Effect of otolaryngology residency program on condence of obstructive sleep apnea managements

According to the importance of obstructive sleep apnea syndrome managements by otolaryngologists, this study was designed to investigate knowledge, attitudes and practice of junior and senior residents of otolaryngology and evaluate the effect of current residency training program on choosing the rst lines of treatment. Methods A total of 110 residents of otolaryngology were selected. Our study tools were obstructive sleep apnea knowledge and attitudes (OSAKA and OSAKA-KIDS) questionnaires. The participants were classied as junior and senior.


Introduction
Sleep disorders are common problems affecting quality of daily life. One of the categories of sleep disorders is respiratory problems. Obstructive sleep apnea-hypopnea syndrome is a common disorder associated with episodes of collapse of upper airway during sleep. Knowing obstructive sleep apnea is important because it has had an increasing incidence rate during recent years 1 . According to different cutoff points of apnea-hypopnea index (AHI), prevalence of obstructive sleep apnea will differ. It is estimated that about 2-4% of general population have this disorder. Prevalence of obstructive sleep apnea is increased along with increasing age and obesity in the world. Obstructive sleep apnea is an independent risk factor for cardiovascular diseases, depression, and diabetes with a great burden on society 2 . It has been observed that nancial burdens had been decreased following to treatment of cases in surveillance of countries 3 .
Prevalence of obstructive sleep apnea in children is about 1.2-5.7% 4 . It has different etiology and complications in comparison to adult patients. The complications consist of growth disorders 5 , pulmonary hypertension and cor pulmonale, systemic hypertension 6 , neurocognitive and neurobehavioral complications 7 .
Most patients with obstructive sleep apnea remain undiagnosed which may be due to lack of knowledge of physicians 8 . According to the importance of management of obstructive sleep apnea by otolaryngologists, this study was designed to investigate knowledge and attitudes of Iranian resident physicians of otolaryngology about this disease by using obstructive sleep apnea knowledge and attitudes (OSAKA) obstructive sleep apnea knowledge and attitudes in children (OSAKA-KIDS) and questionnaire with descriptive and analytical approaches. In addition, we wished to evaluate the effect from number of residency years on choosing the lines of treatment in obstructive sleep apnea.

Materials And Methods
A total of 110 resident physicians of otolaryngology were selected for this questionnaire-based crosssectional study. The participants were selected from junior and senior residents by convenient sampling from the participants of 16th International Congress of Iranian Society of Otorhinolaryngology, Head and Neck Surgery (ICIS-ORLHNS), 27-30 Nov 2018. The participants were classi ed as junior when they were in the rst and second years and senior when they were beyond second year. A place was considered for completing the questionnaires and taking informed consent. Along with the main questionnaires another questionnaire was used for demographic information including years of residency, and their preferred rst, second and third lines of treatment. Our sample size had 80% power to detect signi cant difference between two groups of junior and senior residents with incidence rates of 36% and 64% with 0.05 alpha errors.
Tools of study were OSAKA and OSAKA-KIDS questionnaires. OSAKA was developed by Schotland and Jeffe in 2003 9 , and OSAKA-KIDS was developed by Uong et al. in 2005 10 . Each of the above questionnaires has knowledge and attitude parts. The knowledge part of each questionnaire consists of 18 items with 3 choices of "true", "false" and "I don't know". The attitude part of these questionnaires has 5 items with 5-point Likert scale from "not important" to "extremely important" for 2 items and from "strongly disagree" to "strongly agree" for the other 3 items. The attitude part of the two questionnaires was same so our study had just one attitude part. At the end of the questionnaires, a question was added about choosing the rst, second and third lines of treatment. There were 6 choices of weight loss, avoid supine position during sleep, nasal spray, surgery, CPAP and others. The questionnaires were translated to Persian language by 2 otolaryngologists who were expert in English language and validated by referring to 2 sleep medicine fellowships and 8 otolaryngology academic members who were expert in sleep apnea and English language, and they compared the translated questionnaires with their main versions. Finally, all the authors approved representativeness of the questionnaires. Cronbach alpha was used for reliability of the questionnaires.
Giving correct answer by at least 50% of the junior residents and 70% of the senior residents was considered as acceptable percent for each question of OSAKA and OSAKA-KIDS.
The present study was approved by the ethics committee of Tehran University of Medical Sciences. All the participants gave us informed consent. For statistical analysis Pearson chi-square, independent samples ttest and Kruskal Wallis were used according to their indications using SPSS 24 (IBM, US). Two tailed p value 0.05 was considered as signi cance level.

Results
Among 110 resident physicians, 69 (62.8 %) residents were junior and 41 (37.2%) residents were senior. Fifty percent of junior residents and 51.2 % of senior residents were female. The mean age of junior residents was 28.7 years with standard deviation of 2.4 and the mean age of senior residents was 29 with standard deviation of 2.9 (table 1). Descriptive statistics was done for the individual questions of OSAKA (table 2) and OSAKA-KIDS (table 3). Cronbach alpha for junior and senior residents were 0.42 and 0.72, respectively for OSAKA, and 0.38 and 0.76, respectively for OSAKA-KIDS.

Knowledge part of OSAKA and OSAKA-KIDS
The questions with less than 50% correct answer among the juniors were "Uvulopalatopharyngoplasty is curative for majority of the patients" (40%), "treatment with continuous positive airway pressure (CPAP) can result in nasal congestion" (25%), "Alcohol at bedtime improves obstructive sleep apnea" (46%), "obstructive sleep apnea is more common in women than men" (27%), and "less than 5 apnea/hypopnea is normal in adults " (49%) in OSAKA, and "about 10% of children snore at a regular basis" (45%), "severity of snoring correlates with severity of obstructive sleep apnea in children" (32%), "children younger than 2 years should have polysomnography prior to obstructive sleep apnea surgery" (45%), and "cardiorespiratory monitor can reliably detect central and obstructive apnea in infants" (17%) in OSAKA-KIDS.
The questions with less than 70% correct answer among the seniors were "treatment with CPAP can result in nasal congestion" (34%), "The most common cause of obstructive sleep apnea in children is the presence of large tonsil and adenoid" (53%), "Alcohol at bedtime improves obstructive sleep apnea" (61%), "collar size 43 cm or more in men is associated with obstructive sleep apnea" (58%), "obstructive sleep apnea is more common in women than men" (56%), and "less than 5 apnea/hypopnea is normal in adults" (63%) in OSAKA, and "about 10% of children snore at a regular basis" (51%), "about 2% of children have obstructive sleep apnea" (49%), "Polysomnogram is needed to differentiate primary snoring from obstructive sleep apnea syndrome in children" (68%), "severity of snoring correlates with severity of obstructive sleep apnea in children" (61%), "excessive upper airway muscle tone loss during sleep contributes to obstructive sleep apnea in children" (58%), "snoring is most frequently reported at ages 2-8 years" (56%), "cardiac arrhythmia may be associated with untreated obstructive sleep apnea" (66%), "children with sickle cell disease are at increased risk of obstructive sleep apnea" (29%), "children younger than 2 years should have polysomnography prior to obstructive sleep apnea surgery" (34%), "signi cant OSA can occur without snoring in children" (63%), and " cardiorespiratory monitor can reliably detect central and obstructive apnea in infants" (44%) in OSAKA-KIDS.
Inferentially, signi cant difference was found between junior and senior residents in correct answering of the following questions based on Pearson chi-square test: For OSAKA, "uvulopharyngoplasty surgery is curable for most of the patients" (P <0.001; better answer in the seniors), "overnight sleep study is the diagnostic gold standard of obstructive sleep apnea" (P =0.047; better answer in the seniors), "loosing of tonicity of upper airway muscles during sleep helps formation of obstructive sleep apnea" (P =0.004; better answer in the seniors), "enlarged palatine tonsil and enlarge adenoid are the most prevalent reasons of obstructive sleep apnea in children" (P =0.032; better answer in the seniors), "examination of pharynx, facial bones and cranial bones is useful in a patient suspected to obstructive sleep apnea", (P =0.032; better answer in the seniors), "lack of treatment of obstructive sleep apnea is associated with increased driving accidents" (P =0.008; better answer in the seniors), and "obstructive sleep apnea is more common in women than men" (P =0.003; better answer in the seniors) (table 2); for OSAKA-KIDS, "about 2% of children have obstructive sleep apnea" (P =0.018; better answer in the juniors), "severity of snoring is correlated with severity of obstructive sleep apnea in children" (P =0.003; better answer in the seniors), "children with sickle cell anemia have more risk of obstructive sleep apnea" (P =0.028; better answer in the juniors), and "cardiopulmonary monitoring can con dently detect central and obstructive apnea in infants" (P =0.003; better answer in the seniors) (table 3).

Attitude part of OSAKA and OSAKA-KIDS
In the following cases, for OSAKA, attitude of the juniors and the seniors were different based on Pearson chi-square test in 2 by 5 tables: "obstructive sleep apnea from the viewpoint of a clinical disease" (P =0.004), "Identifying patients with possible obstructive sleep apnea" (P =0.002), "I have enough selfcon dence to nd a patient who is at risk of obstructive sleep apnea" (P =0.001), and "I have enough ability to be involved with patients with obstructive sleep apnea" (P =0.003). No signi cant difference was observed for "I have enough ability to treat the patients with CPAP" (P =0.290). In the following cases, for OSAKA-KIDS, attitude of the juniors and the seniors were different based on Pearson chi-square test in 2 by 5 tables: "obstructive sleep apnea from the viewpoint of a clinical disease" (P =0.002), " nding the diseases resulting in obstructive sleep apnea" (P =0.002), "I have enough self-con dence to nd a patient who is at risk of obstructive sleep apnea" (P =0.003), and "I have enough ability to be involved with patients with obstructive sleep apnea" (P =0.002). No signi cant difference was observed for "I have enough ability to treat the patients with CPAP" (P =0.051) (table 4).
Total score of knowledge and its association with attitude Total score of knowledge was compared between the juniors and the seniors. Senior residents had signi cantly higher total knowledge score for OSAKA based on independent t test (12.73±3.13 VS 10.52±2.63; P <0.001) (table 2). No signi cant difference was observed for OSAKA-KIDS (11.31±3.59 VS 10.69±2.49; P =0.288) (table 3). Association of total score of knowledge with attitude status was analyzed using Kruskal Wallis test. According to this, for OSAKA, total knowledge score was associated with attitude from the viewpoint of clinical importance of sleep apnea in both junior (P =0.025) and senior (P =0.003) residents, total knowledge score was associated with attitude from the viewpoint of clinical importance of nding patients with obstructive sleep apnea in both junior (P =0.006) and senior (P =0.034) residents, total knowledge score was associated with self-attitude to ability of nding patients with obstructive sleep apnea in both junior (P <0.001) and senior (P =0.001) residents, total knowledge score was associated with self-attitude to ability to be involved with patients with obstructive sleep apnea in junior (P =0.028) residents however not in the seniors (P =0.052), and no signi cant association was observed for selfattitude to ability to treat the patients with CPAP in junior (P =0.141) and senior (P =0.139) residents. For OSAKA-KIDS, total knowledge score was associated with attitude from the viewpoint of clinical importance of sleep apnea in senior (P =0.029) but not in junior (P =0.290) residents, total knowledge score was associated with attitude from the viewpoint of clinical importance of nding patients with obstructive sleep apnea in senior (P =0.013) but not in junior (P =0.216) residents, no signi cant association was observed for self-attitude to ability of nding patients with obstructive sleep apnea in junior (P =0.081) and in senior (P =0.392) residents, no signi cant association was observed for self-attitude to ability to be involved with patients with obstructive sleep apnea in junior (P =0.117) and in senior (P =0.478) residents, and no signi cant association was observed for self-attitude to ability to treat the patients with CPAP in junior (P =0.495) and senior (P =0.838) residents.
Correlation of total knowledge score in OSAKA with total knowledge score in OSAKA-KIDS was determined in junior and senior residents. According to this, positive correlation was found for both junior and senior residents (P <0.001).
Choosing the rst lines of treatment Effect of being junior or senior on choosing the rst lines of treatment was analyzed using Pearson chisquare. According to this, signi cant association was found for rst (P =0.006) and third lines (P =0.014) however not in second line (P =0.274). The most frequent choice for the rst line was CPAP (63.8%) and weight loss (41.5%) among junior and senior residents, respectively. The most frequent choice for the third line was weight loss (29.0%) and surgery (22.0%) among junior and senior residents, respectively. which has high rate for sickle cell anemia as 1.3% of population 11 . This knowledge is so important of otolaryngologist surgeons as the crisis would be occurred in operation room 12 . This study showed that during residency training the residents would nd the results which can be get from surgery and importance of preoperative results would have effect on the results of surgery. The inferential results of the attitude part in both OSAKA and OSAKA-KIDS showed that attitude was different between junior and senior residents and could affect their knowledge, except the attitude item about using CPAP. The same attitude about the CPAP therapy would be root from lack of proper education about CPAP device during otolaryngology. This result con rmed more junior residents would choose CPAP than senior residents. Choosing rst and third lines of treatment was different between junior and seniors. CPAP was the rst line in a study in which developed OSAKA-KIDS questionnaire considering this rationale that lack of treatment of obstructive sleep apnea results in serious complications. This questionnaire was mailed to 1195 physicians. All the items had more than 50% correct answering except the question about the role of sickle cell disease with 14.5% correct answering 10 . In our study, this question senior residents had signi cantly lower correct answering (29.3%) compared with junior residents (50.7%) as their medical knowledge about this disease may be decreased during residency due to recede from internal medicine education. investigated referral rate of physicians and its association with knowledge and attitude. Total referral rate was 75%; however, it was not in uenced by knowledge and attitude of physicians. Patients inquiring about obstructive sleep apnea signi cantly increased referral rate with adjusted odds ratio 9.38 16 . Li et al. (2016) in China, studied 560 physicians using OSAKA and their viewpoints on treatment lines. Total knowledge score was 44.87%. The participants ranked treatment lines as weight loss, quit smoking and alcohol, CPAP, avoid fatigue, surgery and drugs. The mentioned lines were different from the lines of our study 17 . Corso et al. (2017) in Italy, studied knowledge and attitude of 370 anesthetists using OSAKA. Total knowledge score was 11.8 in which anesthetists with more than 15 years of experience showed better score compared with anesthesiology residents 18 . Goyal et al. (2018) in India, studied 232 nal-year medical students using OSAKA and OSAKA-KIDS. Total knowledge score was 37.9% and 42.1% for OSAKA and OSAKA-KIDS, respectively. They found that there was not enough knowledge in spite of enough attitude and thinking about the importance of the disorder 19 . Jokubauskas et al. (2018) in a nation-wide study in Lithuania, studied knowledge and attitude of 353 dentists using OSAKA. Increased years of experience was signi cantly associated with less knowledge. There was no signi cant difference between general dentists and specialists 20 . Canadian residents of otolaryngology were evaluated by OSAKA in 2020. The total score of knowledge was 88.9% and in the attitude part they had greatest problem with CPAP and just 15.2% were con dent with in managing CPAP. The senior residents had better knowledge scores and had better con dent towards identifying patients at risk for obstructive sleep apnea, ability to manage these patients and even management of patient with CPAP 21 .

Discussion
Knowledge and insights of physicians about common medical conditions is very important to increase level of public health 22 . Educations should be presented for medical students as well as graduated physicians including residents and specialists. It has been shown that education of the targeted population results in better public health and reduction of burdens 23,24 . The case obstructive sleep apnea is not an exception and the positive results of education has been investigated 25 . This is rst study which analyzed the otolaryngology education program on knowledge and attitude toward obstructive sleep apnea.
From the limitations of our study, selection bias of the participants in the congress can be pointed out.
Voluntary participation helped us to achieve more reliable and patiently answering, however might be resulted in participation of the residents with more interest in research and in the topic. Regarding previous literature, we had some strengths such as simultaneous investigation of OSAKA and OSAKA-KIDS and choosing treatment lines from the view point of otolaryngology residents. Otolaryngology specialists, fellowships, fellows and residents are very important targeted group in this topic.

Conclusion
Knowledge and attitudes about obstructive sleep apnea were different between junior and senior residents. Therefore, resident physicians of otolaryngology need further education. According to the literature knowledge of different specialties were different; in some specialties higher practical experience was associated with better knowledge and in some other groups it was vice versa. Quasi experimental studies are suggested to investigate the outcomes of education on patient management and prevention adverse effect of obstructive sleep apnea.
Practice implications: Otolaryngologists should be aware of obstructive sleep apnea to manage such patients. Therefore, they should be educated and educate the patient.