|Year : 2012 | Volume
| Issue : 2 | Page : 77-82
Knowledge of the asthma guidelines among doctors in a tertiary hospital in Nigeria
Victor Aniedi Umoh1, Ido Edem Ukpe2
1 Department of Internal Medicine, University of Uyo, Uyo, Akwa Ibom State, Nigeria
2 Department of Internal Medicine, University of Calabar Teaching Hospital, Calabar Teaching Hospital, Calabar, Cross River, Nigeria
|Date of Web Publication||27-May-2013|
Victor Aniedi Umoh
Department of Internal Medicine, University of Uyo, Uyo, Akwa Ibom State
Source of Support: None, Conflict of Interest: None
Asthma guidelines are instituted to improve patient care. The extent to which physicians adhere to guidelines will depend on their understanding of such guidelines. This study was designed to evaluate physicians' understanding of the Global Initiative for Asthma (GINA) guidelines. A cross-sectional survey was carried out among physicians in the University of Calabar Teaching Hospital. Thirty-one multiple choice questions based on the GINA guidelines covering seven core areas were administered on 104 physicians, including 74 Internists, 24 Family Physicians and six Respiratory Physicians. Total scores and subscores were calculated for each respondent. A good understanding of the guidelines was determined by at least 50% correct answers. The average total score for the test was 39.5 ± 1.4% (mean ± SEM). Respiratory Physicians recorded the highest total score of 67.2 ± 2.1%. Respiratory Physicians recorded significantly higher scores than Internists in questions related to education, prevention and disease control (P < 0.05). They also recorded significantly higher scores than all other specialties in questions related to diagnosis, pharmacology and therapy (P < 0.05). Only 32 respondents reported attending a Continuing Medical Education program after graduation, and this was a significant predictor of good understanding after controlling for other variables; OR 4.5, (95% CI 1.3-15.6), P = 0.017. Only 20.2% displayed a good understanding of the GINA guidelines. The findings of this survey provide some explanation for the poor level of asthma control seen in daily practice, due in part to poor understanding of asthma management guidelines. Well-structured educational interventions targeting knowledge gaps will improve the understanding of the guidelines.
Keywords: Asthma, GINA guidelines, knowledge
|How to cite this article:|
Umoh VA, Ukpe IE. Knowledge of the asthma guidelines among doctors in a tertiary hospital in Nigeria. Indian J Allergy Asthma Immunol 2012;26:77-82
|How to cite this URL:|
Umoh VA, Ukpe IE. Knowledge of the asthma guidelines among doctors in a tertiary hospital in Nigeria. Indian J Allergy Asthma Immunol [serial online] 2012 [cited 2020 May 26];26:77-82. Available from: http://www.ijaai.in/text.asp?2012/26/2/77/112552
| Introduction|| |
Asthma is a worldwide problem, with an estimated 300 million affected individuals.  The control of asthma symptoms is generally poor, with up to 50% of patients having poor control. ,,, There are several reasons for the poor control of asthma symptoms. ,,,, However, physicians' knowledge and behavior are also important factors when it comes to prescribing the best possible treatment plan, carrying out appropriate follow-up on patients and ensuring adherence to the outlined treatment.  Several treatment guidelines such as the Global Initiative for Asthma (GINA) report  are available for the management of asthma by physicians. These guidelines are not always followed by physicians for a number for reasons, such as inertia of previous practice and inadequate knowledge of the guidelines. 
Previous reports , and anecdotal observations among physicians in our practice setting has shown that poor understanding of the guidelines may play an important role in physician's compliance with the recommendations. It is on this background that this survey was conducted to assess physicians' understanding of the GINA guidelines.
| Materials and Methods|| |
To assess physician understanding of the guidelines, we adapted a validated 31-question, multiple choice test of asthma knowledge from a previous study on the same subject by Doerschug et al.  In that study 31 multiple choice questions based on the recommendations of the National Heart, Lung and Blood Institute (NHLBI) expert panel report 2 of 1997 were developed and administered on physicians in the University of Iowa. Four questions that assessed knowledge of disease severity were modified to assess knowledge of disease control as specified by the current GINA guidelines. The questions were reviewed by two specialist Respiratory Physicians in our Hospital and two others outside our Hospital, and they all adjudged the modified questionnaire to be adequately structured to achieve the study objective, i.e., to evaluate Physicians' understanding of the current asthma management guidelines. The modified questionnaire was pretested on 11 physicians representing physicians from all the cadres and departments of the study population. The pre-test analysis showed the test to be reliable, with good internal consistency, with a Cronbach's alfa coefficient of 0.724 and a discrimination index of 0.75. Physicians from the University of Calabar Teaching Hospital were selected for this survey. This hospital is a tertiary medical facility in the South-Eastern part of Nigeria and serves as a center for undergraduate training of Medical Students and postgraduate specialist training in various fields of Medicine. All cadres of physicians, who, in the course of their duties manage adult patients with asthma (i.e., physicians in the Departments of Internal Medicine, Respiratory Medicine and Family Medicine) from this hospital, were eligible for this survey.
The test questions were divided into core areas of diagnosis of asthma, pathophysiology, patient education, disease assessment, pharmacology, therapeutic modalities, disease control and prevention; the questions were arranged in a random fashion when presented to the physicians. Each question had a single correct answer. A total score and a score for each of the seven core areas was calculated for each participant.
The scores were grouped according to the level of physicians training, i.e., House Officer, Junior Resident, Senior Resident and Consultant, as well as by the specialty of the physicians (Family Medicine, Internal Medicine and Respiratory Diseases). Mean scores for each subgroup were reported and compared using one-way analysis of variance with the Tukey post hoc testing. A P < 0.05 was judged to be statistically significant. A score of at least 50% was indicative of a good understanding of the guidelines.
| Results|| |
One hundred and fifteen questionnaires were distributed to physicians in the hospital. One hundred and seven questionnaires were returned, of which three were incomplete and were removed from the final analysis. Thus, 104 respondents of 115 respondents were included in the final analysis, giving a response rate of 90.4%. There were 64 (61.5%) males and 40 (38.5%) females. The average age of the participants was 33.2 ± 6.5 years, with a majority of the patients being within the 30-39 years age bracket. The average duration of medical practice was 6.9 ± 6.5 years, with a minimum of 1 year and a maximum of 33 years. There were 22 (21.2%) House Officers, three (2.9%) Medical Officers, 49 (47.1%) Junior Residents, 18 (17.3%) Senior Residents and 12 (11.5%) Consultants. The respondents were drawn from three specialties; Internal Medicine with 74 (69.2%) provided the bulk of the respondents, followed by Family Medicine with 24 (23.1%) and, finally, Respiratory Medicine with six (5.8%) respondents. A majority of the respondents (69.2%) had not attended any Continuing Medical Education (CME) seminar or workshop on asthma after graduation, with the average duration from the last attended CME being 3.2 ± 2.9 years, with a range of 10 years [Table 1].
The average total score for the test was 39.5 ± 1.4% (mean ± SEM). The House Officers had the least total score (29.6 ± 2.8%), followed by the Medical Officers, Junior Residents and Senior Residents with 35.5 ± 0.0%, 40.0 ± 1.9% and 43.5 ± 4.1%, respectively. The Consultants had the highest total score of 50.0 ± 3.4% [Figure 1]. A one-way ANOVA test was conducted to explore the impact of respondent's cadre on the total score as a measure of their performance. There was a significant difference in total scores for the five cadres: F (4, 99) =5.0, P = 0.001. The difference in mean scores was large. The effect size calculated using Eta squared was 0.17. Post hoc comparisons using the Tukey HSD test indicated that the mean scores for the House Officers was significantly different from the other cadres, except that of the Medical Officers [Table 2].
|Figure 1: Physicians' performance according to cadre. House officers performed significantly poorer than the other cadres|
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The distribution of total scores by the specialty is shown in [Figure 2]. The Family Physicians had the lowest total score of 37.2 ± 2.5%, followed by the Internist with 38.0 ± 1.6%. The Respiratory Physicians recorded the highest total score of 67.2 ± 2.1%. A one-way ANOVA test was conducted to explore the impact of respondent's specialty on the total score as a measure of their performance. There was a significant difference in total scores for the three faculties: F (2, 101) =13.8, P < 0.0001. The difference in average total scores was large. The effect size calculated using Eta squared was 0.27. Post hoc comparison using the Tukey HSD indicated that the total score obtained by Respiratory Physicians was significantly different from that of the Internists and the Family Physicians. There was no significant difference between the Internists and the Family Physicians [Table 3].
|Figure 2: Physicians' performance according to specialty. Respiratory physicians performed significantly better than physicians in the other specialties|
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Respondents recorded their lowest scores in questions related to asthma education, and the highest scores were recorded in questions related to diagnosis. Medical Officers scored zero in questions related to education, and this was followed by House Officers (4.6 ± 4.5%), then, surprisingly, by Senior Residents with 5.5 ± 5.5%. A one-way ANOVA was used to explore the impact of cadre on the subscores with post hoc comparison using the Tukey HSD [Table 2]. Consultants scored significantly higher than House Officers in questions related to education (P = 0.04), significantly higher than Medical officers in questions related to diagnosis (P = 0.05) and significantly higher than all other cadres in questions related to therapy (P < 0.05).
The impact of specialty on the subscores was explored using a one-way ANOVA with post hoc comparison using the Tukey HSD. Respiratory Physicians recorded significantly higher scores than Internists in questions related to education (P = 0.04), prevention (P = 0.04) and disease control (P = 0.008). They also recorded significantly higher scores than all other specialties in questions related to diagnosis, pharmacology and therapy (P < 0.05). There was no significant difference in the subscores obtained by the Internists and Family Physicians [Table 3].
Impact of CME
Thirty-two respondents reported attending a CME after graduation. The average time from the last attended CME and taking the test was 3.2 ± 2.9 years, with a range of 1 to 11 years. Respondents who had attended a CME recorded a higher average total score than those who had not attended one (45.0 ± 2.7% vs. 37.0 ± 1.7%) t = 2.6, P = 0.011 [Figure 3]. There was no significant relationship between the last CME and the total score [Table 4]. A two-way ANOVA was conducted to explore the impact of CME attendance and specialty on the average total test score. The interaction effect between CME and faculty was significant; F (2, 98) =3.7, P = 0.03, although the effect size was small (partial Eta squared = 0.07).
|Figure 3: Overall performance according to previous CME attendance. Respondents who had a previous CME attendance performed significantly better than those who did not attend any CME post-graduation|
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|Table 4: Correlation of total scores with years of practice and time interval from last CME attendance|
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[Table 5] describes good understanding of the guidelines according to our definition. Twenty-one (20.2%) displayed a good understanding of the GINA guidelines. A previous asthma CME attendance and specialty were significantly associated with good understanding.
Direct logistic regression was performed to assess the impact of a number of factors on the likelihood that respondents will have a good understanding of the GINA guidelines. The full model containing all predictors was statistically significant X 2 (7, N = 104) =29.8, P < 0.0001. The model explained between 25% (Cox and Snell R square) and 39% (Nagelkerke R square) in performance and correctly classified 86% of the respondents. Only prior attendance in asthma CME made a unique statistically significant contribution to the model; OR 4.5, (95% CI 1.3-15.6), P = 0.017 [Table 6].
| Discussion|| |
The United States National Heart, Lung and Blood Institute (NHLBI) in 1993 collaborated with the World Health Organization (WHO) to organize a workshop that led to a Report: Global Strategy for Asthma Management and Prevention (GINA).  This report proposed a comprehensive plan to manage asthma with the goals of reducing morbidity and mortality. This report has been updated regularly and translated into several languages to promote dissemination of information.  In spite of these efforts, and the availability of effective therapy, surveys worldwide show suboptimal control in many populations. ,,,
The average GINA guidelines' understanding for all the respondents in this survey was low, although it is consistent with the performance obtained from a previous survey of physicians' understanding of asthma guidelines by Panlaqui and De Guia.  In that study involving physicians from Family Medicine, Internal Medicine, Pediatrics and Pulmonary Medicine, the average score was 45.8%. It was also comparable to the findings by Ahmed et al. in a similar survey of residents and faculty members in a tertiary hospital in Karachi. Similar surveys from the West have shown better understanding of asthma guidelines. , This discrepancy may be due to the fact that asthma is more common in the Western World, and, as such, Western physicians see more asthma patients and, therefore, there is a low level of participation in asthma management CME in these parts of the world.  Furthermore, most of the issues dealt with in the guidelines, such as the medications and investigations, are not routinely available in developing countries. 
In terms of overall performance, House Officers had the least scores, followed by Medical Officers. The performance significantly improved with cadre and with years of practice, suggesting that understanding of the guidelines improves with clinical experience and training. This finding, although logical and in agreement with previous studies, , is not always the case as physicians may not always improve their knowledge with training. 
In chronic illnesses, like asthma or hypertension, patient management is enhanced if patients are actively involved in the management process. Patient education should be the initial step in involving the patient in the management. "Therapeutic patient education" in self-management improves the outcomes in patients with asthma.  In our study, physicians performed poorly in questions related to patient education, where they recorded the lowest scores. This trend has been observed in some other studies. , This very poor understanding of asthma education strategies may account for the poor control of asthma symptoms among patients.
Strategies that may lead to the elimination or control of asthma triggers are important in the management of asthma and should be incorporated into patient education. Physicians generally had a poor understanding of strategies to prevent exacerbation of asthma. Even Respiratory Physicians could only identify 58% of the preventive strategies correctly.
Despite the positive impact of experience and training on performance, all physician groups displayed a poor understanding of assessing disease control. Even Respiratory Physicians could only correctly classify 55% of the patients. Overall, Physicians correctly classified 31% of the patients.
Appropriate assessment of disease control is essential in the proper management of asthma patients, but, in addition to a poor understanding of assessing of control, all physician groups apart from Respiratory Physicians showed a poor understanding of the therapeutic options available for the management of asthma. Respiratory physicians could correctly identify 73% of appropriate therapeutic options for managing acute exacerbation of asthma, when to initiate controller medications and how to modify therapy when control is not adequate. Overall, physicians could only correctly identify appropriate management strategies in 36% of the cases.
As expected, the attendance in asthma-centered CME had a significant positive influence on the overall performance, and it significantly predicted good understanding of the guidelines after controlling for other variables (OR 4.5, 95% CI = 1.3-15.6). Asthma-based seminars have been shown to have both short-term  and long-term  positive effects on physicians' understanding of management guidelines and patient satisfaction. This study showed an inverse relationship between the time from the last attended CME and the total score, but this was not statistically significant. This may be related to the content and/or structure of such CMEs.
The findings of this survey have shown that there is a poor understanding of the GINA guidelines by physicians managing asthma patients, that there is also a lukewarm attitude toward updating asthma knowledge by physicians and that attendance in an asthma CME was a significant factor for good understanding of asthma guidelines.
| Conclusion|| |
The findings of this survey provide some explanation for the poor level of asthma control seen in daily practice due in part to poor understanding of asthma management guidelines by the managing physician.
The introduction of new patient management guidelines into clinical practice requires changing physician behavior. Altering the attending physician's behavior is a complex process. Physicians must first be aware of new scientific developments or evidence-based practice guidelines. They should then understand the implications of the guidelines to patient care and they must then incorporate these changes into their clinical practice. CME has usually assumed the role for making physicians aware of new guidelines and scientific findings in medicine. To better design CME interventions, it is important to understand the educational needs of the physician audience and, to do this; physicians' understanding of relevant guidelines should be regularly assessed.
The GINA guidelines are now considered to be the "gold standard" for asthma diagnosis and management. On the strength of the results of our study, we can make the following recommendations:
All physicians involved with asthma management can benefit from CMEs focused on the GINA guidelines, and these should be delivered at regular intervals. These educational interventions can and should be tailored to different physician groups based on their training background. Finally, current asthma guidelines should be incorporated and emphasized in the undergraduate curriculum.
Further studies will be required to evaluate Physicians' behavior in terms of conformity with the GINA guidelines and the patient's perception of disease control and the physicians' role in the disease management.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]