Nurse Anesthetists want to "fly solo."

Flawed data - nurse anesthetists are given the least risky cases, and even more so when they are practicing solo. Less sick patients will always do better.TE See the editorial in the NYT. No Harm to Patients From Unsupervised Nurse Anesthetists, Study Finds Medscape Medical News , 2010-08-06

August 6, 2010 — Allowing certified registered nurse anesthetists (CRNAs) to provide anesthesia without physician supervision resulted in no evidence of increased inpatient deaths or complications, a new study published in the August issue of Health Affairs found.

The analysis of Medicare data for 1999 to 2005, encompassing more than 481,000 hospitalizations, found that allowing CRNAs to work independently without oversight by an anesthesiologist or surgeon had little or no effect on mortality and morbidity rates.

Authors Brian Dulisse and Jerry Cromwell, health economists at the Research Triangle Institute in Waltham, Massachusetts, recommended that the Centers for Medicare & Medicaid Services (CMS) permit the nation's 37,000 nurse anesthetists to work independently without first requiring state governments to formally petition for an exemption, as 14 states have already done. "This would free surgeons from the legal responsibility for anesthesia services provided by other professionals. It would also lead to more cost-effective care as the solo practice of CRNAs increases," the authors said.

The research was funded by the American Association of Nurse Anesthetists (AANA), which applauded the study. "Since the late 1990s, we've been on record calling for the elimination of supervision for nurse anesthetist services," AANA President-Elect Paul Santoro, CRNA, MS, told Medscape Medical News. "This antiquated regulation places undue costs on the healthcare system. Local institutions should be free to decide for themselves. This study confirms our position and is supported by several previous studies."

In a blistering response posted on its Web site yesterday, the American Society of Anesthesiologists said theHealth Affairs study "is an advocacy manifesto masquerading as science and does a disservice to the public. It makes dangerous public policy recommendations on the basis of inadequate data, flawed analysis and distorted facts."

CMS reimbursement rules prohibited payments to CRNAs unless they are supervised by either an anesthesiologist or the surgeon. In 2001, CMS issued a rule that states could seek an exemption from the oversight rule.

By 2005, 14 governors in mostly rural states were granted permission to opt out of the supervision requirement. "Solo practice by CRNAs is especially important in rural areas, where anesthesiologists are in short supply," Dulisse and Cromwell write.

The authors used Medicare inpatient (part A) and carrier (part B) data to study inpatient mortality and complications. It included 481,440 hospitalizations, of which 68,744 were in states that opted out of the supervision requirement.

They found that the proportion of surgeries performed in which anesthesia was administered by CRNAs without supervision increased by 5 percentage points in both opt-out and non-opt-out states.

"Despite the shift to more anesthetics performed by nurse anesthetists, no increase in adverse outcomes was found.... In fact, declining mortality was the norm," they said. "The mortality rate for the nurse anesthetist solo group was lower than for the anesthesiologist solo group.

"These results do not support the hypothesis that allowing states to opt out of the supervision requirement resulted in increased surgical risks to patients. Nor do the results support the claim that patients will be exposed to increased risk as a consequence of more nurse anesthetists' practicing without physician supervision," they concluded.

The American Society of Anesthesiologists said the study "reflects the weaknesses of billing data when used to make an assessment of safety and quality." The data do not distinguish between complications resulting from surgery or anesthesia, nor do they discriminate between conditions existing before surgery and those resulting from surgical or anesthetic care.

"The existing Medicare policy requiring physician supervision of nurse anesthesia is rooted in the overwhelming preference of patients, particularly Medicare beneficiaries, for a physician to be responsible for their anesthesia care. Suggesting that this patient preference be pushed aside on the basis of flimsy analytics is irresponsible," said the statement from the American Society of Anesthesiologists.