Advocacy, Research, and Anesthesia Practice Models: Key Studies of Safety and Cost-Effectiveness

Abstract

The practice of anesthesia includes multiple competing practice models, including services delivered by anesthesiologists, independent practice by certified registered nurse anesthetists (CRNAs), and team-based approaches incorporating anesthesiologist supervision or direction of CRNAs. Despite data demonstrating very low risk of death and complications associated with anesthesia, debate among professional societies and policymakers persists over the superiority or equivalence among these models. The American Society of Anesthesiologists uses published findings as evidence for claims that anesthesia is safer when anesthesiologists lead in providing care. The American Association of Nurse Anesthetists cites its own research on safety and cost-efficiency outcomes to defend against these claims. We review and critique studies of the safety outcomes and cost-effectiveness of anesthesia delivery that have been cited in the Federal Trade Commission comment letters related to competition in health care, where each profession has laid out their case for how they ought to be recognized in the market for anesthesia services. The Federal Trade Commission has a role in protecting consumers from anticompetitive conduct that has the potential to impact quality and cost in health care. Thus, it is important to evaluate the evidence used to make claims about these topics. We argue that while research in this area is imperfect, the strong safety record of anesthesia in general and CRNAs in particular suggest that politics and professional interests are the main drivers of supervision policy in anesthesia delivery.

The experience of working with anaesthesia associates in the United Kingdom and the impact on medical anaesthetic training

“…Robust quantitative data on patient safety outcomes relating to care delivered by Anaesthesia Associates in the UK NHS are lacking, in part due to the difficulty of understanding the impact of individual factors within complex multi‐disciplinary care systems 22 . However the lack of evidence of superiority of doctor versus non‐doctor anaesthesia provider on safety outcomes from the established US model supports the views of our interviewees that AAs are an acceptable and safe member of the team 28 …”

“…22 However the lack of evidence of superiority of doctor versus non-doctor anaesthesia provider on safety outcomes from the established US model supports the views of our interviewees that AAs are an acceptable and safe member of the team. 28 Limitations of this study include a small sample and the single-method qualitative nature. Strengths include the diversity of interview sites in terms of experience with AAs, size, location across all 4 nations, varied geography and demography of hospitals included, and specific focus on the impact of AAs on medical anaesthetic training to address concern within the specialty.…”

Anesthesia Care Provided by Nurses

“…4 There is still much debate among anesthesia professionals and policy-makers, regarding the types of anesthesia delivery models that are appropriate and should be used. 5 The purpose of this review is to summarize the evidence regarding clinical effectiveness and cost-effectiveness of anesthesia care provided by nurses versus anesthesia care provided by physicians.…”

State of the anaesthesia workforce in the United States: trends and geographic variation in nurse anaesthetist to physician anaesthesiologist ratios

“…Excessive J-SC is another practice (unrelated to A-SC) resulting from inappropriate editorial requests to quote articles previously published in their journal in order to increase their impact factor (IF). 4 The J-SC is reported as:where the numerator represents the delta IF (contribution of selfcitations to IF).…”

“…3 However, it is not clear whether equivalent clinical outcomes can be expected. Studies comparing the quality of care between anaesthesiologists and CRNAs are not always independent, 4 have been generally assessed as 'low quality' and have been largely inconclusive. 5,6 Moreover, extreme outcomes such as mortality may not be adequate to determine quality and more common, but serious, complications, and discrepancies in resource utilisation related to care by practice model are needed.…”