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NY Times: Anesthesia Risk Minuscule When CRNAs Give Anesthesia, Cost Effective
Editorial
Who Should Provide Anesthesia Care?
Can a highly trained nurse deliver anesthetics as well as a physician who has specialized in anesthesiology, or does the nurse require close medical supervision? That issue emerges from two recent studies and from California’s decision last year to join 14 other states in freeing the nurses from a federal requirement that they be supervised by a physician. Colorado seems poised to join the group.
The issue is potentially important to patients and to health care reformers seeking to restrain costs and reduce reliance on high-priced medical specialists.
The two studies — hotly disputed by the American Society of Anesthesiologists — essentially concluded that there is no significant difference in the quality of care when the anesthetic is delivered by a certified registered nurse anesthetist or by an anesthesiologist. The studies were paid for by the professional association for the nurses, a potential conflict of interest, but were conducted by researchers at respected organizations.
Analysts at the Research Triangle Institute found that there was no evidence of increased deaths or complications in 14 states that had opted out of requiring that a physician (usually an anesthesiologist or the operating surgeon) supervise the nurse anesthetists. The analysts recommended that nurse anesthetists be allowed to work without supervision in all states. Researchers at the Lewin Group judged nurse anesthetists acting without supervision as the most cost-effective way to deliver anesthesia care.
Anesthesia has gotten remarkably safe in recent decades, with roughly one death occurring in every 200,000 to 300,000 cases in which anesthetics are administered during surgery, childbirth or other procedures.
There is not much difference between the two professions in the amount of training they get in administering and monitoring anesthetics. Where the anesthesiologists have a big advantage is in their much longer and broader medical training that, many doctors say, may better equip them to handle complex cases and the rare emergencies that can develop from anesthesia.
From a patient’s point of view, it would seem preferable to have a broadly trained anesthesiologist perform or supervise anesthesia services, but, in truth, the risk is minuscule either way.
Fifteen states have exempted the nurse anesthetists from a Medicare requirement that they be supervised by a physician. California’s move is being challenged in court by physician groups on procedural technicalities. The state’s reasoning, which appears sound, is that patients in areas short on anesthesiologists would lose access to surgery and childbirth services if no one else could deliver the anesthetic. The final decision ultimately rests with the hospitals on how best to serve their patients.
In the long run, there also could be savings to the health care system if nurses delivered more of the care. It costs more than six times as much to train an anesthesiologist as a nurse anesthetist, and anesthesiologists earn twice as much a year, on average, as the nurses do ($150,000 for nurse anesthetists and $337,000 for anesthesiologists, according to a Rand Corporation analysis). Those costs are absorbed by various institutions and public programs within the health care system. As health reformers seek ways to curb medical spending, they need to consider whether this is a safe place to do it.
A version of this editorial appeared in print on September 7, 2010, on page A24 of the New York edition.
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The NYT article quotes 2 studies paid for by crna’s. These studies mainly saw no difference in outcome between CRNA and MD anesthetics yet only compared the outcomes on patients that were low risk ASA 1 and 2 patients. Patients are placed in categories by risk with ASA 1 and 2 being the most healthy and ASA 3 and 4 being the riskiest. The real difference will show itself when comparing care for the sickest patients and during rescue not in the safest situations. I am an anesthesiologist and have worked with great CRNA providers. But there are some who do not have an indepth knowledge that comes with more schooling and residency. They tend to treat things by algorhythm without understanding which works great most of the time. Many CRNAs dont want physician input regarding care until things get very difficult then they want an MD to take over. One situation in particular a hospital we cover a CRNA group is covering the main OR and my group is covering only the cardiac anesthesia. An emergency ruptured aortic aneurysm was called in the middle of the night ( up to 95% mortality) and the CRNA group initially covered the case. This type of case involves the airway, infusing blood at rapid rate, and trying to maintain blood pressure that is rapidly changing. The patient barely made it through the case and had to come back to the OR later in the night for bleeding. Both the surgeon and the CRNA group asked the anesthesiologist group to take over the care of this difficult patient. This put us in a difficult situation of picking up for someone elses substandard care and any patient put under an anesthetic is at risk of having complications. Every patient deserves to have the best chance of surviving a complication.
Not quite correct. Patient populations were not clinically different in the CRNA vs MDA groups. “With the exception of base units, the differences in patient characteristics between the certified registered nurse anesthetist solo and anesthesiologist solo groups, although statistically significant, were clinically minor and would not explain large differences in patient outcomes within opt-out and non-opt-out states.”
Base Units were a point higher in the MDA solo group which indicates more difficult procedures. “This indicates that solo anesthesiologists were performing more complex or difficult procedures than the nurse anesthetist solo group. One might have expected higher relative complexity by nurse anesthetists practicing solo in opt-out states, given their higher proportion of cases. However, many opt-out states are rural, and surgery and anesthesia in those states may be less complex overall than in more urban states. This is because patients with more difficult surgical procedures are referred to major urban hospitals with experienced surgical teams and technologies.”
ASA ‘risk’ Categories are not contained in the “5 percent Medicare Inpatient (Part A) and Carrier (Part B) Medicare limited data set files for 1999–2005.” This was the data set used in the study. ” The files include all Part A claims from facilities and Part B claims from physicians and suppliers for a 5 percent sample of beneficiaries.”
“Because the 5 percent limited data sets do not contain the patient’s measurement on the physical status scale of the American Society of Anesthesiologists, we merged onto the claims the anesthesia base units for the most complex anesthesia procedure (International Classification of Diseases, Ninth Revision, or ICD-9) code for each admission. For example, the base unit for a thyroid biopsy is 3; for cardiac catheterization, 8; and for tracheobronchial reconstruction, 18.” So, the ‘complexity’ or ‘risk’ of a procedure was assumed by the technical difficulty of the procedure rather than the health of the patient. Plenty of ASA >2 patients were treated by the solo CRNAs. After all, these are Medicare patients amongst whom you may have to search high and low to find an ASA 1 or 2.
“All eight comparison cells for mortality had odds ratios less than 1.0, which indicates that mortality occurred with lower probability in all other combinations of provider and opt-out status than it did with solo anesthesiologists in non-opt-out states (the differences are all significant at the 0.05 level). In opt-out states, there were no statistically significant mortality differences between the periods before and after opting out.”
“Unlike mortality, complication rates did not differ between anesthesiologist and certified registered nurse anesthetist solo groups in non-opt-out states. Yet, as with mortality, nurse anesthetists practicing solo in opt-out states had a lower incidence of complications (odds ratios were 0.798 before opting out and 0.813 after) relative to solo anesthesiologists in non-opt-out states. These differences were statistically significant for both time periods.
In opt-out states, complication rates for the nurse anesthetist solo group were essentially identical to those for the anesthesiologist solo group. The difference between complication rates for nurse anesthetist solo and team anesthesia was also not statistically different in opt-out states.”
No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians
Regarding the aortic aneurysm, correct me if i am wrong but if your group covers the cardiac anesthesia, why did you not do the case in the first place since it (if thoracic aorta) IS a cardiac case? Do you not staff the hospital in the middle of the night? Are CRNAs the only providers willing to work at night? Or was it abdominal?
95% mortality rate and the patient survived the surgery AND a trip back for additional bleeding. Sounds like the CRNAs did an excellent job. The case “involves the airway”, “infusing blood at a rapid rate” and “trying to maintain blood pressure that is rapidly changing”? And..??? The airway, bleeding and dramatic changes in blood pressure are THE common day to day challenges for anesthesia providers, not some unique set of problems.
[...] recent study has shown that solo CRNA practice in states who have opted out of the requirement has remained at [...]