Determining The Risk Factors For General Anesthesia Usage .

Determining the RiskFactors for GeneralAnesthesia Usage forCesarean SectionEvanie AngladeSUMR ScholarUniversity of Pennsylvania, 2019Benjamin Cobb, MDMentorHospital of the University of Pennsylvania Obstetric Anesthesia Fellow

Outline Background Project Overview My Roleo Methodso Results My Learning Experience

Cesarean Section (CS) Abdominal surgery to deliver a baby 32% of deliveries in U.S. are by CSo CS is most common non-diagnostic surgical procedure in thecountry1 CS may be required for several reasons Due to advancements in surgical technique,women can request to have CS1. Medline Plus. "Cesarean Section." Medline Plus. Last modified July 20, 2017. Accessed August 9, 2017.https://medlineplus.gov/cesareansection.html.

Anesthesia Type for CS Neuraxial anesthesia CS (NACS) à state ofconsciousnesso Spinalso Epidurals General anesthesia CS (GACS) à state ofunconsciousnesso Asleep with a breathing tube and ventilator

Neuraxial vs. GeneralNeuraxial AnesthesiaLower incidence rate ofGA complications2Lower rate of analgesictransfer to breast milk3Less need for opioids4Being awake for delivery Hypotension2Severe postduralheadaches2Longer to administer2Uncomfortable forpatients already in painGeneral Anesthesia Administered more quickly2PROS CO N S Failed intubation2Aspiration of stomachcontents during intubation2Intraoperative awareness2Respiratory problems2Greater maternal bloodloss22. Afolabi, Bosede B., and Foluso EA Lesi. "Regional versus general anaesthesia for caesarean section." The Cochrane Library (2012).3. Sumikura, Hiroyiki, Hidetomo Niwa, Masaki Sato, Tatsuo Nakamoto, Takashi Asai, and Satoshi Hagihira. "Rethinking generalanesthesia for cesarean section." Journal of anesthesia 30, no. 2 (2016): 268-273.4. Dahl, Jørgen B., Inge S. Jeppesen, Henrik Jørgensen, Jørn Wetterslev, and Steen Møiniche. "Intraoperative and Postoperative AnalgesicEfficacy and Adverse Effects of Intrathecal Opioids in Patients Undergoing Cesarean Section with Spinal Anesthesia A Qualitative andQuantitative Systematic Review of Randomized Controlled Trials." Anesthesiology: The Journal of the American Society of Anesthesiologists 91,no. 6 (1999): 1919-1919.

Neuraxial vs. GeneralNeuraxial AnesthesiaLower incidence rate ofGA complications2Lower rate of analgesictransfer to breast milk3Less need for opioids4Being awake for delivery Hypotension2Severe postduralheadaches2Longer to administer2Uncomfortable forpatients already in painGeneral Anesthesia Administered more quickly2PROS CO N S Failed intubation2Aspiration of stomachcontents during intubation2Intraoperative awareness2Respiratory problems2Greater maternal bloodloss22. Afolabi, Bosede B., and Foluso EA Lesi. "Regional versus general anaesthesia for caesarean section." The Cochrane Library (2012).3. Sumikura, Hiroyiki, Hidetomo Niwa, Masaki Sato, Tatsuo Nakamoto, Takashi Asai, and Satoshi Hagihira. "Rethinking generalanesthesia for cesarean section." Journal of anesthesia 30, no. 2 (2016): 268-273.4. Dahl, Jørgen B., Inge S. Jeppesen, Henrik Jørgensen, Jørn Wetterslev, and Steen Møiniche. "Intraoperative and Postoperative AnalgesicEfficacy and Adverse Effects of Intrathecal Opioids in Patients Undergoing Cesarean Section with Spinal Anesthesia A Qualitative andQuantitative Systematic Review of Randomized Controlled Trials." Anesthesiology: The Journal of the American Society of Anesthesiologists 91,no. 6 (1999): 1919-1919.

Systematic Review Identify factors associated with the use of GACS PubMed, MEDLINE, Scopus, Web of Science, andOvid Embase databases 14 studies from 9 countries between 1998-2015 Emergency CS, maternal demographics, andmaternal comorbidities

GACS Indications/AssociationsIndications Emergent cases Neuraxialcontraindications Failed neuraxialanesthesia Maternal requestAssociations BMI 40 Age 35 Non-obstetricanesthesiologists Perceived lack oftime to giveepidural VAS 3 duringlabor Black race Hispanic ethnicity

GACS Indications/AssociationsIndications Emergent cases Neuraxialcontraindications Failed neuraxialanesthesia Maternal requestAssociations BMI 40 Age 35 Non-obstetricanesthesiologists Perceived lack oftime to giveepidural VAS 3 duringlabor Black race Hispanic ethnicity

Project Overview Question: What factors affect clinicians’ decisionsabout obstetric anesthesia care? Goal: To determine the risk factors of GACS andbetter understand clinician decision-making toultimately, mitigate the use of GACS Mixed methods studyo Quantitative: retrospective cohort studyo Qualitative: surveys and interviews

Significance Large, young population of people affectedo Childbirth is the most common reason for hospital admission in theUS5 Disparities in careo 6% of CS in U.S. are managed with general anesthesia6o 9% of CS at HUP are managed with general anesthesia5. Lange, Elizabeth MS, Suman Rao, and Paloma Toledo. "Racial and ethnic disparities in obstetric anesthesia." In Seminars in Perinatology. WBSaunders, 2017.6. Juang, Jeremy, Rodney A. Gabriel, Richard P. Dutton, Arvind Palanisamy, and Richard D. Urman. "Choice of Anesthesia for CesareanDelivery: An Analysis of the National Anesthesia Clinical Outcomes Registry." Anesthesia & Analgesia 124, no. 6 (2017): 1914-1917.

Specific Aims1. Build two parallel databases (local and national) toelucidate variability relating to obstetric anesthesiacare.1. Using multivariable regression and the databasescreated in SA1, identify the patient-, provider-, andsystem-level risk factors for GACS.1. Using qualitative methods, develop theory aboutclinician decision-making in obstetric anesthesiacare.

HypothesesPatient-level1.2.Demographics, obesity/BMI, parity, and intrapartum disordersare associated with GACS.GACS rate is higher for CS during night and weekend shifts.Provider-level1.2.Obstetric anesthesiologists perform less GACS compared to nonobstetric anesthesiologists.The rate of GACS is lower for patients admitted to FamilyMedicine service compared to Obstetrics service.System-level1.The greater the distance between labor room and operatingroom, the lower GACS rate is.

Study DesignPhase 1Variability inCareIdentificationPhase 2Clinician DecisionMaking TheoryDevelopmentPhase 3Patient-RelatedOutcomesIdentification

Conceptual ModelAttributesProcessOutcomePatientOutcome

Conceptual ModelAttributesProcessOutcomePatientOutcome

Penn Obstetric Database 3 Data Sources1.2.3.Centricity Perinatal & Epic PerinatalInpatient medical recordsAnesthesia Preoperative Forms Includes CS in the HUP L&D unit from July 2013 toJune 2017 4,034 CS 40 variables

Variables of Interest in P codeMarital statusSmoking statusPrenatal careservice Parity Intrapartumdisorders istics Day, month, and On-call (nighttime of deliveryand weekend) Obstetric anes vs.assignment ofnon-obstetricphysiciansanes Gender of anes MFM ob vs. nonMFM ob

POD Race BreakdownHUP Labor and Delivery Patient PopulationNumber of Race/Ethnicity172662

Race/Ethnicity for Anesthesia Type100%Percentage of GACS and AsianBlackEastIndianHispanic/ 674Race/EthnicityPr 0.001

Hour of Delivery by Anesthesia TypePercentage of GACS and NACS100%95%90%GACS85%NACS80%75%0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23Hour of DeliveryPr 0.006

My RolePhase 1Variability inCareIdentificationPhase 2Clinician DecisionMaking TheoryDevelopmentPhase 3Patient-RelatedOutcomesIdentification

My Role: Specific Aims1. Use the Penn Obstetric Database (POD) andmultivariable regression analysis to identify patientlevel risk factors for GACS.1. Learn about the challenges in defining variables tounderstand the effects of risk factors.

My Variable of Interest in P codeMarital statusSmoking statusPrenatal careservice Parity Intrapartumdisorders istics Day, month, and On-call (nighttime of deliveryand weekend) Obstetric anes vs.assignment ofnon-obstetricphysiciansanes Gender of anes MFM ob vs. nonMFM ob

My Variable of Interest in P codeMarital statusSmoking statusPrenatal careservice Parity Intrapartumdisorders istics Day, month, and On-call (nighttime of deliveryand weekend) Obstetric anes vs.assignment ofnon-obstetricphysiciansanes Gender of anes MFM ob vs. nonMFM ob

ZIP Code Variable Proxy for household income Hypothesis: Lower household incomes areassociated with GACS.

My Role: Methods 1000 patient chart reviewo Epic data June 2016 – February 2017o REDCap format conversion with Data Import Tool on Excel Merging databaseso Centricity database and Epic databaseo Overlap July 2013 to June 2017 Classify zip codes by median household incomeo Via Esri Data analysiso Via STATA 14.2

Esri GIS mapping software Updated annually Data sourcesooooAmerican Community Survey (1-year and 5-year estimates)Bureau of Economic Analysis’ Local Personal Income seriesCurrent Population SurveyBureau of Labor Statistics’ Consumer Price Index

Median Household Income for Anesthesia Type100%Percentage of NACS and GACS98%96%94%92%90%GACSNACS88%86%84% 32,984 32,985 47,727 47,728 67,106 67,107 – 99,321 99,322 200,001GACS22271462010NACS1,917812496308141Median Household Income of ZIP codePr 0.035

Prenatal Care Practice for Anesthesia Type100%Percentage of GACS and meMiddle-High incomeOtherGACS2441187NACS2,0851,54247Prenatal Care Practice TypePr 0.001

Patient-related Variable Associated withGACSOdds Ratio95% ConfidenceIntervalp-valueBlack race1.741.36-2.220.00Smoking status1.421.12-1.810.00Single marital status1.761.38-2.240.00Low-income Z.I.P. code1.381.11-1.720.00Low-income prenatal care practice1.481.34-2.510.00Black race1.381.05-1.880.03Smoking status1.381.09-1.760.00Single marital status1.310.99-1.740.54Low-income Z.I.P. code1.050.82-1.330.70Low-income prenatal care practice1.150.89-1.480.25Univariable RegressionMultivariable Regression*Controlled for age, ASA status, HTNsive disorders, neurologic disorders, hematologic disorders, on-calldeliveries, high-risk obstetrics specialty, obstetric anesthesia specialty, gestational age at delivery, obesity,diabetes, thyroid disease, depression.

Limitations ZIP code may not be the best surrogate forhousehold incomeo Ex: 19104 à median household income of 19,000 may befalsely low More impoverished areas further west, wealthier areas closerto Penn Substantial amount of patients from that ZIP codeo Proxy for distance from hospital instead Secondary data

My Learning Experience A well-organized and well-cleaned databasemakes the difference during data analysis Being thorough STATA basics Developing a research question L&D shadowing experience

AcknowledgementsDr. Benjamin CobbHUP OB AnesthesiologistsOfficeJoanne LevySafa BrowneLeonard Davis InstituteWharton Dean’s2017 SUMR Cohort

Questions?

Jul 20, 2017 · Delivery: An Analysis of the National Anesthesia Clinical Outcomes Registry." Anesthesia & Analgesia 124, no. 6 (2017): 1914-1917. Specific Aims 1. Build two parallel databases (local and national) to elucidate variability relating to obstetric anesthesia care. 1. Using multivariable regression and the databases