Perceptions of gender equity in departmental leadership, research opportunities, and clinical work attitudes: an international survey of 11 781 anaesthesiologists.

BACKGROUND: Women make up an increasing proportion of the physician workforce in anaesthesia, but they are consistently under-represented in leadership and governance. METHODS: We performed an internet-based survey to investigate career opportunities in leadership and research amongst anaesthesiologists. We also explored gender bias attributable to workplace attitudes and economic factors. The survey instrument was piloted, translated into seven languages, and uploaded to the SurveyMonkey® platform. We aimed to collect between 7800 and 13 700 responses from at least 100 countries. Participant consent and ethical approval were obtained. A quantitative analysis was done with χ2 and Cramer's V as a measure of strength of associations. We used an inductive approach and a thematic content analysis for qualitative data on current barriers to leadership and research. RESULTS: The 11 746 respondents, 51.3% women and 48.7% men, represented 148 countries; 35 respondents identified their gender as non-binary. Women were less driven to achieve leadership positions (P<0.001; Cramer's V: 0.11). Being a woman was reported as a disadvantage for leadership and research (P<0.001 for both; Cramer's V: 0.47 and 0.34, respectively). Women were also more likely to be mistreated in the workplace (odds ratio: 10.6; 95% confidence interval: 9.4-11.9; P<0.001), most commonly by surgeons. Several personal, departmental, institutional, and societal barriers in leadership and research were identified, and strategies to overcome them were suggested. Lower-income countries were associated with a significantly smaller gender gap (P<0.001). CONCLUSIONS: Whilst certain trends suggest improvements in the workplace, barriers to promotion of women in key leadership and research positions continue within anaesthesiology internationally.

Quantitative Assessment of Statistical Reviews of Patient Safety Research Articles.

OBJECTIVES: For 8.5 consecutive years, all patient safety articles of a journal underwent statistical review before publication. We sought to establish the prevalence of statistical themes in the statistical reviews, consideration of contemporary statistical methods, and their associations with time to journal receipt of authors' revision. METHODS: An initial set of statistical themes was created using the statistical editor's notes. For example, for the statistical theme of "CONSORT checklist," the search term needed was "CONSORT." A complete (exhaustive) list of additional themes was obtained inductively. RESULTS: Among the 273 subsequent reviews for manuscripts that were ultimately accepted, the number of paragraphs that included a theme of a statistical method was only weakly associated with longer revision times (Kendall τ = 0.139 ± 0.039, P = 0.0004). Among the total 3274 paragraphs of statistical reviews, 72.2% did not include a theme of a statistical method (e.g., the editor instead asked the authors to clarify what statistical method had been used) (95% confidence interval [CI] = 70.6%-73.7%, P < 0.0001 versus 50%).Among the 207 manuscripts with a review that included a statistical method, 47.3% included a contemporary topic (e.g., generalized pivotal methods) (95% CI = 40.4%-54.4%). However, among the 911 corresponding paragraphs of statistical review comments, only 16.0% included a contemporary theme (95% CI = 13.7%-18.6%). CONCLUSIONS: The revised versions of patient safety articles, which are eventually to be accepted for publication, have many statistical limitations especially in the reporting (writing) of basic statistical methods and results. The results suggest a need for education of patient safety investigators to include statistical writing.

Is lower-dose sugammadex a cost-saving strategy for reversal of deep neuromuscular block? Facts and fiction.

BACKGROUND: Sugammadex, a γ-cyclodextrin derivative, belongs to a new class of selective relaxant binding agents. Sugammadex was approved 10-years ago by the European medicines agency and today is used in clinical anesthesia and emergency medicine globally. In this review, indications for neuromuscular block, the challenge of neuromuscular monitoring and the practice of under-dosing of sugammadex as a potential cost-saving strategy are discussed. MAIN BODY: Reversal of neuromuscular block is important to accelerate the spontaneous recovery of neuromuscular function. Sugammadex is able to reverse a rocuronium- or vecuronium-induced neuromuscular block rapidly and efficiently from every depth of neuromuscular block. However, since sugammadex was introduced in clinical anesthesia, several studies have reported administration of a lower-than-recommended dose of sugammadex. The decision to under-dose sugammadex is often motivated by cost reduction concerns, as the price of sugammadex is much higher than that of neostigmine outside the United States. However, under-dosing of sugammadex leads to an increased risk of recurrence of neuromuscular block after an initial successful (but transient) reversal. Similarly, when not using objective neuromuscular monitoring, under-dosing of sugammadex may result in residual neuromuscular block in the postoperative care unit, with its attendant negative pulmonary outcomes. Therefore, an appropriate dose of sugammadex, based on objective determination of the depth of neuromuscular block, should be administered to avoid residual or recurrent neuromuscular block and attendant postoperative complications. Whether the reduction in perioperative recovery time of the patient can be translated into additional procedural cases performed, faster operative turnover times, or improved organizational resource utilization, has yet to be determined in actual clinical practice that includes verification of neuromuscular recovery prior to tracheal extubation. CONCLUSIONS: The current review addresses the indications for neuromuscular block, the challenge of neuromuscular monitoring, the practice of under-dosing of sugammadex as a potential cost-saving strategy in reversal of deep neuromuscular block, the economics of sugammadex administration and the potential healthcare cost-saving strategies.

Survey of the National Drug Shortage Effect on Anesthesia and Patient Safety: A Patient Perspective.

BACKGROUND: There are few data on patients' desire to be informed of drug shortages before elective surgery. We surveyed patients who had previously undergone laparoscopic cholecystectomy for their opinions. METHODS: Nine hundred forty-nine Mayo Clinic patients were invited to participate in the survey. The postal survey posed a hypothetical surgical scenario and requested answers regarding the desire to be informed and to postpone scheduled surgery because of neostigmine shortage. Comparison was made with Canadian patients from a hospital in Ontario. RESULTS: Most of the 256 respondents wanted "to be told by the anesthesia doctor about the neostigmine shortage" if there were "slight differences" in side effects between the drug combinations (P < 0.0001). The percentage of patients wanting to know was 76.2% (95% confidence interval, 70.5%-81.3%). Secondary analyses tested the validity and reliability of the survey. With each increase in the differences in substituted drug's side effects, there was a progressive increase in the patients' desire for information (P < 0.0001; 73.2%, 76.2%, and 95.7% of 246, 256, and 253 respondents, respectively) and preference for delaying surgery (P< 0.0001; 33.6%, 39.4%, and 80.9% of 238, 246, and 241 respondents, respectively). There was no association with respondents' sex (P = 0.19), age (P = 0.76), educational level (P = 0.39), or country (United States versus Canada [n = 58]; P = 0.87). CONCLUSIONS: The majority (>50%) of surveyed patients want to be informed of drug shortages that might affect their care.

Cohort study of cases with prolonged tracheal extubation times to examine the relationship with duration of workday.

PURPOSE: The economics of the use of an anesthetic drug or device that produces benefit through reduction in operating room (OR) time depends on the day of the week and the total hours of surgical cases in the OR in which they are performed. Principally, this has to do with different durations of the regularly scheduled workday in the ORs within and among hospitals. We tested hypotheses relevant to the economic benefit of avoiding prolonged tracheal extubation times. METHODS: Observational data were obtained from a multiple-specialty academic tertiary hospital that uses an anesthesia information management system. Prolonged tracheal extubation times were considered those with tracheal extubations occurring 15 min or more after the end of surgery. The assessment of prolonged tracheal extubation times was limited to cases for which the patient's trachea was intubated and extubated while physically in the OR. Percentages were calculated for each of n = 39 four-week periods. Results are reported as mean (standard error of the mean) of these percentages, and the phrases "at most/least" are used to refer to the corresponding 95% confidence limits. RESULTS: At most, 6.1% [mean 5.5 (0.3)%] of the prolonged tracheal extubation times were attributable to cases that did not end during regular workdays from 7:00 AM-10:59 PM. At least 55.6% of prolonged tracheal extubation times occurred during cases on regular workdays and in an OR with more than eight hours of cases and turnovers [mean 57.0 (0.9)%; P < 0.0001]. This percentage was 23.8 (0.8)% larger than for all other cases. CONCLUSIONS: In the absence of an accurate facility-specific cost analysis, prolonged tracheal extubation times should not be treated as fixed costs but as resulting in proportionally increased OR variable costs.

Anesthesiology residents' and nurse anesthetists' perceptions of effective clinical faculty supervision by anesthesiologists.

BACKGROUND: Often anesthesia care is provided by nonfaculty anesthesia providers (e.g., anesthesiology residents and certified registered nurse anesthetists [CRNAs]) under the guidance of faculty anesthesiologists. Performance appraisal of faculty anesthesiologists should therefore include evaluation of this guidance. METHODS: Residents and CRNAs from 3 teaching hospitals gave their "impression of 9 attributes of the hypothetical supervising anesthesiologist who meets … expectations … not … who exceeds expectations or whose activity is below … expectations." Scores were based on the anesthesiologist working with the respondent, not others. A 4-point scale (e.g., 1 = never, 2 = rarely, 3 = frequently, and 4 = always) was used, and the mean was calculated. RESULTS: The participation rate was 51% among CRNAs (N = 153) and 58% among resident physicians (N = 47). There was no association between years since the start of training and supervision scores that met expectations among CRNAs (Kendall τb = 0.01; 95% confidence interval [CI], -0.13 to +0.10; P = 0.90) or residents (τb = 0.03; 95% CI, -0.16 to +0.23; P = 0.77). Most CRNAs (67%) and residents (94%) perceived that supervision that met their expectations was at least "frequent" (score ≥3.0) (both P < 0.0001). The mean ± SD of supervision scores that met expectations was 3.14 ± 0.42 for CRNAs versus 3.40 ± 0.30 for residents. The CRNAs' score mean was 0.26 less than that of residents (P < 0.0001; 95% CI, 0.15 to 0.37 less). There were 30% of CRNAs with scores larger than the residents' mean. CONCLUSIONS: Most CRNAs and residents at 3 teaching hospitals considered faculty guidance that meets expectations to be at least "frequent," regardless of years in practice.