF recommendation for number of

devices available per capita [2]. The fracture risk assessment tool (FRAX®), developed by the

WHO Sheffield group, predicts the 10-year probability of osteoporotic fracture based on either

risk factors alone or in combination with a femoral neck BMD measurement [7]. This risk

calculator has the assed advantages of ability to be calibrated to country specific epidemiology

of hip fractures and longevity. The paradoxical vitamin D deficiency in the MENA region,

despite abundant sunshine almost all year round, highlighted the need for evaluation of vitamin

D deficiency and replacement [8-10] Furthermore, concerns regarding the long-term use of

bisphosphonates has resulted in a substantial decrease in their use in western populations [11].

How widely these issues are recognized and how well they are addressed in the MENA region

is unclear.

The specific objectives of this survey conducted in the region to 1) identify current attitudes

and management practices of physicians in the MENA region with regard to osteoporosis, 2)

gain insight into the perceptions amongst these physicians on the applicability and current

utilization of FRAX® in their practice, 3) assess the medical resources available to the

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

practicing physician involved in osteoporosis care, and 4) identify the unmet needs in

osteoporosis care and barriers to osteoporosis identification and treatment.

MATERIALS AND METHODS:

Survey Design:

The study is based on web-based survey of a pooled data base of physicians in the MENA

region conducted over the period of April 2015 to November 2016. Targeted respondents

consisted of database of attendees to major national and regional endocrine and osteoporosis

meetings. The commercial survey service (Survey Monkey, Palo Alto, CA, USA) was

employed. All target study population received an initial e-mail and 4 subsequent reminders at

weeks interval. A unique e-mail-specific electronic link to the survey questionnaire was

provided. Repeat submissions from the same link were automatically blocked by the survey

server. Survey responses were anonymously collected, stored electronically and analyzed at

the end of the study.

Study population:

The MENA region is a well-recognized geopolitical and economic entity; that includes 22

countries and comprises 6% of the world population. There is no single master database for all

endocrinologists. A large convenience sample included practicing physicians who were

identified on academic databases of health-related bodies, professional groups and recent

continuous professional development events (or e.g. AACE Gulf Chapter annual meetings)

and/or by virtue of their contribution to the medical literature in the subject, mostly

endocrinologists and internists with special interest in endocrinology. In Lebanon, updated

mailing lists of members of concerned societies, members of the Lebanese Society of

Osteoporosis and Metabolic Bone Disorders (OSTEOS), were accessed (endocrinologists,

rheumatologist, internists, gynecologists and radiologists). In Saudi Arabia, the emails were

specifically sent to all individuals associated with the Saudi Endocrine Society. Due to the

heterogeneity of the pool, respondents were asked to identify themselves in terms of specialties,

age group, duration and volume of practice (Table 1), to enable characterization of

demographic and professional profiles similar to previously published surveys-based studies

from the region [12,13]. Only respondents practicing in the MENA region were included in the

analysis. No data could be captured on the non-responders. A total of 616 responses were

received; with an estimated response rate of 10% based on the total number from the combined

email invitation list.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

The survey questionnaire:

The questionnaire was addressed to medical doctors and formulated de novo based on the

objectives of the study although several questions were inspired by questionnaires used in 2

previous studies with similar objectives [14,15]. These questions were adapted to suit regional

circumstances and to address additional contemporary concerns. The questionnaire was user-

friendly, with a simple format and clear instructions. It prevented any deviations from the

response options that were predefined for each question by using a multiple-choices format

with occasional extra options for comments to be added when needed. The questionnaire was

beta-tested by 12 endocrinologists prior to launch. It included 34 questions about the

physicians’ attitude to current issues and the barriers to osteoporosis management in the

following five domains (demography and professional profile, practice profile, resources

availability and utilization, risk assessment and screening for secondary osteoporosis,

management and barrier to osteoporosis care in the practice/country; see Table 1). The survey

was conducted in English being the language used in most professional communications in the

region [see Appendix 1 for full details on survey questions]. The use of common questions

between the current survey and the previous two [14,15], allowed for comparisons on practice

patterns across regions.

Analysis:

The results are expressed in actual numbers as a proportion of total responses per a given

question or adjusted as percentages to account for differences of responses between questions.

For comparisons of proportions between groups we used the Chi-square test, and the online

calculators of the Southwestern Adventist University (http://turner.faculty.swau.edu) was used

for all analyses. P-value< 0.05 was considered statistically significant. Country-wise subgroup

analyses of practice were explored using data from three countries contributing the largest

numbers of respondents namely United Arab Emirates, Saudi Arabia and Lebanon [see

Supplementary Material (Appendix 2)] for intra-regional variations. We also compared our

results with the two previously published surveys from Korea and Asia [14,15] [see

Supplementary Material (Appendix 3)] for inter-regional variations.

RESULTS:

Demographics of respondents

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

Out of 616 responses received, 573 met the entry criteria (viz. medically qualified, agreeing to

participate in the survey, residing/practicing in the MENA region and provided meaningful

responses to the clinical questions). The countries with the largest number of respondents were

United Arab Emirates (36.2%), Saudi Arabia (25%) and Lebanon (13.6%). The gender

distribution showed more males marginally, one third of respondents were 31-40 years, and

almost two thirds were 41-60 years (Table 2).

Professional and practice profiles:

These are detailed in Tables 2 and 3. Nearly one third were endocrinologists, whereas primary

care/family medicine and internal medicine specialists represented around 20% each. Over

half were consultants and 29% were sub-consultant specialists/fellows. The type of clinical

practices were university or teaching hospitals (57.6%), district or community hospitals

(20.2%) or private practice (15.3%). The majority were treating physicians and most worked

in large city-based practices. Existence of osteoporosis management guidelines were reported

by 48.7% of respondents in their respective countries. 82.6% of respondents managed patients

with osteoporosis: over half of respondents treated less than 10 patients a month, 5% between

50 and 100, and only 1.5 % would see more than 100 patients a month. One third of their

patients were described as already being diagnosed with osteopenia or osteoporosis (1/3), a

minority were referred from primary care for DXA screening, or had a new fragility fracture,

whereas a combination of all of these was identified by over half of respondents.

Evaluation of bone health and utilization of FRAX®

Almost 60% of subjects had access to central DXA devices, around 13% to peripheral devices,

and almost a third were not sure or had none (Figure 1A). Although more than three quarters

of subjects classified patients with osteoporosis into risk groups and used densitometry to

assess their patients, BMD reporting was not made by the physicians themselves but rather by

the radiologists in over 83% of the time (Table 3). Only approximately two thirds of physicians

had heard about FRAX, less than half used it in their practice. Forty percent of those who used

FRAX, did so with risk factors and BMD, 6% with risk factors alone, whereas the remaining

54%, used both options depending on the case (Table 3). The models most commonly used

were Lebanon by 47%, Jordan 26.7%, USA 8.6%, followed by UK, Tunisia, Morocco, and

Palestine in very small proportions. Furthermore, over one third of respondents did not know

how to use FRAX, 23% of physicians were too busy and had no time to do it, 18 percent felt

FRAX not to be applicable, or listed no internet access or other reasons (Figure 2A). Screening

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

for vitamin D was done by over 95% of physicians and other routine investigations before

initiating medications by 88.5% of physicians (Table 3). Respondents who do not perform

blood tests gave a variety of reasons (Figure 2B). Over eighty percent of them were not sure

which tests for secondary causes would be relevant, were concerned about costs, and felt the

tests were not relevant or not applicable.

Management of osteoporosis practices and barriers to optimal care:

Several anti-osteoporotic medications were reportedly available in the region including, almost

invariably, oral bisphosphonates (BPs), followed intravenous BPs, and others (Figure 1B). The

majority of physicians were concerned about bisphosphonates and for 73% this has changed

in their practice (Figure 2C). Several factors were identified as the biggest barriers to

osteoporosis care in their corresponding practice/country (Figure 2C). Most notably, these

included lack of physicians’ and patients’ awareness (over 50% each), closely followed by

costs and concerns about safety (Figure 2D).

Variations of practices within the MENA region:

Country-wise subgroup analyses of practice were explored using data from three countries

contributing the largest numbers of respondents namely United Arab Emirates, Saudi Arabia

and Lebanon [see Supplementary Material (Appendix 2)]. The majority of participants

practiced in large cities (> 84%), and over half practiced in university settings but more

respondents from Lebanon were in private practice (26.9 %). Almost half of participants from

Lebanon and KSA were endocrinologists, physicians from UAE were more likely to be in

internal medicine (25%); and 25% were in family medicine in all three countries. Respondents

from Lebanon saw a larger volume of patients with osteoporosis; almost half evaluated

between 10-50 patients with osteoporosis per month, compared with 33% in KSA and 24% in

UAE (Appendix 2). Furthermore, more respondents from Lebanon would use FRAX, and it

was FRAX Lebanon almost exclusively. Half of those who did not use FRAX responded that

it was due to short of time in clinic. However, the FRAX for Jordan, Lebanon, and USA were

used by 48.7%, 19.7% and 10.5% of the respondents from KSA and by 44.3%, 19.3%, and

9.1% of respondents from UAE. Respondents from KSA and UAE who did not use FRAX

attributed their practice to the lack of country model or lack of knowledge of how to use the

model. Access to all types of drugs was substantially higher in the Lebanese, including oral

BP, IV BP, denosumab, teriparatide and strontium ranelate, compared to UAE and KSA

counterparts (Appendix 2).

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

Comparisons of practices in the MENA region, Korea and Asia.

The survey responses pertaining to utilization of densitometry and FRAX® for risk assessment

and to management of osteoporosis in the MENA region are from the present study, Korean

and Asian data were made [14,15]. Differences and similarities are highlighted (Supplementary

Material, Appendix 3). The Korean participants were younger than the other two groups, but

the location and type of practice were similar in the three groups. Although endocrinologists

in all regions were highly represented, there were more so in the MENA survey than in the

Korean and Asian surveys, which included more physicians in musculoskeletal specialties

(orthopedic surgeons, rheumatologists and rehabilitation physicians). More than half, 56% of

respondents have less than 10 cases per month, contrasted with smaller corresponding low

volume care respondents (14% and 21%) in the Korean and Asian groups respectively.

Furthermore, less patients were seen for either DXA assessment or new fragility fracture added

together by the MENA group (13%) compared with the Korean and Asian groups (32% and

24%) respectively. More respondents from the MENA region would assess vitamin D status

and evaluate other biochemical parameters but do less assessment of BMD and personally

review of the BMD images than in the other two surveys. Despite the availability of several

FRAX model in the region, awareness and utility of FRAX was lower in our survey compared

with the other two. Perceived barriers to care optimal care were different in the three groups,

whereas cost was particularly noted by Asian respondents, time restrictions was felt by the

MENA group and restrictions imposed by regulators and funders was noted in the Korean

study.

DISCUSSION:

In this study, we surveyed the perceptions and practices of physicians from the MENA region

to several contemporary issues relevant to osteoporosis management. In particular, we

documented their utility of the FRAX® risk assessment and BMD measurements, availability

and utilization of resources, and attitudes to current concerns about safety of anti-osteoporosis

drugs. More than three quarters do classify their patients with osteoporosis into risk groups

but only two thirds were aware of the FRAX®. Majority of the respondents used bone density

assessment to help them in diagnosis and making treatment decisions using central DXA, but

most scans are reported by radiologists rather than the treating physicians. Those who are aware

of FRAX® did not use it in their practice for several reasons and those who use it seem to be

using several models with unclear justifications. Screening for secondary causes of

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

osteoporosis before initiation of treatment with anti-osteoporosis agents and screening for

vitamin D insufficiency is common practice (Table 3). Several anti-osteoporotic medications

were reportedly available in the MENA region and most physicians were aware of concerns

about bisphosphonate long term use and this has changed their management practice. Perceived

barriers to optimal care for osteoporosis include lack of physicians’ and patients' awareness,

and concerns about safety and costs of medications.

In the MENA region, guidelines are produced by a couple of national and regional bodies

[2,16,17] and there is ready access to guidelines made freely available by several international

societies [6, 18,19]. However, there does not seem to be a clear pattern of clinical management

of osteoporosis as suggested by a couple of small reports from Saudi Arabia and UAE [20-23].

The large proportion indicating BMD assessments might be influenced by selection bias, as all

our respondents. A critical shortage of DXA machines in most MENA countries has been

reported with exception of Lebanon and UAE [2], countries from which a disproportionately

larger number of respondents came. The assessment of bone density is an important step in the

establishment of the diagnosis and the further treatment and monitoring of osteoporosis. BMD

loss has been shown to correlate well with future fracture risk. DXA assessment in patients

with fragility fractures has been shown to vary widely [24]. Strangely, although radiologists

are no-treating physicians, according to this survey they seemed to lead and report DXA scans

more often than endocrinologists and rheumatologists in this region. It could be strongly argued

that radiologists may not be the most suitable specialists to undertake this role within a

comprehensive osteoporosis management program [25]. Although the ISCD and IOF have

conducted several densitometry training courses in the region over the years, our survey did

not specifically assess that point. Another interesting finding that almost all of our participants

had access to at least one form of bone densitometry device and this can partly be explained by

the substantial fraction of participants from large cities, with higher availability of bone

densitometers than in rural areas. Osteoporosis treatment rates have been shown to be crucially

linked to DXA accessibility [26]. Practicing physician ought to be familiar with the proper

performance of the DXA procedure and interpretation of the scan findings themselves [27,28].

The FRAX® risk calculator used to guide intervention thresholds in several national

osteoporosis guidelines [29, 30]. The Lebanese FRAX model is notably the first to be launched

in the region and the most developed [17]. It was based on country-specific national data on

hip fractures, obtained over more than one year and provided the basis for national FRAX based

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

osteoporosis guidelines endorsed by multiple societies and the Lebanese Ministry of Health

[17]. However, the extent of BMD and FRAX use in clinical practice in the region at large is

not known. This survey reveals that over one third of physicians (35.2%) were not aware of

FRAX®, even those who knew about were not be using it consistently, a situation caused by

the lack of knowledge or of a country specific FRAX model (Table 3). Indeed, at the time the

survey was launched only 5 country specific calculators were available. These were for

Lebanon, Jordan, Morocco, Tunisia, and Palestine. Since the survey an additional 3 country-

specific calculators were added in Kuwait (March 2016), Abu Dhabi (Nov 2016) and Iran (Nov

2016), [https://www.shef.ac.uk/FRAX/pdfs/FRAX_Release_Notes.pdf]. The development of

a reliable country-specific FRAX® model requires procurement of high quality hip fracture

incidence data, and life expectancy, at a minimum [29]. In the absence of a country-specific

FRAX model the joint ISCD and IOF position is to recommend the use of a surrogate country

[31]. Efforts should be made towards acquiring such data and producing reliable and validated

models. FRAX is available in phone and hand held calculators and also in paper charts for

practices that are not fully computerized.

Vitamin D deficiency is common in the MENA region despite the abundance of sunshine [32].

Significant vitamin D deficiency might be associated with osteoporosis [8-10,32-33]. In our

survey, universal screening for vitamin D deficiency seems not to be in the majority of practice

in the MENA region. Vitamin D supplementation is safe and cheap for patients with

osteoporotic fractures, and is recommended, if vitamin D deficiency is present, by several

international guidelines [34-36]. Some of the respondents in our survey screen none or only

selected osteoporotic patients using metabolic blood tests. However, finding contributing

factors of osteoporosis for the individual patient is crucial for initiating adequate treatment

[38]. The main reasons cited by the survey respondents who did not routinely screen for

secondary causes in their patients with osteoporosis were lack of knowledge which test to cost

and lack of perceived relevance. These beliefs are ill-founded may lead physicians to take

wrong management decisions. Poor investigation and treatment rates for osteoporosis have

already been shown to be present in many countries [ 24], and constitute a major barrier to

improving patients’ outomes.

Recent concerns have been raised of long-term use of bisphosphonate [11, 37,38]. Over 90%

of the respondents in our survey were aware of these new concerns and have reported having

made changes in their real practice. Similar findings were reported by the recent surveys [14,

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

15]. In order to guarantee individually matched treatment, options should exist for sufficient

choice amongst several anti-osteoporotic drugs. In this survey, the availability of different anti-

osteoporosis medications was reassuring. The fact that bisphosphonates (both oral and

parenteral) are most accessible to the surveyed health care professionals concur with current

recommendations for osteoporosis treatment [18, 38]. A recent report provided comprehensive

guidance on BP therapy duration with a risk-benefit perspective [11], and underscored that 5

years of bisphosphonate use would prevent 160 fractures for each potential AFF incurred.

The biggest barrier was lack of physician and patient awareness almost to an equal extent. This

is partly in line with the Korean survey which showed that lack of patients’ awareness was

considered by physicians as the biggest barrier [15]. However, this is at variance with two

previous studies, both of which reported that cost of treatment was the biggest barrier in the

USA and Asia-Pacific region [14, 39]. Perhaps, the low awareness amongst physicians and

patients creates a falsely low demand environment that masked the cost issue which was the

third biggest barrier identified by the survey respondents. These were followed by concerns

about the safety of medications and restrictions. These findings indicate the urgent need for

educational programs for both patients and physicians.

Some limitations of this study need to be acknowledged. The major limitation, is our sample

is the lack of representativeness of practitioners in the MENA region at large, and that it was

heavily represented by 3 countries, mostly with urban practices, that were university bases in

half of the participants. Also, it is a survey of perception and self-reported practices of

physicians rather than an audit/quality assurance exercise of processes and outcomes of actual

patient populations. However, such model is being increasingly used to gain insight into

physicians’ knowledge, attitudes and practices in many fields of health care, and may represent

a surrogate measure of quality of care particularly in clinical conditions where physicians are

the main drivers of the care. The lack of homogeneity of the respondents may impair the

validity of data on availability of resources as these are country-specific representations and

cannot be readily pooled. Comparison between countries was only exploratory and revealed

more consistent adherence to the country specific FRAX Model in Lebanon than the in UAE

and KSA [Appendix 2]. Indeed, 96% of Lebanese participants were aware of FRAX, a finding

explained by the fact that the Lebanese National Osteoporosis guidelines incorporated FRAX

into their risk assessment strategy as of 2013 [17], as recognized by 81% of participants.

Therefore, FRAX was used by 87% of survey respondents, reflecting the intensity of

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

osteoporosis FRAX-based guideline dissemination sessions in Lebanon since their launch.

More cost-consciousness was observed in the Lebanese respondents and adherence to

regulatory and provider restrictions in Lebanon and UAE than in KSA. Trans-national surveys

have previously been criticized as not the ideal method to assess the modalities of osteoporosis

care and how the resources available for its care are being utilized [12,13]. However, our survey

was an opportunistic exercise building on the common characteristics of the countries of the

region (2). The high access to all types of medications more readily available to the Lebanese

respondents could reflect the relatively higher proportion of specialists likely to treat

osteoporosis.

Comparisons of practice patterns in the MENA region Korea and Asia was possible for

responses pertaining to common questions posed specifically on utilization of densitometry

and FRAX® for risk assessment and to management of osteoporosis [Appendix 3]. Although

the endocrinologists in all three surveys were fairly well represented, the proportionately more

primary care respondents and less orthopedic surgeons in our survey may have influenced the

responses since responses would reflect physicians with less “hands on” acute fracture care and

fracture liaison services. The lower volume and the complexity of osteoporosis care (new

fragility fractures and referral for DXA) in the MENA group than in the Korean and Asian

groups may suggest either a wide spread of osteoporotic patients between specialties or a

limited number of respondents undertaking a leading role in osteoporosis care. Both of these

observations call for more centers of excellence of bone health in the MENA region to enable

accumulation of expertise to deal with more complex cases. Despite differences in some

perceived barriers to optimal care between the three groups, the contribution from low

awareness of patients and physicians remained equally important calling for more education

and of patients and physicians.

More respondents would measure vitamin D and other biochemical parameters but do less

assessment of BMD (and personal review of the images) in the MENA respondents than the

other two studies. The overall awareness and utility of FRAX was lower in our study than in

the other two studies but this was not true for all the countries in the region. The latter calls

for more involvement and training of clinicians to undertake roles in reading and interpretation

of DXA scans of their patients.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

The survey findings did however provide an overall “birds’ eye” view of the state of affairs

that is existent in the MENA region with regard to the osteoporosis care. It provided an insight

into the current diagnostic and treatment resources, perceptions and practices, explored the

awareness and utilization and of FRAX® and identified some important barriers to

osteoporosis care in the MENA region. It may be useful in guiding future educational initiatives

for both patients and physicians. Eight years after the launch of the IOF Middle East/Africa

osteoporosis audit [2], some of the determinants of care gaps identified in audit are still present.

Based on these findings, the two main potential action plans to close the care gap, and improve

osteoporosis care should target professional education, patients’ awareness and enhancing

insurance coverage and improved patients’ access, introducing established osteoporosis

management care pathways and good clinical practices coupled with ongoing quality assurance

programs to monitor progress. Engaging stakeholder physicians and patient societies would be

instrumental to reach that goal.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

Acknowledgment:

The authors would like to express their gratitude to all colleagues who shared their expertise

and opinions by participating in the survey.

Disclosures:

Authors’ contributions:

SAB and GEHF conceived the study and developed the questionnaire. All 3 authors acquired,

compiled and analyzed the data, wrote the manuscript and approved its final version.

Funding:

This study received no funding

Conflict of interest:

None of the authors has any conflicts of interest that may jeopardize the credibility of the

study.

Compliance with ethical principles:

The study was approved by the by the Institutional review board of Sheikh Khalifa Medical

City, Abu Dhabi, UAE. Informed consent was obtained electronically from all individual

participants prior to proceeding to the study. Lack of consent terminates the survey

automatically. All data were extracted and analyzed anonymously.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

REFERENCES:

1. Eastell R, O'Neill TW, Hofbauer LC, Langdahl B, Reid IR, Gold DT, Cummings SR.

Postmenopausal osteoporosis. Nat Rev Dis Primers. 2016 Sep 29;2:16069.

2. El-Hajj Fuleihan G, Adib G, Nauroy L. The Middle East and Africa Regional Audit:

Epidemiology, costs & burden of osteoporosis in 2011. International Osteoporosis

Foundation. Available from: www.iofbonehealth.org. Accessed 7.11.2016.

3. Khosla S, Cauley JA, Compston J, Kiel DP, Rosen C, Saag KG, Shane E. Addressing the

Crisis in the Treatment of Osteoporosis: A Path Forward. J Bone Miner Res. 2017

Mar;32(3):424-430. doi: 10.1002/jbmr.3074. Epub 2016 Dec 29.

4. Eisman JA, Bogoch ER, Dell R, Harrington JT, McKinney RE Jr, McLellan A, Mitchell

PJ, Silverman S, Singleton R, Siris E; ASBMR Task Force on Secondary Fracture

Prevention. Making the first fracture the last fracture: ASBMR task force report on secondary

fracture prevention. J Bone Miner Res. 2012 Oct;27(10):2039-46. doi: 10.1002/jbmr.1698.

Epub 2012 Jul 26.

5. Kanis JA, Johansson H, Oden A, Cooper C, Mccloskey EV; Epidemiology and Quality of

Life Working Group of IOF. Arch Osteoporos 2014; 9(1):166. Doi:10.1007/s11657-013-

0166-8.

6. Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, Lindsay R;

National Osteoporosis Foundation. Clinician's Guide to Prevention and Treatment of

Osteoporosis. Osteoporos Int. 2014 Oct;25(10):2359-81. doi: 10.1007/s00198-014-2794-2.

Epub 2014 Aug 15.

7. Kanis JA, Hans D, Cooper C, Baim S, Bilezikian JP, Binkley N, Cauley JA, Compston JE,

Dawson-Hughes B, El-Hajj Fuleihan G, Johansson H, Leslie WD, Lewiecki EM, Luckey M,

Oden A, Papapoulos SE, Poiana C, Rizzoli R, Wahl DA, McCloskey EV; Task Force of the

FRAX Initiative.

Interpretation and use of FRAX in clinical practice. Osteoporos Int. 2011 Sep;22(9):2395-

411.

8. Fuleihan Gel-H, Bouillon R, Clarke B, Chakhtoura M, Cooper C, McClung M, Singh RJ.

Serum 25-hydroxyvitamin D levels: variability, knowledge gaps, and the concept of a

desirable range. J Bone Miner Res. 2015 Jul;30(7):1119-33. doi: 10.1002/jbmr.2536.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

9. Hoteit M, Al-Shaar L, Yazbeck C, Bou Sleiman M, Ghalayini T, Fuleihan Gel-H.

Hypovitaminosis D in a sunny country: time trends, predictors, and implications for practice

guidelines. Metabolism. 2014 Jul;63(7):968-78. doi: 10.1016/j.metabol.2014.04.009.

10. Bassil D, Rahme M, Hoteit M, Fuleihan Gel-H. Hypovitaminosis D in the Middle East

and North Africa: Prevalence, risk factors and impact on outcomes. Dermatoendocrinol. 2013

Apr 1;5(2):274-98.

11. Adler A, El-Hajj Fuleihan G, Bauer D, Camacho P, Clarke B, Clines G, Compston J,

Drake M, Edwards B, Favus M, Greenspan S, McKinnet Jr R, Pingolo R, Sellmeyer D.

Managing Osteoporosis in Patients on Long-Term Bisphophonate Treatment. Report of a

Task Force of the American Society for Bone and Mineral Research. JBMR 2016; 31(1):16-

35

12. Beshyah SA, Khalil AB, Sherif IH, et al. A survey of clinical practice patterns in

management of Graves disease in the Middle East and North Africa. Endocr Pract. 2017

Mar;23(3):299-308.

13. Beshyah SA, Sherif IH, Chentli F, et al. Management of prolactinomas: a survey of

physicians from the Middle East and North Africa. Pituitary. 2017 Apr;20(2):231-240.

14. Korthoewer D, Chandran M. Osteoporosis management and the utilization of FRAX®: a

survey amongst health care professionals of the Asia Pacific. Arch Osteoporosis 2012; 7 (1-

2):193-200

15. Ha YC, Lee YK, Lim YT, Jang SM, Shin CS. Physicians’ attitudes to contemporary

issues on osteoporosis management in Korea. J Bone Metab 2014; 21:143-149

16. Al-Saleh Y, Sulimani R, Sabico S et al (2015) Guidelines for osteoporosis in Saudi

Arabia: recommendations from the Saudi Osteoporosis Society. Ann Saudi Med 2015, 35:1–

12

17. Chakhtoura M, Leslie WD, McClung M, Cheung AM, Fuleihan GE. The FRAX-based

Lebanese osteoporosis treatment guidelines: rationale for a hybrid model. Osteoporos Int.

2017;28(1):127-137.

18. American Association of Clinical Endocrinologists (2010) Medical guidelines for clinical

practice for the diagnosis and treatment of postmenopausal osteoporosis. Endocr Pract

16(suppl 3):1–37

19. Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological

management of osteoporosis in postmenopausal women: An Endocrine Society Clinical

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

Practice Guideline. J Clin Endocrinol Metab. 2019 May 1;104(5):1595-1622. doi:

10.1210/jc.2019-00221.

20. Alwahhabi BK. Osteoporosis in Saudi Arabia. Are we doing enough? Saudi Med J. 2015

Oct;36(10):1149-50.

21. Sadat-Ali M, Al-Dakheel DA, Azam MQ, Al-Bluwi MT, Al-Farhan MF, AlAmer HA, et

al. Reassessment of osteoporosis-related femoral fractures and economic burden in Saudi

Arabia. Arch Osteoporos. 2015;10:37. doi: 10.1007/s11657-015-0240-5.

22. Bubshait D, Sadat-Ali M. Economic implications of osteoporosis-related femoral

fractures in Saudi Arabian society. Calcif Tissue Int. 2007 Dec;81(6):455-8.

23. Beshyah SA, Al Mehri W and Khalil AB. Osteoporosis and Its management: An

exploratory study of the knowledge, attitudes and practices of physicians working in the

United Arab Emirates. Ibnosina J Med BS 2013; 5(5):270-9.

24. Elliot-Gibson V, Bogoch ER, Jamal SA et al (2004) Practice patterns in the diagnosis and

treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporosis Int 15

(10):767–778.

25. Lewiecki EM, Baim S, Binkley N, et al. Report of the International Society for Clinical

Densitometry 2007 Adult Position Development Conference and Official Positions. South

Med J2008;101:735-9.

26. Cadarette S, Gignac M, Jaglal S et al (2007) Access to osteoporosis treatment is critically

linked to access to dual-energy X-ray absorptiometry testing. Med Care 45(9):896–901.

27. Chami G, Jeys L, Freudmann M et al (2006) Are osteoporotic fractures being adequately

investigated? A questionnaire of GP & orthopaedic surgeons. BMC Fam Pract 7:7.

28. Hans D, Kanis J, Baim S et al (2011) Joint official positions of the International Society

for Clinical Densitometry and International Osteoporosis Foundation on FRAX((R)).

Executive summary of the 2010 Position Development Conference on Interpretation and use

of FRAX(R) in clinical practice. J Clin Densitom 14(3):171–180.

29. Johansson H, Kanis JA, Oden A, et al. BMD, clinical risk factors and their combination

for hip fracture prevention. Osteoporos Int 2009;20:1675-82.

30. El-Hajj Fuleihan G, Chakhtoura M, Cauley JA, Chamoun N. Worldwide Fracture

Prediction. J Clin Densitom. 2017 Jul - Sep;20(3):397-424. doi: 10.1016/j.jocd.2017.06.008.

Epub 2017 Jul 19.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

31. Cauley JA, El-Hajj Fuleihan G, Arabi A, FRAX(®) Position Conference Members.

Official Positions for FRAX® clinical regarding international differences from Joint Official

Positions Development Conference of the International Society for Clinical Densitometry and

International Osteoporosis Foundation on FRAX®. J Clin Densitom. 2011;14(3):240-62.

32. Lips P, Cashman KD, Lamberg-Allardt C, Bischoff-Ferrari HA, Obermayer-Pietsch BR,

Bianchi M, Stepan J, El-Hajj Fuleihan G, Bouillon R. MANAGEMENT OF ENDOCRINE

DISEASE: Current vitamin D status in European and Middle East countries and strategies to

prevent vitamin D deficiency; a position statement of the European Calcified Tissue Society.

Eur J Endocrinol. 2019 Feb 1. pii: EJE-18-0736.R1. doi: 10.1530/EJE-18-0736. [Epub ahead

of print]

33. Nowson CA. Prevention of fractures in older people with calcium and vitamin D.

Nutrients 2010;2:975-84.

34. Rosen CJ, Gallagher JC. The 2011 IOM report on vitamin D and calcium requirements

for North America: clinical implications for providers treating patients with low bone mineral

density. J Clin Densitom. 2011 Apr-Jun;14(2):79-84.

35. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. ; Endocrine Society. Evaluation,

treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice

guideline. J Clin Endocrinol Metab. 2011 Jul;96(7):1911-30.

36. Cesareo R, Attanasio R, Caputo M, et al. Italian Association of Clinical Endocrinologists

(AME) and Italian Chapter of the American Association of Clinical Endocrinologists

(AACE) Position Statement: Clinical Management of Vitamin D Deficiency in Adults.

Nutrients. 2018 Apr 27;10(5). pii: E546.

37. Schilcher J, Michaelsson K, Aspenberg P. Bisphosphonate use and atypical fractures of

the femoral shaft. N Engl J Med 2011;364:1728-37.

38. Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the

secondary prevention of osteoporotic fragility fractures in postmenopausal women

(amended). NICE technology appraisal guidance 161 (amended). National institute for Health

and Clinical Excellence (NICE), London; 2011

39. Simonelli C, Killeen K, Mehle S et al. Barriers to osteoporosis identification and

treatment among primary care physicians and orthopedic surgeons. Mayo Clin Proc 2002;

77(4):334–338.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

Table 1. The five domains of the survey and their corresponding questions.

1. Demography and

professional profile:

Q1-Q9

Confirmation of eligibility an electronic consent, country of practice,

gender and age group. specialty, professional grade, type, nature and

locality of practice,

2. Profile of respondents

clinical practice:

Q10-Q13

Existence of national osteoporosis management guidelines? Do you see

and treat patients with osteoporosis? How many patients with

osteoporosis do you currently see and treat per month? Who is the typical

osteoporotic patient you see?

3. Resource availability

and utilization

Q14-Q19

Do you assess bone density in your patients? What kind of densitometry

device do you have access to in your clinical practice? Who does the

reporting of bone densitometry in your practice? If the reporting of bone

densitometry is done by a physician other than yourself, do you look at

the scan/printout and confirm the reporting physician's findings?

4. Risk assessment and

screening for secondary

osteoporosis:

Q20-Q29

Do you classify your patients with osteoporosis into risk groups? Have

you heard of FRAX ® prior to today? Do you use FRAX ® in your

practice? If you have heard of FRAX ® but don't use it in your practice,

what is the main reason you don't use it? If your country has osteoporosis

treatment guidelines, has FRAX ® been incorporated into the guidelines?

Do you screen for vitamin D sufficiency status in your patients with

osteoporosis and fragility fractures? Do you routinely obtain blood tests

before initiating treatment with anti-osteoporosis agents in your patients?

If you don't obtain blood tests, what is the reason?

5. Management and

barrier to osteoporosis care

Q30-Q34

What medications are available in your country for the treatment of

osteoporosis? Are you aware of concerns about side effects associated

with bisphosphonate use? If you are aware of the recent concerns about

side effects associated with bisphosphonate use, has this awareness

changed your management practice? If your practice with regard to

prescribing bisphosphonates has changed, how has it changed? What do

you perceive as the biggest barrier to osteoporosis care in your

practice/country?

The full version of the survey is available online [Appendix 1].

Table 1 Click here to access/download;Table;MENA OsteoporosisSurvey - Table 1 - Final.docx

Table 2. Demographic and professional profiles of respondents and clinical practice characteristics

Characteristic (N responders) Response options Numbera Per cent (%)a

A. Demographic Characteristics

Country of Residence/Practice

(572)

United Arab Emirates 207 36.2%

Saudi Arabia 143 25.0%

Lebanon 78 13.6%

Rest of Gulf + Iraq 69 12.1%

North Africa 50 8.7%

Pakistan and Iran 20 3.5%

Age (years)

(571)

20–40 168 32.5%

41–50 190 33.3%

51–60 141 24.7%

Above 60 54 9.5%

Gender (571) Male : Female 332 : 239 58 % : 42%

Locality of practice:

(572)

Small town 54 9.4%

Large city 518 90.6%

B. Professional profiles of respondents

Type of profession: (570) Treating/Non-Treating HCP 534/36 93.7%/6.3%

Type of clinical practice:

(569)

Teaching hospital 328 57.6%

Community hospital 115 20.2%

Private practice 87 15.3%

Research- based 10 1.8%

Primary Care 24 4.2%

Other 5 0.9%

Clinical specialty:

(570)

Endocrinology 180 31.6%

Family practice 116 20.4%

General IM 68 11.9%

IM + endocrine interest 44 7.7%

Gynecology 33 5.8%

Specialist IM 31 5.4%

Rheumatology 27 4.7%

Table 2 Click here to access/download;Table;MENA OsteoporosisSurvey - Table 2 - Final.docx

Orthopedics 17 2.3%

Physical medicine 9 1.6%

Others 45 7.8.%

Professional grade: (570) Consultant 313 54.9%

Specialist/Fellow 165 29.0%

Resident 46 8.1%

Other grades 46 8.1%

C. Clinical practice characteristics:

Do you treat osteoporosis? (564) Yes 466 82.6%

No 98 17.4%

Number of osteoporotic patients seen

per month: (466)

Less than 10 261 56.3%

10–20 129 27.8%

21–50 46 9.9%

51–100 21 4.5%

More than 100 7 1.5%

Type of patients seen: (460)

Referred for DXA 28 6.1%

Already diagnosed 135 29.4%

New fragility fracture 26 5.7%

All of the above 271 58.9%

Does your country have osteoporosis

management guidelines? (571)

Yes 278 48.7%

No 174 25.7%

Not sure 146 25.6%

If you have osteoporosis guidelines;

has FRAX® been incorporated in it

(481)

Yes 132 24.7%

No 93 19.3%

Do not know 256 53.2%

a: Responses are expressed as absolute numbers as well as adjusted percentages (calculated per individual

questions). HCP= Health care professional; IM= Internal medicine; DXA= Dual energy X-ray

Absorptiometry.

Table 3. Utilization of densitometry and FRAX® for risk assessment and management of osteoporosis.

Characteristic (responders) Details of answer options Number Per cent

Do you classify your patients with osteoporosis into risk

groups? (526)

Yes 416 79.1%

No 110 29.9%

Do you assess bone density in your patients? (535) Yes 441 82.4%

No 94 18.6%

Who does the reporting of bone densitometry in your

practice? (527)

Myself 96 18.2%

Another physician 449 85.2%

Specialty of who reports bone densitometry in your

practice? (530)

Radiologist 441 83.2%

Endocrinologist 76 14.3%

Rheumatologist 65 12.3%

Clinical physicist 30 5.7%

Have you heard of FRAX® prior to today? (532) Yes 345 64.8%

No 187 35.2%

Do you use FRAX® in your practice? (532) Yes 244 42.2%

No 307 57.8%

If you use FRAX® in your practice, how do you use it?

(223)b

With risk factors alone 13 5.6%

Risk factors +BMD 88 39.5%

Both possibilities 122 54.7%

If you use FRAX® in your practice, which country model

do you use?

(221)b

Lebanon 104 47.1%

Jordan 59 26.7%

USA/UK 19/8 8.6%/3.6%

Tunisia /Morocco/Palestine 6/4/4 2.7%/1.8%/1.8%

Otherc 17 7.7%

Screening for vitamin D status in patients with

osteoporosis? (521)

Yes 497 95.4%

No 24 4.6%

Routine blood tests before initiating anti-osteoporosis

treatment? (514)

Yes 455 88.5%

Nod 59 11.5%

Awareness of concerns about side effects of

bisphosphonates? (505)

Yes 467 92.5%

No 38 7.5%

If aware, has this awareness changed management practice?

(461)

Yes 336 72.9%

No 125 27.1%

a:Absolute numbers as well as adjusted percentages (calculated per question) are presented b: Only responses from those who

confirmed using FRAX in their practice were included. c: Some responses included non-existing models. d: relevant details in

figure.

Table 3 Click here to access/download;Table;MENA OsteoporosisSurvey - Table 3 - Final.docx

Figure 1. Reported access to diagnostic and therapeutic facilities for management of

osteoporosis in the MENA region: A. access to bone densitometry devices and B. access to

anti-osteoporotic medications (n=502). Results are adjusted as percentage of total responses

to the given questions. In both questions, multiple answers were possible. DXA dual-energy

X-ray absorptiometry, SERMs = Selective estrogen receptor modulators.

Figure 1 Click here to access/download;Figure;MENA OsteoporosisSurvey - Figure 1 - Final.docx

Figure 2 Click here to access/download;Figure;MENA Osteoporosis Survey - Figure 2 - Final.docx

Figure 2: Reported patterns of certain osteoporosis management practices: A. Reasons for not using fracture-risk assessment (FRAX) tool (n=296), B.

Reasons for not screening for secondary osteoporosis (n=57) and C. changes in practices in prescribing of bisphosphonates (n=336). D. Perceived

barriers to good osteoporosis care in the MENA region countries from all surveyed physicians (501). Responses are expressed as percentages (adjusted

for the total responses to individual questions).

Management of Osteoporosis in the Middle East and North Africa: A Survey of Physicians’

Perceptions and Practices.

Salem A Beshyah, Yousef Al-Saleh, Ghada El-Hajj Fuleihan

SUPPLEMENTARY MATERIAL

Appendix 1. The actual questions and layout of the survey questionnaire as it appears on the survey

monkey website. Logic is included in question 1 so that only those who provide an informed consent

may proceed to the rest of the questions. The survey instrument is developed de novo mostly based on

review of the literature and two previously published studies with similar objectives. See the methods

section for more details.

Supplementary Material 1 Click here to access/download;Supplementary Material;MENAOsteoporosis Survey-Suppl Mat- Appendix 1 Final.pdf

Management of Osteoporosis in the Middle East and North Africa: A

Survey of Physicians’ Perceptions and Practices.

Salem A Beshyah, Yousef Al-Saleh, Ghada El-Hajj Fuleihan

SUPPLEMENTARY MATERIAL

Appendix 2. Comparisons of Practice Patterns in The Three countries with the largest number of

respondents: United Arab Emirates (UAE), Saudi Arabia (KSA) and Lebanon. Results are presented as

the relative frequencies (%).

Question theme* (Numbers

of responses)

Response options* UAE

(Total: 207)

KSA

(Total:143)

Lebanon

(Total: 78)

P-value

Respondents’ gender

(206, 143, 77)

Men 54.4% 62.9% 49.3% χ2> 4.385 0.112

Women 45.6% 39.1% 50.7%

Respondents’ age

(207, 143, 78)

<30 years 10.1% 3.5% 6.4%

χ2>36.763 0.001

31-40 years 17.9% 40.0% 37.2%

41–50 years 38.2% 32.2% 18.0%

51-60 years 23.2% 20.3% 28.2%

>60 years 10.6% 3.5% 10.3%

Clinical specialty:

(207, 140,78)

Endocrinology 16.9% 45% 44.9%

χ2>56.836 P=0.000

Family practice 25.1% 23.6% 25.6%

General Medicine 21.7% 8.5% -

GIM w endo interest 10.6% - -

Gynecology 6.8% 3.6% 7.7%

Specialist IM 5.3% 6.4% -

Rheumatology 0.5% 0.7% 12.8%

Orthopedics 1.9% 2.1% 6.4%

Physical medicine 2.4% 1.4% 1.3%

Others 6.8% 1.4% 1.3%

Professional grades

(207,141,78)

Seniors 33.3% 61.7% 70.5% χ2>43.692 P=0.000

Mid-grade 34.3% 30.7% 23.1%

Junior and others 32.4% 11.8% 6.4%

Locality of practice:

(206, 141, 78)

Small town 15.1% 5.6% 11.5 % -

Large city 84.9 % 94.4 % 88.5 %

Treating Physician?

(207, 141, 78)

Yes 92.7 % 93.6 % 96.2 % -

No 7.3 % 6.4 % 3.9 %

Type of facility:

(207, 141, 78)

University 44.4 % 63.6 % 59.0 %

χ2>20.871 P=0.002

Community hospital 25.1 % 23.6 % 12.8 %

Private practice 19.3 % 5.7 % 26.9 %

Research- based 2.4 % 1.4 % 0 %

Primary Care 7.3 % 5.0 % 0 %

Other 1.5 % 0.7 % 1.3 %

Do you treat osteoporosis?

(203, 142, 78)

Yes 74.4 % 83.1 % 97.4 % χ2>20.246

P=0.000

Number of osteoporotic

patients seen per month:

Less than 10 72.5% 59.7 % 49.4 % χ2>15.01

P=0.0047 10–20 18.7% 25.2 % 35.1 %

Supplementary Material 2 Click here to access/download;Supplementary Material;MENAOsteoporosis Survey-Suppl Mat- Appendix 2 Final.docx

Question theme* (Numbers

of responses)

Response options* UAE

(Total: 207)

KSA

(Total:143)

Lebanon

(Total: 78)

P-value

(193, 139, 78) 21–50 4.7 % 7.9 % 11.7 % Tested for:

<10,10-20

& >20) 51–100 3.6 % 5.8 % 1.3 %

More than 100 0.5 % 1.4 % 2.6 %

Type of patients seen:

(191, 139, 76)

Referred for DXA 5.8 % 2.9 % 4.0 %

χ2>10.72

P=0.098

Already diagnosed 44.0 % 30.9 % 30.3 %

New fragility

fracture

3.4 % 5.0 % 5.3 %

All of the above 46.6 % 61.2 % 60.5 %

Do you assess BMD in

your patients? (186, 139,

77)

Yes 72.6 % 88.5 % 96.1 % χ2>26.10

P= 0.000

What BMD assessment

device do you have access

to?

(187,136,76)

Central DXA 47.1% 64.0% 72.4% -

Peripheral DXA 15.5% 8.8% 11.8% -

No access 11.8% 3.7% 1.32% -

Not sure 22.5% 22.1% 14.5% -

What is the cost of a BMD

scan in your institution?

(187,136,76)

Not sure 80.1% 80.3% 19.7% χ2>104.499 P=0.0000

25-50 USD 2.7% 1.5% 7.9% -

50-75 USD 3.2% 2.2% 21.1% -

75-100 USD 3.2% 2.3% 25.0% -

100-150 USD 6.5% 6.6% 23.7% -

Who reports BMD in your

practice? (182, 137, 76)

Myself 12.6 % 12.4 % 25.0 % χ2>6.88 p=0.032

Another physician 90.1 % 89.8 % 80.3 %

Specialty of those who

reports of BMD? (183,

137, 77)

Radiologist 91.3 % 97.1 % 54.6 % χ2>82.1

P=0.000 Endocrinologist 5.5% 8.8% 49.4% χ2>92.7

P=0.000

Clinical physicist 6.6% 3.7% 0% -

Rheumatologist 4.4% 2.9% 28.6% -

Looking at scans to

confirm findings?

(183, 136, 77)

Yes 58.5 % 58.8 % 90.9 % χ2>28.4

P=0.000

Awareness of the FRAX®

(186, 139, 74)

Yes 58.1% 66.9 % 96.0 % χ2>35.17

P=0.000

Do you have osteoporosis

guidelines in your country?

(206, 142, 78)

Yes 40.3% 62.7% 83.3% χ2>49.29

P=0.001 No 24.3% 12.0% 2.6%

Not sure 35.4% 25.4% 14.2%

Do your guidelines

incorporate FRAX?

(186, 128, 74)

Yes 20.2% 18.0 % 81.1% χ2>121.1

P=0.000 No 10.1% 26.6 % 2.7 %

Do not know 69.6% 55.5% 16.2.0%

Use of FRAX® in practice:

(106, 137, 77)

Yes 31.5% 38.7% 87.0% χ2>70.70

P=0.000

How do you use FRAX?

(106, 136, 68)

With risk factors

only

4.7 % 3.9 % 4.4 %

χ2>1.794)

P=0.7737 Risk factors and

BMD

28.3 % 37.7 % 32.4 %

Either as available 67.0 % 58.4 % 63.2 %

Question theme* (Numbers

of responses)

Response options* UAE

(Total: 207)

KSA

(Total:143)

Lebanon

(Total: 78)

P-value

If you do not use FRAX;

Why? (108, 69, 13)

Do not know how 45.4% 39.1 % 0 % -

No country-model 28.7% 29.0 % 7.7% -

Tool not applicable 20.4 24.6 % 23.1 % -

Too busy to do it 17.6 % 17.4 % 53.9 % χ2>9.658

P=0.0080 No internet in clinic 4.6 % 14.5 % 23.1 % -

Other reasons 4.6 % 1.5 % 0 -

Do you classify your OP

patients into risk groups?

(181, 136, 77)

Yes 76.2 % 75.0 % 94.8 % χ2>13.91

P= 0.001

Screening for vitamin D

status? (177, 136, 76)

Yes 96.6 % 95.0 % 100 % P=0.187

Screening for secondary

osteoporosis? (175, 136,

75)

Yes 89.7% 91.2 % 89.3 % P=0.880

If you don't obtain blood

tests before initiating

treatment with anti-

osteoporosis agents; what

is the reason?

(84, 70, 25)

Not sure 14.3 12.9 % 8.0 % χ2>4.649

P<0.098

[For cost only]

Cost 16.7 10.0 % 28.0%

Patient refusal 9.5 % 7.1 % 8.0 %

Lack of time 4.8 % 2.9 % 8.0 %

Interpretation is

difficult

2.4 % 0 % 0 %

Irrelevant 3.6 % 5.7% 16.0%

What medications are

available in your country

for the treatment of

osteoporosis?

(164, 134, 76)

Oral BP’s 96.3 % 97.0 % 100 % χ2>2.749;

P=0.253 Intravenous BP’s 65.2 % 62.7 % 90.8 % χ2>20.59;

P=0.000 SERMS 50.6 % 51.5 % 90.8 % χ2>40.848

P=0.000

Denosumab 42.7 % 50.0 % 64.5% χ2>9.87;

P=0.0072

Teriparatide 41.5 % 50.0 % 84.2 % χ2>38.98;

P=0.000

Intranasal calcitonin 32.9 % 30.6 % 84.2% χ2>68.02;

P=0.000

Strontium Ranelate 31.7 % 28.4 5 88.2 % χ2>70.70;

P=0.000

Awareness of concerns

about bisphosphonates

(BP) safety? (168, 133, 76)

Yes 89.9 % 94.0 % 98.7% χ2>6.56;

P=0.0375

Have you changed your BP

prescribing practices? (159,

133, 76)

Yes 72.3 % 78.6 % 68.4 % χ2 > 2.891;

P=0.2356

What are changes made in

BP prescribing?

(155, 123, 69)

Re-evaluate >5yrs 47.1 % 61.8 % 73.9 % χ2>6.102

P=0.0473

Change > 2 years 17.4 % 23.6 % 7.3 % χ2>6.624

P=0.0364 Change > 5 years 10.3 % 17.1 % 18.8 %

Stopped prescribing 3.2 % 4.1 % 2.9 % -

Patients' awareness 47.9 % 60.7 % 53.3 % -

Question theme* (Numbers

of responses)

Response options* UAE

(Total: 207)

KSA

(Total:143)

Lebanon

(Total: 78)

P-value

The perceived biggest

barriers to osteoporosis

care in respondents’

practice or country?

(165, 132, 75)

Doctors' awareness 47.3 % 66.7 % 68.0 % -

Costs of medications 33.9 % 22.7 % 58.7 % χ2 >27.305

P=0.0000 Restrictions by

funders

30.9 % 9.1 % 29.3 % χ2>23.687

P=0.000

Medications’ safety

concerns

30.3 % 26.5 % 28.0 % -

Medications’

effectiveness

concerns

12.1 % 21.2 % 17.3 %

Lack of time 10.9% 17.4 % 6.7 %

Others 3.0 % 2.3 % 4.0 %

* Some of the responses were condensed for space reasons. The full text of all questions and

possible responses is in Supplementary Material Appendix 1 and Table 1.

Management of Osteoporosis in the Middle East and North Africa: A Survey of Physicians’

Perceptions and Practices.

Salem A Beshyah, Yousef Al-Saleh, Ghada El-Hajj Fuleihan

SUPPLEMENTARY MATERIAL

Appendix 3. Comparisons of Practice Patterns in the MENA, Korea and Asia.

The survey responses pertaining to utilization of densitometry and FRAX® for risk assessment and to

management of osteoporosis. Data are adjusted as percentages for the individual questions. MENA

region data are from the present study, Korean and Asian data are derived from references a and d below.

Only findings readily available comparable data available in all three studies were included in the

comparison. Comparisons where possible were made using Chi2 statistics.

Characteristic Answer options MENA

(n=573)

Koreaa

(n=100)

Asiab

(n=247)

P-Value

Respondents’ age (years)

20–40 33% 49% 38%

χ2>21.048 P=0.0018

41–50 33% 37% 34%

51–60 25% 12% 23%

61 or above 9% 2% 6%

Locality of practice: Small town 9% - 7% χ2>0.846

P=0.3577 Large city 91% - 93%

Type of facility: University hospital 58% 61% 62%

χ2>10.074

P=0.0065

For university

and district

categories

District hospital 20% 23% 11%

Private practice 15% - 32%

Primary care 4% - -

Research and other 3% 16% 2%

Clinical specialty:

Endocrinology 40% 34% 23%

χ2>200.81;

P=0.000

Family practice 20% 9% 6%

Internal medicine 25% 6% 5%

Gynecology 6% 8% 6%

Musculo-skeletal

medicine

9% 41% 48%

Others 8% 2% 7%

< 10 61% 14% 21%

Supplementary Material 3 Click here to access/download;Supplementary Material;MENAOsteoporosis Survey-Suppl Mat- Appendix 3 Final.docx

Characteristic Answer options MENA

(n=573)

Koreaa

(n=100)

Asiab

(n=247)

P-Value

Number of osteoporotic

patients seen per month:

10–20 24% 24% 29% χ2>198.713;

P=0.000 21–50 9% 35% 25%

51–100 4% 14% 14%

> 100 1% 11% 11%

Type of patients seen:

Referred for DXA 7% 17% 10%

_ Already diagnosed 34% 26% 23%

New fragility fracture 6% 15% 14%

All of the above 54% 38% 60%

Do you assess BMD in

your patients?

Yes 82% 99% 94% χ2>32.379

P= 0.0000

Who reports BMD in

your practice?

Myself 18% 78% 25% χ2>167.51

P=0.000

(For myself)

Another physician 85% 22% 75%

If not reporting, do you

Look at scans to confirm

findings?

YesC 61% 91% 84% χ2>52.79

P= 0.000

Awareness of the

FRAX® tool:

Yes 65% 88% 76% χ2>27.205

P=0.000

Use FRAX® in practice: Yesd 42% 93% 62% χ2>87.515,

P=0.000

Screening for vitamin D

status?

Yes 95% 59% 25% χ2>418.62

P=0.000

Screening for secondary

osteoporosis?

Yes 89% 52% 36% χ2>418.620

P=0.0000

Reasons for not

screening for secondary

osteoporosis

(56,48,89)

Not sure what test? 32.0% - -

Think it is irrelevant 16.1% 19.0% 45.0%

Cost factors 25% 35.0% 40.0%

Patients refusal 3.6% 17.0% 7.0%

Interpretation difficult 3.6% 13.0% 5.0%

No time 0.5% 17.0% 3.0%

Characteristic Answer options MENA

(n=573)

Koreaa

(n=100)

Asiab

(n=247)

P-Value

Awareness of concerns

about BP safety?

Yes 93% 99% 96% χ2>8.416

P=0.015

Changes in BP

prescribing?

Yese 73% 83% 63% χ2>13.85

P= 0.000

Nature of changes in BP

prescribing?

(339,83,156)

Re-evaluation >5 yrs 61.4% 61.0% 60.0%

Not different Change >5 yrs 13.9% 23.0% 8.0%

Change > 2 yrs 21.5% NA 20.0%

Stopped prescribing 4.1% 1% 5.0%

Perceived Barriers to

osteoporosis care

(501, 100, 247)

Cost 37.3% 28.0% 79.0%

Patient awareness 54.5% 50.0% -

Doctor awareness 52.9% 47.0% -

Restrictions by

funding/regulator

20.2% 47.0% -

Lack of time 11.8% 3.0% -

Safety concerns 24.2% 22.0% -

Effectiveness concerns 14.4% 17.0% -

a. Ha YC, Lee YK, Lim YT, Jang SM, Shin CS. Physicians’ attitudes to contemporary issues

on osteoporosis management in Korea. J Bone Metab 2014; 21:143-149

b. Korthoewer D, Chandran M. Osteoporosis management and the utilization of FRAX®: a

survey amongst health care professionals of the Asia Pacific. Arch Osteoporosis 2012; 7 (1-

2):193-200

c: If reports made by others; d: if aware of FRAX and e: if aware of safety concerns.

Authorship & Disclosure form

Click here to access/downloadAuthorship & Disclosure form

Authorship_&_Disclosure_form -OI-Beshyah.pdf