Postoperative Outcomes Associated With Procedural Sedation Conducted by Physician and Nonphysician Anesthesia Providers: Findings From the Prospective, Observational African Surgical Outcomes Study

Abstract

BACKGROUND: There is an unmet need for essential surgical services in Africa. Limited anesthesia services are a contributing factor. Nonphysician anesthesia providers are utilized to assist with providing anesthesia and procedural sedation to make essential surgeries available. There is a paucity of data on outcomes following procedural sedation for surgery in Africa. We investigated the postoperative outcomes following procedural sedation by nonphysicians and physicians in Africa. We hypothesized that the level of training of the sedation provider may be associated with the incidence of severe postoperative complications and death. METHODS: A secondary analysis of a prospective cohort of inhospital adult surgical patients representing 25 African countries was performed. The primary outcome was a collapsed composite of inhospital severe postoperative complications and death. We assessed the association between receiving procedural sedation conducted by a nonphysician (versus physician) and the composite outcome using logistic regression. We used the inverse probability of treatment weighting propensity score method to adjust for potential confounding variables including patient age, hemoglobin level, American Society of Anesthesiologists (ASA) physiological status, diabetes mellitus, urgency of surgery, severity of surgery, indication for surgery, surgical discipline, seniority of the surgical team, hospital level of specialization, and hospital funding system using public or private funding. All patients who only received procedural sedation for surgery were included. RESULTS: Three hundred thirty-six patients met the inclusion criteria, of which 98 (29.2%) received sedation from a nonphysician provider. The incidence of severe postoperative complications and death was 10 of 98 (10.2%) in the nonphysician group and 5 of 238 (2.1%) in the physician group. The estimated association between procedural sedation conducted by a nonphysician provider and inhospital outcomes was an 8-fold increase in the odds of severe complications and/or death, with an odds ratio (95% confidence interval [CI]) of 8.3 (2.7-25.6). CONCLUSIONS: The modest number of observations in this secondary data analysis suggests that shifting the task of procedural sedation from physicians to nonphysicians to increase access to care may be associated with severe postoperative complications and death in Africa. Research focusing on identifying factors contributing to adverse outcomes associated with procedural sedation is necessary to make this practice safer. (Anesth Analg 2022;135:250-63) KEY POINTS• Question: Is there a difference in patient safety when procedural sedation is conducted by nonphysicians or physicians in Africa? • Findings: This secondary analysis of the African Surgical Outcomes Study (ASOS) suggests an association with severe postoperative complications and death when procedural sedation is provided by a nonphysician in Africa. • Meaning: The health care environment in which procedural sedation is provided by nonphysicians in Afr...

Nonphysician Sedation Providers in Africa: What Counts and What Is Being Counted?

“…In the Target Trial Framework, a key requirement is providing a robust counterfactual comparison. A counterfactual can be thought of as what would have happened to the patients in the absence of the intervention, and in the case of van der Merwe et al, 1 we must be confident; the only important differentiating feature between exposed and unexposed patients was the level of training of their provider.…”

“…8 Its largely descriptive statistical analysis has been highly informative of perioperative outcomes in Africa, which appear to be much worse than previously published global data. In contrast, the Van der Merwe et al 1 study is a small subset of the primary data (336 patients, ~3% of the full cohort), with a more complex comparative statistical analysis, with the authors concluding that receipt of sedation from a nonphysician provider was significantly associated with increased odds of severe complications. While these results must be interpreted with great caution (as we will outline below), the findings raise important questions about perioperative health care systems in Africa.…”

“…With increasing demand for surgical and procedural services facilitated by anesthesia care globally, an answer will continue to be sought. Van der Merwe et al 1 in their article “Postoperative outcomes associated with procedural sedation conducted by physician and non-physician anesthesia providers: findings from the prospective, observational African Surgical Outcomes Study (ASOS)” published in this month’s Anesthesia & Analgesia , have added to this discussion, with a secondary analysis of data from the African Surgical Outcomes Study (ASOS). Although their study provides some interesting insights into the outcomes of procedural sedation across the continent, our opinion is that the question remains largely unanswered.…”

“…Van der Merwe et al 1 ’s observational study was designed to answer a question of causation: does receiving care from a nonphysician anesthesia provider cause patients to have more complications? However, when considering findings from any observational study aiming to make inferences on causation, many important factors must be considered.…”

“…Other strategies to help appraise van der Merwe et al 1 ’s findings are to consider them in the context of knowledge already in hand. The current study, like most, used a frequentist approach to significance testing, in other words, drawing conclusions based on expectations of what would be expected of these data were the study to be repeated many, many times where we truly believed there to be no difference (the null hypothesis).…”