Nurse anesthetist care not equal to physician anesthesiologist-led care, comprehensive evidence-based review finds, American Society of Anesthesiologists® calls for further examination

A recent literature review by the Cochrane Collaboration found no scientific evidence that care provided by a nurse anesthetist is as safe and effective as patient-centered, physician-led anesthesia care, prompting the American Society of Anesthesiologists (ASA®) to call for further examination to measure patient safety and anesthesia care delivery.

The review, “Physician anaesthetists versus non-physician providers of anaesthesia for surgical patients,” attempted to assess the safety and effectiveness of physician-led versus nurse-led anesthesia care delivery.  While the authors stated intent that they “hoped that this [review] may lead to an increase in confidence in the skills of NPAs [nurse anesthetists] within the anaesthetic community,” the comprehensive analysis could not support this premise.

“Based on the review, ASA’s Committee on Health Policy Research is calling for further examination into the issue of anesthesia care delivery and the difference it makes in safety, quality and costs.” said ASA President Jane C.K. Fitch, M.D.  “This investigation will help us study how physician anesthesiologists can continually improve patient care and reduce costs.”  

Key findings of the review were:

• The review did not include any randomized controlled trials (RCT) in which a patient randomly is assigned care from a physician anesthesiologist or a nurse anesthetist (p. 10).  The study’s authors note the ethical and patient safety implications of randomly assigning nurses to cases stating that “randomization may be unacceptable to health service providers, research ethics committees and patients, particularly for high-risk patients and procedures.” (p. 15)  
  
  
• It’s difficult to determine who provides anesthesia care in the studies and the number of cases that actually involved a physician anesthesiologist (p.11).  The data used in the review makes it difficult to determine the types of providers involved in the delivery of care. It is possible that many cases believed to have nurse anesthetists providing care “independently” actually involve physician anesthesiologists. The data also limits the ability to determine if a physician anesthesiologist was available for advice or rescue of a patient managed by a nurse anesthetist if the patient experienced complications.  
  
  
• Nurse anesthetists solo are not providing care to the same type of patients as physician anesthesiologists (p. 13).  The researchers noted that all studies reviewed reported important imbalances with care provided by nurse anesthetists only being more likely to occur in rural, smaller hospitals with fewer facilities. The studies also did not take into account that less complex operations are more likely to be performed at these hospitals which also have more routine admissions and offer less specialized services than hospitals where physician anesthesiologists lead the team.  

The review included no new data and researchers identified more than 8,000 titles/abstracts for the analysis but only six were included in the review.  One of the studies, the “Dulisse” study, which was directly funded and is frequently cited by the American Association of Nurse Anesthetists claims to show the equivalence of nurse anesthetist and physician anesthesiologist care. The review authors determined that the Dulisse study was at “high risk” for bias because of being funded by a nursing advocacy organization.        

ASA recognizes and appreciates that nurses are an integral part of the anesthesia care team but supports physician-led care. Physician anesthesiologists complete nearly double the education and 10 times the clinical training of nurse anesthetists. A nurse anesthetist cannot replace a physician. Based on national and state polling results, the majority of the public want physician anesthesiologists to lead their care.

For more information on the Cochrane Collaboration literature review, please read ASA’s policy brief here.