A recent study by researchers at Stanford University reported that the composition of anesthesia care teams is not linked to differences in patient mortality, hospital length of stay or inpatient care costs.
The researchers, led by Eric C. Sun, MD, PhD, an assistant professor of anesthesiology, perioperative and pain medicine at Stanford University in California, compared care teams including either nurse anesthetists or anesthesiologist assistants under the supervision of a physician anesthesiologist, to detect any differences in postsurgical outcomes.
Dr. Sun and his team compared 421,230 surgical cases that included a nurse anesthetist and 21,868 cases with an anesthesiologist assistant between Jan. 1, 2004 and Dec. 31, 2011. All cases involved a geriatric patient between the ages of 65 and 89 years, and a physician anesthesiologist functioned as the supervisor in all cases.
The investigators found that the mortality rate was 1.6% when the care team included anesthesiologist assistants versus 1.7% for care teams that included nurse anesthetists. Hospital length of stay was shorter and medical spending was slightly less for care teams that involved anesthesiologist assistants, with decreases in length of stay of 0.009 days and a reduction in spending of $56. These differences were not statistically significant.
Currently, anesthesiologist assistants are certified to practice in only 16 states and are required to work directly under a physician anesthesiologist. Nurse anesthetists are certified throughout the United States and function as team members alongside physicians or in a nurses-only model.
Because of the lack of differences found in mortality, length of stay and medical spending, the researchers concluded that the surgical care provided by an anesthesiologist assistant or nurse anesthetist is equivalent when each is supervised by a physician anesthesiologist.
—Deanna DePeau
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What about the overwhelming number of locations that sufficient anesthesiologists (necessary to supervise these anesthesiology assistants) don't care to live? Usual reasons include rural rather than urban locations, relative lack of stimulating cultural institutions, etc..
I'd be curious to know if an in-depth analysis of the difference in acuity of patients between the two groups was performed? I know that, in my geographical region, the Anesthesiologist Assistants tend to be assigned to lower-acuity patients than Nurse Anesthetists.
So you compare 20x as many CRNA to AA cases and found the same %....wow that is really research worthy. It is sad this would even be published. it would be laughed out the research world.
Five reasons that anesthesiologist assistants limit anesthesia flexibility and profitability
There are four groups of anesthesia providers In the United States. Physician Anesthesiologists, Dental Anesthesiologist, Nurse Anesthesiologists and Anesthesiologist Assistants (AA). Dentist, Physician and Nurse Anesthesiologist work in every state of the union autonomously and have since each professions inception.
However, the newcomer AAs, require direct supervision by a Physician Anesthesiologist to practice anesthesia and are currently only licensed in 15 states; they are also not approved for practice in the US Military. Our rapidly evolving healthcare system is best served when all practitioners can provide the full scope of anesthesia services independently/autonomously, thus maintaining practice flexibility and ensuring fiscally responsibility and patient access to care. The following are 5 key reasons why AAs cannot help hospitals, other healthcare facilities and anesthesia departments meet these goals:
1) Inefficient Model: AAs must work directly under a Physician Anesthesiologist in a 1:4 or less ratio depending on state law and billing model without losing significant revenue3. The AA medical direction requirement could lead to delayed starts, fewer cases done per day and higher costs to the system due to CMS TEFRA rules3. It also eliminates AAs as part of the solution to improving access to care in medically underserved areas (such as rural America), and could cost a practice significant revenue due to AAs inability to expand access to care as needed.
2) High Risk for Medicare Fraud: AA practice must be billed as medical direction for maximum revenue generation and in order to avoid high risk for Medicare fraud. The civil fines are up to three times the amount of damages sustained by the government and an additional charge of up to $21,563 per false claim1,2. Criminal penalties may include fines, imprisonment or both. In the 2012 article entitled “Influence of supervision ratios by anesthesiologists on first-case starts and critical portions of anesthetics” in the journal Anesthesiology found that 35% of the time in a 1:2 ratio the required medical direction (TEFRA) rules were not be followed resulting in Medicare fraud which could easily be the case for medically directed AAs1. Facilities may also be at risk for Medicare fraud for not assuring appropriate medical direction of AAs, practices cannot afford this but neither can the facilities they serve.
3) Unsustainable Costs: The medical direction practice model is the most expensive and least efficient due to the requirement of one physician anesthesiologist for every four AAs/Nurse Anesthesiologists. While Nurse Anesthesiologists can work autonomously, thereby expanding services in greater ratios or on their own, AAs generally only work in a maximum 4:1 model. This additional cost of service requires large subsidies from the facility to maintain high cost anesthesia services. Such subsidies are a significant line item expense not sustainable by facilities already under significant downward economic pressure in an uncertain healthcare environment. These additional costs coupled with the high probability of Medicare fraud puts anesthesia practices and facilities at risk.
4) AAs fail to meet demand: The operating room is a dynamic environment with constantly shifting needs. It is not uncommon to have emergency cases and add-ons requiring opening additional ORs and therefore anesthesia providers. While Physician Anesthesiologist and Nurse Anesthesiologists can work autonomously to meet these needs AAs cannot as they are limited by the number of Physician Anesthesiologist available to cover them. This can result in delayed cases, decreased efficiency and lack of flexibility to meet operating room demand and/or increased costs for additional Physician Anesthesiologist to medically direct and non-revenue generating extra bodies waiting for cases. All of which are bad for facility and practice bottom lines.
5) Not Full Service: New graduate AAs have only 2000-3000 hours of experience compared to ~9000 for CRNAs and require no previous clinical experience prior to AA school4,5. This leaves a large gap in clinical capability, skill, experience and clinical acumen entering their programs. By comparison, Nurse Anesthesiologists earn a bachelor’s degree in nursing and attain an average of 2.5 years of critical care experience before entering a nurse anesthesia educational program. Thus, AAs require significant guidance and close direction during the administration of anesthesia and cannot work autonomously.
Today, anesthesia practices and facilities must be more cost conscious than ever. With increasing anesthesia needs, stagnant revenue and facilities seeking to reduce or eliminate anesthesia subsidies from the bottom line, all practices will be required to do more with less. To meet this demand in a cost-effective way it is imperative that practices use practitioners who can provide the full scope of anesthesia services independently/autonomously, limit fraud risk, be highly flexible and increase access. The use of AAs simply does not achieve these goals.
1. Epstein, R. H., & Dexter, F. (2012). Influence of supervision ratios by anesthesiologists on first-case starts and critical portions of anesthetics. Anesthesiology: The Journal of the American Society of Anesthesiologists, 116(3), 683-691.
2. Department of Justice. (2016). The False Claims Act: A Primer. Retrieved from https://www.justice.gov/sites/default/files/civil/legacy/2011/04/22/C-FRAUDS_FCA_Primer.pdf
3. Centers for Medicare Services. (2017). Chapter 12 - Physicians/Nonphysician Practitioners. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf
4. Nova Southeastern University. (2018). Master of Science in Anesthesia (AA). Retrieved from http://healthsciences.nova.edu/healthsciences/anesthesia/forms/brochure.pdf
5. American Association of Nurse Anesthetists. (2017). AANA Position on Anesthesiologist Assistants. Retrieved from https://www.aana.com/docs/default-source/sga-my-aana-web-documents-(members-only)/aana-position-on-aas.pdf?sfvrsn=81be41b1_0
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New Research Confirms Safety of Nurse Anesthetists, Raises Questions about Anesthesiologist Assistants
For Immediate Release: May 30, 2018
For more information, contact: AANA Public Relations
Park Ridge, Illinois—New research published online in the journal Anesthesiology confirms the quality and safety of anesthesia provided by Certified Registered Nurse Anesthetists (CRNAs) while raising questions about the role and value of anesthesiologist assistants (AAs) in patient care.
The study, titled “Anesthesia Care Team Composition and Surgical Outcomes,” was funded by the American Society of Anesthesiologists.
“The value of healthcare professionals is measured in different ways, one of which is the safety and quality of the care they provide,” said Bruce Weiner, DNP, MSNA, CRNA, president of the 52,000-member American Association of Nurse Anesthetists (AANA). “But in today’s healthcare system, other measurable factors that are critically important to meeting the growing patient demand for healthcare services are the cost-effectiveness of the provider and the provider’s ability to ensure patients have access to the care they need.”
According to Weiner, eight research studies published since 2000, including the new study in Anesthesiology, have confirmed that CRNAs are safe providers. In 2010, the landmark RTI study published in Health Affairsshowed that anesthesia care is equally safe whether it is provided by a CRNA working solo, an anesthesiologist working solo, or a CRNA working with an anesthesiologist. Three other studies have confirmed that CRNAs are the most cost-effective anesthesia option and ensure patients access to anesthesia services for surgery, labor and delivery, trauma stabilization, and pain management in rural and other medically underserved areas of the United States.
In the study in Anesthesiology, researchers examined national claims data for more than 443,000 Medicare beneficiaries (2004-2011). CRNAs were involved in more than 421,000 of the cases; AAs assisted in fewer than 22,000 cases. While the researchers concluded that CRNAs and AAs are equally safe providers when working with anesthesiologists, they conceded that a major limitation with the study is that it does not take into consideration supervision ratios between provider types.
“CRNAs are not required by state or federal laws or regulations to be supervised by—or to even work with—an anesthesiologist, while AAs can onlywork under the supervision of an anesthesiologist,” Weiner said. “But when an anesthesiologist does supervise multiple CRNAs, it is typical for the anesthesiologist to rarely be present in the operating room, or not present at all, because CRNAs are capable of working safely and effectively without anesthesiologists and do so all the time.”
By comparison, an AA functions as an assistant to an anesthesiologist and is dependent upon the anesthesiologist’s supervision and direction. While the laws vary by state, anesthesiologists are limited in the number of AAs they can supervise and must always be immediately available to the AAs.
“On the basis of this admitted limitation of the study, it is ridiculous to conclude that an AA who must be closely supervised by an anesthesiologist at all times is as safe as a CRNA who doesn’t even need to work with an anesthesiologist, and often does not,” concluded Weiner.
Access to Care
In the Anesthesiology paper, the researchers observed that CRNAs practice in all 50 states plus the District of Columbia. The researchers also note that 17 states have opted out of the federal physician supervision requirement for CRNAs, which means that in those states supervision by any sort of physician is not required.
AAs, on the other hand, have varying degrees of practice in only 16 states plus the District of Columbia, and only under the supervision and direction of an anesthesiologist. In other words, there are more states that allow CRNAs to practice without physician supervision than states that allow AAs to even practice.
“Given that AAs cannot practice without an anesthesiologist close by, in what possible way can AAs help solve the access to care issue in large medically underserved areas of the United States where anesthesiologists don’t want to set up shop?” asked Weiner. “The answer is, ‘They can’t.’”
Cost-Effective Care
Among the study’s eight major limitations cited by the researchers is one that raises questions about the impact of AAs on medical costs. Other research (especially “Cost Effectiveness Analysis of Anesthesia Providers,” Nursing Economic$, 2016) has clearly demonstrated that the most cost-effective anesthesia delivery model is a CRNA working solo, while the most expensive model is an anesthesiologist supervising a single CRNA (1 to 1 ratio).
“Given that an AA, whose average compensation is close to that of a CRNA, must work in tandem with an anesthesiologist, who makes nearly two and a half times more than an AA or CRNA, it’s impossible to see how an anesthesiologist/AA care team would be any more cost-effective than an anesthesiologist/CRNA care team. On the other hand, it’s easy to see why the researchers didn’t delve into the cost issue,” said Weiner.
“The fact of the matter is the anesthesiologist/AA practice model is an extremely expensive option, and as shown in Anesthesiology, does not improve patient safety,” he said. “Compare this with the study results from Health Affairs and Nursing Economic$ and it becomes clear that CRNAs working solo are the safest, most cost-effective anesthesia delivery model, which is exactly what the U.S. healthcare system needs right now and will need in the years ahead.”
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“The fact of the matter is the anesthesiologist/AA practice model is an extremely expensive option, and as shown in Anesthesiology, does not improve patient safety,” he said. “Compare this with the study results from Health Affairs and Nursing Economic$ and it becomes clear that CRNAs working solo are the safest, most cost-effective anesthesia delivery model, which is exactly what the U.S. healthcare system needs right now and will need in the years ahead.”
https://www.aana.com/news/news-detail/2018/05/30/new-research-confirms-safety-of-nurse-anesthetists-raises-questions-about-anesthesiologist-assistants
New graduate AAs have only 2000-3000 hours of experience compared to ~9000 for CRNAs and require no previous clinical experience prior to AA school4,5. This leaves a large gap in clinical capability, skill, experience and clinical acumen entering their programs. By comparison, Nurse Anesthesiologists earn a bachelor’s degree in nursing and attain an average of 2.5 years of critical care experience before entering a nurse anesthesia educational program (A DOCTORATE IN NURSE ANESTHESIA). Thus, AAs require significant guidance and close direction during the administration of anesthesia and cannot work autonomously.
Today, anesthesia practices and facilities must be more cost conscious than ever. With increasing anesthesia needs, stagnant revenue and facilities seeking to reduce or eliminate anesthesia subsidies from the bottom line, all practices will be required to do more with less. To meet this demand in a cost-effective way it is imperative that practices use practitioners who can provide the full scope of anesthesia services independently/autonomously, limit fraud risk, be highly flexible and increase access. The use of AAs simply does not achieve these goals.
https://www.beckersasc.com/anesthesia/five-reasons-that-anesthesiologist-assistants-limit-anesthesia-flexibility-and-profitability.html