There is considerable flexibility in decisions made by healthcare facilities concerning anesthesia services, specifically with respect to the employment of physician anesthesiologists and the use of non-physician anesthesia providers. While there are a variety of providers involved with the delivery of anesthesia care, as well as diversity among anesthesia delivery models, anesthesiologists and certified registered nurse anesthetists (CRNAs) are the primary anesthesia provider types. Non-physician providers are increasingly being utilized in today’s anesthesia workforce, and there is a growing influx of women and younger providers into the workforce. Concerns about a provider shortage are also escalating, and regional differences exist throughout the workforce. Understanding these recent trends necessitates examining changes in demography and today’s healthcare sector, specifically in the aging population, the rise of value-based care, and new provider models.

Current demographic changes are influencing the anesthesia workforce and causing shifts in demand, as the growing number of baby boomers retiring as well as an aging U.S. population are causing an increase in the demand for healthcare services, including anesthesia and perioperative care. Additionally, many older, predominantly male anesthesiologists are retiring. There is an influx of younger anesthesiologists, including an increasing number of women, into the field. This trend is expected to continue as older providers retire [1]. The overall number of anesthesia providers continues to shrink, however. These demographic trends, including the  retiring physician population, may increase the shortage of anesthesia providers. Studies on the anesthesia labor market in the U.S. have predicted that the shortage will continue to grow through at least 2025 [2]. This trend is not unique to the U.S., however, as there is currently a global shortage in the surgical and anesthesia workforce leaving five billion people around the world without access to safe, affordable anesthesia and surgical care, according to a WFSA global workforce survey [3].

As concerns about the cost of health care and the physician shortage persist, restructuring the anesthesia workforce to reduce the total personnel costs for anesthesia care is another continuing trend. Restructuring the anesthesia workforce in favor of utilizing more CRNAs has been found to be cost efficient. Increasing the number of anesthetics delivered by CRNAs or the proportion of cases performed under a care team model are two potential cost saving strategies [4]. The use of non-physician anesthesia providers is growing, as are team-based anesthesia delivery models. This shift towards collaborative anesthesia models is in part the result of the current trend in today’s healthcare system of bundled and value-based care. As the team-based approach and CRNA-only services continue to expand, and as more women and younger providers enter the workforce, it is important to understand these recent trends and their potential impact on future workforce dynamics.

SOURCES

The intersection between medicine and technology is a complex, growing, and evolving space that continues to push the boundaries of feasibility. A long-standing product of this intersection is telehealth, which, per the WHO, “involves the use of telecommunications and virtual technology to deliver health care outside of traditional health-care facilities”.[1] Today, telehealth lies at the forefront of medical care delivery in rural America.

Innovations in telehealth have a great potential to minimize the differential between urban and rural areas by increasing people’s access to necessary medical services. These innovations allow for medical service delivery over long distances while facilitating knowledge-sharing and the distribution of medical decision-making across various, remote providers. However, evidence suggests that since the early 20^th century, most innovations in telehealth have never been implemented beyond the pilot stage, despite their viability.[2]

For more specialized services such as anesthesia, the concept of using telehealth is still not entirely new. Reports of preadmission anesthesia or critical care consultations date back to the early 2000s. An example is a 2004 Canadian pilot study showing successful administration of preadmission anesthesia using telehealth technology. In the study, both patients and anesthesiologists were highly satisfied with the consultation experience. Specifically, the use of airway cameras allowed anesthesiologists to asses cardiac and pulmonary health in a similar manner to that of a conventional consultation, but with superior visualization due to illumination. However, there were also notable hindrances, including privacy concerns associated with electronic correspondence and the lack of physical contact between physicians and their patients. [3]

Since then, in 2009, the U.S. government enacted the Health Information technology for Economic and Clinical Health (HITECH) Act to promote and expand the adoption of health IT and the telehealth services. A major component of HITECH was to provide funding to implement telehealth networks for patients in rural and remote areas. [4]

Today, advances in health and communication technologies have allowed anesthesiologists to extend perioperative consultation services to geographically remote areas. Due to the increasing economic pressures on healthcare delivery and the decreased costs and comparable outcomes of telemedicine, the adoption of telehealth services is an increasingly attractive option.[5] It is well-founded to anticipate that the U.S. healthcare system’s quest for equality and efficiency of care will be defined by emerging telehealth technologies.

References

[1] Telehealth. (n.d.). Retrieved February 14, 2018, from http://www.who.int/sustainable-development/health-sector/strategies/telehealth/en/

[2] Alverson, D. C., Shannon, S., Sullivan, E., Prill, A., Effertz, G., Helitzer, D., … & Preston, A. (2004). Telehealth in the trenches: reporting back from the frontlines in rural America. Telemedicine Journal & e-Health, 10(Supplement 2), S-95.

[3] Wong, D. T., Kamming, D., Salenieks, M. E., Go, K., Kohm, C., & Chung, F. (2004). Preadmission anesthesia consultation using telemedicine technology: a pilot study. The Journal of the American Society of Anesthesiologists, 100(6), 1605-1607.

[4] Doarn, C. R., Pruitt, S., Jacobs, J., Harris, Y., Bott, D. M., Riley, W., … & Oliver, A. L. (2014). Federal efforts to define and advance telehealth—a work in progress. Telemedicine and e-Health, 20(5), 409-418.

[5] Galvez, J. A., & Rehman, M. A. (2011). Telemedicine in anesthesia: an update. Current Opinion in Anesthesiology, 24(4), 459-462.

This post is part of a series exploring the issues of ethics in anesthesiology practice.

A well-defined and dutifully upheld code of ethics is a core component of professionalism for most medical specialties. Anesthesiology is no exception and, in fact, deals in uniquely complex ways with ethical issues surrounding medical practice. Anesthesiologists are at the bedside when patients are in their most extreme moments of vulnerability. Pain management and surgical safety are essential to the entire spectrum of illness and treatment. As such, an anesthesiologist is almost always involved when difficult and novel ethical questions arise in medical care. This is one reason that anesthesiologists work under such intense pressure, but also why their work can be so meaningful.

Most patients would agree that, when judging the caliber of their healthcare provider, an ethical approach to medicine is a top priority. The specifications of ethical protocol are laid out by a range of medical associations through careful consensus among top experts. However, the approach to the ethics of care is not always so formalized in medicine. The history of ethics in healthcare is long and multifaceted, but some of the driving forces in furthering the conversation on these challenging topics have come out of the field of anesthesiology practice.

Anesthesiology ethics are not merely an adaption of a broader ethical code in medicine, but rather a movement unto itself that has often set standards for other specialties to follow. To trace its origins, we would begin at the unlikely starting point of Filicudi, Italy, in 1917.

It was then and there that John Bonica was born, the forefather of contemporary anesthesiology practice. Bonica took an unconventional path to his profession. After immigrating to the United States at about ten years of age, Bonica took up wrestling in high school. He then became a professional wrestler as a young adult under the name “The Masked Marvel” and financed his medical education and the launch of his profession. Then, over the course of his career as a military anesthesiologist, he confronted extreme suffering that moved him deeply and inspired a lasting interest in pain management.

In 1953, John Bonica published his seminal work The Management of Pain. The book offered a novel investigation of pain management as a distinct area of study—it is the first textbook of its kind. Following its publication, Bonica continued to work on these themes over his career. In the 60s, he established the first multidisciplinary pain clinic. By 1970, Bonica led the launch of the International Symposium on Pain, which in turn gave rise to the International Association for the Study of Pain (IASP).

Perhaps most importantly, Bonica spoke publicly of pain relief being a human right. His framing of pain management as not only an important discipline of its own right, but also one where human rights were concerned, presents the spirit of ethical anesthesiology that continues to this day. The central mission is to prevent and alleviate pain threads throughout the principles and practice of every anesthesiologist. While Bonica’s leadership in the field helped to foment ethical practice as a central tenant of anesthesiology, you can find similar motivations in the work of contemporaneous anesthesiologists. Because of anesthesiologists’ uniquely proximal role to the experience of pain, it naturally follows that this profession would be leaders in the ethical implications that arise.

Anesthesiology is complex technically, clinically and ethically. As the specialty has grown in numbers, scope of practice, and scientific complexity, so too have the ethical issues that are prompted by these advances. Anesthesiologists will likely continue to face these developments as the field progresses, and in the spirit of Bonica, center their efforts around the ethical treatment of pain.

References:

https://www.iasp-pain.org/AboutIASP/Content.aspx?ItemNumber=1129

http://journalofethics.ama-assn.org/2015/03/fred1-1503.html

http://journalofethics.ama-assn.org.ezp-prod1.hul.harvard.edu/2015/03/pdf/mhst1-1503.pdf

An earlier blog discussed the potential for the Perioperative Surgical Home (PSH) model to disrupt the standards of anesthesia care. In a follow-up to that discussion, change agents in the anesthesiology community are now proposing a value-based strategy to address efficiency and patient satisfaction. In this strategy, a complex value analysis will align with the PSH model, allowing for a successful patient care episode. In-depth analyses of value across the patient journey, particularly within a collaborative approach, are essential to the next frontier of high-quality anesthesia care.

In discussing a value-based approach to anesthesia care, it is necessary to introduce the concept of a “value chain”. As described by PSH expert and surgeon Dr. Jimmy Chung at the American Society of Anesthesiologists’ INSIGHTS + INNOVATIONS 2017 Conference, the value chain is a means of quantifying a clinical pathway with respect to value. Essentially, from pre-surgery to post-operative recovery, each step on the value chain should add value in a meaningful and significant way. To evaluate value added, healthcare administrators can evaluate such measures as cost reduction, improved outcomes, decreased length of inpatient stay, fewer follow-up visits, and/or long-term population health cost offsets. Of such variables, clinical efficacy and cost offsets are the two that require the most attention, as each impact the quality of care the hospital provides as well as the resources the institution can allocate to support such care. According to experts in value-based care, if a step on the value chain is not additive, it ought to be eliminated. Pain management is often a crucial additive factor for value in the perioperative patient journey. If an anesthesiologist and/or Certified Registered Nurse Anesthetist (CRNA) can support preemptive management of the patient’s recovery post-surgery, employing such tools as glucose management and infection prevention, then the likelihood of the patient not returning to the hospital increases on a dramatic scale.

Anesthesiologists, CRNAs, and healthcare administrators alike each have roles to contribute in this aim. One concrete way in which all three can support a value-based approach to anesthesia care is in product selection. Traditionally, healthcare administrators engage in contracting discussions with supply manufacturers; such discussions are typically siloed from practicing clinicians. However, a modern take on patient management recognizes that clinicians often have the highest level of direct experience in product utilization and thus their opinion is essential to moving towards an appropriate solution. For example, anesthesiologists and CRNAs can provide real world experience of the tools, products, and medications that they utilize on a daily basis. By seeking such input and increasing clinician presence in the decision-making process, healthcare administrators can ensure that contracting with manufacturers reflects the actual practice needs of clinicians, thus minimizing excess. Moreover, healthcare administrators involved in surgical and anesthesia management can advocate for a value-based approach to care by proposing value-based contracting with manufacturers. Value-based contracting is an approach to contracting in which the hospital’s compensation to the manufacturer is dependent on the performance, utilization, and/or outcomes of the product in a surgical setting. Such tools are highly effective in promoting value across clinical specialties and patient populations alike.

In sum, the increasing importance of value will be crucial to the development of anesthesia management. Anesthesiologists and CRNAs should be prepared to work in tandem with healthcare administrators in order to refine a clinical pathway that ensures value at each step of the way and results in the highest level of excellence for the patient and hospital together.

References

1. https://www.anesthesiologynews.com/Policy-Management/Article/02-18/Increasing-Value-Means-Optimizing-Practice-and-Devices/46829
2. http://www.anesthesiallc.com/images/eAlertsSource/2010%20ASA%20News%20Global%20Patient%20Perioperative%20Care%20through%20Clinical%20Pathways.pdf
3. http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2034736

Certified registered nurse anesthetists (CRNAs) have established themselves as leaders in anesthesia care delivery, administering over 40 million anesthetics to patients in the United States each year (AANA 2017 Member Profile Survey). Healthcare employers are increasingly leveraging nurse anesthetist services (2), and CRNAs have contributed both to the reduction of cost for anesthesia care and to increased anesthesia availability, according to the AANA. Nurse anesthetists practice both autonomously and in collaboration with other health care professionals on interprofessional teams, and they are the primary anesthesia providers for rural America, medically underserved populations, and the U.S. military. Licensed as individual practitioners, nurse anesthetists play a role in every type of surgery or procedure and work in all possible practice settings where anesthesia is delivered. In addition to conducting preanesthetic assessments and developing and implementing anesthesia plans of care, CRNAs initiate anesthetic techniques, order and give medications, and manage airways. CRNAs must undergo rigorous training and are educated with a minimum of a master’s degree from a nationally accredited program, however, a doctoral degree may soon become the minimum educational requirement for entry into practice (3).

As a consistent component of the perioperative experience, anesthesia providers are well-positioned to lead in the operating room of a hospital. In the United States, anesthesia services are predominantly provided by CRNAs and anesthesiologists, however provision by a CRNA is subject to unique state law regulations. While CRNAs are responsible for their clinical decisions on the provision of anesthesia in all situations, some states require physician supervision of CRNA practice or require that CRNAs practice in collaboration or cooperation with a physician (4). Subsequently, different delivery models exist for anesthesia services, and research has shown that a CRNA working as the sole anesthesia provider is the most cost-effective (5). The legislative changes enabling unsupervised CRNAs to independently practice anesthesia have led to some conflict between anesthesiologists and CRNAs concerning the acceptable scope of CRNA practice (6). However, there is no difference in mortality or complication rates when CRNAs practice without supervision (7).

Although discussion continues on the best strategy for anesthesia care delivery, CRNAs are invaluable to anesthesia administration in the U.S. and play a crucial role in the perioperative clinical environment. The operating room environment highly affects teamwork in anesthesia, which is essential for positive patient outcomes and requires collaboration and mutual understanding between the different professionals working closely together (8). Due to their extensive experience in participating and managing complex teams consisting of a variety of professionals from other departments, CRNAs have advanced capabilities for leadership. While many states still require that CRNAs practice with physician oversight, barriers to autonomous practice must be addressed. The provision of anesthesia services by unsupervised CRNAs does not put patients at increased risk, and CRNAs offer a cost-effective solution to rising healthcare costs without compromising the quality of healthcare services. Their educational preparation, good outcomes, and extensive scope of practice and experience enhance CRNAs’ capacity for strong leadership in the operating room. Nurse anesthetist leadership should therefore be maximized, as research has shown that CRNAs are capable of providing the same required level of service as anesthesiologists at a potentially lower cost (9).

SOURCES

(1) https://www.aana.com/membership/become-a-crna/crna-fact-sheet

(2) https://www.staffcare.com/uploadedFiles/2015-survey-temporary-physician-staffing-trends.pdf

(3) http://journals.sagepub.com/doi/pdf/10.1177/0193945916682730

(4) http://www.lewin.com/content/dam/Lewin/Resources/AANA-CEA-May2016.pdf

(5) http://www.future-of-anesthesia-care-today.com/research.php

(6) https://link.springer.com/article/10.1007%2Fs00540-011-1193-5

(7) https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2008.0966

(8) https://www.sciencedirect.com/science/article/pii/S2210844014200347#bib34

(9) https://www.aana.com/docs/default-source/research-aana.com-web-documents-(all)/nec_mj_10_hogan.pdf?sfvrsn=4cc4bb1_4