Nurse Anesthetists, Anesthesiologists, and the VA System: Are Changes Needed?

Susan B. Yox, RN, EdD; Bret S. Stetka, MD; Juan Quintana, CRNA, DNP, MHS; Daniel J. Cole, MD


July 08, 2016

What Does the Evidence Say?

Medscape: What has the research shown about the safety and quality of CRNA and anesthesiologist practice? Have any studies measured specific outcomes? Does the research provide evidence for or against this proposed rule?

Dr Quintana: Since 2000, a plethora of research has been published in a wide range of peer-reviewed journals that confirms the safety of CRNA-provided anesthesia care. The most recent study, titled "Scope of Practice Laws and Anesthesia Complications," appeared in the June 2016 issue of Medical Care.[3] This study, the first of its kind, examined nearly 6 million cases and revealed that scope of practice restrictions and physician supervision requirements for nurse anesthetists have no impact on anesthesia patient safety.

In addition to the Medical Care study, eight other studies have demonstrated that CRNAs are at least as safe as their physician anesthesiologist counterparts. You can peruse the scientific literature here.

The last study to suggest that patients are safer when an anesthesiologist is involved in their care was by Silber and colleagues,[4] published in 2000. This study was fraught with problems, and on January 18, 2001, when the Health Care Financing Administration (now the Centers for Medicare & Medicaid Services) published a 14-page anesthesia rule in the Federal Register,[5] it declared in no uncertain terms that Silber and colleagues' study was not relevant to the issue of physician supervision of nurse anesthetists or quality of nurse anesthesia care. Nonetheless, the ASA inexplicably continues to hang its hat on this dismissed and outdated research.

Incidentally, CRNAs are the only anesthesia providers who acquire actual healthcare experience before entering their educational programs. As the research has shown, they are extremely well-prepared to provide the high-quality of care that they do. Bottom line: Evidence trumps opinion.

Dr Cole: No independent studies show that nurses can ensure the same outcomes [as physicians], and the VA's own internal evaluation of relevant studies doesn't support a policy change. The evaluation looked at relevant studies of health outcomes of patients receiving care from nurse anesthetists practicing independently. The VA's Quality Enhancement Research Initiative (QUERI) could not discern "whether more complex surgeries can be safely managed by nurse anesthetists."

The only studies that claim equivalent outcomes are biased and were funded by the AANA or its foundation. In fact, a recently published study[3] thanks Juan F. Quintana, AANA president, in the acknowledgments as a member of the study's technical expert panel.

An independent study published in the peer-reviewed journal Anesthesiology[4] showed that in 1000 cases in which an anesthesia or surgical complication occurred, physician anesthesiologists prevented almost seven deaths, demonstrating the importance of physician-led anesthesia care.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.