Anaesthesia and evidence-based medicine

Comparative effectiveness and safety of physician and nurse anaesthetists: a narrative systematic review †

BACKGROUND

Despite widespread debate on the merits of different models of anaesthesia care delivery, there are few published data on the relative safety and effectiveness of different anaesthesia providers.

METHOD

We conducted a systematic search for, and critical appraisal of, primary research comparing safety and effectiveness of different anaesthetic providers.

RESULTS

Our search of Medline, EMBASE, CINAHL, and HMIC for material published between 1990 and April 2003 yielded four articles of relevance to the question. The studies used a variety of methodologies and all had potential confounding factors limiting the validity of the results.

CONCLUSIONS

In view of the paucity of high-level primary evidence in this area, it is not possible to draw a conclusion regarding differences in patient safety as a function of provider type. There are difficulties in classifying events as "anaesthesia-related", and also in the variable definitions of "supervision" and "anaesthesia care team". We suggest that existing attempts to show differences in outcome might usefully be complemented by studies examining measures of anaesthetic process.

Assessing the evidence on case management

BACKGROUND

Evidence on the impact of case management is contradictory.

AIMS

To discuss two different systematic reviews (one conducted by the authors and one conducted through the Cochrane collaboration) that came to contradictory conclusions about the impact of case management in mental health services.

METHOD

We summarised the findings of the two reviews with respect to case management effectiveness, examined key methodological differences between the two approaches and discuss the impact of these on the validity of the results.

RESULTS

The differences in conclusions between the two reviews result from the differences in inclusion criteria, namely non-randomised trials, data from unpublished scales and data from variables with skewed distributions. The theoretical and empirical effects of these are discussed.

CONCLUSIONS

Systematic reviewers may face a trade-off between the application of strict criteria for the inclusion of studies and the amount of data available for analysis and hence statistical power. The available research suggests that case management is generally effective.

Risk perception and communication: recent developments and implications for anaesthesia

This review begins by outlining the history of probability theory, exposing cultural differences between scientists and lay people in the way risks are viewed. The basic principles of the science of risk perception are described, and the various methods of communicating risk in health care, both verbal and numerical, are then discussed critically. These concepts are then applied to the practice of anaesthesia. Risk perception may affect anaesthetists' choice of career and may be involved in the genesis and evolution of critical incidents; we also discuss possibilities for training in risk perception issues. The place of risk communication in informed consent and its ethical implications are discussed.

A survey of Australasian obstetric anaesthesia audit

In order to develop a minimal obstetric anaesthesia dataset based on current Australasian clinical audit best practice, we carried out a postal survey of 69 Australasian anaesthetic departments covering an obstetric service. We asked about data being collected, specifically concerning the high risk obstetric patient, epidural analgesia and postoperative anaesthetic review. Examples of any data collection forms were requested. Of the 66 responses, 35 departments (53%) were not collecting any audit data. Twenty-six of the 31 departments (84%) performing obstetric anaesthesia audit responded to our follow-up telephone survey. Eighteen departments believed that there had been an improvement in patient care as a result of their audit and 13 felt that the benefits outweighed the costs involved. However, only six departments (9%) had performed an audit cycle. The importance of feedback to patients or hospital staff and the incidence of post dural puncture headache (PDPH) were cited by some as priorities for obstetric anaesthesia audit. There was however no consistency as to what data should be collected. Many responses suggested a perceived need to collect clinical data without knowing what to do with it. Our survey has highlighted confusion between three distinct objectives; a dataset for obstetric anaesthesia record keeping, data required for continuing patient management in hospital and, a specific minimal dataset for clinical audit purposes. We conclude that current Australasian obstetric anaesthesia audit strategies are inadequate to develop a minimal dataset for cost-effective clinical audit.

Evidence-based methods to improve anaesthesia and intensive care

This review concerns the application of the methods of clinical epidemiology to problems in anaesthesia and intensive care. It explores the quality of evidence to guide clinical decision-making and health policy provided by experimental and various non-experimental research designs. Ten recent publications in anaesthesia and intensive care are analysed to provide relevant examples.