Evidence Based Studies for Strategic - PowerPoint Presentation

Slide1

Evidence Based Studies for Strategic Discussions/Battles

Dr. Juan F. Quintana DNP, MHS, CRNA

Slide2

Why?

Challenges

Supervision Efforts

Barriers to practice

AAs

Lack of Identification

Attempts to transfer regulation to Medical Boards

Slide3

21st century studies

1. Lewin Group/Hogan

–

Cost Effectiveness of Anesthesia Providers (2010)

2. Research Triangle Institute (RTI)/Cromwell - No Harm Found Study

3. Lewin Group/

Negrusa

–

Scope of Practice Barriers (2016)

4. Geographic Imbalance Anesthesia Providers/ Liao,

Quraishi

, Jordan (2015)

5. Dexter and Epstein

Slide4

Lewin Group – Cost Effectiveness Anesthesia

Cost Effectiveness of Anesthesia Providers

May/June 2010 Journal of Nursing Economic$

http://

www.aana.com

/

newsandjournal

/News/Pages/062110-Study-Sh

ows

-CRNA-Only-Anesthesia-Delivery-Most-Cost-Effective-.

aspx

Slide5

Lewin Group – Cost Effectiveness Anesthesia

The study assesses the cost effectiveness of CRNAs and Anesthesiologists with regard to Cost of Education, Quality of Care, Cost Effectiveness of Anesthesia Practice Models and Access to Care.

Slide6

Lewin Group – Cost Effectiveness Anesthesia

Evaluated Literature and Data for both CRNA and MDAs

Education

Direct Costs, Opportunity Costs, Value of Services

Quality

Claims – Nationwide Inpatient Sample,

Ingenix

Database, National Ambulatory Surgery Sample

Anesthesia Practice Models

MDA, CRNA, ACT model, Supervision model

Access

CRNA vs MDA location by US Counties

Slide7

Lewin Group Cost Effectiveness

Summary

Education

To educate a CRNA ~ $200k /MDA ~ $1.2M

Quality

Data = no difference in Quality/Safety by anesthesia provider or model

Anesthesia Practice Models

CRNA-only anesthesia most cost effective

CRNA collaboration 2nd most cost effective

Access

CRNA provide greater access to rural communities

Slide8

Lewin Group - ASA response

1

. Invalid because the AANA paid for it.

a.

Lewin group acts independently using their data

b.

Peer Reviewed Article

c.

IF the AANA didn’t pay for it then who would put up the $$$

2.

CRNAs are not more cost effective, CMS pays us the same

a.

While CMS pays the same, but most commercial insurance companies do not.

b.

The salaries of MDAs are 2x CRNA, the

hospital

must then absorb the cost of MDAs out of its own pocket = more cost to the system

Slide9

Research Triangle Institute – No Harm Found

No Harm Found When Nurse Anesthetists

Work Without Supervision by Physicians

Health Affairs

, Brian

Dulisse

and Jerry Cromwell,

2010(29):1469-1475.

https://

www.healthaffairs.org

/

doi

/full/10.1377/hlthaff.2008.0966

Slide10

Research Triangle Institute – No Harm Found

This article explores whether the change in CMS policy toward anesthesia supervision had a negative impact on patient outcomes. We begin by examining the absolute level and time trends of adverse patient outcomes within the states that opted out and those that did not.

Focus on Mortality and Complications

Slide11

Research Triangle Institute – No Harm Found

Additional notes:

Examined whether there was a material change in the provision of anesthesia services away from anesthesiologists in favor of certified registered nurse anesthetists.

Whether there is evidence of different outcomes associated with the two types of anesthetists.

Whether case-mix complexity differed between opt-out and non-opt-out states and by anesthetist training.

Slide12

Research Triangle Institute – No Harm Found

For the nerds:

5 percent Medicare Inpatient (Part A) and Carrier (Part B) Medicare limited data set files for 1999–2005

Provides three full years of post-opt-out data for six of fourteen opt-out states and at least two full years of data for eleven opt-out states.

Inpatient only using base units as a measure of complexity

T-tests to measure differences in adjusted mortality rates between opt-out and non-opt-out states within each stratum.

Estimated logistic regressions using indicators for state opt-out status before/ after opt-out and for anesthesia provider, to determine the effects of these variables on the probability of mortality and complications. 

Slide13

RTI - No Harm Found

Evaluated

MDA only (AA), CRNA only (QZ) and ACT (QK/AD/QX)

Pass Through facilities surgical procedures included

500,000 cases reviewed from 1999-2005

Compared Opt Out vs Non Opt Out States

Slide14

RTI - No Harm Found

Results from 1999 – 2005 Change in providers

Opt out Non Opt Out

CRNA 21% ⬆ 9.7% ⬆

MDA 42% ⬆ 44.5% ⬇

ACT 37% ⬇ 45.8% -

Creating obvious concerns for our MDA colleagues in ACTs.

Slide15

RTI - No Harm Found

Results from 1999 – 2005 Complexity of cases

Opt out Non Opt Out

CRNA 7.2% 7.2%

MDA 8.3% 8.4%

ACT 7.6% 7.6%

Cases w/ higher base units done most frequently by MDAs.

Slide16

RTI - No Harm Found

Results from 1999 – 2005 Mortality (averaged)

Opt out Non Opt Out

CRNA 2.27% 3.04%

MDA 2.88% 3.34%

ACT 2.04% 2.86%

Note the ACT had the lowest mortality. Question which provider resulted in the reduction of mortality?

Slide17

RTI - No Harm Found

Mortality Complications

Non Opt Out Opt Out Opt Out Non Opt Out Opt Out Opt Out

Before After Before After

MDA 1.00 0.797 0.788 1.00 0824 0.818

CRNA 0.899 0.651 0.689 0.992 0.798 0.813

Team 0.959 0.708 0.565 1.067 0.927 0.903

Slide18

RTI - No Harm Found

Summary

Analysis found no evidence to suggest that there is an increase in patient risk associated with anesthesia provided by unsupervised certified registered nurse anesthetists.

We conclude that patient safety was not compromised by the opt-out policy.

Opting Out would lead to more-cost-effective care as the solo practice of certified registered nurse anesthetists increases.

Slide19

RTI – ASA response

1. Invalid because the AANA paid for it.

a.

RTI group acts independently using their data

b.

Peer Reviewed Article

c.

IF the AANA didn’t pay for it then who would put up the $$$

2. Inaccurate study because many ACT groups use the QZ modifier to bill for services.

a

. ACTs fail to meet TERFRA rules/ fear fraud.

b. Using QZ admits MDAs are depending on CRNA independent judgement.

3. Underpowered study

Slide20

Lewin Group/Negrusa – Scope of Practice

Scope of Practice Laws and Anesthesia Complications: No Measurable Impact of CRNA expanded Scope of practice on Anesthesia-related Complications

Medical Care,

Negrusa

,

Brighita

PhD; Hogan, Paul F. MS; Warner, John T. PhD; Schroeder,

Caryl

H. BA; Pang, Bo MS,

October 2016 - Volume 54 - Issue 10 - p 913–920

.

http://journals.lww.com/lww-medicalcare/Citation/2016/10000/Scope_of_Practice_Laws_and_Anesthesia.4.aspx

Slide21

Lewin Group – Scope of Practice

Talking Points

5.7 million

anesthesia cases x5 larger than the largest sample ever used in previous anesthesia outcomes studies

First to focus on effects of state SOP laws and anesthesia delivery models on patient safety

No evidence that the odds of a complication differ by SOP or delivery model.

Slide22

Lewin Group – Scope of Practice

Interesting additional findings

8 /10k anesthesia procedures had a complication

Complications 4x more likely inpatient vs outpatient

Complications increased depending on characteristics, comorbidities and the procedure.

Complications higher in OB services

Complications higher in

Gyn

services

Slide23

Lewin Group – Scope of Practice ASA response

Invalid because the AANA paid for it.

Lewin group acts independently using their data

Peer Reviewed Article

IF the AANA didn’t pay for it then who would put up the $$$

Inaccurate study because many ACT groups use the QZ modifier to bill for services.

Slide24

Epstein & Dexter – MDA Supervision on First Starts and Critical Portions of Anesthesia

Influence of Supervision Ratios by Anesthesiologists on First-case Starts and Critical Portions

Richard H. Epstein, M.D., C.P.H.I, M.S.,* Franklin Dexter, M.D.,

Ph.D

https://

www.aana.com

/advocacy/

federalgovernmentaffairs

/Documents/Influence_of_Supervision_Ratios_by%2028.pdf

Slide25

Epstein & Dexter – MDA Supervision on First Starts and Critical Portions of Anesthesia

Background:

Anesthesia groups may wish to decrease the supervision ratio for

nontrainee

providers

.

The number of operating rooms that an anesthesiologist can supervise concurrently is determined by the probability of multiple simultaneous critical portions of cases (

i.e.

, requiring presence) and the availability of cross-coverage.

A simulation study showed peak occurrence of critical portions during first cases, and frequent supervision lapses. These predictions were tested using real data from an anesthesia information management system.

Slide26

Talking points

Written by MDAs based on a French study.

15,656 cases reviewed over 1 year @ Thomas Jefferson Univ.

1:2 ratio MDA:CRNA successful ~

65%

of the time

resulting in 22.2 min delays in start

1:3 ration MDA:CRNA successful ~

1%

of the time

MDAs by their own studies show they are not meeting TEFRA supervision /medical direction rules

IF they can’t meet TEFRA rules for CRNAs who CAN function independently, how can they meet them for AAs.

Epstein & Dexter

–

MDA Supervision on First Starts and Critical Portions of Anesthesia

Slide27

ASA talking points – none

Oped

by a couple of MDAs.

Epstein /Dexter response http://

anesthesiology.pubs.asahq.org

/

article.aspx?articleid

=1934228

Concluded: “Anesthesiologists have led the development of the science of OR management. Hopefully they will also play a large role in its application at their facilities. We stand by the appropriateness of the methodology and the conclusions of our paper.

2

  “

Epstein & Dexter

–

MDA Supervision on First Starts and Critical Portions of Anesthesia

Slide28

Geographic Imbalance - Liao, Quraishi, and Jordan

Geographical Imbalance of Anesthesia Providers and Its Impact on the Uninsured and Vulnerable Populations

Nursing Economic$,

C. Jason Liao,

Jihan

A.

Quraishi

, and Lorraine M. Jordan, 2015 October

https://www.aana.com/docs/default-source/research-aana.com-web-documents-(all)/liao-quraishi-jordan-nursing-economics-2015.pdf?sfvrsn=d0cb4bb1_4

Slide29

Geographic Imbalance - Liao, Quraishi, and Jordan

The purpose of this study was to determine if there is a relationship between socioeconomic factors related to geography and insurance type and the distribution of anesthesia provider type.

Slide30

Geographical Imbalance of Anesthesia Providers

Provider-to-population ratio was calculated as the number of anesthesia providers (CRNAs or MDA respectively) per 10,000 people.

Compared to MDAs, CRNAs are

more likely

to be found in counties where populations have lower median incomes but also where unemployment, the uninsured, and Medicaid are more densely populated.

Slide31

Geographical Imbalance of Anesthesia Providers

Lessening restrictions on CRNA practice would improve the opportunity for CRNAs to better serve the 47 million uninsured and vulnerable populations

Slide32

ASA talking points

NONE

Geographical Imbalance of Anesthesia Providers

Slide33

Needleman & Minnick – Anesthesia Provider Model and Maternal Outcomes

Needleman, J., & Minnick, A.F. (2009). Anesthesia provider model, hospital resources, and maternal outcomes.

Health Services Research, 44

(2 Pt 1), 464-482.

doi

: 10.1111/j.1475-6773. 2008.00919.x

Slide34

Talking points

1,141,641 OB patients from 369 hospitals in six representative states

Hospitals using only CRNAs, or CRNAs and MDAs, do not have systematically poorer maternal outcomes compared with hospitals using anesthesiologist-only models

Needleman & Minnick

–

Anesthesia Provider Model and Maternal Outcomes

Slide35

Silber study

Study of 5,972

medicare

patients post

Chole

/TURP

Did

NOT

mention CRNAs at all did not evaluate anesthesia.

Evaluated Failure to save from post op complications

CMS (HCFA: 2001) After eliminating the supervision rule, response: In the rule, HCFA found that there was “no compelling scientific evidence that an across-the-board federal physician supervision requirement for CRNAs leads to better outcomes.”

Medicare and Medicaid programs; hospital conditions of participation: anesthesia services.

Fed

Regist

.

January 18, 2001; 66(12):4674-4684.

Slide36

Famous MDA quotes Stoelting response to Abstein study

…the participation of certified registered nurse anesthetists (CRNAs) in delivery of anesthesia care would have ceased many years ago if there was evidence that this participation resulted in a less favorable outcome compared with anesthesia personally administered by an anesthesiologist.” [Robert K.

Stoelting

, MD, Department of Anesthesia, Indiana

Uni

-

versity

School of Medicine, Indianapolis;

Anesthesia & Analgesia

. December 1996, 82:1347, Letters to the Editor.]

Slide37

Evidence Based Studies for Strategic Discussions/Battles

Dr. Juan F. Quintana DNP, MHS, CRNA

THANK YOU!!