|Year : 2019 | Volume
| Issue : 8 | Page : 648-652
Obstructive sleep apnoea and its knowledge and attitude among Indian anaesthesiolgists – A survey study
Sohan Lal Solanki, Nupur Karan, Swapnil Y Parab
Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
|Date of Web Publication||9-Aug-2019|
Dr. Sohan Lal Solanki
Department of Anaesthesiology, Critical Care and Pain, 2nd Floor, Main Building, Tata Memorial Centre, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
Background and Aims: Obstructive sleep apnoea (OSA) has an estimated prevalence of 2%–4% in adult population and is increasing. Most of these are detected late which is the cause for higher perioperative morbidity. This survey was aimed to seek the level of knowledge and attitude of Indian anaesthesiologists towards OSA. Methods: The OSA Knowledge and Attitude (OSAKA) questionnaire (23-statements) was distributed to the anaesthesiologists attending the difficult airway conference in December 2017. The first section has 18 statements pertaining to OSA knowledge. The second section consists of five statements to evaluate self-confidence in the management of OSA. Age, gender, professional title, type of hospital, years of experience, and bariatric experience were analysed. Results: 205 out of 350 participants responded. In all, 201 (57.4%) fully completed responses were analysed. The mean ± standard deviation knowledge and attitude scores were 12.01 ± 2.88 (66.72% ± 16%) and 18.16 ± 3.75 (72.64% ± 15%) respectively. On exclusion of junior residents (n = 56), knowledge and attitude scores of qualified anaesthesiologists were 12.7 ± 2.55 (70.55% ± 14.16%) and 18.78 ± 3.91 (75.12% ± 15.64%), respectively. Anaesthesiologists with bariatric experience had a significantly higher attitude score when compared with those who do not practice bariatric surgeries (P < 0.01). There is weak but significant, positive linear correlation between knowledge and attitude score (rs= 0.370, P < 0.01). Conclusion: Deficit of adequate knowledge about OSA exists among Indian anaesthesiologists. Experience of managing cases with OSA seems to improve knowledge and attitude towards OSA.
Keywords: Anaesthesiologists, attitude, obstructive, sleep apnoea, surveys and questionnaires
|How to cite this article:|
Solanki SL, Karan N, Parab SY. Obstructive sleep apnoea and its knowledge and attitude among Indian anaesthesiolgists – A survey study. Indian J Anaesth 2019;63:648-52
|How to cite this URL:|
Solanki SL, Karan N, Parab SY. Obstructive sleep apnoea and its knowledge and attitude among Indian anaesthesiolgists – A survey study. Indian J Anaesth [serial online] 2019 [cited 2019 Oct 15];63:648-52. Available from: http://www.ijaweb.org/text.asp?2019/63/8/648/264193
| Introduction|| |
Obstructive sleep apnoea (OSA) is a growing disorder in modern society. Community-based epidemiological studies from several parts of India have estimated that the prevalence of OSA is 2.4%–4.9% in men and 1%–2% in women. Increasing incidence of obesity can further swell up the population suffering from OSA. It has been demonstrated that the incidence is substantially higher in the bariatric surgery patients (up to 70%). A large group of patients with moderate or severe OSA may remain undiagnosed and untreated due to lack of awareness among the patients and their physicians. Stigma associated with snoring and poor availability of centres doing polysomnography studies are other factors which make the diagnosis of OSA difficult. Untreated OSA can lead to multiple cardiovascular, neurological and haematological complications, and make these patients prone to perioperative complications. To standardise the management of patients with OSA, the American Society of Anesthesiologists has issued guidelines for intraoperative management of OSA in 2006.
Studies have suggested that educational interventions for physicians are needed to improve the identification and treatment of patients with OSA., With an intention to develop the educational strategies for physicians, Schotland and Jeffe developed Obstructive Sleep Apnoea Knowledge and Attitude (OSAKA) questionnaire [Appendix]. Before this questionnaire was developed, there was only one survey instrument – 'ASK ME' which did not focus on OSA particularly. Data obtained from the response of 115 out of 236 physicians in Washington University Physicians Network were used to formulate OSAKA questionnaire. This questionnaire was then used in various countries to objectively assess the knowledge and attitude of physicians towards OSA. In India, with increasing population and incidence of obesity, anaesthesiologists are likely to encounter the patients with OSA more frequently in their practice. Hence, we conducted this survey to assess the knowledge and attitude of Indian anaesthesiologists towards cases with OSA.
| Methods|| |
This survey protocol was exempted from review by Institutional Ethics Committee of Tata Memorial Centre Mumbai – India (IEC/1117/1985/001, dated November 21st, 2017). This survey study was conducted in accordance with the principles of Declaration of Helsinki 2013. The printouts of OSAKA questionnaire were distributed to the Indian anaesthesiolgists (faculty and delegates) attending Tata Memorial Centre – Difficult Airway Conference (TMC-DAC) in December 2017. This was a national-level conference attended by the anaesthesiologists from all over India. A priori written informed consent was not taken. Successful filling and returning of the questionnaire was considered as consent for participation in the survey. Participants consisted of trainee junior residents, doctors working in teaching institutes, government hospitals, private hospitals, and freelance anaesthesiologists.
The OSAKA questionnaire is a self-administered 23-item questionnaire. It takes less than 10 minutes to be completed. The first section has 18 statements covering five domains: (1) epidemiology, (2) pathophysiology, (3) symptoms, (4) diagnosis and (5) treatments pertaining to OSA knowledge. Knowledge items are in a true-or-false format along with 'do not know' choice as a third response to minimise the effect of guessing. It is scored as an incorrect response during the response rate calculations. Each correct answer was given a score of 1. Incorrect answers and questions which were not attempted were scored as zero. A total of 18 questions are there in first section with a maximum score of 18 and lowest score of zero. A high score indicates more knowledge and low score indicates lack in knowledge about OSA and its management.
The second section consists of five statements: two statements regarding the importance of identifying patients with OSA before anaesthesia and three statements to evaluate the service providers' self-confidence in the management of patients with OSA during the perioperative period. The response to attitude questions was measured on a 5-point Likert scale, ranging from 1 to 5 (1 = strongly disagree; 2 = disagree; 3 = neither agree nor disagree; 4 = agree; and 5 = strongly agree). It carries a maximum score of 25 and lowest score of 5. A high score indicates more confidence and attitude and low score indicates lack in confidence about OSA identification and its management among anaesthesiologists.
Demographic data included age, gender, professional title (professor, associate professor, assistant professor, senior resident, trainee junior resident or freelance consultant anaesthesiolgist), type of hospital (teaching hospitals/institutes or non-teaching hospitals) and number of years of practice after post-graduation.
Data were presented using descriptive statistics. Wilcoxon–Mann–Whitney U-test was used to assess the significant differences in total knowledge and attitude scores between the anaesthesiologist's gender, age, professional title and number of years in practice. Rank analysis of covariance (ANCOVA) was also applied to verify the eventual significant difference in the attitude score and anaesthesiologist's characteristics. P values below 0.05 were considered statistically significant. Spearman's correlation was used to calculate the correlation between knowledge and attitude score.
| Results|| |
Out of 350 distributed copies of OSAKA questionnaire, 205 responses were collected. Four out of 205 responses were excluded because those were incompletely filled. Thus, we had a response rate of 57.4% (201/350), and we assumed that a response rate of >50% is reliable.
Demographic data including age, gender, professional titles and number of years of anaesthesia practice are shown in [Table 1]. The mean and standard deviation (SD) knowledge score (%) was 12.01 ± 2.88 (66.72% ± 16%). The mean and SD attitude score was 18.16 ± 3.75 (72.64% ± 15%). None among the 201 participants was able to correctly answer the entire set of 18 knowledge statements. The mean and SD of the total score obtained for the domains of epidemiology, pathophysiology, symptoms, diagnosis and treatment of OSA were 1.68 ± 0.87, 3.18 ± 0.88, 3.07 ± 0.93, 2.05 ± 0.95 and 2.02 ± 1.05 respectively [Table 2]. Anaesthesiologists with bariatric surgery experience had a higher mean percentage knowledge score (72.61±12.72 vs 69.61±17.66) than their counterparts although the difference was not statistically significant (P = 0.24) but they had a significantly higher attitude score (80.08±15.12 vs 72.88±15.44, P=0.01) than anaesthesiologists with no experience of bariatric surgeries [Table 3]. There is no difference in percentage knowledge and attitude scores between male and female anaesthesiologists and anaesthesiologists from teaching or non-teaching hospitals. ANCOVA rank analysis confirmed statistically significant difference in knowledge (P < 0.01) and attitude score (P < 0.01) of different professional titles.
|Table 3: Knowledge and attitude score analysis in qualified anaesthesiologists and junior trainee residents|
Click here to view
Since 27% of our participants in this survey were trainee students of anaesthesiology, we did a separate analysis of qualified anaesthesiologists excluding the trainee residents. The mean percentage knowledge and attitude scores of trainee students were significantly less than those of qualified anaesthesiologists [Table 3]. Among qualified anaesthesiologists, the mean and SD knowledge score was 12.7 ± 2.55 (70.55% ± 14.16%). The mean and SD attitude score was 18.78 ± 3.91 (75.12% ± 15.64%). Among the qualified anaesthesiologists, the differences in the knowledge and attitude scores according to age and number of years of practice were found to be non-significant. The results of the subset analysis are shown in [Table 3].
There is weak but significant, positive linear correlation between knowledge and attitude score among the Indian anaesthesiologists (rs= 0.370, P < 0.01) [Figure 1].
| Discussion|| |
An important finding of this survey is the deficit in the knowledge about OSA among anaesthesiologists with special interest in difficult airways. Also, trainee students of anaesthesiology were found to have significantly less scores than qualified anaesthesiologists. Anaesthesiologists with higher experience and higher professional titles were found to have better knowledge and attitude towards OSA. To our knowledge, this is the first survey of knowledge and attitude towards OSA among Indian anaesthesiologists. Similar surveys had been conducted among anaesthesiologists and physicians regarding awareness about OSA in other parts of the world.,
Corso et al., by a similar survey, demonstrated deficit of knowledge about OSA and its treatment among Italian anaesthesiologists. When compared with a survey by Corso et al., participants in our survey were comparatively young in age (mean age: 36 vs 45 years) and experience (median 8 vs 15 years). The mean knowledge score of Indian anaesthesiologists was better than that of Italian anaesthesiologists. The percentage of correct responses given by the Indian anaesthesiologists participating in this survey was similar to the Italian survey (66%) and slightly better than the survey by Wang et al. (62%). Erbaş et al. did OSA survey by asking a different set of questions among 134 Turkish anaesthesiologists and found that although 97% of anaesthesiologists felt that the diagnosis of OSA is important, only 53% of anaesthesiologists were found to be confident of recognising patients with OSA. As compared with Turkish anaesthesiologists, percentage knowledge about OSA diagnosis and management domains were 68% and 50.5%, respectively, in Indian anaesthesiologists.
When compared with anaesthesiologists, practitioners from other specialties were found to have better knowledge with an average of knowledge responses of 76% in the Schotland and Jeffe survey, 78% among family practitioners, 79% in cardiologists and internists and 67% for paediatricians. These results could have been because of better training programs and frequent encounters with patients having OSA in the clinical practice and higher number of OSA-related publications in various specialties other than anaesthesiology.
In our survey, trainee students were found to have significantly less knowledge and attitude scores than qualified anaesthesiologists. With increase in age, experience and higher professional titles, the knowledge and attitude towards OSA improved. In addition, those who practice anaesthesia for bariatric surgery were found to have better attitude towards OSA than those who do not practice anaesthesia for bariatric surgeries. These results show that Indian anaesthesiologists gain knowledge of OSA out of their professional experience and practice. The formal education regarding the diagnosis and management of OSA during post-graduation training in anaesthesiology seems lacking. Teaching time for sleep disorders and its perioperative management during anaesthesia residency training program is not known. Students in anaesthesiology do not get formal training about OSA in their curriculum. As a result, trainee students have poor knowledge of OSA and this reflects in their poor attitude scores as well.
To nullify the effect of trainee students on overall knowledge and attitude score, we performed a subgroup analysis of qualified anaesthesiologists excluding trainee students. In this analysis, differences in the knowledge and attitude scores according to age and number of years of anaesthesia practice were found to be non-significant. No difference in the knowledge and attitude scores was found between genders. Good performance was noticed in the Indian anaesthesiologists in the 'attitude' questionnaire. This is in contrast to the findings of Corso et al. where significant difference in the attitude score between gender and professional title was found, indicating that care givers overestimated their ability.
Anaesthesiologists with better knowledge of OSA are more confident in managing such patients. This is suggested by the positive correlation between knowledge and attitude score. However, it was interesting to note that more than 50% of respondents in our survey were confident in managing patients with OSA but performed averagely in the treatment domain of the knowledge questionnaire. Efforts like pre- and post-seminar/conference questionnaire would help them understand the situation better.
A similar survey among Italian anaesthesiolgists suggested that inclusion of the 'STOP-BANG questionnaire' in the Operating Room Checklist would improve awareness of anaesthesiologists towards OSA. We agree with this suggestion to improve awareness on OSA among Indian anaesthesiologists. In addition, we suggest the allocation of dedicated hours to training about OSA in the resident's teaching schedule. Teaching modules for trainees and other practicing anaesthesiologists can be introduced in various national-, regional- and local-level academic meetings and pre- and post-teaching questionnaire can help monitor progress.
The limitation of this survey is small sample size as the estimated number of total anaesthesiologists in India is greater than 30,000. However, this survey was conducted in a national conference focussing on difficult airway and was likely to capture practitioners with special interest in difficult airway. We cannot exclude the influence of peers in answering the questionnaire. Also, this is a self-report survey and is subject to systemic bias.
| Conclusion|| |
Deficit of adequate knowledge about OSA exists among Indian anaesthesiologists. Experience of managing cases with OSA seems to improve knowledge and attitude towards OSA.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Appendix|| |
OSAKA questionnaire can be reached at: Schotland HM, Jeffe DB. Development of the obstructive sleep apnea knowledge and attitudes (OSAKA) questionnaire. Sleep Med 2003;4:443-50. https://doi.org/10.1016/ S1389-9457(03)00073-X.
| References|| |
Sharma SK, Katoch VM, Mohan A, Kadhiravan T, Elavarasi A, Ragesh R, et al
. Consensus and evidence-based Indian initiative on obstructive sleep apnea guidelines 2014 ( first edition). Lung India 2015;32:422-34.
] [Full text]
Osman AM, Carter SG, Carberry JC, Eckert DJ. Obstructive sleep apnea: Current perspectives. Nat Sci Sleep 2018;10:21-34.
Memtsoudis SG, Cozowicz C, Nagappa M, Wong J, Joshi GP, Wong DT, et al
. Society of anesthesia and sleep medicine guideline on intraoperative management of adult patients with obstructive sleep apnea. Anesth Analg 2018;127:967-87.
Wang CL, Li XZ, Cai XL, Pan XL, Min J. Anesthesiologist's knowledge and attitudes about obstructive sleep apnea: A survey study. Sleep Breath 2012;16:41-6.
Southwell C, Moallem M, Auckley D. Cardiologist's knowledge and attitudes about obstructive sleep apnea: a survey study. Sleep Breath 2008;12:295-302.
Schotland HM, Jeffe DB. Development of the obstructive sleep apnea knowledge and attitudes (OSAKA) questionnaire. Sleep Med 2003;4:443-50.
Corso RM, Sorbello M, Buccioli M, Carretta E, Nanni O, Piraccini E et al
. Survey of knowledge and attitudes about obstructive sleep apnoea among Italian anaesthetists. Turk J Anaesthesiol Reanim 2017;45:146-52.
Erbaş M, Kiraz HA, Şimşek T, Şahin H, Toman H, Hancı V. Turkish anaesthesiologist's experiences of anaesthetic management of patients with obstructive sleep apnea (OSA). Turk J Anaesthesiol Reanim 2015;43:253-62.
Cherrez Ojeda I, Jeffe DB, Guerrero T, Mantilla R, Santoro I, Gabino G, et al
. Attitudes and knowledge about obstructive sleep apnea among Latin American primary care physicians. Sleep Med 2013;14:973-7.
Tamay Z, Akcay A, Kilic G, Suleyman A, Ones U, Guler N. Are physicians aware of obstructive sleep apnea in children? Sleep Med 2006;7:580-4.
Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro C, Sun Y. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth 2012;108:768-75.
[Table 1], [Table 2], [Table 3]