Anesthesiologists’ Attitudes Toward Randomization to General versus Neuraxial Anesthesia for Cesarean Delivery

Involving patients in treatment decisions is fundamental to high-quality intrapartum care.1 The 2016 American Society of Anesthesiologist (ASA) practice guidelines for obstetric anesthesia recommend that anesthesiologists “consider selecting neuraxial techniques in preference to general anesthesia for most cesarean deliveries”; however, they also state that “the decision to use a particular anesthetic technique for cesarean delivery should be individualized,”2 including through consideration of patient preferences and values.Gaps in evidence regarding the safety and acceptability of general versus neuraxial anesthesia challenge efforts to incorporate patient preferences into decision-making in this context.3 For example, past trials have not considered intraoperative pain, which impacts 1 in 10 patients undergoing cesarean delivery under neuraxial anesthesia.4 Airway risks historically attributed to general anesthesia have decreased over time,5,6 limiting the relevance of older studies to contemporary practice. Moreover, general anesthesia may offer potential advantages for patients who have severe anxiety about undergoing surgery while awake or who strongly prioritize avoiding pain during surgery.Randomized comparisons of general versus neuraxial anesthesia for cesarean delivery could increase the ability of patients who lack strict contraindications to either anesthesia type to participate in treatment choices. Few data exist to characterize the willingness of anesthesiologists to facilitate such trials by providing randomly assigned treatments to consenting patients. We thus interviewed U.S. and Canadian anesthesiologists to assess attitudes toward a hypothetical trial that would randomize consenting healthy parturients to neuraxial versus general anesthesia for elective cesarean delivery.This project was part of a larger qualitative study7 exploring trial enrollment decisions by anesthesiologists in a randomized trial comparing spinal versus general anesthesia for hip fracture surgery.8,9 The University of Pennsylvania (Philadelphia, Pennsylvania) Institutional Review Board exempted this study from review.We conducted semistructured interviews among generalist anesthesiologists who had treated trial patients at four U.S. and one Canadian hospital using a structured interview guide (supplemental appendix, https://links.lww.com/ALN/D328). Hospitals were selected based on the number of patients enrolled in the original trial and site investigator willingness to assist with recruitment. Participants were recruited via email, provided verbal consent, and received $75 U.S. dollars for participating. After completing the main interview questionnaire, which focused on decisions regarding participation in the hip fracture trial (reported separately),7 we asked participants to imagine a hypothetical study that would randomly assign healthy, consenting parturients to spinal versus general anesthesia for nonurgent cesarean deliveries and comment on their anticipated willingness to administer spinal or general anesthesia as randomly assigned. Participants provided information on demographics and years in practice and answered two items adapted from the Research Attitudes Questionnaire.10Interviews were professionally transcribed; J.C. and M.D.N. each independently reviewed all transcripts and characterized each participant as being willing or unwilling to permit randomization. M.D.N. annotated the relevant section of each transcript to identify themes articulated by individuals with affirmative versus negative responses; J.C. reviewed all annotation, and disagreements were resolved by consensus. We used simple hypothesis tests to compare demographics, and Research Attitudes Questionnaire item responses for respondents with negative or affirmative responses. P < 0.05 indicated statistical significance.Of 25 participants, 23 were male (92%) and 2 were female (8%). Fifteen (60%) practiced in the United States and 10 (40%) practiced in Canada; 88% worked at hospitals with anesthesiology residency programs. All respondents viewed neuraxial anesthesia as a preferred option over general anesthesia for cesarean delivery. Eighteen participants (72%) stated that they would permit a patient to be randomly assigned to neuraxial versus general anesthesia, versus 7 (28%) who would not. For those indicating willingness, all specified that their response was conditional on safeguards being in place (e.g., informed consent, institutional review board approval, eligibility criteria).Respondents who indicated unwillingness to permit randomization cited perceptions of greater risks with general anesthesia and an effort to maintain adherence to community norms and standards of practice. Respondents who indicated willingness to permit randomization cited uncertainties regarding the superiority of neuraxial anesthesia in all cases, and honoring patient choices regarding trial participation (table 1).The mean years in practice was 20 ± 4 versus 13 ± 2 for those who were not willing to randomize versus those who were (P = 0.12). As measured on a scale of 1 (disagree completely) to 5 (agree completely), the mean level of agreement with the statement “I have a positive view about medical research in general” was 4.9 ± 0.1 versus 5.0 ± 0.0 for those unwilling versus willing to randomize, respectively (P = 0.11); mean agreement with the statement “clinicians all have some responsibility to help others by facilitating medical research” was 3.9 ± 0.5 versus 4.6 ± 1.4 (P = 0.048).Interviewed anesthesiologists varied in their attitudes toward clinical trial randomization to neuraxial versus general anesthesia for elective cesarean delivery. Although all respondents preferred neuraxial anesthesia, respondents differed in their views regarding the certainty of underlying evidence and the importance of adhering to individual or group norms of practice versus honoring patient choices. Attitudes regarding clinicians’ responsibilities to facilitate medical research differed across respondents who would versus would not be willing to permit randomization.Our study is limited by our use of a convenience sample of general anesthesiologists practicing at four U.S. and one Canadian hospital, all of whom participated in a previous randomized trial; as such, results may not generalize to obstetric anesthesiologists, other hospitals, or clinicians who may be reluctant to participate in research in general. Responses to hypothetical scenarios may differ from actual behavior; respondents who indicated a willingness to accept randomization could still decline participation in an actual trial. We did not evaluate patient, family, or obstetrician perspectives.Our work has implications for research. Given potential advantages and disadvantages to both neuraxial and general anesthesia for cesarean delivery, rigorous outcome comparisons could aid patients who lack contraindications decide between these two techniques. Our findings indicate that some anesthesiologists may view randomization as an appropriate approach for such comparisons. Moreover, they suggest that differences in clinicians’ attitudes may relate to beliefs about the strength of available evidence; the importance of personal or group norms of practice versus honoring patient choices; and beliefs about physicians’ responsibilities to facilitate medical research.This study was supported in part by funding from the Institute for Translational Medicine and Therapeutics (ITMAT) at the University of Pennsylvania (Philadelphia, Pennsylvania) and by Grant Number UL1TR001878 from the National Center for Advancing Translational Science (Bethesda, Maryland). Dr. Clapp was supported by the National Institute on Aging (NIA) of the National Institutes of Health (Bethesda, Maryland) under Award Number U54AG063546, which funds NIA Imbedded Pragmatic Alzheimer’s Disease and AD-Related Dementias Clinical Trials Collaboratory (NIA IMPACT Collaboratory). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Advancing Translational Science or the National Institutes of Health.The authors declare no competing interests.Appendix, https://links.lww.com/ALN/D328