A Survey of Knowledge, Attitudes and Practices of Doctors in General Practice in Singapore Towards Chronic Obstructive Pulmonary Disease Dr David Cheong, Dr Lim Fong Seng, Dr Tan Tze Lee, Mr Arul Earnest, Dr See Toh Kwok Yee, Dr Stephen Tong

Rationale for Study The prevalence of COPD in Singapore is set to increase due to: Ageing population in Singapore (age >65 9.3% in 2011 to 10.5% in 2013) (MOH)1 Increasing prevalence of smoking 12.6% in 2004 to 14.3% in 2010 (MOH)1 How does Singapore compare to regional countries in COPD care? GPs have different levels of training. Does post-grad training improve care of COPD? Singaporean private sector GPs prescribe and dispense – does this impact on prescribing habits? Local (MOH) guidelines in process of being revised – window of opportunity to provide input to the guidelines. Old guidelines (2006) withdrawn. 1. https://www.moh.gov.sg/content/moh_web/home/statistics/Health_Facts_Singapore.html

Hypothesis Under-diagnosis of COPD Under-utilisation of spirometry Awareness of guidelines low Inappropriate management – asthma medication (ICS/LABA) as first-line therapy Cost pressures in private sector affect prescribing Singaporean GPs are more likely to follow COPD guidelines than GPs from other Asian countries – comparison to Aisanov’s study2 2. Z Aisanov, CX Bai, O Bauerie et al. Primary care physician perceptions on the diagnosis and management of chronic obstructive pulmonary disease in diverse regions of the world. International Journal of COPD 2012;7: 271-282

Methodology Study design: cross-sectional survey Population: members of the College of Family Physicians Singapore (n=1619) Survey questionnaire: 22 close-ended questions KAP and practice profile. Postal survey with follow-up

Results - Demographics Response rate 26% (425/1619) Majority of GPs in the 30-50 year age group (62%) Average no. years of practice 18.7 years Sex distribution about equal (52% male, 48% female) GPs with post grad (GDFM, MMed & equivalent) make up 68% GPs in private sector make up 68% Demographics compare similarly to Aisanov’s study in Asia (China, Hong Kong, Japan, South Korea and Taiwan except for sex distribution where >80% of respondents were male.

Results - Knowledge COPD Prevalence Risk factors 21% either under-estimated prevalence (12%) or did not know the prevalence (9%) 52% correctly estimated prevalence 6-15% Risk factors 99% correctly identified smoking as a risk factor 49% identified outdoor air pollution as a risk factor (haze?) 23% thought PTB was a risk factor

Results - Knowledge Diagnosis (based on 1st & 2nd choice) 88% chose history and physical examination (50-76% Asia) 46% chose spirometry (50-66% Asia) 39% chose CXR (28-54% Asia)

Results - Attitudes COPD guideline use Barriers to treatment 43% used COPD guidelines (22-84% Asia, 22% HK, 84% China) GOLD followed by MOH guidelines most frequently used GPs with post grad more likely to use guidelines (50% vs 28%, P<0.05) Barriers to treatment 50% cited doctor’s lack of knowledge 63% cited patient’s lack of knowledge 83% cited patient’s lack of compliance 64% cited cost of medications

Results - Practices Spirometer access Only 33% of GPs had access to spirometry (46-85% Asia) 23% chose spirometry as 1st choice in diagnosis (10-40% Asia) GPs in private practice less likely to have access to spirometer (22% vs 63%, P<0.05) GPs who don’t have access are less likely to use spirometry (69% vs 31%, p<0.05) GPs with post grad more likely to use spirometry (51% vs 35%, p<0.05)

Results - Practices Drug usage most commonly used drugs are inhaled ICS±LABA (43%) but only 18% are GOLD C or D patients in Singapore inhaled short acting bronchodilators (42%) inhaled long acting beta agonist/ anticholinergics are less commonly used (29%) Private sector GPs used more ICS+LABA than public sector GPs (45% vs 17%, P<0.05) No difference in private vs public sector usage of LAMA/LABA (numbers too low)

Results - Practices Drug stock 3 times more GPs stocked inhaled ICS±LABA than inhaled LAMA/LABA Less private GPs stock inhaled LAMA than public sector GPs (12% vs 43%, p<0.005)

Limitations Response rate of 425/1619 (26%) may not be representative of College members College members may not be representative of entire GP population in Singapore Answers rely on recall and perception and may not reflect actual practice

Summary of results COPD in Singapore is under-recognized Diagnosis is made on history and PE rather than by spirometry Use of spirometry alarmingly low, especially in private sector Less than half use COPD guidelines This was similar to other Asian countries Inhaled ICS±LABA most commonly prescribed as 1st line treatment while inhaled LAMA/LABA were less prescribed. Private sector GPs stocked less LAMA/LABA GPs with post grad tended to follow guidelines Lack of knowledge (both doctor & patient) was strongly cited as a barrier to treatment Cost of medications and patient compliance were also strong barriers

Conclusions Singapore is unfortunately no better than our neighbours in following COPD guidelines More needs to be done to educate doctors and patients about COPD More access to spirometry for private GPs needed Better training of doctors improve guideline adherence The costs of medications (esp LAMA/LABA) needs to be addressed