Anesthesiology Administered by MD's or CRNA's

[glutamate23]

I am glad to hear that your grandson is doing well. Do you know who the anesthia was provided by: was it a cerified register nurse anesthesiologist(CRNA), or an medical doctor that specialized in Anesthesiology. It is quite common now a days for crna's to adminster the anesthesiology instead of an actual M.D. This is quite alarming in my opinion considering the difference in education levels between CRNA and the Anesthesiology Docs. Anesthiology docs on average are educated for 12 years as opposed to the 6 years that the CRNA's recieve. Next time anyone in your family undergoes surgery you should reqeust that an Anesthiology Doctor adminster the anesthesia, they are much more knowledgable and more capable of handling emergencys that might arise during surgery.
Glutamate

[lawmed]

I am glad to hear that your grandson is doing well. Do you know who the anesthia was provided by: was it a cerified register nurse anesthesiologist(CRNA), or an medical doctor that specialized in Anesthesiology. It is quite common now a days for crna's to adminster the anesthesiology instead of an actual M.D. This is quite alarming in my opinion considering the difference in education levels between CRNA and the Anesthesiology Docs. Anesthiology docs on average are educated for 12 years as opposed to the 6 years that the CRNA's recieve. Next time anyone in your family undergoes surgery you should reqeust that an Anesthiology Doctor adminster the anesthesia, they are much more knowledgable and more capable of handling emergencys that might arise during surgery.
Glutamate

You have NO clue what you are talking about. Get your record expunged, get an education, improve your spelling and hopefully you will some day be in a position to talk about something with authority...or even give advice.

"Hi I am a pre-med student in the state of texas, that is about to apply to medical school hopefully next year. I got arrested twice(all charges in texas) when I was in highschool. I have about 4 charges on my record, three were dismissed, and I have one conviction of MIP of alcohol. The charges occured about five years ago. I have been reading a lot of threads and from what i understand the dismissed charges can be expunged, but all i can do with the conviction is try to get a pardon. Ok so lets say i go ahead and try to get the dismissed charges expunged off my record. Once my record is expunged, how would i get all the private background search companys to erase expunged recordes that were obtained prior to the expunction? Would I have to contact one by one. I hope not, considering there is like a zillion private background search companys.
Glutamate

Hello all, I have a qeustion for all you malpractice lawyers out there. If a physician were to do something that harmed a patient, and it was later found out that the physician suffered from a mental illness that was undercontrol with treatment, would the fact that the doc is mentaly ill be used to argue that the doc was uncompetent when practicing medecine at the malpractice trial?"

Until then, you are criminally ignorant when it comes to anesthesia.

[glutamate23]

You have NO clue what you are talking about. Get your record expunged, get an education, improve your spelling and hopefully you will some day be in a position to talk about something with authority...or even give advice.



Until then, you are criminally ignorant when it comes to anesthesia.

How exactly is my post criminaly arrogant. Can you please direct me to any laws that state, I can not voice my opinions, and opinions of other doctors that I have talked to including a board certified anesthesiologist in my family. All I recomended was to reqeust Anesthesiologist Doctor when undergoing surgery. Its not like im practicing medecine without a licenese to practice. Who do you think adminsters anesthesia when a DOCTOR undergoes surgery. I am willing to bet that the vast majority of docs go out there way to get a board certified anesthesiologist. You posting other qeustions that I had about an expungment of my record to discredit my post was pretty low. We all make mistakes in life, I have learned from my mistakes. I am hopefully next year going to matriculate into an MD/PhD program due to my hardwork and gods grace. Hopefully one day I will be able to research the pathophysiology of personality disorders and other mental illnesses to help people like you.
Glutamate23

[glutamate23]

--------------------------------------------------------------------------------

Hello all, I have a qeustion for all you malpractice lawyers out there. If a physician were to do something that harmed a patient, and it was later found out that the physician suffered from a mental illness that was undercontrol with treatment, would the fact that the doc is mentaly ill be used to argue that the doc was uncompetent when practicing medecine at the malpractice trial?

The reason I posted this qeustion, is due to medical students and doctors that suffer from treatable mental illness being scared to start support groups for docs that suffer from mental illness. Most people I have spoken to on another forum believe that malpractice lawers would use this information against docs during a malpractice trail. Thank you for indirectly answering my qeustion. You would obviously use any kind of dirt you can dig up.

[lawmed]

IGNORANT...not arrogant....although.....

Perhaps you were unaware that:

1. over 80% of the rural hospitals in America are served by CRNAs alone.
2. Over 60% of all anesthetics in the country are delivered by CRNAs.
3. CRNAs have safely been providing anesthesia for over 100 years.
4. CRNAs practice in every anesthesia specialty.
5. Uninformed, false statements lead to needlessly frightening patients, and lawsuits. Depending on the setting, the statement below could be actionable for tortuous interference, restraint of trade, libel/slander, etc.

"Next time anyone in your family undergoes surgery you should reqeust that an Anesthiology Doctor adminster the anesthesia, they are much more knowledgable and more capable of handling emergencys that might arise during surgery.
Glutamate"

There is absolutely no medical evidence, based on outcomes or morbidity, that this statement is true. What should the benefactor of your wisdom do if their local hospital has no Anesthesiologist? What if an emergency arises? Your advice, as posted, would lead a prudent person to bypass any hospital without an Anesthesiologist, despite a need for emergency surgery. Suppose that person died, whether from waiting for the Anesthesiologist they insisted on, or during their travel to the "much more knowledgable and more capable" provider, based on your guidance?

By the way, the vast majority of surgeons I know request a CRNA for their anesthesia. If you post an "opinion" in a forum like this that is without basis, and misleads others, you should be ready to be challenged. Especially if you post information regarding your criminal record and a mental illness inquiry at the same time. I mean...Jeeeeez...

[glutamate23]

"Next time anyone in your family undergoes surgery you should reqeust that an Anesthiology Doctor adminster the anesthesia, they are much more knowledgable and more capable of handling emergencys that might arise during surgery.
Glutamate"

There is absolutely no medical evidence, based on outcomes or morbidity, that this statement is true

You are incorrect, there is medical evidence that proves this statement is true. Here is a link to a study I found on PubMed by Silber that proves my statement is correct.

http://www.ncbi.nlm.nih.gov/entrez/q..._uids=10861159

Here is a section of the RESULTS: Adjusted odds ratios for death and failure-to-rescue were greater when care was not directed by anesthesiologists (odds ratio for death = 1.08, P < 0.04; odds ratio for failure-to-rescue = 1.10, P < 0.01),
and here is the CONCLUSION: Both 30-day mortality rate and mortality rate after complications (failure-to-rescue) were lower when anesthesiologists directed anesthesia care. These results suggest that surgical outcomes in Medicare patients are associated with anesthesiologist direction, and may provide insight regarding potential approaches for improving surgical outcomes.

Like I said, MD>CRNA.
glutamate

[deadlock]

But then a more recent study
http://www.ncbi.nlm.nih.gov/entrez/q...=pubmed_docsum states that statistically there is no difference in healthy mothers who have had c-section:

after regression analysis, this difference was not significant (odds ratio for CRNA vs. anesthesiologist complications: 1.046 to 1, 95% confidence interval 0.649-1.658, p =.85)

Personally, I am biased. I prefer anesthesiologist. My surgery was done with anesthesiologist doing the induction and finished with CRNA.

Professionally, cost effective procedures when patient is not a high risk, multisystem disease.

Glutamate, good work!

[lawmed]

The Sibler study DOES NOT show a difference in anesthesia outcomes between a CRNA and MD. It is a flawed, useless effort according to HCFA, NIM, NIH and numerous other organizations and experts. Read on....

To date, every study comparing outcomes in anesthesia care by MDs and CRNAs has conclusively found no difference. So convincing are these studies, that no further studies have been proposed.

In the anesthesia rule published in the January 18, 2001, Federal Register by HCFA/CMS, the administration dismissed all claims by ASA and the Pennsylvania study research team that the study examined CRNA practice . HCFA/CMS stated the following:

"We have also reviewed a more recently published article by Dr. Silber (July 2000) and colleagues from the University of Pennsylvania. This article also is not relevant to the policy determination at hand because it did not study CRNA practice with and without physician supervision." (p. 4677)

"One cannot use this analysis to make conclusions about CRNA performance with or without physician supervision." (p. 4677)

"Even if the recent Silber study did not have methodological problems, we disagree with its apparent policy conclusion that an anesthesiologist should be involved in every case, either personally performing anesthesia or providing medical direction of CRNAs." (p. 4677)

Nurse anesthetists have been providing quality anesthesia care in the United States for more than 100 years. In administering more than 65 percent of the anesthetics given annually, CRNAs have compiled an enviable safety record. No studies to date that have addressed anesthesia care outcomes have found that there is a significant difference in patient outcomes based on whether the anesthesia provider is a CRNA or an anesthesiologist.

The practice of anesthesia has become safer in recent years due to improvements in pharmacological agents and the introduction of sophisticated technology. Recent studies have shown a dramatic reduction in anesthesia mortality rate to approximately one per 250,000 anesthetics.

The vast majority of anesthesia-related accidents have nothing to do with the level of education of the provider." [Blumenreich GA, Wolf BL. "Restrictions on CRNAs imposed by physician-controlled insurance companies." AANA Journal. 1986;54:6:538-539, at page 539.

The most common anesthesia accidents are lack of oxygen supplied to the patient (hypoxia), intubation into the esophagus rather than the trachea, and disconnection of oxygen supply to the patient. All of these accidents result from lack of attention to monitoring the patient, not lack of education. In fact, the Harvard Medical School standards in anesthesia are directed toward monitoring, which reiterates the basic point - most anesthesia incidents relate to lack of attention to monitoring the patient, not lack of education.

In the April 2003 AANA Journal, Dr. Michael Pine, a board-certified cardiologist widely recognized for his expertise in analyzing clinical data to evaluate healthcare outcomes, and a team of researchers published the results of a study titled "Surgical Mortality and Type of Anesthesia Provider." The study analyzed the effect of different types of anesthesia providers—specifically Certified Registered Nurse Anesthetists (CRNAs) and physician anesthesiologists—on the death rates of Medicare patients undergoing surgery. [Pine, M, Holt, KD, Lou, YB. "Surgical Mortality and Type of Anesthesia Provider." AANA Journal. 2003;71:109-116.]

The researchers studied 404,194 Medicare cases that took place from 1995-1997 in 22 states. Only cases with clear documentation of type of anesthesia provider were studied, and adjustments were made for differences in case mix, clinical risk factors, hospital characteristics, and geographic location. The types of surgical procedures included carotid endarterectomies, cholecystectomies, herniorrhaphies, mastectomies, hysterectomies, laminectomies, prostatectomies, and knee replacements.

The Pine study yielded the following important findings:

Mortality rates were similar for CRNAs and anesthesiologists working individually.

There was no statistically significant difference in the mortality rate for CRNAs and anesthesiologists working together versus CRNAs or anesthesiologists working individually.

There was no statistically significant difference in the mortality rate for hospitals without anesthesiologists versus hospitals where anesthesiologists provided or directed anesthesia care.

That while their findings differed from those of Silber et al. they were consistent with earlier research and with current data which estimate that anesthesia-related deaths today are as low as 1 in 200,000 to 300,000 cases. [To Err is Human: Building a Safer Health System. Kohn, LT, Corrigan, JM, Donaldson, MS. Washington, DC: National Academy Press. 1999.]

That based on the surgical procedures included in the study, inpatient surgical mortality is not affected by whether the anesthesia provider is a CRNA or an anesthesiologist.

Pine Versus Silber. The Silber/Pennsylvania study which was published nearly three years before the Pine study, contained glaring methodological deficiencies that Pine et al. endeavored to avoid. Specifically, approximately two- thirds of the cases which Silber et al. classified as not involving an anesthesiologist in the patient care either A) actually did have an anesthesiologist involved in some, but not all, of a patient's procedures, or B) had no bill for the anesthesia care (making it impossible to confirm whether an anesthesiologist was or was not involved).

Further, cases in which anesthesiologists worked alone were not distinguished from those in which CRNAs and anesthesiologists worked together. Finally, only cases in one state—Pennsylvania—were included in the Silber study.

This failure by Silber et al. to more accurately quantify the cases in which anesthesiologists were involved led the researchers to conclude that there was an increase of 2.5 deaths per 1,000 patients when an anesthesiologist was not involved in the case. This inflated ratio was alarmingly out of sync with the Institute of Medicine's (IOM's) published report that anesthesia mortality rates today are approximately 1 death per 200,000 to 300,000 anesthetics administered, a ratio also routinely cited by the American Society of Anesthesiologists (ASA). [To Err is Human: Building a Safer Health System. Kohn, LT, Corrigan, JM, Donaldson, MS. Washington, DC: National Academy Press. 1999.] Had Silber et al. identified a more accurate (i.e., larger) number of cases as involving anesthesiologists, the ratio obviously would have been much different.

More studies that found no difference in outcome between CRNA and MD administered anesthesia:
Bechtoldt, Jr, AA. "Committee On Anesthesia Study. Anesthetic-Related Deaths: 1969-1976." North Carolina Medical Journal. 1981;42:253-259.]

Forrest, WH. "Outcome - The Effect of the Provider." In: Hirsh, R, Forrest, WH, et al., eds. Health Care Delivery in Anesthesia. Philadelphia: George F. Stickley Company. Chapter 15.1980:137-142

In 1994, the Minnesota Department of Health (DOH), as mandated by the state Legislature, studied the provision of anesthesia services by CRNAs and anesthesiologists. The department reached four conclusions, including the following:

There are no studies, either national in scope or Minnesota-specific, which conclusively show a difference in patient outcomes based on type of anesthesia provider. [page 23, DOH study.

National Academy of Sciences Study
This study was mandated by the U.S. Congress and performed by the National Academy of Sciences, National Research Council. The report to Congress stated:

"There was no association of complications of anesthesia with the qualifications of the anesthetist or with the type of anesthesia." [House Committee Print No. 36, Health Care for American Veterans, page 156, dated June 7,1977.1

Based on a comparison of 1988 data from St. Paul Fire and Marine Insurance Company, at the time the country's largest provider of liability insurance for CRNAs (but no longer providing liability coverage for healthcare professionals), and 2004 data from CNA Insurance Company, currently the largest insurer of CRNAs, insurance premiums for nurse anesthetists have decreased nationally a total of 39 percent in that time span. (This pertains to claims-made coverage, typically for self-employed CRNAs.) The premium drop is detailed in the appendix titled, "Nurse Anesthetist Professional Liability Premiums: Premium Changes from 1988 to 2004." The appendix details premium information for CRNAs, both on a state-by-state basis and nationally.

The decrease in CRNA malpractice insurance premium rates demonstrates the superb anesthesia care that CRNAs provide. The rate drop is particularly impressive considering inflation, an increasingly combative legal system, and generally higher jury awards

Hope this helps.....

[lawmed]

Sibler debunked:

1. 7,665 patients (3.5%) died within 30 days of surgery.

2. Although the study found 258 more deaths of patients who may not have had an anesthesiologist involved in their case, the researchers' adjustments for differences among patients and institutions reduced the number by 78% (to 58 deaths).

3. The 58 "excess" deaths could be due to numerous, equally plausible factors, for example:

A. Faulty design of the study

B. Inaccurate or incomplete billing data (e.g., most of the 23,010 "undirected" cases used had no bill for anesthesia care)

C. Unrecognized differences among patients (e.g., medical information on patients' bills was insufficient to permit complete adjustment for their initial risks)

D. Unrecognized differences in institutional support (e.g., information about hospital characteristics was inadequate to permit full assessment)

E. Medical care unrelated to anesthesia administration (e.g., post- operative medical care provided by anesthesiologists or by other medical specialists who are more likely to be at hospitals in communities where anesthesiologists are plentiful)

The end result is a statistically insignificant difference in negative outcomes between anesthesiologist-directed and nonanesthesiologist-directed cases.

Complication Rates. After adjusting for case mix and severity, the study found no statistically significant difference in complication rates when nurse anesthetists were supervised by anesthesiologists or other physicians. Dr. Pine noted that poor anesthesia care is far more likely to result in significant increases in complication rates than in significant increases in death rates. Therefore, Dr. Pine concluded that this finding strongly suggests that medical direction by anesthesiologists did not improve anesthesia outcomes.

Failure to Rescue. For the most part, failure to rescue occurs when a physician is unable to save a patient who develops nonanesthesia complications following surgery. Therefore, it is not a relevant measure of the quality of anesthesia care provided by nurse anesthetists. It is a relevant measure of postoperative physician care, however.

Patients Involved in More than One Procedure. For reasons not explained in the abstract, patients involved in more than one procedure were assigned to the nonanesthesiologist physician group if for any of the procedures the nurse anesthetist was supervised by a physician other than an anesthesiologist. It is impossible to measure the impact of this decision by the researchers on the death, complication, and failure to rescue rates presented in the abstract.

To emphasize the importance of this, consider the following hypothetical scenario: A patient is admitted for hip replacement surgery. A nurse anesthetist, supervised by the surgeon, provides the anesthesia. The surgery is completed successfully. Three days later the patient suffers a heart attack while still in the hospital and is rushed into surgery. This time the nurse anesthetist is supervised by an anesthesiologist. An hour after surgery, and for reasons unrelated to the anesthesia care, the patient dies in recovery. According to the researchers, a case such as this would have been assigned to the nonanesthesiologist group!

Patients Who Were Not Billed for Anesthesia Services. As noted in the discussion on death rates, most of the "undirected" cases had no bill for anesthesia care. The actual figure is 14,137 patients, or 61% of the 23,010 patients defined as undirected. The researchers 'flimsy rationale for lumping all nonbilled cases in the undirected category is as follows: "The 'no-bill' cases were defined as undirected because there was no evidence of anesthesiologist direction, despite a strong financial incentive for an anesthesiologist to bill Medicare if a billable service had been performed' (emphasis added). Of course, one might ask how many of those cases were not billed because an anesthesiologist had a bad patient outcome.

[lawmed]

Professionally, cost effective procedures when patient is not a high risk, multisystem disease.

What is this based on? The thousands of patients operated on each and every day, who are high risk, with multi-system disease, and have a CRNA as their sole anesthesia provider might disagree. Science disagrees. Insurance companies disagree. Hospitals disagree.