Abstract
Obstructive sleep apnea (OSA) has various complications for individuals’ health. This study aimed to evaluate the factors for referring obstructive sleep apnea patients to otolaryngologists in Iranian residency entrance examination volunteers. This cross-sectional study recruited volunteer participants from the Iranian Residency Entrance Examination on March 2, 2018. The Obstructive Sleep Apnea Knowledge and Attitudes (OSAKA)/the Obstructive Sleep Apnea Knowledge and Attitudes in Children (OSAKA-KIDS) Questionnaires were distributed among residents attending exam preparation. Number of years working as a physician, number of adult and pediatric patients visited during the academic rank in residency examination, and the main specialty during general physician education in which they get familiar with obstructive sleep apnea were documented. The effect of the mentioned variables evaluated on patient referral preference specialty. Of the 95 volunteers, 57.9% were female; mean age was 29.6 ± 3.3 years. The overall knowledge score of the OSAKA questionnaire was 9.85 ± 3.9 and for the OSAKA-KIDS questionnaire was 9.2 ± 4.9. In patients under 18 years of age, the most frequent referrals were from otolaryngology specialists (51.2%). The only factor which had positive significant effect on adult patient referral preference was source of obstructive sleep apnea knowledge during general physician taring (p < 0.001). Given the low awareness about OSA in candidates for the residency entrance exam and the high importance of this treatable disease, the need for comprehensive training courses during residency is warranted and the adequacy of sleep apnea education through all involved specialty during general physician education should be improved.
Keywords: Obstructive sleep apnea, Residency entrance exam, Knowledge, Attitude, Training
Introduction
Obstructive sleep apnea (OSA) is an important risk factor for community health, one that has increased over the last 20 years [1]. OSA is defined as an apnea-hypnotic index more than 5 times per hour; 2–9% of the population are affected [2]. The prevalence of OSA increases with increasing weight and age [3]. It is known as an independent risk factor for cardiovascular disorders, depression, and diabetes, and has imposed a heavy financial burden on communities [4, 5].
Following successful treatment of OSA, the financial burden on health care systems is significantly decreased [6]. Therefore, if OSA is not diagnosed, it leads to adverse health and economic consequences. Unfortunately, 82% of men and 93% of women with moderate to severe OSA are not diagnosed[7, 8], which may be due to the ignorance regarding this sleep disorder in physicians, as well as in non-medical individuals in the community[9]. Despite the high prevalence and high importance of OSA in Iran, there has been no study on the extent of physicians' knowledge about this syndrome. Thus, this study aimed to develop a tool for evaluating Iranian adolescent sleep apnea in Persian and to measure the amount of Iranian physician’s knowledge.
The prevalence of OSA in children is 1 to 3% [10, 11].The causes and characteristics of children with OSA differ from adults, although their complications are equally important [12, 13].OSA syndrome can cause serious complications, including developmental disorders, pulmonary hypertension, systemic hypertension, and neurocognitive and neurobehavioral complications among affected children [14, 15]. Failure to treat OSA (in both adults and children) negatively affects health-related quality of life and imposes heavy health and economic burdens on the country's health system, as well as multiple referrals to physicians [16, 17].Studies have shown that physicians lack information and understanding about OSA in children [18, 19].It is thus important to examine the knowledge and attitudes of physicians about OSA in children. Therefore, the current study addresses knowledge and attitude of physicians (volunteers of the residency entrance examination) about OSA and its therapeutic approaches.
Materials and Methods
Study Design and Participants
This study (approved by ethics committee of Tehran University of Medical Sciences No.136385) was a cross-sectional study. Subjects were volunteers from the Iranian Residency Exam who participated on March 2, 2018 at Kamran Ahmadi's educational institute, and were eligible to choose their major. Given that there were 11,832 participants and considering CI 95% and 10% margin of error, the sample size was calculated as 95.
Study Measures
Two available validated questionnaires for assessment of physicians' knowledge and attitude towards obstructive sleep apnea in adults (OSAKA) and children (OSAKA-KIDS) were used. The OSA knowledge and attitudes (OSAKA) questionnaire was developed in 2003 by the University of Pennsylvania, while another version was developed for children (OSAKA-KIDS).
The questionnaires were first translated into Farsi by two translators. Then, they were translated by two fellows of sleep medicine and eight otolaryngology specialists who were fluent in English. The translated questionnaires were compared with the original version and participant transferability was confirmed. The questionnaires were then distributed among participants attending an educational institute for residency exam preparation. After describing the study and obtaining informed consent, of 200 candidates, 95 completed the questionnaires.
The questionnaires included demographic information, academic and professional qualifications, year of graduation, number of years working as a physician, location(s) of practice, number of adult and pediatric patients visited during the day, number of adult patients and children referred with OSA symptoms, number of patients who underwent sleep apnea treatment themselves (and type of treatment), number of people referred to the referring physician, and the result of the rank of residency entrance exam.
Statistical Analysis
Pearson’s test was used for the quantitative analysis of correlation, and Kruskal–Wallis was used for correlation of the quantitative and qualitative analysis. A P-value of less than 0.05 was considered significant. To assess the reliability of the questionnaires, Cronbach's alpha was used.
Results
Of the 200 volunteers, 95 completed the questionnaire (Response Rate: 47.5%): 57.9% were female; and the mean age was 29.6 ± 3.3 years (range: 25–47 years). In terms of the number of years since graduation, individuals ranged from 0 to 15 years, with a mean of 3.7 ± 2.7 years. The rank obtained in the residency entrance exam ranged from 1 to 7000, with a mean of 1635 ± 1632.
The two OSAKA and OSAKA-KIDS questionnaires have some overlapping questions (e.g. question 10 of OSAKA questionnaire and question 8 of OSAKA-KIDS questionnaire). In the OSAKA questionnaire, 80% answered the question correctly, as shown in Table 1 and in the OSAKA-KIDS questionnaire, 73.7% answered it correctly, as shown in Table 2, this difference was not statistically significant.
Table 1.
The number of volunteers who answered each question correctly in the OSAKA questionnaire
| ID | Question | Correct answer (%) |
|---|---|---|
| 1 | Obstructive sleep apnea in women can show only fatigue | 77.9 |
| 2 | Uvulopalatopharyngoplastysurgery is healing for most people with obstructive sleep apnea | 32.6 |
| 3 | The approximate incidence of obstructive sleep apnea among adults is 2 to 10% | 36.8 |
| 4 | Most patients with obstructive sleep apnea have snoring | 67.4 |
| 5 | Sleep apnea is associated with high blood pressure | 78.9 |
| 6 | Overnight sleep tests at the sleep clinic are the gold standard for detecting obstructive sleep apnea | 68.4 |
| 7 | Treatment with CPAP (continuous positive airway pressure) can cause nasal congestion | 16.8 |
| 8 | Laser ovuloplasty is a good treatment for severe obstructive sleep apnea | 16.8 |
| 9 | Loss of upper airway muscle tone during sleep may contribute to obstructive sleep apnea | 74.7 |
| 10 | The most common cause of obstructive sleep apnea in children is the presence of large palatine tonsils and large adenoid | 80 |
| 11 | Examination of the bones of the face, skull, and throat is useful for the evaluation of a person suspected of having obstructive sleep apnea | 75.8 |
| 12 | Drinking alcohol at bedtime can improve obstructive sleep apnea | 60 |
| 13 | Untreated obstructive sleep apnea is associated with an increase in traffic accidents | 77.9 |
| 14 | The neck circumference (43 cm or more) in men is associated with obstructive sleep apnea | 45.3 |
| 15 | Obstructive sleep apnea is more common in women than in men | 33.7 |
| 16 | CPAP is the first line of treatment for severe obstructive sleep apnea | 45.3 |
| 17 | It is normal for adults to have less than 5 apnea or hypopnea | 22.1 |
| 18 | Untreated sleep apnea may be associated with cardiac arrhythmias | 74.7 |
Table 2.
The number of volunteers who answered each question correctly in the OSAKA-KIDS questionnaire
| ID | Question | Correct answer (%) |
|---|---|---|
| 1 | Children with obstructive sleep apnea may present with symptoms of hyperactivity | 66.3 |
| 2 | About 10% of children snore permanently | 28.4 |
| 3 | Almost 2% of children have obstructive sleep apnea | 27.4 |
| 4 | Obstructive sleep apnea in children may be associated with increased pulmonary hypertension | 72.6 |
| 5 | Polysomnography is needed to differentiate early snoring from obstructive sleep apnea syndrome | 74.7 |
| 6 | Snoring severity (from mild to severe) is associated with severity of obstructive sleep apnea in children | 40 |
| 7 | Excessive loss of the airway muscles tone during sleep may help children with obstructive sleep apnea | 64.2 |
| 8 | The large palatine tonsils and the large adenoid are the most common causes of obstructive sleep apnea in children | 73.7 |
| 9 | Children with suspected obstructive sleep apnea should undergo thorough head, neck and throat examinations | 76.8 |
| 10 | Children with untreated obstructive sleep apnea may develop learning disorders | 76.8 |
| 11 | Snoring is most commonly reported at ages 2 to 8 years | 17.9 |
| 12 | Untreated obstructive sleep apnea may be associated with cardiac arrhythmias | 63.2 |
| 13 | Children with sickle cell anemia are at higher risk of obstructive sleep apnea | 23.2 |
| 14 | Children younger than 2 years before surgery for obstructive sleep apnea should be examined by polysomnography | 46.3 |
| 15 | In children without snoring, there may be significant obstructive sleep apnea | 56.8 |
| 16 | Inappropriate growth may indicate obstructive sleep apnea in infants and young children | 69.5 |
| 17 | Children with severe obstructive sleep apnea may experience transient worsening of respiratory symptoms after adenotonsillectomy | 34.7 |
| 18 | Cardiopulmonary monitoring can reliably detect central and obstructive apnea in infants | 12.6 |
The Cronbach's alpha coefficient was 0.80 for the OSAKA questionnaire and 0.9 for the OSAKA-KIDS questionnaire. The overall knowledge score of the OSAKA questionnaire was 9.85 ± 3.9 and for the OSAKA-KIDS questionnaire was 9.2 ± 4.9. The two scores were correlated in Pearson's correlation analysis (p < 0.001). No significant association was found in the analysis of the residency entrance exam rank and OSAKA questionnaire scores in the Pearson test (p = 0.923). No significant association was found in the analysis of the association between the residency entrance exam rank and the OSAKA-KIDS questionnaire in the Pearson test (p = 0.85). Descriptive statistics of the volunteer’s attitude toward obstructive sleep apnea syndrome in pediatrics and adults are summarized in Tables 3 and 4.
Table 3.
Answers to questions about how to attitude toward obstructive apnea in patients < 18 years
| Question | Response | Percentage |
|---|---|---|
| Pediatric sleep apnea obstruction is a clinical disease | Not important | 1.2 |
| A little important | 0 | |
| Important | 45.9 | |
| Very important | 35.3 | |
| Extremely important | 17.6 | |
| Finding children who may have obstructive sleep apnea is important | Not important | 0 |
| A little important | 1.1 | |
| Important | 34.7 | |
| Very important | 38.9 | |
| Extremely important | 14.7 | |
| I have enough confidence to find children who are at risk of obstructive sleep apnea | Completely disagree | 6 |
| Disagree | 25 | |
| Neither disagree nor agree | 47.6 | |
| Agree | 19 | |
| Completely agree | 2.4 | |
| I have enough ability to deal with children with obstructive sleep apnea | Completely disagree | 9.5 |
| Disagree | 40.5 | |
| Neither disagree nor agree | 42.9 | |
| Agree | 7.1 | |
| Completely agree | 0 | |
| I have enough ability to treat children with CPAP | Completely disagree | 22.6 |
| Disagree | 51.2 | |
| Neither disagree nor agree | 25 | |
| Agree | 1.2 | |
| Completely agree | 0 |
Table 4.
Answers to questions about how to attitude toward obstructive apnea in patients > 18 years
| Question | Response | Percentage |
|---|---|---|
| Sleep apnea obstruction is a clinical disease | Not important | 1.2 |
| A little important | 0 | |
| Important | 49.4 | |
| Very important | 37.3 | |
| Extremely important | 12 | |
| Finding children who may have obstructive sleep apnea is important | Not important | 1.2 |
| A little important | 1.2 | |
| Important | 47 | |
| Very important | 37.3 | |
| Extremely important | 13.3 | |
| I have enough confidence to find people who are at risk of obstructive sleep apnea | Completely disagree | 3.7 |
| Disagree | 11 | |
| Neither disagree nor agree | 42.7 | |
| Agree | 39 | |
| Completely agree | 3.7 | |
| I have enough ability to deal with patients with obstructive sleep apnea | Completely disagree | 3.7 |
| Disagree | 30.5 | |
| Neither disagree nor agree | 48.8 | |
| Agree | 15.9 | |
| Completely agree | 1.2 | |
| I have enough ability to treat patients with CPAP | Completely disagree | 23.2 |
| Disagree | 53.7 | |
| Neither disagree nor agree | 19.5 | |
| Agree | 2.4 | |
| Completely agree | 1.2 |
Regarding the source of greatest familiarity with OSA during their study course, 58.9% received information from pulmonary training, 31.6% from ENT, and 8.5% from other specialties or sub-specialties.
In patients under 18 years of age, the most frequent referrals were from otolaryngology specialists (51.2%). Other specialties included pediatricians (26.3%), pulmonary specialists (15%), sleep medicine specialists (6.3%), and others (1.3%), respectively.
In patients > 18 years, the most frequent referral was from ENT, at 50.6%. Other referral sources included pulmonary (37.0%), sleep medicine specialists (11.1%), and other fields (1.2%).
Regarding the number of patients visited per week, 25.3% of participants visited less than 10 patients/week, 20% between 10 and 50 patients, 14.7% between 50 and 100 patients, 7.4% between 100 and 200 patients, and 32.6% more than 200 patients. Of the total number of patients under 18 years, 95.1% of study participants reported that these made up less than 25% of their patients, while and 4.9% reported that these made up 25–50% of those who presented with OSA symptoms.
Regarding patients > 18 years presenting with OSA symptoms, 97.6% reported that these cases made up less than 25% of their patients, while 2.4% reported that these cases made up 25–50%.
In terms of asking about OSA symptoms, 86.7% of volunteers reported that they asked less than 25% of patients, 8.4% between 25 and 50%, 2.4% between 50 and75%, and 2.4% more than 75% of patients.
Regarding questions about OSA symptoms in patients > 18 years, 83.1% of the respondents cited asking less than 25% of patients, 12% between 25 and 50%, 3.6% between 50 and 75%, and 1.2% more than 75%. In terms of treatment of patients with OSA under 18 years of age, 93.8% had offered treatment to less than 25% of patients, 5% between 25 and 50% of patients, and 1.3% over 75% of patients.
In terms of voluntary self-treatment of patients with OSA over 18 years of age, 87.8% reported less than 25% of patients, 11% between 25 and 50% of patients, and 1.2% between 50 and 75% of patients. The first line of treatment for patients under the age of 18 with OSA was weight loss, as 42.1% of volunteers reported. The first line of treatment for patients over 18 years of age with OSA was weight loss, as reported in 76.8% of cases.
There was no significant difference between the number of patients visited per week by physicians volunteering for the residency entrance exam with the OSAKA and OSAKA-KIDS scores (p = 202 for the correlation of the number of patients visited with the overall knowledge score of the OSAKA questionnaire, and p = 0.45for the OSAKA-KIDS questionnaire). There was no relationship between the number of years of graduation from general medicine and the OSAKA-KIDS questionnaire (p = 0.79). There was no relationship between the number of years of graduation from general medicine and the OSAKA questionnaire (p = 0.74). There was no association between volunteers’ age and the knowledge component of the OSAKA questionnaire (p = 0.69). The mean OSAKA score was 10.9 in males and 9.8 in females, which was statistically significant (p = 0.04). The mean OSAKA-KIDS score was 10.3 in males and 9.2 in females, which was not statistically significant (p = 0.12) in the Kruskal–Wallis test. There was no significant relationship between the scores of the attitudes and the knowledge score in the Kruskal–Wallis test.
The only factor which had association with adult patient referral was source of obstructive sleep apnea education during general physician training. In volunteers who had otolaryngology as main source of sleep apnea knowledge during their training 76.9% primary referred to otolaryngologists and in volunteers who had pulmonology as main source of training 40% referred patients for sleep apnea symptoms to otolaryngologist this difference was significant (p < 0.000). The other factors including OSAKA knowledge score, attitude results and the years since graduation had no significant relation with referral preference.
Discussion
OSA is an important disease with various adverse health consequences, including cardiovascular and metabolic ones [4, 5]. However, it has effective treatments, and early diagnosis and treatment can prevent adverse complications. Therefore, it is very important for physicians to understand and treat this disease. The residency entrance exam is one way to get general practitioners into specialist areas. This test is held annually in Iran, and contains questions related to many areas of general medicine. In the past 10 years, only two of the 1500 questions were related to OSA, reflecting the negligence of the examiner towards this disease. The OSA knowledge and attitudes (OSAKA) questionnaire was developed in 2003 by the University of Pennsylvania [20], while another version was developed for children (OSAKA-KIDS) [21].
Across the field, the average score was 13.3 [22], which was much higher than the score for Iranian candidates. There was a significant relationship between the ways of dealing with knowledge scores, but no significant association was found in the present study, which may indicate that this area, despite its importance, has not received appropriate focus in medical education. The original test did not find a relationship between gender and the OSAKA test score, but the present study found that males had a higher score, which may be due to the higher incidence of OSA in males, possibly resulting in more attention outside the educational system. An inverse relationship was originally found between age and work experience with the OSAKA score, but the current study did not find an association. This could be due to the lack of educational improvement for OSA in Iran in recent years.
In a US study performed using the OSAKA Questionnaire in 2013, the mean knowledge score was 65%, or 11.7, indicating a low level of general practitioners' knowledge in Iran, especially given that the present study was for volunteers for the residency entrance exam. Their results were not gender-differentiated (as opposed to the present study) and did not correlate with years of graduation (unlike the present study). In their study, 73.5% of those found people at risk for OSA had a good confidence, 35.4% had enough confidence in the management of obstructive sleep apnea, and 22.1% had confidence in treating patients with obstructive sleep apnea. However, in the present study, the percentages were much lower but with the same decline (42.7, 17.1 and 3.6%) [23, 24].
In a study conducted in Ecuador in 2018, the average new graduate score was 52.1 percent or 9.3, while the average of those who working as physicians was 10.8, which was similar to the results of the present study [25]. In a study conducted in Nigeria 2015 using the OSAKA questionnaire, the mean knowledge score was 7.6, which was lower than the present mean [26]. Regarding treatment, they had similar scores (41%, 16.1%, and 16.8%, respectively, in finding, managing and treating for them, and 42.7, 17.1, and 3.6%, respectively for the present study).
A study published in 2015 showed that the number of patients referred to the general practitioner was proportional to the awareness of the individuals in the OSAKA questionnaire. The score of this group of New York physicians was 14, which was much higher than the present study [27]. In a study conducted in India using the OSAKA and OSAKA-KIDS questionnaires, the knowledge score of OSAKA was 6.828 ± 2.94 and OSAKA-KIDS was 7.578 ± 3.65, which was lower than the present study. The authors called for a change in the educational curriculum [28].
Lack of effective education, leading to improved knowledge and attitude about OSA among our general practitioners preparing for the residency exam, is an important educational issue which should be addressed by different authorities. Including related materials in available educational content and receiving education from well-trained lecturers in the field are highly recommended to improve the current inefficient education regarding OSA. Test-enhanced learning (TEL) is one of this study’s recommendations.
TEL has had a good effect on university education, for example, in improving medical education both before and after graduation, as well as improving long-term information retention. Theories behind TEL suggest that memory is enhanced by stimulating the process of information retrieval [29].
Our study showed that the source of obtaining knowledge about sleep apnea is an important factor from general physician to otolaryngologist. It has been shown that in selected cases sleep apnea surgeries have better survival outcome than CPAP as the compliance of this device is challenging [30]. Therefore, quality of sleep apnea education through all involved specialty during general physician education should be improved and parameters which predict success of oropharyngeal surgeries such as large tonsils should be included for proper patient management.
Limitation of the Study
Due to the stress of the candidates regarding their residency examination, their self-reports may be subject to bias, however, appropriate opportunity was provided for relaxation while waiting to complete the questionnaires.
Conclusion
The results of this study showed that, given the cheapness of TEL and the importance of OSA disease, incorporating questions related to this topic into the residency entrance exam could improve physicians’ knowledge. Furthermore, this study showed that the score obtained in this test was not correlated with the score of OSA knowledge, which underlines this issue. Knowledge of sleep apnea is a problem for both children and adults, and as such, must be included in the current medical education curriculum. It should be also noted that the adequacy of sleep apnea education through all involved specialty during general physician education should be improved.
Acknowledgements
Those who participated in this study are kindly acknowledged. The manuscript has been read and approved by all authors.
Funding
No funds, grants, or other support was received.
Availability of Data and Materials
Data and material of present work are available by Reza Erfanian by email ().
Compliance with Ethical Standards
Conflict of interest
The authors have no conflicts of interest to declare that are relevant to the content of this article.
Footnotes
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Contributor Information
Khosro Sadeghniiat-Haghighi, Email: sadeghniiat@tums.ac.ir.
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Zahra Banafsheh Alemohammad, Email: alemohammadz@sina.tums.ac.ir.
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Reza Erfanian, Email: r_erfanian@sina.tums.ac.ir.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data and material of present work are available by Reza Erfanian by email ().