The Daily Dose • Thursday, May 27, 2021

Promoting and Highlighting Global Anesthesia Research and Shared Decision-Making

Allison M. Janda, MD

Leaders in global research emphasized the need for high-quality, evidence-based research in this current time of rampant misinformation and disinformation, the need for a global approach to research, and emphasis on shared decision-making with our patients during the World Federation of Societies of Anaesthesiologists panel, “Evidence in the Era of Distrust: Maintaining Scientific Honesty While Remaining Socially Relevant” on May 16 at the IARS 2021 Annual Meeting. 

Adrian Gelb, MD, President of the World Federation of Societies of Anaesthesiologists and Professor (emeritus) Department of Anesthesia & Perioperative Care, University of California, San Francisco, and Davy Cheng, MD, MSc, FRCPS, FCAHS, CCPE, Treasurer of WFSA Board of Directors, EPiCOR Research Chair, Medical Director of the MEDICI Centre (Medical Evidence, Decision Integrity & Clinical Impact), and Distinguished University Professor & Former Acting Dean, Schulich School of Medicine & Dentistry, Western University at London, moderated this excellent panel.

How Can We Be Evidence-Based in the Face of Evidence Reversals, Over-Hype, and Research Misconduct

Janet Martin, PharmD, MSc (HTA), PhDeq, Associate Professor in the Department of Anesthesia & Perioperative Medicine and Department of Epidemiology & Biostatistics at the Schulich School of Medicine & Dentistry, University of Western Ontario, was the first panelist and presented a talk titled, “How Can We Be Evidence-Based in the Face of Evidence Reversals, Over-Hype, and Research Misconduct.” She first focused on the “infodemic” which has accompanied the COVID-19 pandemic and how challenging it can be to distinguish between fake information and facts. She presented lessons learned from the experience in this pandemic.

Her first lesson was, “Epidemics lead to distrust in science.” Misinformation, or unintentional mistakes or inaccuracies, and disinformation, or fabricated or deliberately manipulated content, have been rampant throughout the pandemic and this false information can be weaponized into doubt and undermine facts and evidence presented by the scientific community. Confirmation bias only perpetuates this and makes it incredibly challenging to change the minds of people believing misinformation and disinformation.

Lesson two was, “Viral epidemics lead to infodemics.” The avalanche of information released during the epidemic makes it incredibly challenging to filter out the poor-quality information. Lesson number three was, “We too may inadvertently amplify mistrust and misinformation.” Dr. Martin presented the fallacy of presenting a lack of evidence as a lack of fact or lack of association, and explained that this can lead to inaccurate conclusions. She also highlighted that releasing premature findings or overstating evidence can amplify mistrust. Lesson number four was, “Viral epidemics amplify the need for valid research.” Even within the field of anesthesiology, various issues including p-hacking, hypothesizing after results are known (HARKing), and publication bias were found in the literature. We also are very biased in the geography of our accepted publications with a very strong predominance of high-income countries. Dr. Martin emphasized that we need to move towards acceptance of work from developing countries to better understand our research questions from a global perspective. The final and fifth lesson was, “Our pandemics require global research.” Dr. Martin emphasized the advantages of joining together globally to perform the highest quality, inclusive research as possible.

Ethical, Cultural, and Practical Challenges of Developing & Implementing Global Anesthesia Research

Angela Enright, OC, MB, FRCPC, Clinical Professor of Anesthesia from the University of British Colombia, presented next and focused on discussing the ethical, cultural and practical challenges when planning and conducting anesthesia research globally. She explained that the resources are extremely variable when research is conducted throughout the world including factors someone from a high-resource area may not consider. Importantly, those from high-resource countries may not fully grasp the relevant research questions that may best benefit a group when conducting research in a low-resource country. It is important to incorporate the input of researchers from a host country in developing, implementing, analyzing and publishing a project, she asserted. Additionally, there are existing barriers for practitioners and patients within lower resource countries. Dr. Enright provided examples such as the health risks of the researchers within low-resource countries who have limited access to safe healthcare and challenges obtaining high-speed internet or technology to conduct research. Patient barriers regarding participation, autonomy, the patient health and demographics exist and is important to consider the implications of these barriers when conducting global research to appropriately explain the risks and benefits of research in this social and cultural context.

There are many advantages to conducting global research including involving trainees in research, training researchers in conducting research and writing, reviewing and editing of manuscripts, developing research networks and hubs, and developing and implementing new technology. Dr. Enright cited the example of the ASOS study as developing an excellent model for creating a research network and producing high-quality research. She also discussed operational research which is a “discipline that uses advanced analytical methods to better understand complex systems and aid in decision-making,” and has been utilized by UNICEF and the World Health Organization over the years. There is an excellent year-long operational resource course (Acute Care Operational Research) to help mentees develop a research idea, plan their project, conduct their research and analyze their findings with the assistance of experienced mentors. Dr. Enright emphasized that researchers in low- or middle-income countries are typically not the first or senior author on research projects conducted in these areas and more effort should be dedicated to mentoring researchers in low-resource countries to promote them to the first and senior author positions.

Shared Decision-Making in the Perioperative Setting: A Complex Multi-Faceted Construct

Hilary Grocott, MD, FRCPC, Professor in the Departments of Anesthesia, Perioperative and Pain Medicine and Surgery, from the University of Manitoba, was the final panelist and focused on shared decision-making. In his talk, Dr. Grocott defined shared decision-making, reviewed historical perspectives, and explained why and how we should engage in shared decision making with our patients as well as challenges surrounding shared decision-making.

He started with a case study for a patient with aortic stenosis and the decision to select a bioprosthetic or mechanical valve for her upcoming aortic valve replacement. This example emphasized the importance of the patient’s wishes, concerns and values in this medical decision. Dr. Grocott defined shared decision-making as “the process of using the best available evidence to support patients in making health care decisions based on the patient’s own values, preferences and beliefs.” He emphasized that historically, decision-making was very paternalistic. However, in the 1990s, we transitioned to an informed consent model which promoted information sharing with the patient. Since then, we have been moving towards a true shared decision-making model which incorporates the patient’s values and preferences.

To achieve shared decision-making, he explained that the providers must seek patient participation, help explore treatment options, assess patient values and preferences, reach a decision with your patient together and evaluate your patient’s decision. In this model it is important to discuss the risks and benefits in the considerations and discussions with a patient. Risks to consider include the anesthetic risk, surgical complications, procedural or perioperative risks and loss of independence. There are many challenges in discussing or assessing these risks since there are no reciprocal considerations of the facts, no one clinician has access to all the data and there is a high level of uncertainty regarding assessing, understanding and communicating risks to a patient. Dr. Grocott emphasized the importance of communication with the patient and this can be limited by insufficient time, poor prognostic accuracy, lack of a clinician’s skill in communication as well as the patient’s education level and potential for inadequate numeracy and statistical illiteracy, contributing to barriers in interpreting data. He suggested using a pictograph or other alternative ways of communicating risk, using absolute risk, and equating risk to tangible activities to which a patient can relate to help mitigate the impact of inadequate numeracy and statistical illiteracy and facilitate effective communication and improved understanding to best participate in shared decision-making.