Anesthesia's unneeded duplication

Would you pay two mechanics with equivalent skills to both work on your car if one of them could do the job alone?

Obviously not, yet that's the kind of unnecessary cost you're likely to pay if you're among the many patients every year who get sick or injured and require anesthesia.

Two groups of medical professionals are trained to administer anesthesia: nurses who have been specially trained as nurse anesthetists and physicians specially trained as anesthesiologists. Despite compelling evidence that both groups provide equally safe anesthesia care, the majority of states, including Maryland, still adhere to a federal government rule requiring nurse anesthetists to be supervised by physician anesthesiologists when providing care to Medicare and Medicaid patients.

Ironically, this is the same federal government that recently passed a sweeping health care reform bill with a focus on reducing cost and improving access. Astute governors in 15 states have recognized that the requirement for supervision adds cost, and they have put the medical and financial interests of their citizens ahead of custom by "opting out" of participation in this practice.

Did they sacrifice the safety of their citizens in doing so? After all, don't physician anesthesiologists attend medical school rather than nursing school prior to receiving their specialized training in anesthesia? Yes, they do, and training to become a physician is indeed longer in duration and has a different focus than training to become a nurse.

But three well-respected physician anesthesiologists addressed this discrepancy 33 years ago when they wrote the following in their textbook Introduction to Anesthesia: "It is apparent that the physician anesthesiologist offers greater depth of training than the nurse anesthetist, but this does not necessarily qualify the physician as a better anesthetist. By achieving the technical skills and the appropriate experience and knowledge, a conscientious nurse can easily surmount the gap in training."

Today, postgraduate education and clinical training in the specialty of anesthesia is remarkably similar for both groups, occurring in the same settings. As a result, both groups can independently provide an equivalent level of safe and effective anesthesia care.

A recent analysis found that in states whose governors opted out of the Medicare and Medicaid requirements for physician supervision of nurse anesthetists, there was no increase in patient complications or deaths. The independent report by RTI International recommended that nurse anesthetists be allowed to practice without supervision in all states.

Other experts have reached the same conclusion. Physician and nursing leaders at a January 2010 conference sponsored by the Josiah Macy Jr. Foundation agreed that regulatory and reimbursement policy barriers often prevent the efficient and effective use of nurse practitioners. They called for all providers of care to practice "at the top of their licenses." In rural areas across the country where there are no physician anesthesiologists, nurse anesthetists do practice independently at the top of their licenses by providing anesthesia care to patients who would otherwise not have access to it.

So how wasteful is a system in which we train physician anesthesiologists who will ultimately supervise nurse anesthetists? According to the Rand Corporation, it costs somewhat more than six times as much to train a physician anesthesiologist as to train a nurse anesthetist, and the anesthesiologist earns twice as much on average per year. Similarly, a 2010 study of anesthesia delivery models by the Lewin Group found the most cost-effective delivery model by far is nurse anesthetists working without supervision.

More importantly, both the Rand and Lewin Group studies found there is no significant difference in quality of care when a certified registered nurse anesthetist delivers anesthesia versus a physician anesthesiologist.

These compelling findings are not a recent revelation. In 1980, the Centers for Disease Control and Prevention said the frequency of adverse outcomes associated with anesthesia was so low that a full-scale study of the issue was unwarranted.

How much longer will we continue to embrace a system of anesthesia care that costs substantially more money without enhancing safety? Consumers of anesthesia care across the country are paying for two mechanics when they only need one. It is past time to change the process and get the job done in the most efficient and cost-effective manner.

Catherine L. Gilliss is dean of the Duke School of Nursing and president of the American Academy of Nursing. Her e-mail is

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