• Anesthesiology · Feb 2019

    Anesthesiologist Specialization and Use of General Anesthesia for Cesarean Delivery.

    Why is this important?

    The numerous benefits of neuraxial anesthesia (spinal, epidural, combined spinal-epidural) versus general anesthesia for cesarean section are well established.

    While maternal and emergent risks for general anesthesia are well known (ethnic groups; emergencies; maternal disease), Cobb et al. present the highest quality evidence to date showing obstetric anesthesia specialization is associated with a lower GA rate.

    What did they do?

    The researchers conducted a retrospective cohort study at a large metropolitan teaching hospital (Philadelphia, Pennsylvania) over a 4 year period, comparing general anesthesia versus neuraxial, and obstetric-specialized1 vs generalist anesthesiologists for 4,217 singleton CS deliveries.

    And they found?

    The total study GA rate was 9.0%. Two-thirds of CS anesthesia was provided by seven specialist obstetric anesthesiologists, versus one-third provided by 33 generalists.

    Specialist obstetric anesthesiologists demonstrated a significantly lower GA rate, 7.3% vs 12.1% (OR-CI 0.45-0.79). This difference persisted for the urgent/emergent CS sub-group, though not for after-hours delivery.

    Nonetheless several non-provider factors were more strongly associated with GA such as emergency CS (⇡ 7-fold), maternal medical indications for CS (⇡ 3-fold), and after-hours CS (⇡ OR 33%).

    Thus care by a specialist obstetric anesthesiologist is associated with an almost-30% reduction in GA for CS .

    "...consider selecting neuraxial techniques in preference to general anesthesia for most cesarean deliveries." - ASA obstetric anesthesia task force. 2

    Between the lines...

    The individual obstetric-specialized anesthesiologists in this study had an almost 10-fold greater cesarean case load than did the average generalist. Whether the outcome difference was due to technical expertise, decision making or a combination, one message here is that you get better at what you do when you intentionally do more of it.


    1. A specialized obstetric anesthesiologist was defined as having completed an obstetric anesthesia fellowship or specialist practice for at least 5 years with 33% full-time obstetric anesthesia case-load. 

    2. ASA Obstetric Anesthesia Practice Guidelines

    summary
    • Benjamin T Cobb, Meghan B Lane-Fall, Richard C Month, Onyi C Onuoha, Sindhu K Srinivas, and Mark D Neuman.
    • From the Departments of Anesthesiology and Critical Care (B.T.C., M.B.L-F., R.C.M., O.C.O., M.D.N) Obstetrics and Gynecology (S.K.S.), Perelman School of Medicine of the University of Pennsylvania the Leonard Davis Institute of Health Economics, and the Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania (B.T.C., M.B.L-F., M.D.N.), Philadelphia, Pennsylvania.
    • Anesthesiology. 2019 Feb 1; 130 (2): 237-246.

    What We Already Know About This TopicObstetric specialty societies recommend neuraxial anesthesia, when possible, for cesarean deliveryCurrent data regarding the association of obstetric anesthesiologist specialization and use of general anesthesia for cesarean delivery remain lacking WHAT THIS MANUSCRIPT TELLS US THAT IS NEW: Maternal and provider factors are strongly associated with use of general anesthesia for cesarean deliveryPatients receiving care from obstetric-specialized anesthesiologists are 29% less likely to receive general anesthesia for cesarean delivery BACKGROUND:: Guidelines for obstetric anesthesia recommend neuraxial anesthesia (i.e., spinal or epidural block) for cesarean delivery in most patients. Little is known about the association of anesthesiologist specialization in obstetric anesthesia with a patient's likelihood of receiving general anesthesia. The authors conducted a retrospective cohort study to compare utilization of general anesthesia for cesarean delivery among patients treated by generalist versus obstetric-specialized anesthesiologists.MethodsThe authors studied patients undergoing cesarean delivery for live singleton pregnancies from 2013 through 2017 at one academic medical center. Data were extracted from the electronic medical record. The authors estimated the association of anesthesiologist specialization in obstetric anesthesia with the odds of receiving general anesthesia for cesarean delivery.ResultsOf the cesarean deliveries in our sample, 2,649 of 4,052 (65.4%) were performed by obstetric-specialized anesthesiologists, and 1,403 of 4,052 (34.6%) by generalists. Use of general anesthesia differed for patients treated by specialists and generalists (7.3% vs. 12.1%; P < 0.001). After adjustment, the odds of receiving general anesthesia were lower among patients treated by obstetric-specialized anesthesiologists among all patients (adjusted odds ratio, 0.71; 95% CI, 0.55 to 0.92; P = 0.011), and in a subgroup analysis restricted to urgent or emergent cesarean deliveries (adjusted odds ratio, 0.75; 95% CI, 0.56 to 0.99; P = 0.049). There was no association between provider specialization and the odds of receiving general anesthesia in a subgroup analysis restricted to evening or weekend deliveries (adjusted odds ratio, 0.76; 95% CI, 0.56 to 1.03; P = 0.085).ConclusionsTreatment by an obstetric anesthesiologist was associated with lower odds of receiving general anesthesia for cesarean delivery; however, this finding did not persist in a subgroup analysis restricted to evening and weekend deliveries.

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    Notes

    summary
    1

    Why is this important?

    The numerous benefits of neuraxial anesthesia (spinal, epidural, combined spinal-epidural) versus general anesthesia for cesarean section are well established.

    While maternal and emergent risks for general anesthesia are well known (ethnic groups; emergencies; maternal disease), Cobb et al. present the highest quality evidence to date showing obstetric anesthesia specialization is associated with a lower GA rate.

    What did they do?

    The researchers conducted a retrospective cohort study at a large metropolitan teaching hospital (Philadelphia, Pennsylvania) over a 4 year period, comparing general anesthesia versus neuraxial, and obstetric-specialized1 vs generalist anesthesiologists for 4,217 singleton CS deliveries.

    And they found?

    The total study GA rate was 9.0%. Two-thirds of CS anesthesia was provided by seven specialist obstetric anesthesiologists, versus one-third provided by 33 generalists.

    Specialist obstetric anesthesiologists demonstrated a significantly lower GA rate, 7.3% vs 12.1% (OR-CI 0.45-0.79). This difference persisted for the urgent/emergent CS sub-group, though not for after-hours delivery.

    Nonetheless several non-provider factors were more strongly associated with GA such as emergency CS (⇡ 7-fold), maternal medical indications for CS (⇡ 3-fold), and after-hours CS (⇡ OR 33%).

    Thus care by a specialist obstetric anesthesiologist is associated with an almost-30% reduction in GA for CS .

    "...consider selecting neuraxial techniques in preference to general anesthesia for most cesarean deliveries." - ASA obstetric anesthesia task force. 2

    Between the lines...

    The individual obstetric-specialized anesthesiologists in this study had an almost 10-fold greater cesarean case load than did the average generalist. Whether the outcome difference was due to technical expertise, decision making or a combination, one message here is that you get better at what you do when you intentionally do more of it.


    1. A specialized obstetric anesthesiologist was defined as having completed an obstetric anesthesia fellowship or specialist practice for at least 5 years with 33% full-time obstetric anesthesia case-load. 

    2. ASA Obstetric Anesthesia Practice Guidelines

    Daniel Jolley  Daniel Jolley
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    Care provided by specialist obstetric anaesthetists/anesthesiologists is associated with a lower rate of general anaesthesia for cesarean delivery than generalist care.

    Daniel Jolley  Daniel Jolley
     
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