Unsupervised Nurse Anesthetists Pose No Increased Risk, Study Says

Allowing nurse anesthetists to provide anesthesia services without supervision from a doctor does not put patients at risk, according to a study in an issue of Health Affairs.

The study’s authors say the findings call into question a requirement that nurse anesthetists be supervised by an anesthesiologist or surgeon to receive Medicare reimbursement. States can “opt out” of the requirement, but only by petitioning the Centers for Medicare & Medicaid Services. The study confirms that certified registered nurse anesthetists, who receive high-level training, are able to provide the same level of services as anesthesiologists at potentially lower cost.

 “This study shows that patient safety was not compromised by the opt-out policy,” says Jerry Cromwell, a senior fellow in health economics at the Research Triangle Institute and coauthor of the study. “We recommend that CMS change the policy so that governors no longer have to petition for their states to opt out of this Medicare requirement.”

The study analyzed rates of death and complications from surgery in the 14 states that “opted-out” and found no increase in the odds of a patient dying or experiencing complications. They also found no significant differences when they compared patient outcomes across three scenarios: certified registered nurse anesthetists working without anesthesiologist supervision, anesthesiologists working alone, or the two types of provider working together on a case.

Cromwell and coauthor Brian Dulisse, a health economist at RTI, analyzed 481,440 hospitalizations covered by Medicare. They found that the frequency of nurse anesthetists’ providing anesthesia without anesthesiologist supervision grew from 1999 to 2005. As of 2005, 21% of surgeries in opt-out states and 10% in non-opt-out states used nurse anesthetists without anesthesiologists, as opposed to 17.6% and 7% in 1999. The authors speculate that the increase could be due to anesthesiologists’ taking on more privately insured cases and leaving more Medicare cases to certified registered nurse anesthetists.

The researchers also found that although nurse anesthetists are trained to handle very complex cases, anesthesiologists, on average, work on more of these cases, which involve greater risk of death. The authors hypothesize that anesthesiologists, who can choose their cases more often than can certified registered nurse anesthetists, prefer more complex, better-paying, cases. Anesthesiologists also are more prevalent in teaching hospitals that perform more complex surgery.

“Nurse anesthetists get essentially the same training in anesthesia as anesthesiologists. So in this case, a nurse is just about a perfect substitute for the doctor,” says Cromwell. “Eliminating physician supervision will not only allow nurses to do what they are trained and highly qualified to do, but it will encourage hospitals and surgeons to use a more cost-effective mix of anesthetists.”

Using nurse anesthetists more broadly could help save on health care costs because they typically earn less than anesthesiologists, the authors say.

See also:

Nurse Anesthetists Battle Overlooks Rural Doctor Shortage

Doctors Sue To Stop Nurse Anesthetists From Administering Anesthesia