Access to Anesthesia Care is Universally Lacking Both in Providers and in a Universal Solution

Young May Cha, MD

Providing equitable access to anesthesia care is a problem that affects all countries, regardless of World Bank economic designation. The COVID-19 pandemic aggravated an already problematic issue. On Friday, May 17, Angela C. Enright, MB, FRCPC, clinical professor emeritus at the University of British Columbia and executive editor of Anesthesia & Analgesia, moderated the session, “Anesthesia & Analgesia: Access to Anesthesia Care – A Universal Challenge?” Three speakers presented three unique approaches to this global problem.

Canada is a high-income country, and yet it lags behind other nations in number of anesthesia providers per 100,000 people. Beverley A. Orser MD, PhD, FRCPC, FRSC, professor and chair of the department of anesthesiology and pain medicine at the University of Toronto, explained how this shortage is having an inequitable effect on rural areas. The number of birthing centers has decreased, and women must travel longer distances to obtain maternity care. Much of rural anesthesia in Canada is provided by family practice anesthetists, but these providers are leaving the field at an alarming rate. There is also a large gender disparity in the Canadian anesthesia workforce. These issues raise concern for factors contributing to high levels of burnout and factors that may be deterring women from entering and staying in this workforce.

To address this issue, the University of Toronto has created a roadmap for building up the anesthesia workforce in Canada that is redesigning and expanding the anesthesia care team to include anesthesia assistants. They are also creating new educational opportunities, such as resident electives in rural communities, to encourage them to fill this understaffed niche. To mitigate burnout and to answer the needs of the family practice anesthetists, they have created educational seminar series, mentoring relationships, and avenues for these anesthetists to “phone a friend” and consult with other anesthesia providers. They are also in collaboration with other fields like aerospace to incorporate new technologies, such as virtual reality and augmented reality.

Jaideep J. Pandit, MA, DPhil, FRCA, DM, professor of anaesthesia at the University of Oxford and editor-in-chief of Anesthesia & Analgesia, then presented the workforce shortages in the United Kingdom (UK) and a cautionary tale of how solutions to this problem must be instituted carefully. Despite an increase in the number of anesthesia consultants in the UK, there has been a steady decline in case hours performed. Many factors are thought to contribute to this including the COVID-19 pandemic, patient complexity, and the increase in part-time anesthesia work. Both top-down and bottom-up models of the UK anesthesia workforce estimate a 20% shortage, and there are estimated to be over 8 million UK patients waiting for surgery.

Under the assumption that anesthesia assistants (AAs) would be a cost-effective way to fill this gap, the UK health service began to train AAs. The UK does not practice a supervisory model, and anesthesia services are provided by consultant anesthesiologists and staff associate specialists (SAS). Rather than being a cost-effective addition, Dr. Pandit’s analysis showed that AA salaries were sometimes exceeding consultant salaries. Decreasing the AA salary or increasing the clinical time required in an AA contract would make the position less desirable, but, at this rate, the addition of AAs will increase the cost of UK anesthesia care. Recruitment for the AA program is currently suspended.

Dr. Pandit proposed three possible solutions to this problem. One is resource smoothing, in which cases are moved to the weekends to create space during the week. The second is to adopt the mindset of an “infinite game,” in which all anesthesia providers work collaboratively. The third is a 3-tier model of anesthesia in which healthy, awake patients are cared for with distant supervision or nursing-led sedation, more complex patients are cared for in a multiperson supervisory model, and 1:1 care is reserved for the patients of the highest complexity and acuity.

Bruce Biccard, MBChB, FCA (SA), FFARCSI, MMedSci, professor and second chair in the department of anaesthesia and perioperative medicine at Groote Schuur Hospital and the University of Cape Town, South Africa, presented some of the unique challenges for anesthesia care in low- and middle-income countries (LMICs).  The African nations also suffer from geospatial access, and estimates of need range from 4 to 22 times the current capacity. There is also a high rate of complications, most commonly infection and maternal hemorrhage, that is difficult to improve given the limited resources available.

Dr. Biccard founded the African Perioperative Research Group (APORG) and enlisted over 500 sites in 36 African countries to provide a rich data source to address these issues. The group instituted a risk calculator to flag high-risk patients, but this intervention alone did not alter patient outcomes. Due to the lack of granular data in the network, it is unknown if the flagged patients received additional postoperative surveillance or other medical escalation. Next proposed steps are to use a standard dataset from the sites and to revise the data collection processes to improve data granularity.