SAMBA also established a category “Best” Research Award in 1990, as part of its annual meeting, and an “Outcome” Research Award in 2000. The recipient of the latter that year was Lee Fleisher, MD. In 2009, Dr. Fleisher edited the second edition of the text Evidence-Based Practice of Anesthesiology.12 Many members of SAMBA were contributing authors or coauthors. Several chapters, such as those devoted to discharge criteria, office-based anesthesia, and the management of postoperative nausea and vomiting, are of particular importance in ambulatory surgery.
The problem with many of the conclusions in these chapters and in a recent textbook on the subject13 is not what is described or recommended but the variability in the availability and strength of the supporting evidence. Recommendations could only be made using the “best available” information. This problem persists in the development of the Practice Parameters, Guidelines, and Advisories of ASA and in the “consensus” Guidelines of Postoperative Nausea and Vomiting (PONV) developed by SAMBA.9–11
A good illustration of this issue is the ASA’s Practice Guidelines for Postanesthetic Care.14 Three of the recommendations are based on “insufficient literature”; that is, “there are too few published studies to investigate a relation (linkage) between a clinical intervention and a clinical outcome.” Nevertheless, the recommendations are generally well accepted by the ambulatory anesthesia community. They include:
- Urination is required only in selected patients.
- Ingestion of clear liquids without vomiting is not part of the routine discharge criteria.
- A mandatory minimum stay in the recovery room is not required.
Despite the ASA’s exhaustive methodical process and model, “An astonishing number of recommended practices in these (ASA) publications are based on expert consensus after our task forces have come up empty-handed in their quest for high quality evidence.”15
SAMBA has developed a less-exhaustive process for the development of guidelines. The first of these was guidelines for the management of postoperative nausea and vomiting,9 and more recently published guidelines on glucose management for the ambulatory patient.11 These guidelines were developed using a shorter time cycle with less money and have no ASA counterpart, thus adding valuable information for practicing anesthesia providers.
A very recent, provocative editorial addresses some of the problems we face today when developing guidelines, advisories, and other “authoritative statements.”16 The authors state, “… it is inevitable (we hope) that consensus statements based on opinions, however well-intentioned and thoroughly constructed, will require revision based on scientific advancement and new evidence.”
The editorial was written because of new evidence17 that calls into question a recommendation contained in the American Society of Regional Anesthesia’s consensus statement from their 2002 conference on Neuraxial Anesthesia and Anticoagulation.18
In addition, the authors of the editorial question whether many organizations, foundations, and groups should remain in the business of providing statements, guidelines, and parameters for anesthetic practice. To a great many of them, we say “cease and desist.” In part, their criticism revolves around the design of the model. They also question the size of the sponsoring organization and its ability to adequately fund the effort and to debate the initial recommendations of the final product in an open forum.
In my opinion, many of the conclusions in the preceding editorial are controversial. Yet, the fact remains that much of our practice and the advice we receive as to the “standard of care” is not based on hard data. This is not limited to the field of anesthesiology. To quote: “The poverty of our healthcare information is an embarrassment … simply try to find out how many people died from heart attacks or pneumonia or surgical complications—and you will discover that the most recent data are at least three years old, if they exist at all ….”c
WHERE WE ARE GOING
There are, however, exceptions; for example, one noncardiac surgical model with ongoing data collection is the National Surgical Quality Improvement Program (NSQIP). This was established in 1994 and is a nationally validated, outcome-based, risk-adjusted, peer-controlled program analyzing 30-day morbidity and mortality in United States Veterans Administration (VA) hospitals. Their results have led to marked improvements in surgical care throughout the VA system.19
Their model has also been validated in a number of non-VA hospitals under an Agency for Healthcare Research and Quality federal grant to the American College of Surgeons (ACS NSQIP).20 An example of the application of some recently collected, published data describes the development of the use of a morbidity and mortality risk calculator for colorectal surgery.21 Unfortunately, neither NSQIP nor ACS NSQIP collects data on the conduct of anesthesia although ASA status is recorded and has been validated as a risk factor.
The NSQIP and ACS NSQIP are also very expensive to administer and are not “user-friendly.” Data from one NSQIP case consists of 163 data points per case, recorded actively by a specially trained and designated “abstractor.” This time-consuming and expensive model limits the number of cases that can be culled and the number of hospitals that are able to participate.d
Both ASA and SAMBA have recognized that it will be impossible to develop accurate and timely advice for our members without an ongoing data collection system dedicated to our specialty’s needs. These include “Benchmarkings,” “Best Practices,” “Quality Improvement,” Maintenance of Certification in Anesthesiology, as well as “Pay for Performance.”
This is the direction we must go. Fortunately, both organizations (SAMBA and ASA) have recognized the urgency of the situation. In 2008, the ASA created the Anesthesia Quality Institute (AQI).e Its task is to collect and disseminate data across the breadth of anesthesia practices in the United States, including groups from the largest universities to the smallest private practices. It will be accomplished by creation and administration of the National Anesthesia Clinical Outcome Registry. Unlike NSQIP, data will be collected by the passive capture of digitized information from anesthesia billing systems, quality management programs, hospital information technology platforms, and anesthesia information management systems.
Similar, to ASA’s efforts, SAMBA has launched the SCOR program (SAMBA Clinical Outcomes Registry). Data will be collected using a paper diary during the case to enter the data later, or on a user-friendly short form (web-based entry) during patient care. This is intended for use in any ambulatory surgery facility.
Although this effort will be directed toward the massive population of anesthesiologists who provide care in a variety of ambulatory surgical settings, the success of both AQI and SCOR relies on sharing and interpreting data. “Establishing connections between an anesthesia registry and emerging registries in organizations such as our subspecialty societies … is demanding but critical.”15 Fortunately, the leadership of SCOR and AQI is working on a means to share data collected by both groups and to have a single report of these data generated by SAMBA that will be shared with participating groups and hospitals.
a Memo from the desk of Bernard V. Wetchler, MD, 1984 (undated).
b Epstein BS, Levy ML, Thein MH, Coakley CS. Evaluation of fentanyl as an adjunct to thiopental–nitrous oxide–oxygen anesthesia for short surgical procedures. Anesthesiol Rev 1975;2:24–9.
c Gawande A. Testing, testing. The New Yorker. December 14, 2009.
d Dutton RP. Counterpoint: out with the old, in with the new! ASA Newsletter 2010;74:18–9.
e Dutton RP. Data exchange in the information age: creation of the Anesthesia Quality Institute. AUA update 2009. Winter: pp 3, 8.
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© 2011 International Anesthesia Research Society
21. Cohen ME, Bilimoria KY, Ko CY, Hall BL. Development of an American College of Surgeons National Surgical Quality Improvement Program: morbidity and mortality risk calculator for colorectal surgery. J Am Coll Surg 2009; 208: 1009–16