Survey of gastroenterologists' awareness and implementation of AGA guidelines on osteoporosis in inflammatory bowel disease patients: are the guidelines being used and what are the barriers to their use?

Julianne H Wagnon, David A Leiman, Gregory D Ayers, David A Schwartz
Inflammatory Bowel Diseases 2009, 15 (7): 1082-9

BACKGROUND: The American Gastroenterology Association (AGA) published guidelines to assist clinicians in the evaluation and management of osteoporosis in inflammatory bowel disease (IBD) patients. Two studies suggest that when clinicians utilized the guidelines, the majority of their IBD patients were appropriately screened and treated for metabolic bone disease. The aim was to study whether physicians who say they use the AGA Guidelines are, in fact, following the recommendations, and to assess the barriers preventing the use of the guidelines in the management of osteoporosis in their IBD patients.

METHODS: In all, 1000 physicians were selected from the AGA membership list and mailed a survey inquiring into awareness and implementation of the guidelines on osteoporosis in IBD patients. The barriers to implementation of the guidelines were also assessed. The sum of 21 self-reported clinical practices (absence = 0, presence = 1) was used to evaluate adherence to the guidelines. A value of 0 implied no adherence while a score of 21 meant complete adherence.

RESULTS: Of 304 responders, 27 fellows, 8 retirees, and 11 incomplete responses were not included in the analysis; thus, 258 respondents were the subject of this analysis. Slightly less than half of the responders used the guidelines in decision-making (126, 49%) or in the management (110, 42%) of their IBD patients. Using the scoring system described above, clinicians self-reporting use of the guidelines had a significantly higher clinical practice score than those who did not use the guidelines (Wilcoxon rank sum test; P < 0.0001). Only 18% (12 of 68) of clinicians whose practice was comprised of <or=25% IBD patients used the guidelines compared to 60% (113/187) physicians who cared for more IBD patients (chi-square test; P < 0.0001). Physicians who saw more IBD patients (>25%) were also more likely (97/187 = 52%) to assess and treat osteoporosis in their IBD patients. Conversely, only 16% (11/68) of physicians who saw <or=25% IBD patients treated osteoporosis (chi-square test; P < 0.0001). The main reason physicians (n = 115) gave for not utilizing the guidelines was because they felt that IBD should be the focus of the visit (48, 42%); 34 (30%) reported that osteoporosis should be managed by another physician. Other barriers cited were lack of time (13, 11%), cost (10, 9%), and lack of knowledge (10, 9%).

CONCLUSIONS: Most of the responding physicians do not utilize the AGA Guidelines on metabolic bone disease in IBD patients. The physicians who self-reported utilizing the guidelines were actually adhering to the recommendations. Further education regarding the impact of metabolic bone disease in IBD patients and the importance of the guidelines is needed, particularly as it addresses the barriers set forth above.

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