Sleep Medicine 14 (2013) 973–977
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Sleep Medicine journal homepage: www.elsevier.com/locate/sleep
Original Article
Attitudes and knowledge about obstructive sleep apnea among Latin American primary care physicians Ivan Cherrez Ojeda a,⇑, Donna B. Jeffe b, Thomas Guerrero c, Ronnie Mantilla d, Ilka Santoro e, Gustavo Gabino f, Juan C. Calderon a, Fernan Caballero g, Jose Mori h, Annia Cherrez i a
Respiralab Research Center Kennedy Hospital, Guayaquil, Ecuador Division of Health Behavior Research, Department of Medicine, Washington University School of Medicine, Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, MO, USA c Mental Health Research Institute /Brown University, Providence, RI, USA d Capital Health Regional Medical Center, Trenton, NJ, USA e Respiratory Division, Federal University of Sao Paulo, Brazil f Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA g Medical Center La Trinidad, Caracas, Venezuela h Department of Allergy and Immunology, Clínica San Borja, Lima, Peru i University of Heidelberg, School of Medicine, Heidelberg, Germany b
a r t i c l e
i n f o
Article history: Received 31 December 2012 Received in revised form 1 June 2013 Accepted 12 June 2013 Available online 22 August 2013 Keywords: Obstructive sleep apnea Attitudes Knowledge Primary care OSAKA questionnaire Validation
a b s t r a c t Objectives: We aimed to evaluate Latin American primary care physicians’ knowledge and attitudes about obstructive sleep apnea (OSA) using a Spanish-language version of the OSA Knowledge and Attitudes (OSAKA) questionnaire and to evaluate its psychometric properties. Methods: We used a cross-sectional survey of general practice physicians in Ecuador, Peru, and Venezuela who completed the Spanish-language version OSAKA questionnaire. Results: Of 684 primary care physicians surveyed, 367 (65%) responded (mean age, 45 years; range, 21– 75 years). Mean total knowledge (proportion of 18 items correctly answered) was 60% (range, 0–100%). Less than half of physicians correctly answered the questions about the association between OSA and hypertension. We found no significant differences in overall knowledge in gender or time since graduation (65 years vs >5 years). Although 73.5% of the physicians felt confident in identifying patients at risk for OSA, only 35.4% felt confident in managing those patients and 22.1% felt confident in managing patients with continuous positive airway pressure (CPAP) therapy. The Spanish-language version of the OSAKA questionnaire had comparable psychometric properties to the English-language version. Conclusions: This Spanish-language version of the OSAKA yielded considerable variance in Spanishspeaking physicians’ knowledge about OSA and confidence in identifying and managing patients with OSA. Focused OSA education for Latin American general physicians is needed. Ó 2013 Elsevier B.V. All rights reserved.
1. Introduction Recognition of obstructive sleep apnea (OSA) as an important health risk factor has grown over the last 20 years [1]. It is estimated that 2–5% of the adult population is at risk for OSA, defined as an apnea-hypopnea index (AHI) >5 events per hour [2–4]. The prevalence of OSA might increase in parallel with the rise in obesity and in a generally longer lifespan [5–7]. A high frequency of sleep-related symptoms has been reported in the general Hispanic population [8].
⇑ Corresponding author. Address: Respiralab Research Center, Kennedy Hospital Delta Seccion, Guayaquil, Ecuador. Tel.: +593 42288450; fax: +593 42288457. E-mail address: icherrez@yahoo.com (I. Cherrez Ojeda). 1389-9457/$ - see front matter Ó 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.sleep.2013.06.005
OSA is an independent risk factor for cardiovascular diseases, depression, and diabetes mellitus [9,10], with a substantial societal economic burden [11]. Following treatment for OSA, healthcare expenditures were found to significantly decrease among patients who were adherent to treatment [12]. Therefore, OSA can lead to a multitude of consequences when left undiagnosed or untreated. Unfortunately, an estimated 82% of men and 93% of women with moderate or severe OSA have remained undiagnosed [13,14], which may be attributed to a lack of sleep health knowledge among patients and also among physicians [15]. Despite the high prevalence and clinical significance of OSA, little is known about primary care Latin American physicians’ ability to identify and manage patients with OSA [16]. The aim of our study was to evaluate the knowledge and attitudes of OSA among Latin American primary care physicians using a Spanish-language
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version of the OSA Knowledge and Attitudes (OSAKA) questionnaire, which was originally developed in the United States [17,18]. We also evaluated the psychometric properties of this Spanish-language version of the OSAKA questionnaire.
In addition to the OSAKA questionnaire, the survey included questions related to age, gender, year of medical school graduation, and years in medical practice. 2.3. Data analysis
2. Methods 2.1. Study design We conducted an anonymous cross-sectional survey of primary care physicians (family practitioners and residents training in this discipline) who were attending scientific medical conferences in six cities, including Quito and Guayaquil, Ecuador (July 2010 to September 2010); Lima, Peru (June 2011); and Caracas, Valencia, and Maracaibo, Venezuela (May 2010 to September 2010). The surveys were administered during international meetings of allergy, asthma, and respiratory medicine in Guayaquil, Lima, and Caracas. In Valencia and Maracaibo, the study was conducted during local conferences about allergy and respiratory medicine. We consulted with our institutional committee who approved the study. After receipt of participants’ verbal consent, the survey was voluntarily completed; no financial incentive was offered.
2.2. Study survey We used the OSAKA questionnaire to measure physician’s knowledge and attitudes about OSA [17,18]. The OSAKA questionnaire was developed and validated in the United States to assess physicians’ knowledge and attitudes concerning the identification and management of patients with OSA [17,18]. We used a rigorous method of validation of the translated version of the OSAKA [19], which we briefly described. Two of the investigators translated the OSAKA to Spanish. Next the Spanish-language version was translated to English by a third investigator who did not know the original version of OSAKA. Then the back-translated Englishlanguage version of the new Spanish-language questionnaire was compared with the original English-language version; each item on the back-translated English-language version was ranked by 30 individuals who were bilingual and independent of the study team for comparability and similarity of interpretability with the same item on the original English-language version. Any translated item with a mean score >3 (seven was the worst agreement and one was the best agreement) was formally reviewed and corrected. The revised item was then translated back to English and compared again with the original English-language version of that item. This process continued until the mean scores for each item indicated a valid version (63 on each of the comparability and interpretability rankings, and preferably <2.5 on the interpretability rankings) [19]. The OSAKA questionnaire consisted of 18 knowledge items and 5 questions related to attitudes about OSA. The knowledge items covered OSA domains, including epidemiology, pathophysiology, symptoms, diagnosis, and treatment. Options for response to the OSAKA knowledge questions were true or false with a third option of do not know, which was scored as an incorrect response. The total knowledge score was computed as the percentage of correct answers to the 18 knowledge questions and ranged from zero to 100%. The first two attitude questions asked about the importance of OSA, and responses were scored on a five-point Likert scale, ranging from one (not important) to five (extremely important). The remaining three attitude questions dealt with one’s confidence in diagnosing and treating patients with OSA, and responses were scored from one (strongly disagree) to five (strongly agree). Mean scores were computed for each of the two attitude scales.
We used descriptive statistics to summarize responses to the individual questions on the OSAKA questionnaire. We used v2 tests to compare proportions across countries, gender, and years in practice after medical graduation (stratified by 65 years after graduation or >5 years). Spearman rank correlation coefficients were used to assess the relationships between the OSAKA knowledge total score and attitudes about sleep apnea. Statistical tests were performed using SPSS version 13 (SPSS, Inc, Chicago, IL, 2000). A P value of less than .05 was considered significant for all tests.
3. Results Of the 684 primary care physicians who received a survey, 367 (65%) returned a completed questionnaire. The mean (standard deviation [SD]) age of respondents was 45 years (SD, 11 years; range, 21–75 years), with 53% being women. The mean (SD) number of years in practice was 18 years (SD, 11 years; range, 0–47 years), with 81% who reported having graduated more than 5 years ago. 3.1. Knowledge The mean total knowledge score (proportion of 18 items correctly answered) was 60.0% (range, 0–100%) among the 367 general practice physicians in our sample, using the Spanishlanguage OSAKA questionnaire compared with 73.4% among the 108 participants in internal medicine, pediatrics, and family medicine in the original study, using the English-language version [17,18]. Mean knowledge scores significantly differed using v2 tests among physicians surveyed in Peru, Venezuela, and Ecuador (Table 1). Cronbach a for the 18 items on the knowledge measure was 0.58 using the Spanish-language version of the OSAKA compared with a of 0.69 reported using binary data of the English-language version [17]. Less than 50% of physicians correctly answered the questions about the association between OSA and hypertension, uvulopalatopharyngoplasty as curative therapy in OSA, continuous positive airway pressure (CPAP) therapy produces nasal congestion, women with OSA may present with fatigue alone, and a collar size of 17 inches or larger is associated with OSA. Less than 30% of the physicians correctly answered that <5 apnea or hypopnea per hour is normal in adults and that laser-assisted uvuloplasty is an appropriate treatment for severe OSA (Table 1). We found no significant differences in overall knowledge in gender or by time since graduation (65 years vs >5 years). There were differences among the participants in the three countries in the proportions of correct answers to specific items about the physician’s knowledge about OSA (Table 1). Lower proportions of physicians in Ecuador compared with physicians in Peru and Venezuela correctly answered the questions about uvulopalatopharyngoplasty being curative therapy for the majority of patients with OSA, the relations between OSA and car accidents, and between OSA and collar sizes of 17 inches or larger. A lower proportion of physicians in Venezuela compared with physicians in Peru and Ecuador correctly answered the question about estimated prevalence of OSA. Lower proportions of physicians in Venezuela compared with physicians in Peru and Ecuador correctly answered the questions about CPAP producing nasal congestion and about the prevalence of OSA. As shown, 5 of the 18
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Table 1 Proportion of correct answers to the knowledge items on the Obstructive Sleep Apnea Knowledge and Attitudes questionnaire, stratified by researched countries (N = 367). OSAKA questions
Total % N = 367
Peru % n = 93
Venezuela % n = 85
Ecuador % n = 189
P value*
1. Women with OSA may present with fatigue alone 2. Uvulopalatopharyngoplasty is curative for the majority of patients with OSA 3. The estimated prevalence of OSA among adults is between 2% and 10% 4. The majority of patients with OSA snore 5. OSA is associated with hypertension 6. An overnight sleep study is the gold standard for diagnosing OSA 7. CPAP therapy may cause nasal congestion 8. Laser-assisted uvuloplasty is an appropriate treatment for severe OSA 9. The loss of upper airway muscle tone during sleep contributes to OSA 10. The most common cause of OSA in children is the presence of large tonsils and adenoids 11. A craniofacial and oropharyngeal examination is useful in the assessment of patients with suspected OSA 12. Alcohol at bedtime improves OSA 13. Untreated OSA is associated with a higher incidence of automobile crashes 14. In men a collar size 17 inches or greater is associated with OSA 15. OSA is more common in women than men 16. CPAP is the first therapy for severe OSA 17. Less than 5 apneas or hypopneas per hour is normal in adults 18. Cardiac arrhythmias may be associated with untreated OSA Mean total knowledge score
91.3 88.8 85.0 85.0 83.4 81.2 77.1 65.1 62.7 59.7 57.8
46.2 51.6 73.1 84.9 58.1 84.9 42.5 22.6 89.2 95.7 88.2
35.3 56.5 37.6 92.9 56.5 71.8 17.6 18.8 87.1 88.2 87.1
43.9 32.8 59.3 88.9 42.3 18.9 36.5 16.4 78.8 90.5 82.5
.28 <.001 <.001 .24 .02 .09 <.001 .45 .05 .18 .38
49.6 43.1 42.5 36.5 34.3 25.3 18.5 60.0
81.7 65.6 38.7 68.8 69.9 31.2 83.9 65.4
83.5 78.8 49.4 69.4 61.2 21.2 88.2 61.2
79.9 54.0 29.6 61.4 54.0 24.3 84.1 54.3
.76 <.001 .006 .30 .04 .27 .64 <.001
Abbreviations: OSAKA, Obstructive Sleep Apnea Knowledge and Attitudes questionnaire; OSA, obstructive sleep apnea; CPAP, continuous positive airway pressure. Pearson v2 tests for comparisons of rates among the three surveyed countries.
*
items were correctly answered by less than 50% of participants across all three of the studied countries. Only a few of the knowledge items significantly differed by number of years since medical school graduation. Among physicians in Peru, a greater proportion of physicians who graduated 65 years ago correctly answered that laser-assisted uvuloplasty is not an appropriate treatment for severe OSA compared with the proportion of those >5 years after graduation (83.3% vs 46.9%; P = .018). Among physicians in Venezuela, a greater proportion of physicians who graduated >5 years ago correctly answered that a collar size of 17 inches or larger is associated with OSA in men (55.2% vs 23.5%; P = .020). Among physicians in Ecuador, a greater proportion of physicians who graduated >5 years ago correctly answered the three questions related to laser uvuloplasty (18.8% vs 0%; P = .009), loss of upper airway muscle tone during sleep contributing to OSA (81.9% vs 63.0%; P = .026), and alcohol at bedtime not improving OSA (81.9% vs 63.0%; P = .026), compared with physicians who graduated 65 years ago. However, total knowledge scores did not significantly differ in number of years after medical school graduation (65 years vs >5 years).
3.2. Attitudes Among all respondents, 71.7% answered that OSA was an important or an extremely important clinical disorder, and 73.3% reported identifying patients at risk for OSA was important or extremely important. In addition, 73.5% of all physicians felt confident in identifying patients at risk for OSA. However, only 35.4% felt confident in managing patients with OSA, and only 22.1% felt confident in managing patients with CPAP therapy. Principal components analyses of the five attitude items resulted in two factors, and we compared our findings with the findings reported using the original English-language version [17]. The internal consistency of the two-item factor pertaining to the importance of OSA and its diagnosis was high, with a Cronbach a of 0.86 (original version, a = 0.92); this factor was similar in the internal consistency of the three-item factor pertaining to physician confidence in identifying and managing patients with OSA, with a Cronbach a of 0.74
(original version, a = 0.75). We also ran a factor analysis forcing all five items on one factor, and our Cronbach a for these five items was 0.69 (original version, a = 0.79). Spearman rank correlations between knowledge total score and each of the attitudes items were low (Table 2).
4. Discussion OSA remains a highly underdiagnosed condition in the general population. Furthermore, most primary care providers do not systematically screen patients for OSA and fail to identify comorbidities in high-risk patients [20,13,21]. In our study, we sought to evaluate a Spanish-language version of the OSAKA questionnaire [17] using a rigorous method of validation described by Sperber [19]. We surveyed Latin American primary care physicians in three South American countries regarding their knowledge of OSA and its treatment and their attitudes about the importance of OSA and their confidence in being able to identify and manage patients with OSA. Our results should be interpreted within the context of medical education of primary care physicians and with the consideration of how the survey was developed and validated. Not only did we follow a rigorous procedure outlined by Sperber [19] for validating a translated version of a previously developed questionnaire, we also ran psychometric tests on the measures to compare with reliability statistics reported by Schotland and Jeffe [17]. About one-third of the knowledge items, especially knowledge about epidemiology, diagnosis, and treatment of OSA, were incorrectly answered by more than 50% of all general practice physician respondents, regardless of the country where they were surveyed. This finding indicates that both undergraduate and graduate medical education coursework and clinical experiences should be developed to augment training in the identification and management of patients with OSA. However, more than 70% of surveyed physicians felt confident in being able to identify patients at risk for OSA, though only 35% felt confident in managing patients with OSA. The low correlation between knowledge and confidence in managing patients with OSA could reflect some self-protection bias in physicians’ reporting about their confidence.
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Table 2 Spearman correlation coefficients among mean scores of each attitude item, each attitude subscale, and total knowledge on the Obstructive Sleep Apnea Knowledge and Attitudes questionnaire. 1
2
Importance of 1. OSA as a clinical disorder 2. Identifying patients with OSA 3. Importance of subscale score
3
4
5
6
– .76à .95à
.92à
Confidence in 4. Identifying at-risk patient 5. Managing patients with OSA 6. Managing patients on CPAP 7. Confidence subscale score
.26à .12* .04 .16
.26à .09 .00 .13*
.27à .11* .02 .15
.50à .35à .73à
.59à .87à
Total attitude and knowledge scores 8. Overall attitude score 9. Overall knowledge score
.81à
.55à .22à
.52à .17
.56à .21à
.72à .25à
.76à .25à
.66à .15
7
8
.89à .27à
.32à
9
Abbreviations: OSA, obstructive sleep apnea; CPAP, continuous positive airway pressure. * P < .05. P < .01. à P < .001.
The Cronbach a for the Schotland and Jeffe [17] data was .69 using binary (correct/incorrect) responses to the 18 items. The Cronbach a was .58 for the Spanish-language version of the OSAKA using the binary data. Because we measured knowledge about OSA, we could not expect to observe similar values across studies for Cronbach a, which measures internal consistency of items on a continuous measure and may be affected by the difficulty of the test, the spread in scores, and the length of the examination. We would not be expected to observe a similar Cronbach a for knowledge if one sample had higher knowledge scores than another sample, which is what we observed when we compared the knowledge scores for the Schotland and Jeffe [17] sample and for our Latin American sample of physicians. The internal consistency of items on this measure of knowledge also might have been affected by characteristics of the testing situation (e.g., completion of a mailed survey in private [17] compared with completion at a busy conference with potential distractions) or by characteristics of the individual (e.g., fatigue, memory, attention). The correlations between knowledge and importance of OSA also were low and insignificant, which is similar to findings reported in the original paper [17]. Because the Cronbach a for the two attitudinal subscales (i.e., importance a = .86 and confidence a = .74) were higher than the five-item factor (a = .69), we recommend only using the two separate attitudinal subscales for future research using the Spanish-language version of OSAKA, as the two subscales measure different constructs which are not highly correlated. OSA is a risk factor for arterial hypertension; knowledge of this risk was correctly reported by only approximately 50% of the physician participants in our study. This lack of physician knowledge about an important clinical outcome of OSA could affect the diagnosis of arterial hypertension and increase the risk for later complications. A large proportion of general practice physicians who were surveyed also believed that laser uvuloplasty was curative for severe OSA, which is incorrect. Such beliefs could possibly delay referral of patients to a specialist to initiate CPAP, which is the preferred treatment for patients with severe OSA. Therefore, the challenge for general physicians is not only to learn how to detect OSA in patients who are at high risk for OSA, but also to either initiate treatment or to refer these patients to specialists for further examination and treatment. There also were differences in knowledge in the country where among physicians were surveyed, with physicians surveyed in Peru having higher total knowledge scores, especially in epidemiology and adverse reactions from CPAP treatment compared to
physicians surveyed in Ecuador and Venezuela. It is unknown if these differences in knowledge reflect differences in OSA education in these three countries, as conference attendees were from various countries. Other studies have demonstrated that older physicians reported lower adherence to treatment guidelines for patients with diabetes mellitus [22], and another study found a negative correlation between years in practice and OSA knowledge using the OSAKA [17]. However, we found no significant difference in total OSA knowledge by years in practice (65 vs >5 years since graduation) in our study. This phenomenon among the countries surveyed in our study may reflect a lack of adequate information regarding sleep disorders at the undergraduate and graduate medical education levels. In addition, it also may reflect that this problem is the same across countries. We believe that Latin American medical schools and residency programs need urgent attention to improve general practice physicians’ knowledge of OSA to improve diagnosis and treatment of this condition. Inadequate training among the primary care residency programs underlies the low levels of knowledge of the diagnosis and treatment of OSA [23]. Knowledge scores were somewhat lower in our study than in the original OSAKA study [17], with a mean 60.0% correct in our study compared with a mean 73.4% correct using data from the original study (percentage previously unpublished). This Spanish-language translation of the OSAKA questionnaire was developed to help evaluate an educational intervention for residents who are trained in the diagnosis and treatment of OSA, and it will be used to evaluate the results of our training program. In addition, the OSAKA questionnaire can be used to explore the knowledge of students who finish their medical education to detect if there is a low knowledge about OSA among recent medical graduates, and these results also could influence the development of sleep education programs at the level of undergraduate medical education. Our study had some limitations. First this was a cross-sectional survey of general practice physicians attending conferences in three South American countries. Thus, we cannot infer causation from any of the associations we observed, and we also cannot generalize our results to Spanish-speaking physicians practicing in other countries, as medical education about OSA might differ in other Spanish-speaking countries in important ways. Indeed, we observed significant differences in knowledge among physicians surveyed in three Latin American countries in our study. Whether or not physicians in other countries report similar or different levels of knowledge about OSA using the OSAKA compared with
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physicians surveyed here is an empirical question which requires further study. In addition, the general practice physicians who travel to medical meetings are likely to routinely attend educational programs, and therefore these physicians might have more updated medical knowledge than the larger group of general practice physicians practicing in the community who do not attend continuing medical education meetings. Thus, knowledge about OSA in the larger population of general practice physicians is likely to be even lower than the knowledge reported on our survey of medical conference attendees. Another limitation is that 81% of the physicians in our sample reported graduating >5 years ago; therefore, we should be cautious in generalizing our results to physicians with fewer years in practice after graduation. One respondent who reported to be 21 years of age may have been a student; however, we included this individual’s data in the analysis, because dropping these data from the analysis would not alter the direction or significance of our findings. Additionally, even though knowledge scores differed among the three countries, we cannot infer that doctors who attended a conference in a particular country were from that country or that they received their medical education in the country where the conference took place. Future studies are needed to determine the validity and reliability of our translated OSAKA questionnaire in Latin American and other Spanish-speaking physician populations. Incorporating OSA-focused educational interventions during medical school and residency training programs should help to improve physicians’ knowledge about OSA as well as the detection and treatment. Latin American pulmonology societies should offer sleep disorder sessions at continuing medical education conferences and create OSA education programs for general physicians such as those that currently exist for asthma or chronic obstructive pulmonary disease. Conflict of interest The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2013.06.005.
Acknowledgment We express our gratitude and acknowledgment to MECOR-ATS Program Director A. Sonia Buist M.D, MECOR Latin-American Program Director Ana Maria Menezes M.D.; and the MECOR Faculty: Sandra Wilson, PhD; Bill Vollmer, PhD; Juliana Ferreyra M.D; and David Gonzalez PhD for their contribution to the development of the study. We want to thank to Dr. Edwin Soria and Dr. Luis Espinoza from Southern Medical Corporation (CorpSur) for their support in data collection as well as Andrea Fernandez, Gabriela Sanchez, Jazmin
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