The evaluation of primary care physicians' knowledge on common respiratory diseases: Findings of Action Now Study: an online survey of primary care physicians in China


 Background

Primary care plays an important role in the management of respiratory diseases and primary care physicians’ ability is the cornerstone.
Methods

An e-questionnaire was distributed to attendees of respiratory diseases academic conferences in China from July, 2017 to December, 2018 to assess primary care physicians’ knowledge level of asthma, CAP, COPD and influenza in China.
Results

The feedback rate was 100%, including 4815 valid questionnaires, 3802 (79.0%) from community hospitals and 1013 (21.0%) from township hospitals. The average score of the questionnaire was 83.31(± 20.397) and 72.12(± 20.898) in township and community hospitals (P༜0.05), respectively. 61.4%, 48.7% and 42.5% of the primary care physicians were aware of clinical manifestations of COPD, asthma and simple influenza. 85.7%, 8.1%, 16.1% and 1.0% knew how to diagnose COPD, asthma, CAP and influenza, respectively. 94.4% of the physicians didn’t know bronchodilators for COPD; 53.7% knew non-pharmacological treatments for COPD. 73.6% were unable to deal with asthma attacks. 65.1% didn’t know what the most essential and important treatment for influenza was. 92% physicians didn’t know the management for stable COPD; 3.0% knew all prevention and management measures for asthma. 37.9% knew all the preventive measures for CAP. 44.9% didn’t know the important role of influenza vaccine in preventing influenza and its complications.
Conclusions

Primary care physicians in China had a poor knowledge on asthma, CAP, COPD and influenza, but township hospitals physicians had a better knowledge than community hospitals physicians.


Introduction
Respiratory diseases are the most common diseases in China [1] and large amount of medical and societal resources have been spent on these diseases. On the one hand, there is a tremendous population of chronic non-communicable respiratory diseases patients. It estimated that there were 99 million patients with chronic obstructive pulmonary disease (COPD) [2] and 43.7 million patients with asthma [3] in China, with an impressed prevalence of 13.7% [2] and 4.3% [3] , respectively. On the other hand, the incidence and mortality of acute communicable respiratory diseases are also rising yearly in China. The incidence of in uenza has increased from 14.9381/100,000 in 2009 to 33.0994/100,000 in 2017; the excess mortality of all causes caused by in uenza was (6.94-17.2)/100,000 [4] . What's more, in uenza virus ranks rst among viruses caused community-acquired pneumonia(CAP) [5] . In recent years, China has even experienced several out-breaks of in uenza and the increasing excess mortality of in uenza caused some kind of social panic [6,7] .
Although township hospitals are superior medical institutions of community hospitals, both of them are representatives of primary care institutions in China [8] . They are the rst line in management of respiratory diseases and primary care physicians' ability is the cornerstone. In the ghting against COVID-19, primary care in China have made great contributions, and they can play a more important role in the management of common respiratory diseases. National strategies [9,10] have been released to promote and enhance the development of primary care. Meanwhile, guidelines for management of CAP [5,11] and in uenza [12] in primary care are updated as conditions changing. Furthermore, chronic respiratory diseases' prevention and treatment is one of the major actions of Healthy China 2030 Action Plan [13] .
To help strategies fully implemented, the current management ability of primary care physicians on respiratory diseases should be assessed. In order to solve the pivotal problems in management of respiratory diseases in primary care and to optimize the capacity building of primary care physicians, the Chinese Alliance for Respiratory Diseases in Primary Care (CARDPC) was founded in 2015. The role and responsibility of the alliance is to promote the standardized management procedures of common respiratory diseases in primary care by providing systematically training, developing and disseminating guidelines of common respiratory diseases for primary care [14] . Since the establishment of the organization, besides annual conferences, CARDPC has undertaken a series of efforts to improve the ability of primary care physicians to manage common respiratory diseases, including Action Now program.
Action Now stands for "Assessment of CAP, asthma, in uenza, and COPD knowledge", a national survey conducted from 2017 to 2018 aiming at comprehensively exploring the knowledge of these four common respiratory diseases among primary care physicians in China. An underlying objective is to identify primary care physicians' knowledge weak areas in current primary care practice and use the ndings to design further education programs.

Methods
The cross-sectional online survey was conducted by electronic questionnaire. A QR-Code and web link of the questionnaire were created by Wenjuanxing, a research consultancy specialising in online research. People visited the questionnaire by scanning the QR-Code via the prominent social APP Wechat or by clicking the web link on laptop. The questionnaire (online supplementary le 1) was administered to attendees of the conferences hold by CARDPC across the country. Participation was by choice of the individual. Attendees who agreed to take part in the survey were only able to complete the questionnaire once under the guidance and supervision of the on-site investigators and then submitted on-line. All respondents were anonymized. Data collection continued from July, 2017 to December, 2018, the questionnaire was available at any time during this time period.
The questionnaire consisted of two parts, demographic characteristics information and knowledge survey questions. Demographic characteristics included gender, age, education level, number of experiences years, current vocational title, specialty, region, and grade of institutions. Knowledge survey questions were assessed using items adapted from the relevant guidelines [5,12,15,16] and focused on four core aspects: (1) epidemiology and clinical characteristics/features; (2) diagnostic criteria; (3) treatment; (4) preventive measures. Open questions were also used to explore their needs of training for the four diseases, and the results would be reported in another paper in the near future. Descriptive statistics were used to present demographic characteristics of respondents. Continuous variables were expressed as the mean ± standard deviation, and categorical variables were presented as relative frequencies and percentages. And correct rates of individual questions were compared by community and township hospitals using chi-squared statistics. The t-test and 95% con dence intervals (CIs) were used to assess whether differences in scores between the two different medical institutions were signi cant. values less than 0.05 were considered as statistically signi cant. No imputation was performed for missing data.

Results
A total of 7391 people attended the conferences hold by CARDPC. Among them, 7353 attendees visited the questionnaire via Wechat and 38 via web link. Overall, 7391 questionnaires were returned with a 100% response rate. Responses were eligible if the respondent was: a primary care physician working in community or township hospitals, including General Practitioner, respiratory physician, Traditional Chinese-West medical physicians and internal physician; managing respiratory diseases in community or township hospitals; and had fully completed the questionnaire.

Characteristics of respondents
Overall, 64.6% respondents were women, 92.8% respondents were younger than 50 years old. Approximately two thirds (67.0%) of them had a Bachelor degree. 38.8% respondents had been in practice for less than 10 years, 47.9% had an intermediate vocational title, more than half (65.2%) of them were specialized in General Practice. 71.1% respondents practiced in community hospitals. There was an over representation of respondents from north China (70.3%) compared to south China (0.3%) (Supplementary Table 1).

Knowledge evaluation
It was clear from the results of the study that the overall knowledge of COPD, asthma, CAP and in uenza among respondents was inadequate. Diagnostic criteria 85.7% of the respondents were aware of the diagnosis standard of COPD, however, 45.3% of them didn't know the criteria of GOLD II COPD. Only 8.1% of them were aware how to diagnose asthma, meanwhile, only 16.1% of them were able to correctly make the clinical diagnosis of CAP. Very few respondents were aware of the pathogenic diagnostic specimens of CAP(2.1%), the standardized diagnosis of in uenza(1.0%, 46/4815) and (0.5%,25/4815) the diagnostic criteria for severe in uenza.

The treatment
The vast majority (94.4%) of the respondents didn't correctly choose bronchodilators for COPD; just over one-half of them (53.7%) knew the non-pharmacological treatments for COPD. Furthermore, 73.6% of respondents were unable to properly deal with asthma attacks; only 9.4% of them chosen the right treatment plan for newly diagnosed mild asthma patients. For young adults with no underlying disease, only 2.1% of respondents correctly selected all of the initial empirical anti-infective therapy for CAP. More than half of respondents (65.1%) didn't know what the most essential and important treatment for in uenza is.

Preventive measures
Most respondents (92%) didn't pick out all the management for stable COPD; nearly one third of them (27.7%) knew the duration of daily oxygen inhalation (>15 hours) for long-term home oxygen therapy. Only 3.0% of respondents selected all prevention and management measures for asthma. Just over one third of respondents (37.9%) knew all the preventive measures for CAP. For in uenza, nearly half of physicians (44.9%) didn't know the important role of in uenza vaccine in preventing in uenza and its complications.
Correct rate details of each item in each disease were shown in Supplementary Table 3 and   Supplementary Table 4.

Summary
With the help of the most prominent Chinese social medium Wechat, which made a terri c contribution to the response rate of the survey, this survey allowed more insight into primary care physicians' knowledge on COPD, asthma, CAP and in uenza. However, from the results we can see that primary care physicians' knowledge on these four common respiratory diseases was signi cantly poor. On the whole, either the average score of the questionnaire or the average score of each disease was less than 60% of the corresponding part. Foremost, physicians can't correctly identify the clinical features of each disease. Only 61.4% of physicians were aware of the clinical features of COPD, less than half of them knew clinical characteristics of asthma and in uenza (48.7% and 42.5%, respectively). What's worse, they knew less about the diagnosis criteria of asthma, CAP and in uenza. Only 8.1%, 16.1% and 1.0% of them can make right diagnosis of asthma, CAP and in uenza, respectively. Although, it was grati ed to see that more than 85% of the primary care physicians knew how to diagnose COPD, almost half (45.3%) of respondents didn't know the criteria for GOLD II COPD. This was related to a series of policies [17][18][19] on COPD management which have increased and strengthened the relative training on COPD.
Even though physicians in township hospitals had a better knowledge of these diseases, the knowledge level of in uenza between them was similar, which may be due to the incidence of in uenza has increased yearly in China so that the government has attached great importance to in uenza training. The knowledge of treatment was even worse. Compared with the high correct rate of COPD diagnosis, a very small proportion of physicians were aware of bronchodilators for COPD. As the most two common chronic non-communicable respiratory diseases, only 8% and 3% were aware of the management of stable COPD and asthma, respectively. Above all, physicians at township hospitals had a better knowledge level than community hospital physicians, which provided a possibility for referrals between township hospitals and community hospitals for common respiratory diseases, but a sound knowledge reserve is a prerequisite. From the above, we can see that primary care physicians' knowledge on these common respiratory diseases needs to be greatly improved. However, in view of the outstanding performance of primary care in combating COVID-19 pandemic, we also believe that with high-quality training primary care physicians will manage these diseases very well.

Strengths and limitations
This is the rst and largest study to assess primary care physicians' knowledge on CAP, asthma, in uenza, and COPD simultaneously, with such a huge sample, high response rate and broad geographical areas in China. Although only 65.1% of the questionnaires were analyzed nally, the sample size of the study was still the largest of its kind. Though the sample population was unevenly distributed, it was su cient to get an overview of the current knowledge level of primary care physicians about these four common respiratory diseases.
However, due to the survey was conducted on conferences, the number of attendees from each area were related to the places of the conferences, which resulted in some areas were overrepresented while some were underrepresented. Thereby the generalizability of the ndings for some provinces or cities was limited. For more comprehensive view to present a thorough picture of knowledge level of primary care physicians in speci c areas, surveys like this but with more physicians to take part in are needed so as to provide more individualized and targeted training for certain regions.
Comparison with existing literature There were studies to investigate primary care physicians' knowledge of COPD and asthma [20][21][22][23][24][25] around the world, and the conclusions were nearly the same, that is, primary care physicians' knowledge of COPD and asthma were insu cient. Similar studies have also been carried out in China, but in relatively smaller sample size and were only regionally based [26,27] . Nevertheless, seldom studies focused on knowledge assessment of in uenza either in the world or in China. There was one study assessed the knowledge of CAP, but just in one city [28] .
Implications for Research and/or practice Respiratory diseases account for signi cant health service and societal costs in China, but the knowledge of common respiratory diseases among primary care physicians is not optimistic. Up to 2017, there were less than 8000 respiratory physicians registered in China [1] . However, it's far from enough for these respiratory physicians to manage more than 140 million people with respiratory diseases. It is a crisis time for respiratory diseases management in China and primary care must take action now. Although the current knowledge level of primary care physicians were unsatisfactory, the training programs initiated by CARDPC across the country is going on. Action Now study laid the foundation for the follow-up training programs and future quality improvement work. An updated education program would be designed based on these ndings, then a set of courses that are more targeted, practical and more in line with primary care physicians' needs will be launched. Furthermore, under the furtherance of CARDPC, the rst guideline of COPD, asthma and CAP management in primary care have been released, and medications for these common respiratory diseases have been introduced to primary care institutions in some areas with the help of CARDPC. Up to the end of 2018, there were 29 branches of CARDPC spread in 29 provinces or municipalities [29] ( Supplementary gure 2).
As a member of the International Primary Care Respiratory Group (IPCRG), CARDPC actively participates in primary care research work and international collaborations on respiratory diseases, and strives to build a comprehensive respiratory diseases management system in primary care settings in China. In the COVID-19 pandemic, CARDPC also played a leading role in the prevention and control in primary care in China. We believe that with the attempts and facilitation of CARDPC, management of respiratory diseases in primary care in China will make great progress in the near future.

Declarations
Ethics approval The study was approved by Peking University First Hospital Research Ethics Committee (REC).
Consent for publication All authors have read and approved the nal draft for publication.
Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Provenance and peer review Not commissioned; externally peer reviewed.