Introduction

Deep vein thrombosis (DVT) is a significant global health issue characterized by the formation of blood clots in the deep venous system1. The burden of DVT is substantial, both medically and economically2. DVT can lead to severe and fatal post-surgical complications3,4. In the context of orthopedic surgery, particularly hip or knee arthroplasty, the risk of DVT is remarkably increased5. DVT is a primary and foremost preventable cause of global mortality6. Prioritizing the prevention of DVT overtreatment is a crucial strategy in effectively reducing thrombosis-related events7.

This preventative approach encompasses three main pillars: pharmacological interventions, mechanical methods, and general patient care. Pharmacological measures typically involve anticoagulants like heparin or warfarin, which are critical in both preventing and treating DVT8. Mechanical methods, including the use of elastic compression stockings, can prevent post-thrombotic syndrome (PTS) in DVT patients9. Early mobilization, regular exercise, and adequate hydration are fundamental in lowering the incidence of DVT among hospitalized patients10,11. Hence, it is imperative for healthcare providers, especially orthopedics, vascular surgery, and anesthesiology, to cultivate a comprehensive understanding of DVT prevention.

The knowledge, attitude, and practice (KAP) model, which posits that individual behaviors are influenced by one’s knowledge and attitude, is of paramount importance in public health research. This model underpins the theory that the examination of behavioral practice in healthcare should be complemented by an assessment of both knowledge and risk perception, a methodology often implemented through KAP surveys12,13,14. In the context of DVT, a condition marked by high incidence and severe risks, particularly in postoperative scenarios, the application of the KAP model is particularly vital. This research aims to explore and understand the current knowledge, attitude, and practice of orthopedic, vascular surgery, and anesthesiology doctors in the realm of DVT prevention. Gaining these insights is critical for identifying knowledge gaps, misconceptions, and deficiencies in current preventive measures.

Several studies have investigated the KAP of orthopedic, vascular surgery, and anesthesiology doctors regarding the prevention of DVT; however, these studies have not been conducted within the Chinese context15,16,17,18, which is has unique features, like a very large population to serve and a rapid medical system development that had to match the rapid economic development and Westernization of several lifestyle habits. Furthermore, traditional Chinese medicine holds an important place in the Chinese healthcare system along Western medicine19,20,21. The results observed in China, a developing country, could also help improve the situation of other countries in a similar situation. Gaining a better understanding of the situation of different countries and areas around the globe could help provide a better understanding of the strategies for DVT prevention. Therefore, this study aimed to examine the KAP of orthopedic, vascular surgery, and anesthesiology doctors regarding postoperative DVT prevention in surgical patients in China.

Materials and methods

Study design and participants

This cross-sectional study included orthopedic, vascular surgery, and anesthesiology doctors at Shanxi Bethune Hospital and the Shanxi Medical Science Institute between November 22 and December 13, 2023. The inclusion criteria targeted orthopedic, vascular surgery, and anesthesiology doctors from the departments of orthopedics, vascular surgery, and anesthesiology within Bethune Hospital, as well as relevant orthopedic, vascular surgery, and anesthesiology doctors from tertiary or secondary hospitals across the province and those outside the province. Interns, rotating doctors, and physicians in advanced training were excluded. Ethical approval was obtained from the Ethics Committee of both institutions (approval #YXLL-2023-241), and informed consent was obtained from all participants.

Questionnaire

The questionnaire was developed based on the Guidelines for Prevention of perioperative venous thromboembolism in Chinese Orthopedic Trauma Patients (2021)22, Chinese Guidelines for the Prevention of Venous Thromboembolism in Major Orthopedic Surgery23, and Chinese Expert Consensus on Mechanical Prevention of Venous Thromboembolism24. The initial version of the questionnaire was reviewed, revised, and refined by a panel of five experts, comprising two vascular orthopedic, vascular surgery, and anesthesiology doctors, two orthopedic specialists, and one anesthesiologist. A pilot study involving 27 respondents was conducted to test the questionnaire’s reliability, resulting in a Cronbach’s α of 0.719.

The final questionnaire, presented in Chinese, covered four key dimensions and consisted of 40 items. These dimensions included 11 items on socio-demographic information, 14 on knowledge (K), 9 on attitude (A), and 6 on practice (P). For statistical analysis, scores were assigned based on the response options for each item. In the knowledge section (items 1–14), correct answers were awarded 1 point each, while unclear or incorrect answers received 0 points, allowing for a total score range of 0–14. In the attitude dimension, a five-point Likert scale was employed, spanning from very positive (5 points) to very negative (1 point), thereby yielding a score range of 9 to 45. Similarly, the practice dimension also utilized a five-point Likert scale, with a score range of 6–30. A score exceeding 70% of the total possible score in each dimension was considered indicative of adequate knowledge, positive attitude, and proactive practice25.

Questionnaire distribution and quality control

An online questionnaire was developed utilizing the Sojump website (https://www.wjx.cn/), and a QR code was generated for data collection through WeChat. Participants scanned the QR code to access and complete the questionnaire. In order to guarantee the questionnaire’s quality and comprehensiveness, all items were made mandatory. Following the collection of questionnaires, data quality assessments were performed, and any questionnaires exhibiting logical errors or repeated response patterns were deemed invalid and excluded.

Statistical analysis

The minimal sample size was estimated based on 5–10 times the number of KAP items based on the sample size estimation methods for surveys26,27. Hence, the minimal sample size was 145–290. When accounting for a 10% invalid questionnaire rate, the minimal sample size was 160–319.

The statistical analysis was performed using SPSS 22.0 (IBM, Armonk, NY, USA) and AMOS 24.0 (IBM, Armonk, NY, USA). The normal distribution of continuous data was checked using the Kolmogorov-Smirnov test. Continuous data conforming to the normal distribution were presented as means and standard deviations (SD) and analyzed using the t-test (two groups) or ANOVA (more than two groups). Continuous data conforming to the skewed distribution were presented as medians (P25, P75) and analyzed using the Wilcoxon-Mann-Whitney U-test (two groups) or the Kruskal-Wallis analysis of variance (more than two groups). Categorical data were displayed as n (%). Pearson’s correlation analysis was employed to assess correlations among knowledge, attitude, and practice. A Structural Equation Modeling (SEM) framework was developed based on the following hypotheses: (1) Knowledge exerts a direct influence on both attitude and practice, and (2) Attitude directly affects practice. The model fit was evaluated using root mean square error of approximation (RMSEA), incremental fit index (IFI), Tucker–Lewis index (TLI), and comparative fit index (CFI). A two-sided P-value less than 0.05 was considered statistically significant.

Results

Initially, 326 questionnaires were collected. After excluding those with incorrect answers to the trap question (21 cases), missing age data (3 cases), and all identical responses in the KAP dimensions (8 cases), 294 valid questionnaires remained for analysis. The characteristics of the participants are shown in Table 1.

Table 1 Demographic characteristics and KAP scores.
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The mean knowledge, attitude, and practice scores were 9.94 ± 1.91 (possible range: 0–14), 37.12 ± 2.94 (possible range: 9–45), and 23.02 ± 3.64 (possible range: 6–30), separately. The orthopedic, vascular surgery, and anesthesiology doctors employed in different departments are more likely to have different knowledge scores (P = 0.002). Furthermore, participants of different genders (P < 0.001), professional titles (P = 0.011), departments (P < 0.001), and years of practice (P = 0.006) were more likely to have distinct practice scores (Table 1).

The distribution of knowledge dimension revealed that the two knowledge items with the highest correctness rates were K3 with 98.30% and K4 with 97.62%. The two items with the lowest correctness rates were K2, with 34.35%, and K12, with 43.20% (Table 2). Details of the responses in the attitude dimension and the practice dimension are shown in Tables S1 and S2.

Table 2 Knowledge dimension.
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The correlation analyses revealed significant positive correlations between knowledge and attitude (r = 0.182, P = 0.002), knowledge and practice (r = 0.234, P < 0.001), and attitude and practice (r = 0.281, P < 0.001), respectively (Table 3).

Table 3 Correlation analysis.
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The multivariate logistic regression analysis suggested that working in other departments was independently associated with a positive attitude (OR = 0.435, 95% CI: [0.195 0.969], P = 0.042) (Table 4). Furthermore, attitude score (OR = 1.249, 95% CI: [1.127 1.385], P < 0.001) and working in the anesthesiology department (OR = 0.309, 95% CI: [0.158 0.603], P = 0.001) were found to be independently associated with good practice (Table 5).

Table 4 Univariate and multivariate analysis of attitude dimension.
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Table 5 Univariate and multivariate analysis of practice dimension.
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The SEM showed that knowledge had direct effects on attitude (β = 0.894, P < 0.001) and practice (β = 1.786, P < 0.001). Moreover, attitude has a direct impact on practice (β = 0.338, P = 0.017) (Table 6; Fig. 1). The fit indices in Table S3 collectively showed that the questionnaire fits the KAP model well.

Table 6 SEM results.
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Fig. 1
figure 1

Structural Equation Modeling.

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Discussion

Orthopedic, vascular surgery, and anesthesiology doctors in this study demonstrated adequate knowledge, positive attitude, and proactive practice regarding DVT prevention in surgical patients. These findings suggest that efforts should focus on sustaining and reinforcing the existing knowledge, attitude, and practice among orthopedic, vascular surgery, and anesthesiology doctors to further enhance the quality of DVT prevention in orthopedic patient care. Continuous education and training programs may be beneficial in achieving this goal.

A study in Cyprus revealed that nurses had a generally good knowledge of DVT but a poorer knowledge of DVT risk and prophylaxis and a poor practice of DVT prevention15. In Saudi Arabia, nurses displayed high knowledge and practice toward DVT16. In Pakistan, healthcare providers displayed poor KAP toward DVT, displaying a profound underestimation of the risks of DVT and related complications in hospitalized patients17. Among Nigerian surgeons, only 33.3% had a good knowledge of DVT, and only 20% had good related practice despite 83.5% of them having encountered at least one case of pulmonary embolism in their career18. These results suggest that the KAP of healthcare providers toward DVT is variable among countries but could tend to be low. Most available data are from developing countries but suggest that the practice of DVT could be improved, which could translate into better patient outcomes. China is also a developing country that shares medical challenges similar to those of other countries in the same situation. Sharing findings among such countries could help improve international practice regarding DVT.

In this study, a key finding was the significant influence of the professional title held by doctors, with those holding associate senior/senior titles exhibiting higher practice scores, indicating that greater experience or seniority may contribute to more proactive DVT prevention practice. It aligns with previous research that has emphasized the role of experience and seniority in shaping medical practice and adherence to guidelines28,29. Nurses in Cyprus with more experience had higher knowledge scores than less experienced nurses15. In the present study, the physicians’ experience was not independently associated with attitude or practice scores.

In the multivariate analyses, attitude score and departmental affiliation emerged as independent factors associated with the practice, further underscoring the significance of these factors in shaping doctors’ DVT prevention practice. Doctors with more positive attitudes were more likely to exhibit proactive practice, aligning with previous research emphasizing the link between attitude and clinical behaviors30,31. Additionally, participants from the anesthesiology department exhibited the lowest practice scores, which may be attributed to their departmental focus primarily on intraoperative care and pain management, potentially leading to less exposure and emphasis on postoperative DVT prevention strategies. This situation underscores the importance of interdisciplinary education and collaboration, especially beneficial techniques from orthopedics and vascular surgery that could be adapted to improve outcomes in anesthesiology, which could facilitate the sharing of best practices and specialized knowledge, thus enhancing DVT prevention practices across all departments involved in patient care.

The correlation analyses revealed significant positive associations between knowledge and attitude, knowledge and practice, and attitude and practice. These findings emphasize the interdependence of these factors in influencing DVT prevention efforts among orthopedic, vascular surgery, and anesthesiology doctors. As knowledge is a precursor to attitude formation and attitude guide behaviors, interventions targeting knowledge enhancement and attitude improvement may yield positive impacts on practice16,32.

The SEM analyses provided further insights into the relationships among these variables. The well-fitting SEM model indicated that knowledge had direct effects on both attitude and practice, reinforcing the importance of knowledge as a foundational component. Moreover, attitude exhibited a direct impact on practice, suggesting that cultivating a positive attitude may lead to more proactive DVT prevention practice. These results align with the theory of planned behavior, which posits that attitude, subjective norms, and perceived behavioral control collectively influence behavioral intentions and subsequent behaviors33,34.

In light of these findings, it is recommended that educational interventions and training programs consider the influence of professional titles and departmental affiliations. Tailored strategies should target orthopedic, vascular surgery, and anesthesiology doctors at different professional levels and within specific departments to maximize the impact of DVT prevention efforts35,36. Additionally, efforts to enhance knowledge and cultivate positive attitudes among orthopedic, vascular surgery, and anesthesiology doctors should be prioritized, as these factors have demonstrated significant associations with proactive practice37,38. Collaborative efforts between hospital administration, department heads, and surgical teams can facilitate the implementation of targeted interventions to improve DVT prevention practice in orthopedic care settings.

In examining the knowledge dimension, our findings indicate that orthopedic, vascular surgery, and anesthesiology doctors possessed a high level of understanding regarding DVT prevention in surgical patients. However, some knowledge gaps were identified, particularly concerning the incidence of DVT in specific fracture types. To further enhance their knowledge, it is recommended to focus on providing continuous education and updates specifically tailored to fracture-related DVT risks. Additionally, ongoing training programs that emphasize the latest evidence and best practices in DVT prevention can ensure that orthopedic, vascular surgery, and anesthesiology doctors stay updated with the evolving field39,40.

In assessing the attitude dimension, our study found that orthopedic, vascular surgery, and anesthesiology doctors generally held positive attitudes toward DVT prevention practice in orthopedic care. A significant majority believed in the importance of patient education and the necessity of using standard DVT risk assessment tools. However, a portion of respondents felt that DVT prevention should not solely rely on healthcare providers, indicating a potential area for intervention to emphasize shared responsibility between providers and patients. To build on these positive attitudes, healthcare institutions can promote a culture of shared responsibility between healthcare providers and patients for DVT prevention. Encouraging healthcare professionals to actively engage in interdisciplinary collaboration can lead to the development of more comprehensive and effective prevention strategies. Furthermore, regular reviews and updates of DVT prevention guidelines should be institutionalized to ensure the adoption of the latest evidence-based practice7,41.

Regarding the practice dimension, our results revealed room for improvement in certain aspects of DVT prevention practice among orthopedic, vascular surgery, and anesthesiology doctors. While a notable proportion reported adhering to the latest guidelines on DVT prevention, there were areas of concern. For instance, professional training on DVT prevention was received by a minority of orthopedic, vascular surgery, and anesthesiology doctors, suggesting a potential gap in education and training opportunities. In order to address these, healthcare institutions should prioritize ongoing professional development programs and provide opportunities for orthopedic, vascular surgery, and anesthesiology doctors to receive specialized training in DVT prevention. Emphasizing the importance of patient education and involving patients in the prevention process can lead to better adherence to preventive measures. Moreover, promoting interdisciplinary teamwork and communication among healthcare professionals can enhance the implementation of evidence-based DVT prevention practices42,43. Continuing education is essential to strengthen the KAP toward DVT and could take various forms tailored to the needs and the target audience, including lectures, podcasts, interactive websites, and discussions. Since DVT is relevant to several medical specialties and categories of healthcare providers, multidisciplinary education activities should be encouraged to allow the participants to share different views. Future studies should aim at designing, implementing, and evaluating education and training interventions for healthcare providers in China. Such interventions could also be exported to other countries in similar situations.

This study has its limitations. Firstly, the data were collected from limited institutions within a specific geographical area, which may limit the generalizability of the findings to a broader population. A response bias due to available time is possible, possibly preventing physicians with more busy schedules from participating in the study. In addition, the limited geographical representativeness could lead to bias due to local practices, policies, and available medical resources. Secondly, this study was cross-sectional, preventing the analysis of causality. The study relied on self-reported responses from orthopedic, vascular surgery, and anesthesiology doctors, which may introduce response bias and potential overestimation of knowledge, attitude, and practice related to DVT prevention. Finally, the impact of the medical faculty experience on the KAP of the physicians was not evaluated in the present study. Future research should expand multi-center data collection across diverse regions, conduct longitudinal studies to assess causality, and systematically evaluate more comprehensive demographic information, such as the impact of medical faculty experience on clinical practices.

Conclusions

In conclusion, this study found that orthopedic, vascular surgery, and anesthesiology doctors exhibited adequate knowledge, positive attitude, and proactive practice concerning DVT prevention in surgical patients. Based on these findings, it is recommended that healthcare institutions continue to support and enhance the knowledge and practice related to DVT prevention in orthopedic surgery, with a particular focus on reinforcing positive attitudes and considering department-specific training to further improve patient care and outcomes.