Clinical trial NCT04438811: Task-based Credentialing for Medical Officers in Spinal Anesthesia
Official title: Task-based Credentialing for Medical Officers in Spinal Anesthesia: An Innovative Approach to the Specialist Workforce Crisis in Rural Indian Hospitals Curriculum Training of Medical Officers
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Spinal Anesthesia
Task Sharing in Anesthetic Delivery in Areas With Limited Access to Care
Keywords: global health
Lead sponsor: Harvard Medical School (HMS and HSDM)
Sponsor class: OTHER
Collaborators: name: Ashwini Health System, Gudalur, India
name: Harvard Center for Global Health, Dubai
name: Boston Children's Hospital
name: Program in Global Surgery and Social Change, Harvard Medical School
First posted: 2020-06-19
Enrollment: 486
Sex: ALL
Minimum age (years): 18
Maximum age (years): 65
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: yes
Allocation: RANDOMIZED
Intervention model: PARALLEL
Intervention model description: This is a non-inferiority, randomized trial. Patients will be randomized to receive a protocolized spinal anesthetic from a consultant anesthetist or a trained medical officer. Failure rates and need for rescue will be assessed as primary outcomes.
Primary purpose: TREATMENT

Brief summary: Test the safety and effectiveness of training medical officers in the provision of spinal anesthesia in a rural hospital context using a non-inferiority randomized trial.

The safety and effectiveness of the MOs will be evaluated through a non-inferiority trial in which patients are randomized to care by a trained MO or an anesthesiologist. The primary outcomes are safety (adherence to adapted anesthesia safety checklist- see supporting documents "Adapted Anesthesia Safety Checklist") and effectiveness (adequate analgesia) of spinal anesthesia.

Detailed description: The vast majority of the world is without access to surgical and anesthesia care, and a severe workforce shortage is a major contributing factor. The Lancet Commission on Global Surgery (LCoGS) demonstrated that Africa and South Asia, home to over a third of the global population, lay claim to just 12% of surgeons, anesthesiologists and obstetricians. This workforce shortage may be particularly severe for anesthesia care given that anesthesiologist make up less than 20% of surgical care providers globally. In a series of qualitative interviews, providers across three continents noted that in rural and under-resourced areas, it was unlikely that there was a surgeon and an anesthesiologist in the same place.

In India, the concerns of under-provision of human resources in the rural area are especially severe. The Lancet commission on Global Surgery estimates that while 68% of Indians live in rural areas, only 22% of the health care workforce does. For specialist services, which are even more urbanized, the disparity is likely greater. The result is that, in South Asia, 95% of people are estimated to lack access to safe, affordable and timely surgical care.

In India, which is home to nearly 400 medical schools, it may be posited that the country is well positioned to close this gap. However, the number of postgraduate training seats - 14,000 countrywide - are entirely insufficient for the 50,000 doctors that graduate each year. With only 1500 postgraduate training seats for anesthesia, a graduate who may otherwise aspire to train in anesthesia instead remains generalist MO or seeks training elsewhere. The World Health Organization suggests that a presence of anesthesiologists in rural India may be so scarce it is "non-existent.". It has also been estimated that 43% of the Indian population lives more than 50km from their nearest health center, 76% of which do not have an anesthesiologist.

The result of these human resource limitations, is that rural Indian surgeons often administer anesthesia for their patient prior to performing necessary surgeries or medical officers with only ad hoc training provide anesthesia care. The de facto standard of care in rural India, ends up being the provision of anesthesia by a surgeon or untrained medical officer. While advocacy towards increasing post-graduate education must continue, it is also clear that interim measures are needed to improve upon current baseline practices.

One such measure suggested by the Disease Control Priorities 3 (DCP3), the LCoGS, and others is the concept of "task-based credentialing." In this model of credentialing, physicians are trained and credentialed in a limited set of procedures. Task sharing - a process by which non-specialists take on whole-sale the tasks typically performed by a specialist - is prevalent in the provision of anesthesia care worldwide. However, a recent meta-analysis evaluated outcomes for task-sharing in anesthesia in 15 LMIC and found that administration of anesthesia by a non-physician was a risk-factor for maternal mortality. To mitigate these concerns, task-based credentialing focuses on the training of non-specialist medical officers in a discrete, well-defined task and includes training to deal with the possible complications. This task-based training would serve as an improvement on the de facto standard of care in rural India by providing specific training in place of ad hoc learning.

The provision of spinal anesthesia is thought to be well-suited for this form of training. The procedure involves the injection of a local anesthetic agent into the subarachnoid space. This allows for analgesia and anesthesia below the level of injection. This procedure is widely used in general surgery, obstetric surgery, and orthopedic surgery. Moreover, the use of spinal anesthesia is particularly well-adapted to rural care as it is less expensive than general anesthesia and has a lower requirement of infrastructure and disposables when compared to general anesthesia.

Test the safety and effectiveness of training medical officers in the provision of spinal anesthesia in a rural hospital context using a non-inferiority randomized trial.

The safety and effectiveness of the MOs will be evaluated through a non-inferiority trial in which patients are randomized to care by a trained MO or an anesthesiologist. The primary outcomes are safety (adherence to adapted anesthesia safety checklist- see supporting documents "Adapted Anesthesia Safety Checklist") and effectiveness (adequate analgesia) of spinal anesthesia.

Eligibility criteria: Inclusion Criteria:

Inclusion criteria for MOs

* Consent to participate in practical training and clinical trial (consent process will be repeated)
* Successful completion of the theoretical and simulation training
* Be deemed safe to continue to practical training by their supervising Anesthesiologist
* Feel comfortable to proceed to practical training

Inclusion criteria for patients

* Age 18-65
* Undergoing one of the surgeries noted in supporting document "List of surgeries for patient inclusion criteria" or otherwise deemed appropriate for spinal anesthesia as determined by surgeon and supervising anesthesiologist

  * Willingness to provide informed consent
  * ASA (American Society of Anesthesiology Physical Status Classification System) grades I and II

Inclusion criteria for Consultant Anesthetists

* Anesthetist licensed to practice independently with availability to provide care at one of the selected sites

Exclusion Criteria:

Exclusion criteria for MOs

* Recent suspension from clinical practice
* Due to change sites or retire before the expected end date of the trial

Exclusion criteria for patients

* Obese (BMI \> 35)
* Refusal of consent to participate in trial

Primary outcomes:
measure: Successful delivery of spinal anaesthesia
timeFrame: Assessed pre-operatively following recruitment and consent (day 0 of the follow up period)
Secondary outcomes:
measure: Post-operative Complications
timeFrame: Reviewed at two time points - on discharge from healthcare facility or day 3 post-operatively (whichever occurs first) and day 10-14 post-operatively
measure: Patient experience measures
timeFrame: Reviewed at two time points - on discharge from healthcare facility or day 3 post-operatively (whichever occurs first) and day 10-14 post-operatively
measure: Intraoperative Complications
timeFrame: Assessed intraoperatively during surgical procedure
Other outcomes:
Locations:
city: Boston
country: United States
facility: Boston Children's Hospital
state: Massachusetts
city: Ganiyari
country: India
facility: JSS Hospital
state: Chhattisgarh
city: Gudalur
country: India
facility: Ashwini Hospital
state: Tamil Nadu
city: Harur
country: India
facility: Sittilingi Tribal Hospital
state: Tamil Nadu
Study officials:
affiliation: Boston Children's Hospital, Harvard Medical School, Program in Global Surgery and Social Change
name: Craig D McClain, MD, MPH
role: PRINCIPAL_INVESTIGATOR
References:
citation: Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, Bickler SW, Conteh L, Dare AJ, Davies J, Merisier ED, El-Halabi S, Farmer PE, Gawande A, Gillies R, Greenberg SL, Grimes CE, Gruen RL, Ismail EA, Kamara TB, Lavy C, Lundeg G, Mkandawire NC, Raykar NP, Riesel JN, Rodas E, Rose J, Roy N, Shrime MG, Sullivan R, Verguet S, Watters D, Weiser TG, Wilson IH, Yamey G, Yip W. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015 Aug 8;386(9993):569-624. doi: 10.1016/S0140-6736(15)60160-X. Epub 2015 Apr 26. No abstract available.
citation: Grimes CE, Bowman KG, Dodgion CM, Lavy CB. Systematic review of barriers to surgical care in low-income and middle-income countries. World J Surg. 2011 May;35(5):941-50. doi: 10.1007/s00268-011-1010-1.
citation: Hoyler M, Finlayson SR, McClain CD, Meara JG, Hagander L. Shortage of doctors, shortage of data: a review of the global surgery, obstetrics, and anesthesia workforce literature. World J Surg. 2014 Feb;38(2):269-80. doi: 10.1007/s00268-013-2324-y.
citation: Bergstrom S, McPake B, Pereira C, Dovlo D. Workforce Innovations to Expand the Capacity for Surgical Services. In: Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, editors. Essential Surgery: Disease Control Priorities, Third Edition (Volume 1). Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2015 Apr 2. Chapter 17. Available from http://www.ncbi.nlm.nih.gov/books/NBK333504/
citation: Holmer H, Lantz A, Kunjumen T, Finlayson S, Hoyler M, Siyam A, Montenegro H, Kelley ET, Campbell J, Cherian MN, Hagander L. Global distribution of surgeons, anaesthesiologists, and obstetricians. Lancet Glob Health. 2015 Apr 27;3 Suppl 2:S9-11. doi: 10.1016/S2214-109X(14)70349-3. No abstract available.
citation: Dubowitz G, Detlefs S, McQueen KA. Global anesthesia workforce crisis: a preliminary survey revealing shortages contributing to undesirable outcomes and unsafe practices. World J Surg. 2010 Mar;34(3):438-44. doi: 10.1007/s00268-009-0229-6.
citation: Ng-Kamstra JS, Greenberg SLM, Abdullah F, Amado V, Anderson GA, Cossa M, Costas-Chavarri A, Davies J, Debas HT, Dyer GSM, Erdene S, Farmer PE, Gaumnitz A, Hagander L, Haider A, Leather AJM, Lin Y, Marten R, Marvin JT, McClain CD, Meara JG, Mehes M, Mock C, Mukhopadhyay S, Orgoi S, Prestero T, Price RR, Raykar NP, Riesel JN, Riviello R, Rudy SM, Saluja S, Sullivan R, Tarpley JL, Taylor RH, Telemaque LF, Toma G, Varghese A, Walker M, Yamey G, Shrime MG. Global Surgery 2030: a roadmap for high income country actors. BMJ Glob Health. 2016 Apr 6;1(1):e000011. doi: 10.1136/bmjgh-2015-000011. eCollection 2016.
citation: Raykar NP, Yorlets RR, Liu C, Greenberg SL, Kotagal M, Goldman R, Roy N, Meara JG, Gillies RD. A qualitative study exploring contextual challenges to surgical care provision in 21 LMICs. Lancet. 2015 Apr 27;385 Suppl 2(Suppl 2):S15. doi: 10.1016/S0140-6736(15)60810-8. Epub 2015 Apr 26.
citation: Alkire BC, Raykar NP, Shrime MG, Weiser TG, Bickler SW, Rose JA, Nutt CT, Greenberg SL, Kotagal M, Riesel JN, Esquivel M, Uribe-Leitz T, Molina G, Roy N, Meara JG, Farmer PE. Global access to surgical care: a modelling study. Lancet Glob Health. 2015 Jun;3(6):e316-23. doi: 10.1016/S2214-109X(15)70115-4. Epub 2015 Apr 27.
citation: MUZAFFARNAGAR, I. Special Report: Why India's medical schools are plagued with fraud. Available from: http://www.reuters.com/article/us-india-medicine-education- specialrepor-idUSKBN0OW1NM20150617.
citation: Shetty, D., Reform medical education, transform healthcare, in The Times of India. 2015.
citation: Cherian M, Choo S, Wilson I, Noel L, Sheikh M, Dayrit M, Groth S. Building and retaining the neglected anaesthesia health workforce: is it crucial for health systems strengthening through primary health care? Bull World Health Organ. 2010 Aug 1;88(8):637-9. doi: 10.2471/BLT.09.072371. Epub 2010 May 10. No abstract available.
citation: Dare AJ, Ng-Kamstra JS, Patra J, Fu SH, Rodriguez PS, Hsiao M, Jotkar RM, Thakur JS, Sheth J, Jha P; Million Death Study Collaborators. Deaths from acute abdominal conditions and geographical access to surgical care in India: a nationally representative spatial analysis. Lancet Glob Health. 2015 Oct;3(10):e646-53. doi: 10.1016/S2214-109X(15)00079-0. Epub 2015 Aug 13.
citation: Jamison DT, Alwan A, Mock CN, Nugent R, Watkins D, Adeyi O, Anand S, Atun R, Bertozzi S, Bhutta Z, Binagwaho A, Black R, Blecher M, Bloom BR, Brouwer E, Bundy DAP, Chisholm D, Cieza A, Cullen M, Danforth K, de Silva N, Debas HT, Donkor P, Dua T, Fleming KA, Gallivan M, Garcia PJ, Gawande A, Gaziano T, Gelband H, Glass R, Glassman A, Gray G, Habte D, Holmes KK, Horton S, Hutton G, Jha P, Knaul FM, Kobusingye O, Krakauer EL, Kruk ME, Lachmann P, Laxminarayan R, Levin C, Looi LM, Madhav N, Mahmoud A, Mbanya JC, Measham A, Medina-Mora ME, Medlin C, Mills A, Mills JA, Montoya J, Norheim O, Olson Z, Omokhodion F, Oppenheim B, Ord T, Patel V, Patton GC, Peabody J, Prabhakaran D, Qi J, Reynolds T, Ruacan S, Sankaranarayanan R, Sepulveda J, Skolnik R, Smith KR, Temmerman M, Tollman S, Verguet S, Walker DG, Walker N, Wu Y, Zhao K. Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition. Lancet. 2018 Mar 17;391(10125):1108-1120. doi: 10.1016/S0140-6736(17)32906-9. Epub 2017 Nov 25.
citation: Gnanaraj J, Jason LY, Khiangte H. High quality surgical care at low cost: the diagnostic camp model of Burrows Memorial Christian Hospital (BMCH). Indian J Surg. 2007 Dec;69(6):243-7. doi: 10.1007/s12262-007-0034-0. Epub 2008 Jan 28.
citation: Federspiel F, Mukhopadhyay S, Milsom P, Scott JW, Riesel JN, Meara JG. Global surgical and anaesthetic task shifting: a systematic literature review and survey. Lancet. 2015 Apr 27;385 Suppl 2:S46. doi: 10.1016/S0140-6736(15)60841-8. Epub 2015 Apr 26.
citation: Sobhy S, Zamora J, Dharmarajah K, Arroyo-Manzano D, Wilson M, Navaratnarajah R, Coomarasamy A, Khan KS, Thangaratinam S. Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Glob Health. 2016 May;4(5):e320-7. doi: 10.1016/S2214-109X(16)30003-1.