Unsupervised nurses may soon give anaesthetics in United States

British Medical Journal,  April 8, 2000  by Deborah Josefson

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Nurse anaesthetists in the United States may soon be able to give anaesthetics to some patients without the supervision of a doctor.

After deliberating for more than two years, the Health Care Financing Administration, which provides health insurance to an estimated 74 million Americans through the Medicare, Medicaid, and State Children's Health Insurance Program, has announced that it will remove the requirement that all nurse anaesthetists who provide anaesthesia to Medicare patients must be supervised by a physician.

Until now, when anaesthesia was administered to patients with Medicare, nurse anaesthetists had to be supervised by physicians in order for hospitals and ambulatory surgery centres to be reimbursed for the non-anaesthesia portion of the care.

This rule has been in effect since 1966 when the Medicare programme was established. The agency first proposed changing the rule in December 1997. Under the proposal, individual states will have the authority to decide whether nurse anaesthetists should be supervised or not.

The announcement was met with alarm by anaesthesiologists (physicians or dentists who specialise in anaesthesiology), who fear that a lack of supervision by physicians will compromise the quality of care, however, it was supported by nurse anaesthetists, who contend that certified nurse anaesthetists deliver safe, high quality anaesthesia on a par with that of anaesthesiologists but at lower cost.

Certified registered nurse anaesthetists are advanced practice nurses with graduate level education. According to the American Association of Nurse Anesthetists, they deliver about 65% of the 26 million episodes of anaesthesia in the United States and most of the anaesthesia in rural areas.

Over the past two years, the association has lobbied the agency for the passage of the rule, emphasising that advances in monitoring equipment, pharmaceuticals, and anaesthesia education have greatly improved safety. For instance, 20 years ago, there was I death for every 10000 people who had anaesthesia, while today the death rate is 1 in 240 000.

Dr Ronald Mackenzie, president of the American Society of Anesthesiologists, agreed that the safety of anaesthesia has improved greatly but pointed out that this level of safety was achieved only with the involvement of anaesthesiologists. He criticised the agency's, decision and indicated that a recent but as yet unpublished study involving 65 000 Medicare patients in 219 hospitals in Pennsylvania had found that there was a 28% higher death rate among patients receiving anaesthesia care from unsupervised certified registered nurse anaesthetists.

The association and other doctors are lobbying Congress to pass a bill, the Safe Seniors Assurance Study Act of 1999, which will reverse the agency's decision. It has also called for a national study comparing the safety outcomes of the two groups but because of the scarcity of complications overall the undertaking was deemed to be too costly by the Centers for Disease Control in 1990.

Moreover, in 1994 a study by the Minnesota Department of Health found that there were no studies, either national or specific to Minnesota, that conclusively found a difference in outcomes of patient care when anaesthesia was delivered by either of the two types of providers.

The Health Care Financing Administration claims that its proposal will not affect the quality of care but only defer the scope of practice to states. Dr Mackenzie, however, argues that since Medicare is a national programme, national standards should apply.

"This is about people, not government. It is about patients' rights, not states' rights: the right of Medicare beneficiaries in every state to the best available medical care during anaesthesia.

"If the [Health Care Financing Administration's] proposal is approved, Medicare patients would be subjected to potentially 50 different levels of anaesthesia care in this country not only [according to] where they live but where they may travel [to] as well," Dr Mackenzie said.

Deborah Josefson San Francisco

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