The American Association of Nurse Anesthetists (AANA) - sponsored paper published in the August 2010 issue of Health Affairs, titled “No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians,”1 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.
The Institute of Medicine (IOM) reported that in the past 25 years, anesthesia mortality rates have been reduced from two deaths per 10,000 anesthetics administered to one death per 200,000-300,000 anesthetics administered.2 This achievement did not occur spontaneously: it is the product of forward-thinking ASA leaders and physician scientists. The development of new monitors, adoption of safety standards, creation of the Anesthesia Patient Safety Foundation, the ASA Closed Claims Project and, most recently, the Anesthesia Quality Institute are evidence of decades of our members’ commitment to improving patient safety through genuine science.
The Health Affairs paper reflects the weaknesses of billing data when used to make an assessment of safety and quality. These billing data were not created for this purpose and do not distinguish between complications resulting from surgery or anesthesia, nor do they discriminate between conditions existing prior to surgery and those resulting from surgical or anesthetic care. Thus, meaningful analysis of anesthesia outcomes is impossible from billing codes alone. Using the anesthetic-related mortality frequency reported by the IOM,2 the 481,000 cases analyzed in the AANA-sponsored paper would have produced two deaths related to anesthesia, an obviously insufficient number to support any conclusions about mortality. This exemplifies the gross inadequacy of the paper to draw conclusions about anesthesia outcomes. Nonetheless, the authors ignore these critical limitations and advise altering Medicare policy, adhering to AANA’s advocacy agenda. And they make no apology for the disturbing trend in their own data toward increasing frequency of mortality and complications in nurse-administered anesthesia during the opt-out “experiment” as compared to improved outcomes in physician and care-team cases.
The paper acknowledges that anesthesiologists care for patients undergoing the most complex procedures, but does not recognize that this is also true for the sicker patients undergoing even routine surgery. Even if one accepted the study’s assertion that outcomes were equivalent, this would point to mortality far higher than expected in the nurse anesthesia group caring for a decidedly lower-risk population. In a scientific study funded by the Agency for Healthcare Research and Quality (AHRQ), investigators at the University of Pennsylvania found that the presence of an anesthesiologist prevented more than six excess deaths per 1,000 cases in which an anesthesia or surgical complication occurred.3 This represents compelling evidence that anesthesiologists’ capacity to provide life-saving medical care should be reflected in standards of care.
Dulisse and Cromwell assert that the training of nurse anesthetists and anesthesiologists is essentially equivalent. Since nurse anesthetists receive approximately two and a half years of training following the bachelor’s degree and anesthesiologists spend eight years preparing for practice after the pre-medical undergraduate education (four in medical school and four in residency), this claim defies arithmetic. The prolonged period of training is to acquire the knowledge base and skills to provide expert care of the patient and all their co-existing disease before, during and after surgery. Years of experience managing complex disease in hundreds of patients, training 80 hours weekly, prepares the anesthesiologist to do more than administer anesthetic drugs and perform procedural tasks. It provides them the ability to rescue patients who have significant perioperative problems. This broad responsibility is what makes anesthesiology the practice of medicine.
ASA member anesthesiologist Ann C. Still, M.D., a former nurse anesthetist provides additional perspective on the difference between a nurse’s care and a physician anesthesiologist’s care. “Having cared for patients as a CRNA and now as an anesthesiologist, I see daily how safe patient care requires a physician’s training.” Anesthesiologists serve as the leaders of anesthesia care teams because their level of skill and training is necessary for the safety of the patient.
The authors also make the claim that unsupervised nurse anesthesia is more “cost effective.” Considering that the payment for anesthesia services under Medicare’s system (adopted by most private insurers, too) is identical whether provided by an unsupervised nurse, solo physician or the physician/CRNA team, the fallacy of the “cost effective” claim is evident.
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.4 Suggesting that this patient preference be pushed aside on the basis of flimsy analytics is irresponsible and is reminiscent of the “scientific studies” purchased by the tobacco industry to demonstrate the safety of tobacco. Americans understand the value of physician care, just as we saw through the false reports that promoted cigarettes.