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Patient- and Hospital-Level Factors Associated with the Use of General Anesthesia for Cesarean Delivery.
Abstract Number: T2B-3
Abstract Type: Original Research
Compared with neuraxial anesthesia (NA), general anesthesia (GA) for cesarean delivery (CD) is associated with increased risk of adverse maternal outcomes. GA is provided in 5.5 % of CDs (1). Characterizing factors associated with the use of GA may identify targets to reduce CDs under GA and improve maternal safety. To date, research has focused on patient-level factors associated with the use of GA (e.g., women comorbidities) (2). However, hospital-level factors could also be targets. Indeed, higher GA use is suggested in teaching hospitals (1). This study aimed to characterize all hospital-level factors associated with the use of GA for CD.
Patient-and hospital-level factors and GA for CD were identified in the 2003-2014 New York State Inpatients Database (SID) and the American Hospital Association file. New York is the only SID providing data on anesthesia care. Hospital-level factors included 13 variables encompassing structural characteristics, staffing, and case-mix. Multilevel modeling was used to identify factors associated with the use of GA.
Of 760,926 CDs, 4.9% were performed under GA. This proportion decreased from 7.5% in 2003 to 2.9% in 2014 (P < 0.001). In the final multilevel model, the following patients-level factors were significantly associated with the use of GA (Table): maternal age < 19 years, racial minority, self-pay insurance, not residing in a large metropolitan area, higher comorbidity index, non-elective admission, emergent CD, intrapartum CD, and admission during weekend. Five hospital-level factors were also significantly associated with the use of GA: non-teaching status, proportions of high-risk pregnancies < 15% or > 30%, increased proportion of minority women, annual CD volume < 500 or > 1500, and 2 or 3 neonatal level-of-care.
Adjusting for a high number of confounders in a large dataset, we did not confirm a higher GA use in teaching institutions compared with non-academic centers. Increased staffing during weekends, improving process of care in non-teaching hospitals (e.g.better equipment and skills to perform NA), or referring high-risk women to specialized centers may be actionable interventions to improve maternal safety (3). Mechanisms accounting for the use of GA in minority women, low- and-high CD volume hospitals, and level 2 or 3 hospitals remain to be determined.
1.Anesth Analg 2017;124:1914-7.
2.Int J Obstet Anesth 2011;20: 10-6.
3.Acad Med 2012;87:701-8.