The latest good news for all of us

dgenthusiast · Aug 18, 2010

I encourage people to actually critically read the entire study, not the news articles, before posting on it. It's not a matter of "typical flamers" starting arguments. It's hard to discuss literature when one party (for example, the original poster) has not even read the study beyond an abstract or what a journalist wrote.

Two things that drastically hurt this study's conclusions:

1. "This research was funded by the American Association of Nurse Anesthetists."

It's hard to deny that the AANA doesn't have an agenda to push, namely that of increased scope of practice and independent rights for advanced practice nurses. It's sort of how you wouldn't trust a study on a new drug when the company that's making the drug puts out the study.

2. The study itself states: "In opt-out and non-opt-out states, the mean number of base units in the anesthesiologist solo group was about a full point higher than in the certified registered nurse anesthetist solo group (p

Easier cases (ie. those performed by CRNAs) = lower mortality?! Shocking!

What I'd like to see in the future is a study that, instead of relying on existing Medicare data, which is pretty weak in the first place, looks at a prospective database that's set up precisely to detect changes in outcome with different levels of supervision.

But, once again, I highly recommend that you actually read the study and draw your own conclusions from it rather than relying on what journalists (with minimal training in critically reading literature) say. Don't get into the bad habit of posting "conclusions" from studies that you yourself have never read. Don't let someone else do the thinking for you.

dgenthusiast · Aug 18, 2010

Response of the President of the ASA (http://www.beckersasc.com/anesthesia/asa-president-offers-6-observations-on-study-of-crnas-as-sole-provider-of-anesthesia-services.html):

"Dr. Alexander A. Hannenberg: As President of the ASA, I appreciate the opportunity to provide important perspective on the study "No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians" from the anesthesiologists' viewpoint. The following is ASA's overview of the study along with the resources that support the points.

1. The study's methodology relies on weak billing data:

- It examines data based around the -QZ modifier, which overstates independent practice by a CRNA
  - It does not distinguish between complications resulting from surgery or anesthesia
  - It does not discriminate between conditions existing prior to surgery and those resulting from surgical or anesthetic care
  - A surgeon is still present and participating in patient care in opt-out states
  [*]481,000 cases analyzed in the study would have produced two deaths related to anesthesia, an obviously insufficient number to support any conclusions about mortality

2. Anesthesiologists are experts in patient safety. Recent data showed one death per 200,000-300,000 anesthetics administered. (Committee on Quality of Healthcare in America, Institute of Medicine: "To Err is Human, Building a Safer Health System." Edited by Kohn L, Corrigan J, Donaldson M. Washington, National Academy Press, 1999, p. 241)

3. Anesthesiologists not only care for patients undergoing the most complex procedures (base unit differential) but also the sicker patients undergoing all procedures (unrecognized selection bias). These considerations would suggest dramatically better outcomes for CRNAs, but this is not seen. In fact, CRNA only cases (-QZ) actually showed worsening mortality and complications, while other groups improved (see table below). Even equivalent outcomes with lower risk cases is a troubling finding. And the most significant improvement in mortality and complications took place in the anesthesia care team (ACT) model of practice, further supporting the value of anesthesiologists involvement in care. (Reference: Jeffrey Silber, MD, PhD, 2000 study "Anesthesiologist Direction and Patient Outcomes": >6 excess deaths/1000 cases from failure to rescue from surgical or anesthetic complication in absence of anesthesiologist)

From Table 4 in "No Harm Found When Nurse Anesthetists Work Without Supervision" study:

The authors of the study make no apology for the disturbing trend in their own data toward increasing frequency of mortality and complications in nurse-administered anesthesia during the opt-out "experiment" as compared to improved outcomes in physician and ACT cases.

4. Cost of care is equivalent. Considering that the payment for anesthesia services under Medicare's system (adopted by most private insurers, too) is identical whether provided by an unsupervised nurse, solo physician or the physician/CRNA team, the fallacy of the "cost effective" claim is evident.

5. The study understates the differences in training of anesthesiologists and nurse anesthetists. Nurse anesthetists typically receive approximately 2.5 years of post-baccalaureate education; anesthesiologists receive eight years, including a broad foundation in general medicine, intensive care and pain management. The prolonged period of training is to acquire the knowledge base and skills to provide expert care of the patient and all their co-existing disease before, during and after surgery.

6. Overwhelming public preference for physician supervision (A 2001 study by The Terrance Group, titled "National Anesthesia Study III: A Survey of Public Opinion Attitudes," revealed that 70 percent of all respondents (and 77 percent of Medicare beneficiaries) would oppose allowing a nurse anesthetist to administer anesthesia without medical supervision if an MD could supervise the nurse at no additional cost to the patient. Sixty-three percent of all respondents (and 70 percent of Medicare beneficiaries) opposed the decision to drop the requirement for anesthesia supervision by a doctor.). Public policy should reflect this preference."

t2krookie · Aug 19, 2010

ahh dg!!! you heard me calling you!!!

soo if mds back in 2001 does a study on cited imperfect billing data (says so in its abstract) and comes to a conclusion and another crna favoring study uses billing information with the same weaknesses (noted in the abstract), how do you come to a conclusion that one is self serving and the other not ? ohh, i forgot to mention you have never seemed to show much in the way of respect for patient choice (reference our previous discussions on nps rating higher satisfaction levels than mds) but now such data is pertinent? well i guess ya gotta use the tool appropriate to the problem. if it's a nail use a hammer, and if it's a screw use a driver. we all do that to one extent or another so i understand completely. now before the flames get hot, i wanna say i really respect your tenacity. you are obviously a very intelligent person and i really appreciate you coming here. gives me the impetus to educate myself and do research.

ohh, before we go on, i'll post a little snippet from the same article you are quoting in the same fashion (just the part i wanna emphasize)

"this was a retrospective analysis based on administrative claims data and is limited by the associated errors inherent in using such data.(billing information on "one" states medicare patients. can't have that!! ohh wait, this is the md study so its ok to use such data) the accuracy of our definitions for anesthesiologist direction (or no direction) is only as reliable as the bills (or lack of bills) submitted by caregivers. we also cannot rule out the possibility that unobserved factors leading to undirected cases were associated with poor hospital support for the undirected anesthetist and patient. local, temporal, even psychologic factors may play a part in patient outcome, and such factors may not be noted in the available data set. for example, if anesthesiologists had a tendency not to submit bills for patients who died within 30 days of admission, our results could be skewed in favor of directed cases. although our clinical experience suggests that this scenario is quite unlikely, we cannot rule out this possibility. we also cannot rule out the possibility that undirected cases occur more often in emergency situations that developed outside of the emergency department"(silber et al, 2000)

"for example, if anesthesiologists had a tendency not to submit bills for patients who died within 30 days of admission" now this just can't be happening. what would be the point? almost as cheap a shot as the description of the crna favoring article in the asa position 1st paragraph.

anywho, what is important is that we can all read english and see from our own point of view. i still have no access to more than the abstract (not gonna pay 12$ for it) so i have yet to pour over the details to gauge the accuracy of the asa critique. it did not cite anything other than the comparison article, a "do you want a doctor or a crna? questionnaire", the old silber, 2000 article, and a article on the state of medical errors which i found quiet provocative and not very complimentary towards physicians or nurses.

matter of fact, i found in that last article what i "think" may be something holding back various medical boards from wanting to look tooooo deep into outcome studies. just imagine if we all had to retake our licensing boards periodically? specialty boards are retaken by board certified physicians and are one path for np specialties (in my state at least) but imagine if mds had to retake medical boards!!! here's an excerpt from the last article(to err is human, building a safer health system, 1999) in the citation of the asa position statement;

"[color=#632423]the iom report called for such licensing bodies

to "implement periodic re-examinations and re-licensing of

doctors, nurses, and other key providers, based on both com-

petence and knowledge of safety practices." 90

no state medical boards require routine testing of skills and

competency. 91 requirements for license renewal are general-

ly limited to continuing education, despite research indicat-

ing that continuing education alone has little or no impact on

practitioner competency. 92 once practitioners earns medical

license, they may never have to demonstrate their medical

competency again. professionals can become incompetent

over time because they don't keep up with current medical

knowledge, they suffer from drug addiction, alcoholism or

mental illness, or they just weren't that good in the first place

and their shortcomings only become evident as they treat

patients day after day. without ongoing testing, these kinds

of problems may not be recognized by licensing agencies

before serious harm occurs"(jewell & mcgiffert, 2009)

found here:

www.safepatientproject.org/safepatientproject.../safepatientproject.org-todelayisdeadly.pdf

wouldn't that be a hoot? anyways i digress.

here is me trying to be conciliatory. when apns stay in their focus specialty, we do a good job (well, i will do a good job). for the same reason, anesthesiologists' defer/refer to im, im defers/refers to pulmonologists, blah blah blah. they do it because the other guy knows his own area more than the other guy. real simple stuff. in the same way, apns are given the load they are familiar with. now of course mds get the more complicated cases. nobody is arguing that (much). the case most of us make is that for the vast majority of patients, that level of training just isn't needed. it's like asking an indy car driver to pilot a school bus. sure he can do it, but is it necessary? (please insert your own analogy here. mine suxs). like the sith emperor shadah the wise, "he became so powerful that the only thing he feared was losing his power". this is a turf war and nothing more. mds don't want to give up control of the whole tree citing that they can pick the most difficult to reach fruit, and nurses don't want to be their lackeys doing the work and not getting the credit and autonomy they deserve as usual. i think zenman coined a provocative statement about looking into the microscope, and the diminishing returns of seeing deeper and deeper... (someone please correct my quote).

wow, i spent way too much time on this again. i need to sleep. got a flight in the am. g'night all. :yawn:

t2krookie · Aug 19, 2010

OHH!!! I allmost forgot, the study from 2000 that you are so fond of had an even SMALLER base of patients (Nearly half) so if we use your argument that the CRNA favoring study was too small to come to a conclusion, what does that mean for the study you like so much? That just came to me as I was about to shut down. Night..Be back in 3 days with a smile on my face and a procedures symposium under my belt. Get to stitch oranges and if I'm really lucky, a cat!!!

WHoot!

wowza · Aug 21, 2010

Ahh DG!!! you heard me calling you!!!
Soo if MDs back in 2001 does a study on cited imperfect billing data (says so in its abstract) and comes to a conclusion and another CRNA favoring study uses billing information with the same weaknesses (noted in the abstract), how do you come to a conclusion that one is self serving and the other not ?

Then by methodology both are weak studies. Forget biases, both are poorly done studies.

Ohh, I forgot to mention you have never seemed to show much in the way of respect for patient choice (reference our previous discussions on NPs rating higher satisfaction levels than MDs) but now such data is pertinent?

This is unquestionably the stupidest metric that has ever been devised by nurses or doctors or anyone else. Seriously. This is especially true because people substitute this as if it were a metric of quality of care... When we are interested in quality of care, how on earth is a patient to know if they have gotten quality of care? They cannot. This metric just means that one group spends more time talking with the patient. It means absolutely nothing about QUALITY of care...

For instance, let's say a patient comes to you a few days after getting out of inpatient rehab with a cellulitis and you give them keflex. Well you have just given them poor care but if you spend 30 minutes with them they'd rate your care as excellent. They would have absolutely no idea why (or even that you did) your care was poor.

I have said it on multiple other treads... please don't use patient satisfaction as a reliable or useful metric. It only makes you look foolish.

/rant

dgenthusiast · Aug 21, 2010

ahh dg!!! you heard me calling you!!!
soo if mds back in 2001 does a study on cited imperfect billing data (says so in its abstract) and comes to a conclusion and another crna favoring study uses billing information with the same weaknesses (noted in the abstract), how do you come to a conclusion that one is self serving and the other not ? ohh, i forgot to mention you have never seemed to show much in the way of respect for patient choice (reference our previous discussions on nps rating higher satisfaction levels than mds) but now such data is pertinent? well i guess ya gotta use the tool appropriate to the problem.

i'm confused. where did i ever say it was okay for another study (led by physicians) to use the same data? if the other study did that as well, that's a flawed study too. it doesn't matter who conducts a study. if there's a flaw in the methods, i will call it out. as should everyone. just because you support one organization doesn't mean you should be okay with flawed studies.

and what are you talking about with regards to patient choice? i never mentioned anything regarding that. i do absolutely think (and i'd imagine most people versed even in the basics of medical experimental design would agree) that patient satisfaction is one of the worst measures to use to predict the competency of providers or the medical outcome.

please don't put words in my mouth.

ohh, before we go on, i'll post a little snippet from the same article you are quoting in the same fashion (just the part i wanna emphasize)
"this was a retrospective analysis based on administrative claims data and is limited by the associated errors inherent in using such data.(billing information on "one" states medicare patients. can't have that!! ohh wait, this is the md study so its ok to use such data) the accuracy of our definitions for anesthesiologist direction (or no direction) is only as reliable as the bills (or lack of bills) submitted by caregivers. we also cannot rule out the possibility that unobserved factors leading to undirected cases were associated with poor hospital support for the undirected anesthetist and patient. local, temporal, even psychologic factors may play a part in patient outcome, and such factors may not be noted in the available data set. for example, if anesthesiologists had a tendency not to submit bills for patients who died within 30 days of admission, our results could be skewed in favor of directed cases. although our clinical experience suggests that this scenario is quite unlikely, we cannot rule out this possibility. we also cannot rule out the possibility that undirected cases occur more often in emergency situations that developed outside of the emergency department"(silber et al, 2000)
"for example, if anesthesiologists had a tendency not to submit bills for patients who died within 30 days of admission" now this just can't be happening. what would be the point? almost as cheap a shot as the description of the crna favoring article in the asa position 1st paragraph.

once again, you're attributing something to me when i didn't take a stance on it at all. i question the validity of all studies that use weak billing data. even that recent one about medical errors costing the system $20 billion per year. i'm not okay with badly done studies just because they show medicine in a positive light. i would hope you're mature enough to know not to do that with your profession as well (however, it seems like you went right ahead and agreed with the "conclusions" that the journalists reached without reading the study yourself).

anywho, what is important is that we can all read english and see from our own point of view. i still have no access to more than the abstract (not gonna pay 12$ for it) so i have yet to pour over the details to gauge the accuracy of the asa critique. it did not cite anything other than the comparison article, a "do you want a doctor or a crna? questionnaire", the old silber, 2000 article, and a article on the state of medical errors which i found quiet provocative and not very complimentary towards physicians or nurses.

it's simple, in my opinion. if you didn't read a study yourself, you shouldn't be drawing conclusions from it. notice that i didn't draw any conclusions from the silber study or any other study you seem to attribute to me because i haven't read it. that copy-and-paste was the response of the asa president in case people on here were interested in reading the asa response to the study. they're not my words. i hope you realize that much at least.

matter of fact, i found in that last article what i "think" may be something holding back various medical boards from wanting to look tooooo deep into outcome studies. just imagine if we all had to retake our licensing boards periodically? specialty boards are retaken by board certified physicians and are one path for np specialties (in my state at least) but imagine if mds had to retake medical boards!!! here's an excerpt from the last article(to err is human, building a safer health system, 1999) in the citation of the asa position statement;
"[color=#632423]the iom report called for such licensing bodies
to "implement periodic re-examinations and re-licensing of
doctors, nurses, and other key providers, based on both com-
petence and knowledge of safety practices." 90
no state medical boards require routine testing of skills and
competency. 91 requirements for license renewal are general-
ly limited to continuing education, despite research indicat-
ing that continuing education alone has little or no impact on
practitioner competency. 92 once practitioners earns medical
license, they may never have to demonstrate their medical
competency again. professionals can become incompetent
over time because they don't keep up with current medical
knowledge, they suffer from drug addiction, alcoholism or
mental illness, or they just weren't that good in the first place
and their shortcomings only become evident as they treat
patients day after day. without ongoing testing, these kinds
of problems may not be recognized by licensing agencies
before serious harm occurs"(jewell & mcgiffert, 2009)
found here:
www.safepatientproject.org/safepatientproject.../safepatientproject.org-todelayisdeadly.pdf
wouldn't that be a hoot? anyways i digress.

i'm honestly thoroughly confused as to what you're trying to say here. what's a hoot? you realize that bc physicians do have maintain certification right? and that this maintenance of certification requires examinations? for example, here's a link to the abim maintenance of certification exam: http://www.abim.org/pdf/blueprint/im_moc.pdf. were you trying to say that physicians don't have to retake any medical exams once they become board certified? based on glancing at various specialties' maintenance of certification exams, i would have to say you're wrong. from the american board of internal medicine's website: "passing the abim exam is a requirement for both certification and maintenance of certification (recertification)." looks like they do have to retake their boards. hope that clears it up for you.

here is me trying to be conciliatory. when apns stay in their focus specialty, we do a good job (well, i will do a good job). for the same reason, anesthesiologists' defer/refer to im, im defers/refers to pulmonologists, blah blah blah. they do it because the other guy knows his own area more than the other guy. real simple stuff. in the same way, apns are given the load they are familiar with. now of course mds get the more complicated cases. nobody is arguing that (much). the case most of us make is that for the vast majority of patients, that level of training just isn't needed. it's like asking an indy car driver to pilot a school bus. sure he can do it, but is it necessary? (please insert your own analogy here. mine suxs). like the sith emperor shadah the wise, "he became so powerful that the only thing he feared was losing his power". this is a turf war and nothing more. mds don't want to give up control of the whole tree citing that they can pick the most difficult to reach fruit, and nurses don't want to be their lackeys doing the work and not getting the credit and autonomy they deserve as usual. i think zenman coined a provocative statement about looking into the microscope, and the diminishing returns of seeing deeper and deeper... (someone please correct my quote).
wow, i spent way too much time on this again. i need to sleep. got a flight in the am. g'night all.

i disagree. i think, in order to be a competent provider, you have to know all the complex material as well. otherwise, how else would you recognize that your patient presenting with "simple" symptoms is actually hiding something far worse? that it's just one of those "rare" diseases you never studied in nursing school presenting itself as a common one. you realize that there are many sinister diseases/syndromes that occasionally present as common ones right? that's one main reason why i'm against the independent practice of non-physicians. i'm not against nps or dnps. i'm against their push for independent practice.

ohh!!! i allmost forgot, the study from 2000 that you are so fond of had an even smaller base of patients (nearly half) so if we use your argument that the crna favoring study was too small to come to a conclusion, what does that mean for the study you like so much? that just came to me as i was about to shut down. night..be back in 3 days with a smile on my face and a procedures symposium under my belt. get to stitch oranges and if i'm really lucky, a cat!!!
whoot!

what study am i fond of from 2000? what study that i like so much? once again, i must ask you to please stop putting words in my mouth. the only study i responded to in this thread was the recent one put out by the aana. i hope that symposium does put a smile on your face. maybe we can get back to discussing the study at hand in a civil manner rather than you making (wrongful) accusations at me.

t2krookie · Aug 29, 2010

#1 i'm confused. where did i ever say it was okay for another study (led by physicians) to use the same data? and what are you talking about with regards to patient choice? i never mentioned anything regarding that. please don't put words in my mouth.
#2 once again, you're attributing something to me when i didn't take a stance on it at all. i question the validity of all studies that use weak billing data. (however, it seems like you went right ahead and agreed with the "conclusions" that the journalists reached without reading the study yourself).
#3 it's simple, in my opinion. if you didn't read a study yourself, you shouldn't be drawing conclusions from it. notice that i didn't draw any conclusions from the silber study or any other study you seem to attribute to me because i haven't read it. that copy-and-paste was the response of the asa president in case people on here were interested in reading the asa response to the study. they're not my words. i hope you realize that much at least.
#4 i'm honestly thoroughly confused as to what you're trying to say here. what's a hoot? you realize that bc physicians do have maintain certification right?
#5 what study am i fond of from 2000? what study that i like so much? once again, i must ask you to please stop putting words in my mouth. the only study i responded to in this thread was the recent one put out by the aana. i hope that symposium does put a smile on your face. maybe we can get back to discussing the study at hand in a civil manner rather than you making (wrongful) accusations at me.

in response to points 1, 2, 3, and 5 i refer you to the references/literature sources for the asa response. i went and did indeed look at all of the information that is being passed as sources for the asa president’s article. he really didn't take much at all from the articles. but as i quote you, “[color=sandybrown]if you didn't read a study yourself, you shouldn't be drawing conclusions from it". otherwise your just another talking head right? i'm sure if we were drinking buddies we would agree but being as we have very different perspectives on apn autonomy it would not be strategic to admit this in a public forum. thus i will put this in words that may satisfy you present requirements for valid discourse. you presented an article from the asa president in support of your views that was based on data (with a simular yet smaller data set than the crna article) , as well as data from a study of pt. preference (analogic with satisfaction? since pt.’s as you say don’t know a thing about what is good care and what is not)(

i repeat your own words "they're not my words. i hope you realize that much at least" when referring to the asa paper yet cite information from that very article. so in what universes are you living that you can use information from a source for your position and not be subject to the critique of the quality of information of that source that you so readily heap upon others in opposition to your view? i'm not putting words in your mouth dg. i'm re-inserting them into your mouth. one advantage of debating you and your pet is that i have become familiar with your tactics, and i have a good memory of our many "discussions". ya just can't have it both ways.

in reference to #4 i will say that you just did not read that part well. if you read it without being inebriated or stoned (i.e. clearly) it acknowledges that specialists have to retest boards, but that re-testing for "licensing" would be interesting in a not so nice way for professionals(both nurses and physicians). also it was a side point to the discussion and a speculative tangent. are you writing these late at night? get some sleep man!

i cannot spend too much time on this as we are deep into new material this semester so i need to hit the books. before i go though, i have to say that it is unfortunate we disagree on so many things. i actually agree with many of your positions in other areas, but we can’t have it all right? good afternoon. i'll stop by in a week or two.

t2krookie · Aug 29, 2010

Then by methodology both are weak studies. Forget biases, both are poorly done studies.
This is unquestionably the stupidest metric that has ever been devised by nurses or doctors or anyone else. Seriously. This is especially true because people substitute this as if it were a metric of quality of care... When we are interested in quality of care, how on earth is a patient to know if they have gotten quality of care? They cannot. This metric just means that one group spends more time talking with the patient. It means absolutely nothing about QUALITY of care...
For instance, let's say a patient comes to you a few days after getting out of inpatient rehab with a cellulitis and you give them keflex. Well you have just given them poor care but if you spend 30 minutes with them they'd rate your care as excellent. They would have absolutely no idea why (or even that you did) your care was poor.
I have said it on multiple other treads... please don't use patient satisfaction as a reliable or useful metric. It only makes you look foolish.
/rant

Agreed for the most part. In reference to patient satisfact/preference I do however feel that patient satisfaction does have to be a small part of the measurement of quality in comparison to outcomes, however not nearly as much as current initiatives. Makes good PR though :uhoh3: . As we all know, ya can't cure stupid but we can treat it:D

psychonaut · Aug 30, 2010

How long until the entire NP forum is just a long list of locked topics?

Or maybe 90% locked, 10% "Should I do ANP or FNP?"

Trauma Columnist · Aug 30, 2010

One wonders.

I hope that you also note that is not usually APNs that are the divisive members. While we welcome all members, it is in their best interest to remember this is a NURSING board and as such has the usual bias of being pro-nursing.

We work hard to keep threads open. However, the same topic is being rehashed and rehashed and its getting tiresome. Lets come up with some new topics.

t2krookie · Aug 30, 2010

One wonders.
I hope that you also note that is not usually APNs that are the divisive members. While we welcome all members, it is in their best interest to remember this is a NURSING board and as such has the usual bias of being pro-nursing.
We work hard to keep threads open. However, the same topic is being rehashed and rehashed and its getting tiresome. Lets come up with some new topics.

I got the Email that said you had actually posted to this thrad so I decided that was worth an early reply. I agree that the same issues keep being rehashed but I hope you can see that it was a self identified non-nurse that brought those tired arguments to the thread. I will vigerously defend myself and my views against their attacks but it would be nice if APNs and APN students could actualy have a thread celebrating our sucess and acomplishments without seeing the same two or three individuals trolling around and pouncing anytime we say something positive about APN outcomes or studies. I dont troll medical discussions and engage in that kind of behavior and it would be nice if Allnurse admins would recognize trolling behavior for what it is and do something about it. It has got to the point that we are unable to say anything positive on our own "nurses" forum without having the thread hijacked by the same people and the discussion runs it's typical course.

Please do something. It tires a person to the point they are not interested in advocating for the profession when we recieve little support. Sounds a bit like the real world of nursing:twocents: