Specially trained nurses administering anesthesia to patients had the same safety record as anesthesiology doctors or similar nurses working under the supervision of doctors, new research funded by a nurses association reports. But the head of a national anesthesiologists group says the study is flawed and misleading.
In 2001, the federal agency that administers Medicare payments to health care providers allowed states to opt out of a rule requiring that certified registered nurse anesthetists be under the oversight of a surgeon, anesthesiologist, or other doctor. Four years later, 14 states -- not including Massachusetts -- had chosen this route.
Jerry Cromwell and Brian Dulisse, health economists in the Waltham office of the North Carolina-based Research Triangle Institute, studied rates of death and complications before and after the Medicare opt-out provision was adopted. Their study, which was funded by the American Association of Nurse Anesthetists, appears today in the journal Health Affairs.
The authors analyzed more than 481,000 hospitalizations paid for by Medicare from 1999 through 2005. The proportion of procedures in which nurse anesthetists worked without physician supervision grew in all states, from 17.6 percent to 22.5 percent in opt-out states and from 7 percent to 12 percent in the other states. Nurse anesthetists are allowed to work “solo,” that is, without the supervision of a physician in many states. The supervision rule applies to how Medicare pays for anesthesia services. In opt-out states, the same amount is paid, whether a nurse anesthetist, an anesthesiologist, or a team of nurse anesthetist and anesthesiologist do the work.
Deaths and complication rates were not statistically different, Cromwell and Dulisse conclude from their analysis. They also say that the training of nurse anesthetists and anesthesiologists is similar as it relates to providing anesthesia and suggest nurse anesthetists are a lower-cost alternative to anesthesiologists.
“We recommend that Medicare change the policy so that governors no longer have to petition for their states to opt out of this requirement,” Cromwell said in an interview.
Dr. Alexander Hannenberg, president of the American Society of Anesthesiologists and an anesthesiologist at Newton-Wellesley Hospital, said there are serious limitations and flaws in the study. “To take such a study and suggest it should be the driver of public policy is irresponsible,” he said in an interview.
Compared to nurse anesthetists, anesthesiologists take care of patients undergoing more complex procedures, as well as patients who are sicker before they have routine operations, Hannenberg said. If anything, that difference in case severity should make outcomes better for patients having anesthesia from nurse anesthetists rather than the same, he said.
The authors acknowledge the different kinds of patients that the nurses and doctors treat, but Cromwell attributed that to anesthesiologists’ choosing to work in teaching hospitals where more complex cases pay more.
Hannenberg also said deaths from anesthesia are so rare -- one death per 200,000 to 300,000 anesthetics administered, according to the Institute of Medicine -- that a study of 480,000 cases is “grossly underpowered to identify any trend in anesthesia-related mortality.”
And he disputed the idea that training and quality are equivalent.
“I think two years versus eight years sums it up,” he said.
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