Management Trend and Attitude Regarding Osteoporotic Vertebral Compression Fracture: A Comparative Study Between Surgeons and Internists


 Background: Osteoporotic vertebral compression fracture (OVCF) is the most common form of osteoporotic fracture, both surgeons and internists included in the management of that. This study aimed to identify whether a discrepancy exists between spinal surgeons and internists in the diagnosis and management of OVCF.Method: This comparative study included 124 spinal surgeons and 47 internists in the WeChat group of the Society of Osteoporosis and Bone Mineral Research. They were sent a self-administered electronic questionnaire that asked about practice pattern, diagnosis trend, and management choice in OVCF management. The validity of the survey was examined in advance.Results: A significantly higher percentage of surgeons obtained T2-weighted images scan with fat suppression than internists. A significantly higher proportion of spinal surgeons provided surgical treatment as first-line treatment and considered fracture as the most important aspect in OVCF management than internist. No significant difference was observed in the use of dual-energy X-ray absorptiometry scan, in performing laboratory examination, or in the collaboration rate between the two groups.Conclusion: Differences exist between internists and spinal surgeons in imaging diagnosis, choice of therapeutic schedule, and attitude to osteoporosis treatment in the management of OVCF.


Background
Osteoporotic vertebral compression fracture (OVCF), the most common form of osteoporotic fracture, is pervasive in older population with osteoporosis [1]. OVCF can cause chronic pain, progressive vertebral deformity with sagittal imbalance, decreased quality of life, and shorter survival time [2,3]. Osteoporotic vertebral fracture causes huge burden on medicine, public health, and economy. The cost of OVCF is signi cantly higher than that of other fragile fractures, and it would continuously increase in the future [4].
However, the management of OVCF might not be su ciently considered by physicians. The rate of clinical diagnosis of OVCF ranges from only one quarter to one third [3,5], and underdiagnosed vertebral fracture is a worldwide problem [6]. It is important to determine if patients with fragility fractures have osteoporosis and to provide timely treatment in order to reduce the risk of future fracture. However, whether kyphoplasty or vertebroplasty should be used in the treatment of osteoporotic vertebral fractures remains controversial, with different scienti c societies giving contradictory recommendations [1,7]. Even osteoporosis treatments are debated, as different departments have different medication adherence programs and patient outcomes [8,9].
Unlike other osteoporotic fractures, OVCF is not typically managed in an orthopedic environment, and patients could also consult internists rst to determine the condition and obtain treatment. The different educational backgrounds and attitudes between spinal surgeons and internists may result in different treatments and patient outcomes [9]. However, no studies to date have examined the management trend and attitude among physicians of different specialties who treat OVCF. This study aimed to assess and compare the management trend and attitude of orthopedic surgeons and internists regarding the medical treatment of their patients with OVCF in order to nd the gap between the disciplines.

Methods
Brie y, we carried out a comparative study to determine any differences between surgeons and internists on the management of osteoporosis vertebral fractures.
The study protocol has been approved by the Ethics Committee of Tangdu Hospital. In October 2019, an electronic survey using Sojump, a platform for professional online surveys (Shanghai Information Technology Co., Shandong, China), was sent to the WeChat group of the Society of Osteoporosis and Bone Mineral Research, which includes endocrinologists, spinal surgeons, surgeons, and internists from other departments associated with management of osteoporosis. WeChat, an application used broadly on smartphones, has a monthly usage of more than 1 billion [10]. It is a promising tool for data collection whose validity and feasibility have been tested, and it has been used in many studies [11]. The selfdesigned questionnaire was developed for this study, which is provided as Additional File 1. It is based on a literature review and interviews with spinal surgeons and internists. Questions were focused on the respondents' demographic information, opinions regarding appropriate diagnosis and treatment of OVCF, and related responsibilities.
To qualitatively examine the clarity and validity of the survey, four experts (two surgeons and two internists associated with management of osteoporosis) critiqued the questionnaire; after which, the questionnaire was recti ed according to their comments. To quantitatively identify the validity of the study, the scale-level content validity index (S-CVI) was calculated [12]. Another 10 experts ( ve spinal surgeons and ve internists) were asked to rate the overall questionnaire from 1 to 4 (1 = not relevant, 2 = somewhat relevant, 3 = quite relevant, 4 = highly relevant). Then, the S-CVI was computed as the number of experts who ranked the whole survey 3 or 4 divided by the total number of experts. A scale with excellent content validity should have an S-CVI ≥ 0.8, the S-CVI in this study was 0.85, the quantitative validity was veri ed. Of the 499 surgeons and 159 internists in the WeChat group who received the questionnaire, 124 surgeons and 47 internists completed the questionnaire, corresponding to response rates of 24.8% and 29.6% respectively.
Data are presented as frequencies and percentages. We used Sojump and Statistical Package for the Social Sciences (SPSS) version 20.0 (IBM Corp., Armonk, NY, USA) for the data analysis. Sojump was used to conduct descriptive analysis automatically. SPSS was used for the Fisher's exact test and Pearson's correlation to explore the correlation between the characteristics of the respondents and the other items in the questionnaire. P < 0.05 was considered statistically signi cant.

Results
Overview and population demographics A total of 171 respondents (124 surgeons and 47 internists) from 26 provinces and 60 cities across mainland China were included. The demographic data are described in Table 1. The sex proportion in the two groups was varied. The two groups were similar in terms of age, years of practice, and job title at baseline; however, the proportion of surgeons from tertiary university teaching hospitals was slightly larger than that for internists (Table 1). internists agreed to that (P = 0.006) (Fig. 1).
We found that physicians from nontertiary hospitals had signi cantly lower rate of diagnosis based on DEXA scan and additional T2-weighted imaging than physicians from tertiary hospitals (P = 0.000), but no difference was found in laboratory examination, usage of surgical treatment, and attitude on most important management for physicians from different types of hospitals. Physicians from nontertiary hospitals had a relatively lower rate of collaboration (Table 2). Although no signi cant difference was found in the diagnosis and management trend of OVCF between physicians with different job titles, we found a relatively lower collaboration rate for students and residents than attending doctors (Table 3).

Discussion
In this study, we compared the current status of management trend and attitude in practice pattern between orthopedic surgeons and internists who treat OVCF. We found no difference between the two groups regarding obtaining DEXA scan, performing laboratory examination, and team collaboration. However, the two groups signi cantly differed in obtaining additional T2-weighted image with fat suppression, attitude on management choice, and the most important concern in the management of OVCF. We also found that the rates of collaboration and image-based diagnosis were lower for physicians from nontertiary hospitals, and the collaboration rate was lower for students and residents. This study analyzed the management trend and attitude of orthopedic surgeons and internists regarding the treatment of patients with OVCF, which, to our knowledge, has not been studied before.
The DEXA scanning rates in previous studies ranged from 1.4% in a retrospective cohort study by Barton et al [13] to 32.0% in Hawaii in a study by Nguyen et al [14] and to 52.9% in South Korea in a study by Park et al [15], which differ from the results of our study, as most of the physicians in our study agreed to performing DEXA bone mineral density (BMD) scan to middle-aged and elderly patients with suspected OVCF. The results of previous studies and our results suggest that the rate of BMD measurement has increased over the years; however, doctors' knowledge and attitude may not translate into action in diagnosis. Our result also indicated that the type of hospitals may be an in uencing factor.
An additional T2-weighted image with fat suppression is necessary to identify abnormalities in regions with abundant fat, which is the only way to determine the potentially painful vertebrae in old-aged patients who have more fat at the vertebrae [16]. It is better in identifying acute and hidden lesions before cement augmentation than plain radiographs and computed tomography scans. Similar to a nationwide population-based study in South Korea that found that the rate of magnetic resonance imaging (MRI) was only 35% for patients with OVCF [17], our study found that the rates of T2-weighted imaging with fat suppression were 67.74% for surgeons and 36.17% for internists. It indicates that the importance of MRI scanning has been ignored by different physicians in the diagnosis of OVCF, and a difference existed between surgeons and internists.
The issue of choosing nonsurgical management, vertebroplasty, or balloon kyphoplasty in the treatment of OVCF remains complicated [18]. The heterogeneity of the patient population, including those with negative manifestation in MRI, varied symptoms, insu cient response to conservative treatment, etc., was found be the reason behind the management choices [19]. However, the in uence of differences in discipline has rarely been studied. Schupfner et al [19] found that surgeons tend to choose balloon kyphoplasty as their main treatment, whereas more nonsurgeons chose vertebroplasty. On the contrary, our result showed that nonsurgical management was the rst-line treatment for both groups, but more surgeons chose surgical treatment, whereas more internists insist on conservative treatment. Except for the diversity of respondents between Schupfner et al's study and ours, we note that Schupfner et al investigated only three nonsurgeons (two radiologists and one internist) and ve surgeons. The results of Schupfner et al and our results suggest that a difference in management choice indeed exists between surgeons and internists, as surgeons and radiologists tends to choose surgical management, whereas internists prefers nonsurgical management.
For patients with OVCF, the rate of osteoporosis diagnosis after fractures has signi cantly increased, whereas the rate of osteoporosis treatment has only increased minimally [20]. Barton et al [15] found that only 15% of patients had calcium or vitamin D supplementation or had FDA-approved osteoporosis medication following vertebral fractures. Unsurprisingly, 38% had another vertebral fracture within 2 years following the rst one. Previous studies found that osteoporosis treatment after fragility fractures might be in uenced by factors such as BMD measurement, fracture history, and hospitalization, which might lead to a higher prescribing rate [21]. Our study investigated whether the differences in discipline are an in uencing factor and found signi cant difference between the two groups. We found that most internists were more concerned with osteoporosis treatment, whereas the proportion of surgeons with the same concern was only two thirds. The result of previous studies and our result suggest that the hospital medical staff play an important role in the management of osteoporosis after fragility spinal fractures, and a difference might exist between different disciplines, in which internists might contribute more.
The collaboration among disciplines in osteoporosis was globally initiated, and its advantages have been reported in previous studies, including increased e ciency and better treatment coordination [22,23].
Correspondingly, our study showed that most physicians were willing to collaborate with different disciplines. Hjalmarso et al [24] found that a practice pattern with a horizontal structure would trigger free action of the professionals and would encourage a changeable leadership, which would balance the topdown structure and improve the outcome of interprofessional collaboration. In our study, we also found the feasibility of a horizontal structure in collaboration and that both surgeons and internists were willing to subjectively take leadership of the team. The results of the study of Hjalmarso et al and our results suggest that physicians are willing to take the leadership in a team, and a horizontal practice pattern with changeable leadership is feasible. We also noted that the sense of collaboration might be disparate among physicians from different grades of hospitals and physicians with different job titles.
Our study is the rst to compare the management trend and practice pattern for patients with OVCF between orthopedic surgeons and internists. However, our study has some limitations. First, a signi cant difference in sex ratio was found between the two groups. Although only a few surgeons in our study were women, it conforms to a previous report that female surgeons dominated only 10-20% of the surgical workforce [25]; thus, we believe that it may not be a bias. Second, compared with internists, more surgeons were from teaching hospitals, which might bias the estimation. Besides, in our study, most physicians were from tertiary hospitals, and doctors with senior professional titles had the highest proportion among the respondents, which indicates that our result may be more optimistic than the reality. Third, this is a self-assessment study, and deviation might exist compared with the real condition.
Further studies are needed to demonstrate the result more conclusively. Although our study has some de ciencies, they are not cofounders to the conclusion.  Figure 1