| Background and Objectionsleep apnea-hypopnea syndrome (SAHS) is a clinical condition identified by recurrent apnea or hypopnea in sleep. There is variety of causes, and the result is intermittent hypoxemia and hypercapnia and sleep disorder. According to the etiology, symptoms, signs, and polysomnography (PSG), SAHS is divided into obstructive sleep apnea hypopnea syndrome (OSAHS) and central sleep apnea hypopnea syndrome (CSAHS).OS AS is a common disorder that affects 2-4% of the adult population in America. Incidence of OSAS in China is around 4%. If unrecognized and untreated, OSAS may cause daytime hypersomnolence, cognitive impairment, systemic hypertension, pulmonary hypertension, myocardial infarction, cardiac arrhythmias, stroke, or increased risk of motor vehicle crashes. OSAS is defined as having five or more apneas-hypopneas per hour of sleep (apnea-hypopnea index, AHI) accompanied by either excessive daytime sleepiness or two or more episodes of choking or gasping during sleep, as well as recurrent awakenings, unrefreshing sleep, daytime fatigue, or impaired concentration or memory. The American Academy of Sleep Medicine classification of OSAS severity considers both AHI (AHI classification:5-15 for mild, 15-30 for moderate and >30 for severe) and degree of daytime sleepiness.In 1836, the British writer Dickens’s described the character of Pickwick in the novel "Pickwick":Obesity, snoring, daytime sleepiness and so on. With the application of EEG in clinical in 1929, and as a measurement for evaluation of sleep in 1937, the mystery of sleep was gradually opened. Aserinsky and EKleitman found rapid eye movement (REM) sleep in 1955. Bickelmann et al. named Pickwick syndrome by Obesity, lethargy, cyanosis, hypoxemia, hypercapnia and polycythemia in 1956. The official reports of sleep apnea syndrome were published in French and German medical journals from 1965. SAHS began to receive the attention of the medical profession.Han Shiyang reported 2 typical cases of obstructive sleep apnea syndrome (OSAS) caused by tonsil and adenoid hypertrophy in 1982. This was the first report of China’s medical staff on the disease. Since then, Chinese scholars began to recognize the disease, especially at the end of 1990s, the subject have been greatly improved. Professionals recognized SAHS was common in male, obesity and elderly. It can cause serious sleep disorder, mainly sleep fragmentation and structure disorder. The symptoms were snoring, apnea in the night of sleep, morning dizziness and daytime sleepiness, seriously affecting the quality of life. The emergence of frequent nocturnal hypoxia, caused a series of pathologic changes, would result in multiple organ damage. The medical personnel found that the characteristic of the disease was high incidence, many complications and long-term harm through long-term observation and verification.OSAS was only introduced as a disease in Chinese medical textbooks for the past ten or more years. Hence, this field of knowledge was not undertaken by many physicians during their undergraduate education. Wang et al. found that anesthesiologists lacked adequate knowledge of OSAS, and had low confidence pertaining to patients with OSAS. Few researchers have focused on the attitude and knowledge of doctors with different specializations towards OSAS, which is the purpose of the current study. There is no existing questionnaire pertaining to this field in China. Thus, we adapted the obstructive sleep apnea knowledge and attitudes (OSAKA) questionnaire developed by Schotland et al., which is a good tool for evaluating a physician’s attitude and knowledge in identifying and managing patients with OSAS.It is useful to first determine the baseline level of familiarity of physicians and specific areas of weakness in a physician’s knowledge base for OSAS in order to develop effective educational strategies.We redesigned the questionnaire based on the current knowledge of physicians towards OSAS and applied it for this current study.Methods and materials1.QuestionnaireA self-reported questionnaire was drafted from the obstructive sleep apnea knowledge and attitudes questionnaire (OSAKA). The questionnaire consisted of three parts. The first section consisted of demographical data, Such as gender, age, title, position, whether having outpatient, professional, hospital level, whether a sleep center was present, et al. The second section consisted of questions associated with attitudes of medical practitioners towards SAHS. It consisted of six problems. ①Do you think snoring may be a disease? ② Are you familiar with SAHS? ③Do you think SAHS need aggressive treatment?@Would you like to learn more about SAHS? ⑤Which department would you like to recommend snoring patients for a consult?⑥Which treatment would you choose? The answer of the first question was yes or no. Question second to fourth and sixth were listed with a five-point Likert scale, which included disagree very much, somewhat disagree, neutral, somewhat agree, agree very much. The answers of question five and six were multiple choices. The third section aimed to assess the knowledge of professionals on SAHS. The questions included risk factors, symptoms, related diseases and treatments. Answer of the treatment problem accorded to the 6th attitude problem. If the selection was 1 or 2 point recorded a negative answer. If you choose 3-5 point recorded a positive answer. There were a number of options in each question, and the answers were multiple choice. The right selection score one point, however the wrong one or the unselected one did not score point. The correct rate= the correct number/standard answer number* 100%.2. Survey sample and procedureIn this study, we investigated a total of 7 hospitals. There were affiliated hospital, general hospital and different levels of hospitals. It covered different levels of medical staff.100 medical staffs were randomly selected in every hospital, which included all clinical professional doctors and nurses, even related to the medical management departments. Uniform questionnaires were mailed to a coordinator in the other six hospitals. All questionnaires were recovered by mail after a month, regardless of whether the questionnaires were completed or not. All questionnaires unified into the computer. No economic incentive was offered in the course of this investigation. The research protocol was approved by the ethics committee of the Mianyang Central Hospital, and all physicians provided informed consent.3.GroupingThe survey groups varied according to different conditions. According to the gender responds were divided into two groups of men and women. According to the occupation, the subjects were divided into two groups of doctors and nurses. From the hospital address, staffs were divided into the south (SYR) or north (NYR) Yangtze River groups. The tertiary hospital (TH) and the lower-level hospital (LLH) were divided from the hospital level. The investigation objects were divided into more than 45 years (>45) and less than 45 years (<45) old according to age. Because the patient contacted with the clinic doctor firstly, so the investigation objects were divided into outpatient (O) group and non outpatient (NO) group. The relevant professionals (RP) group included doctors from the following categories:sleep center, respiratory medicine, neurology, ENT and dentistry. The remaining doctors were included in the non-relevant professionals (NRP) group. According to whether the hospital was presented a sleep center, responds were divided into sleep center (SC) group and non sleep center (NSC) group.4. Statistical analysisData were entered into an SPSS 20.0 dataset. Descriptive statistics was used to describe all respondent characteristics and knowledge. Kruskal-Wallis H was performed to compare differences between different hospitals based on respondent characteristics.Independent sample t test was performed to compare differences of knowledge scores between two groups. ANOVA was performed to compare differences in three groups. Binary logistic regression was used to assess correlations between staffs’ characteristics and the first attitude question. Ordinal logistic regression analysis was used to assess the correlations between the staffs’information and the Likert 5 score questions. All reports were two-tailed P values. Bivariate correlation analysis was performed to assess the relationships between the medical staffs attitude and knowledge.Results1.InformationA total of 630 questionnaires,593 were returned (94.13%). There are 3 questionnaires in which knowledge and attitude is not complete, judged as invalid questionnaires. So 590 valid questionnaires, the effective recovery rate was 93.65%.The respondents were at the age of 34.96+8.89 years old.88 people (14.9%) were older than 45 years, and 502 people (85.1%) were less than 45 year old. There were 299(50.7%)male and 291 (49.3%)female,483(81.9%) doctors and 107 (18.1%) nurses. From the title, there were 227 (38.5%) primary title,205 (34.7%) intermediate grade,158 (26.8%) senior titles, there were 305(51.7%) staffs in SYR group and 285(48.3%) staffs in NYR group,306 (51.9%) in TH group and 284 (48.1%) in LLH group,171 (29.0%) in RP group and 419(71%) in NRP group.223 (37.8%) respondents had outpatient, nearly half of the staffs (312,52.9%)worked in the hospital at where a sleep center was present.There were no significant differences in the distribution of sex (P=0.108), while there were statistically significant in the others between the various hospitals (P=0.000).2. AttitudeMost of the staff (563,95.42%) knew that snoring may be a disease. Binary logistic regression showed that there were significant difference between the groups: the hospital level (B=-1.312, P= 0.012, OR= 0.269), the LLH group thought more that snoring may not be a disease; hospital address (B=1.117, P= 0.044, OR= 3.054), the NYR group thought more that snoring may be a disease; age (B= 3.468, P= 0.001, OR= 32.076), less than 45 years old groups thought more that snoring may be a disease; sleep center (B=-1.380, P= 0.011, OR= 0.252),SC group thought that snoring may not be a disease. There were no significant differences between other groups (P> 0.05).For the question "Are you familiar with SAHS?", Ordinal logistic regression found that there were significant deference in the following groups:according to the hospital address (P= 0.000), according to the occupation (P= 0.000) and by professional (P= 0.002). There were no significant differences in other groups (P> 0.05). According to the estimated parameter, doctors’self-evaluation were more understanding of SAHS (estimate parameters=1.692), while SYR group (estimated parameter=-1.006) and NRP group (estimate parameters=-0.766) were on the contrary.The third question "do you think that the SAHS need aggressive treatment?", Ordinal logistic regression found that there were significant deference in the following groups:according to the hospital address (P= 0.013), according to the occupation (P= 0.000) and by professional (P= 0.003). Others did not have significant differences (P> 0.05). According to the estimated parameter, SYR group (estimated parameter=-0.648) and NRP group (estimate parameters=-0.749) did not recommend SAHS to aggressive treatment, while doctors recommend SAHS to active treatment (estimate parameters=1.117).For the question "Would you like to learn more about SAHS?", Ordinal logistic regression found that there were significant deference in the following groups: according to the hospital level (P= 0.000), according to the hospital address (P= 0.052) and by professional (P= 0.014). There were no significant differences in other groups (P> 0.05). According to the estimated parameter, SYR group recommended to learn more about SAHS (estimate parameters= 0.417), while TH group (estimated parameter=-0.838) and NRP group (estimate parameters=-0.511) were on the contrary.For problems "Which department would you like to recommend snoring patients for a consult? "(answers in multiple choice), most of the medical personnel selected ear, nose and throat (411,71.36%) and respiratory medicine(377,65.59%); nearly half of the medical staff chose sleep center (281,49.32%). At the same time, other professional, such as dental (41,6.95%), Department of Neurology(49,8.31%), Department of Endocrinology(29,4.92%), Department of Cardiology (70,11.86%) and Department of Geriatrics(24,5.76%)were only in about 10%. In addition, sum of the choice of a few departments (e.g. brain surgery, Gastroenterology, Department of Nephrology) were 13.19%.The following were attitude of medical personnel for the treatment of SAHS.There was significant deference in the following groups on weight loss:by age (P= 0.001), by occupation (P= 0.002) and by professional (P= 0.006). According to the estimated parameter, elder respondents (estimate parameters= 0.092), doctors (estimated parameter= 0.890), NSC group (estimate parameters= 0.513) recommended to lose weight more, while NRP group were on the contrary (estimated parameter=-0.673).For the attitude of quit smoking and alcohol, there was significant deference in the following groups:by hospital address (P= 0.001), by occupation (P= 0.051), by professional (P= 0.000) and whether there was present a sleep center (P= 0.040). According to the estimated parameter, doctors (estimated parameter= 0.524), NSC group (estimate parameters= 0.472) recommended to quit smoking and alcohol, while SCR group (estimate parameters=-0.759) and NRP group (estimate parameters =-0.911) were not recommended.For the attitude of avoid fatigue, TH group (P= 0.000. estimated parameter= 0.855), primary title(P= 0.027, estimated parameter= 0.868), Intermediate title(P= 0.036, estimated parameter= 0.592) and NSC group (P= 0.000, estimate parameters = 0.933) agreed avoid fatigue more, while SCR group (P= 0.000,estimate parameters =-1.358) and NRP group (P= 0.001,estimate parameters=-0.664) were not agreed. Others did not have significant deference (P> 0.05)..There was significant deference at the attitude of drugs. TH group (P= 0.000. estimated parameter= 1.256), and NSC group (P= 0.000, estimate parameters= 0.802) agreed more, while SCR group (P= 0.000,estimate parameters=-1.256) were not agreed. Others did not have significant deference (P> 0.05).For the attitude of CPAP, there was significant deference in the following groups: by hospital level (P= 0.027), by hospital address (P= 0.001), by occupation (P= 0.000) and by age (P= 0.008). Elder staff (estimated parameter= 0.008), TH group (estimate parameters= 0.525) and doctors (estimated parameter= 0.000) recommended to CPAP, while SYR group (estimate parameters=-0.741) and NRP group (estimate parameters=-1.104) were not recommended.For the attitude of surgery, there was significant deference in the following groups:by hospital level (P= 0.049), by hospital address (P= 0.008) and by occupation (P= 0.000). TH group (estimate parameters= 0.525) and doctors (estimated parameter= 0.000) recommended to surgery, while SYR group (estimate parameters=-0.741) were not recommended. 3. KnowledgeAverage of Medical personnel’s knowledge question total correct number was 12.31+5.59. The average total correct rate was 45.59%+20.68%. The highest correct rate was the treatment (84.95%+22.57%), others were poor.We compared the average total correct rate of knowledge among groups of medical personnel. There was significant difference in the following group:male was higher than female (P= 0.000). The age> 45 years old group was higher than age< 45 years old group (P= 0.000). The doctor group was higher than that of the nurses group (P= 0.000). The TH group was higher than LLH group (P= 0.000). The NO group is lower than the O group (P= 0.000).The NRP group was lower than the RP group (P= 0.004). The SC group was higher (P= 0.001). The title was higher, the total average correct rate was higher (P= 0.000).The risk factors of SAHS were compared in different grouping. The average accuracy was lower in men than in women (P= 0.001). That of aged over 45 was higher (P= 0.000). The average accuracy of doctor group was higher than that of nurse group (P= 0.000). TH group was more than LLH group (P= 0.000). NO group was lower than that of O group (P= 0.000). The SC group were higher (P= 0.000). The higher title had the higher average accuracy (P= 0.000).The symptoms of SAHS were compared in different grouping. The average correct rate was lower in men than in women (P= 0.013). That of aged over 45 was higher than in less than 45 years old group (P= 0.000). The average accuracy of doctor group was higher than that of nurse group (P= 0.000). TH group was more than LLH group (P= 0.000). NO group was lower than that of O group (P= 0.000). The SC group were higher (P= 0.012). The higher title had the higher average accuracy (P= 0.000). These differences were significant. There were statistically significant differences in different titles (P= 0.000). There were statistical differences by multiple comparison (between primary and secondary, between junior and senior P = 0.000, between intermediate and advanced P= 0.001).The comparison of SAHS related diseases was the following. The average correct rate was higher in men than in women (P= 0.000). The more than 45 years group was higher than less than 45 years group (P= 0.000). The doctor was higher than the nurses (P= 0.000).TH group was more than LLH group (P= 0.000). NO group was lower than that of O group (P= 0.000). The NRP group is lower than the RP group (P= 0.001). Sleep center group was higher than that of non sleep group (P= 0.000). Between different professional title groups the correct rate is higher in higher professional title (between primary and intermediate P= 0.013, between junior and senior, intermediate and advanced P= 0.000). The difference between hospital address groups was not significant (P= 0.577).The comparison of SAHS treatment was the following. The average correct rate of NRP group is lower than that of the RP groups (P= 0.001). The SC group higher than that in NSC group (P= 0.021) and primary title below intermediate title (P= 0.011). There was no statistical significance in other groups.The SYR Group and the NYR group had no statistical significance in the comparison above (P> 0.05).4. The relationship between knowledge and attitudeThe knowledge of the investigated medical personnel about SAHS and their attitude of question second to fourth has positive correlation (r= 0.247, P= 0.000).Conclusion1. Most of the medical staffs realized snoring may be a disease.2. Most of the medical staffs would recommend snoring patients to the ear, nose and throat (ENT), the Department of respiratory medicine for treatment. About half of them would recommend snoring patients to the sleep center for treatment. Of course, there were few staffs recommended to the department which had little relevance.3. The medical staffs who were in the group of doctors, the NYR group and the RP group thought themselves knew SAHS a lot. At the same time, they also believe that the SAHS should be aggressive treated. The staffs who were in the SYR group, the LLH group and the RP group thought medical staffs should study more knowledge of SAHS.4. The choices of the respondents in the treatment of SAHS options were different. The elder medical staffs and them in the doctor group, RP group was not present prefer lose weight. Doctors, the NYR group, RP and agreed quit smoking and alcohol more. The primary and intermediate title respondents and those in the TH group, the NYR group, the RP group and NSC group supported avoid fatigue more. For drug treatment, more staffs in the TH group, the NYR group and NSC group selected. The elder respondents and those in the doctor group, the TH group, the NYR group and RP group agreed CPAP more. The respondents in the doctor group, the TH group and the NYR group agreed operation more.5. The knowledge of treatment of SAHS was mastered better by medical personnel. However the knowledge for the risk factors of SAHS, symptoms and the related diseases was poor. The medical staff among males, doctors, elder, higher titles, higher level of hospital, O group, RP group and SC group, master the SAHS knowledge better. There were no differences of the knowledge of SAHS grasped by medical personnel in different regions.6. The medical staffs with more knowledge of SAHS were more aware of the importance of SAHS and the necessity of the treatment. |
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