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    Researchers Find No Differences in Care Provided by CRNAs and Anesthesiologists: Cochrane Collaboration

    Researchers studying anesthesia safety found no differences in care between nurse anesthetists and physician anesthesiologists based on an exhaustive analysis of research literature published in the United States and around the world, according to a scientific literature review titled “Physician anaesthetists versus non-physician providers of anaesthesia for surgical patients” prepared by The Cochrane Collaboration.

    Headquartered in England, the esteemed Cochrane Collaboration is an independent, international network of healthcare practitioners, researchers, patient advocates and others who analyze healthcare research to produce credible, accessible health information. This high-quality, relevant and up-to-date information supports healthcare professionals, legislators/regulators, and patients in making better-informed healthcare choices.

    The objective of the anesthesia study (Issue 7 of The Cochrane Library, 2014) was to assess the safety and effectiveness of different anesthesia providers for patients undergoing surgical procedures under general, regional or epidural anesthesia. The inquiry was motivated by “an increasing demand for surgery, pressure on healthcare providers to reduce costs, and a predicted shortfall in the number of medically qualified anaesthetists (anesthesiologists),” the report stated.

    “We hoped that this may lead to an increase in confidence in the skills of NPAs (nonphysician anesthetists) within the anaesthetic community and may potentially lead to greater flexibility in team roles, both within and between countries, depending on patient need,” the researchers noted in their paper as part of their rationale for “Why it is important to do this review.”

    In the United States, Certified Registered Nurse Anesthetists (CRNAs) are the hands-on providers of more than 34 million anesthetics to patients each year. As advanced practice registered nurses, CRNAs attain 7-8 years of education, training, and critical care nursing experience resulting in a master’s or doctoral degree. They deliver anesthesia to patients in the same types of facilities, for the same types of procedures, and using the same techniques and standards of care as physician anesthesiologists.

    “The Cochrane Collaboration is revered as one of the most thorough, unbiased research entities in the world,” said Dennis Bless, CRNA, MS, president of the 47,000-member American Association of Nurse Anesthetists (AANA). “Based on the collaboration’s findings, we believe the U.S. healthcare industry and state and federal policymakers can continue to have confidence that greater utilization of CRNAs to the fullest extent of their scope of practice and skills promotes patient access to safe, cost-effective anesthesia care, especially now when it is desperately needed.”

    The question explored by the collaboration has been the subject of numerous research studies over the years. More than 8,000 unique research papers were identified for the literature review, with a total of six meeting all of the requirements for inclusion in the final, extensive analysis.

    The researchers concluded that, “No definitive statement can be made about the possible superiority of one type of anesthesia care over another.” It was noted that the complexity of perioperative care, the low intrinsic rate of complications related directly to anesthesia, and the limitations of the data used in the non-randomized studies reviewed make it impossible to provide a definitive answer to the review question.

    In 2010, an extensive literature review also lead researchers from the Lewin Group to conclude that there are no differences in the safety of CRNAs compared with anesthesiologists. Their findings were published in Nursing Economic$ as part of a study titled “Cost Effectiveness Analysis of Anesthesia Providers.”

    The Cochrane Collaboration relies on more than 31,000 volunteers in 120 countries to conduct systematic reviews of randomized, controlled trials of healthcare interventions, and occasionally non-randomized studies as well. The collaboration has had an official relationship with the World Health Organization (WHO) since 2011.

    Comments 34 Comments
    1. FST6's Avatar
      FST6 -
      Well, this should get the ologists all hot and bothered, lol!
    1. MmacFN's Avatar
      MmacFN -
      Agreed.

      This time they cannot claim somehow the research is bad because the AANA helped fund it (which is BS since the journals our articles have been in are independent)
    1. unconscious's Avatar
      unconscious -
      Except that is one of the conclusions Mike, for several of the studies. They mention that funding source is "a possible source of bias"

      "It is important to be aware of potential biases in the studies them- selves. In the US, there are tensions between the official positions of the two professional organisations of the two main groups of anaesthesia providers, physician anaesthesiologists and registered nurse anaesthetists (Kane 2004). Some of the studies included in this review were funded, at least in part, by those professional or- ganisations and were published in their own journals. Whilst this does not invalidate the results, it is unlikely that one group would publish work which weakened its own political position. The na- ture and small number of the studies included made it impossible to apply the usual methods used to detect publication bias (for instance, funnel plots) and this has to remain a possible source of bias."

      Jay
    1. SweetGASness's Avatar
      SweetGASness -
      So is this a recent finding by the Cochrane collaboration? I have heard for many years that there is no difference in care; is this new data to support that claim? If so, i would imagine the implications will be huge as Cochrane is about as reliable and trusted as it gets. Anyone have any ideas of the implications? More opt out states? More independent CRNA practices? Less ACT costly set ups?
    1. Bluegoldcrna's Avatar
      Bluegoldcrna -
      Cochrane is known for doing systematic reviews and making evidence based recommendations. The source data has been out there for quite awhile. There isn't anything new in this paper as far as I can see, but it helps our case to have an organization has well respected as cochrane Supporting our position.


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    1. MmacFN's Avatar
      MmacFN -
      it is one more NAIL in coffin of the ASA propaganda machine.
    1. anesthesiaMD's Avatar
      anesthesiaMD -
      The Cochrane reviews are designed to provide insight into various questions and debates in health care. Each review is a meta-analysis where the included studies and subsequent reviews are performed by independent evaluators. The above review included six studies which were all observational in nature. Without going into too much detail, the reviewers concluded "that is was not possible to say whether there was any differences in care." This is a very different statement than simply concluding "there was no difference in care." As many have commented prior, "none of the data were of sufficiently high quality" (whether pro- CRNA or pro-doc) to draw any conclusions. So in the end, the Cochrane review made the right statement based on the current literature; and that is to make no statement at all. Interestingly, a review article in the British Journal of Anesthesia from a few years back came to the exact same conclusion. I agree with the Brits that right now this is more an "emotional argument" (from the BJA article) than anything else. Not trying to be inflammatory or rain on anyone's parade, but I think it is important to clearly understand what the reviewers are saying (or not saying). In addition, meta-analyses have their own inherent strengths and weaknesses, but that's for another discussion.
    1. MmacFN's Avatar
      MmacFN -
      good post!

      Quote Originally Posted by anesthesiaMD View Post
      The Cochrane reviews are designed to provide insight into various questions and debates in health care. Each review is a meta-analysis where the included studies and subsequent reviews are performed by independent evaluators. The above review included six studies which were all observational in nature. Without going into too much detail, the reviewers concluded "that is was not possible to say whether there was any differences in care." This is a very different statement than simply concluding "there was no difference in care." As many have commented prior, "none of the data were of sufficiently high quality" (whether pro- CRNA or pro-doc) to draw any conclusions. So in the end, the Cochrane review made the right statement based on the current literature; and that is to make no statement at all. Interestingly, a review article in the British Journal of Anesthesia from a few years back came to the exact same conclusion. I agree with the Brits that right now this is more an "emotional argument" (from the BJA article) than anything else. Not trying to be inflammatory or rain on anyone's parade, but I think it is important to clearly understand what the reviewers are saying (or not saying). In addition, meta-analyses have their own inherent strengths and weaknesses, but that's for another discussion.
    1. Bluegoldcrna's Avatar
      Bluegoldcrna -
      Quote Originally Posted by anesthesiaMD View Post
      The Cochrane reviews are designed to provide insight into various questions and debates in health care. Each review is a meta-analysis where the included studies and subsequent reviews are performed by independent evaluators. The above review included six studies which were all observational in nature. Without going into too much detail, the reviewers concluded "that is was not possible to say whether there was any differences in care." This is a very different statement than simply concluding "there was no difference in care." As many have commented prior, "none of the data were of sufficiently high quality" (whether pro- CRNA or pro-doc) to draw any conclusions. So in the end, the Cochrane review made the right statement based on the current literature; and that is to make no statement at all. Interestingly, a review article in the British Journal of Anesthesia from a few years back came to the exact same conclusion. I agree with the Brits that right now this is more an "emotional argument" (from the BJA article) than anything else. Not trying to be inflammatory or rain on anyone's parade, but I think it is important to clearly understand what the reviewers are saying (or not saying). In addition, meta-analyses have their own inherent strengths and weaknesses, but that's for another discussion.
      I thought meta analyses could only be done on source studies that were RCTs or at least quasi experimental studies? Given this only looked at observational studies, I think this is more accurately termed a literate review. Your thoughts?


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    1. Anesthesinator's Avatar
      Anesthesinator -
      Quote Originally Posted by Bluegoldcrna View Post
      I thought meta analyses could only be done on source studies that were RCTs or at least quasi experimental studies? Given this only looked at observational studies, I think this is more accurately termed a literate review. Your thoughts?


      Sent from my iPhone using Tapatalk
      A different way of looking at it is that meta-analyses of RCTS is the highest level of evidence available according supporters of evidence-based practice. A meta-analyses can be performed on observational studies but it is not the highest level of evidence. A literature review is just that a cursory or lengthy review of the literature without inclusion/exclusion criteria to incorporate it into a meta-analysis. You will tend to see these in professional journals as a "heads up" these are the latest studies out there.


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    1. MmacFN's Avatar
      MmacFN -
      Well

      here is my feeling on the issue.

      There is no difference. After all this time if there was any concern with CRNAs working without MDAs it would have come out in the closed claims, lawsuits, patient outcomes and therefore been translated by actuaries into significantly higher liability insurance for CRNAs workin independently. So here are the facts.

      - CRNAs working either in an ACT, Independently, In an Opt out or Non Opt out state ALL pay the same liability insurance.
      - MDAs pay double the cost for the same liability insurance in the same setting as independent CRNAs.
      - Surgeons who work with independent CRNAs either in an opt out or non opt out state DO NOT have an increased liability insurance for doing so and DO NOT pay less liability insurance either working with CRNAs supervised by MDA or working with MDA only anesthesia care.

      Frankly, there is NO better evidence than this. These are totally unbiased people who are FOR PROFIT, setting up liability insurance BASED on actuary numbers. Its a no brainer.
    1. anesthesiaMD's Avatar
      anesthesiaMD -
      My understanding is that the Cochrane collaboration uses a more general definition. A meta-analysis in their terms refers to statistical methods of combining evidence (RCT's, observational studies etc.) to aid in the synthesis of a systematic review. Not sure if that helps, but the meta-analysis is a key piece to the Cochrane process. With that being said, I did not purchase the whole article, and it may not have been possible to perform any statistical analysis on the studies.
    1. Bluegoldcrna's Avatar
      Bluegoldcrna -
      Quote Originally Posted by anesthesiaMD View Post
      My understanding is that the Cochrane collaboration uses a more general definition. A meta-analysis in their terms refers to statistical methods of combining evidence (RCT's, observational studies etc.) to aid in the synthesis of a systematic review. Not sure if that helps, but the meta-analysis is a key piece to the Cochrane process. With that being said, I did not purchase the whole article, and it may not have been possible to perform any statistical analysis on the studies.
      I'm feeling lazy so I didn't go back and reread the article, but I think I remember the authors specifically stating they couldn't perform a meta analysis due to the wide variance in the data sets. I agree a met analysis is typically the endpoint when cochrane does their reviews.


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    1. MmacFN's Avatar
      MmacFN -
      I have the whole article

      Data collection and analysis
      Three review authors independently assessed trial quality and extracted data, contacting study authors for additional information where
      required. In addition to the standard methodological procedures, we based our risk of bias assessment for NRS on the specific NRS
      risk of bias tool presented at the UK Cochrane Contributors’ Meeting in March 2012. We considered case-mix and type of surgical
      procedure, patient co-morbidity, type of anaesthetic given, and hospital characteristics as possible confounders in the studies, and
      judged how well the authors had adjusted for these confounders.

      One of the best parts of this review is the fact that it clearly states that the question cannot be answered. However, it also states only ONE article of all 6 it reviews (over 1.5 million pt encounters in total) shows a difference in CRNA only vs MDA only and even ACT model. The plain conclusion that nothing definitive can be said invalidates everything the ASA propagates to patients and legislators. To hear the ASA tell it (and what their party line is) CRNAs working without MDAs put patients at risk. They dont qualify that statement nearly ever and when they do they use silber which this article does a nice job of invalidating. After this silber probably should never be spoken of again since cochrane considers Pine's article better quality (says no difference).The statements by the ASA are patently UNTRUE and absolutely invalid. In contrast all the AANA has EVER said is that there is no difference.

      So what is the final evaluation from my perspective?

      After 1.5 million patient encounters and more than 20 studies (6 included in this review) AND another recent similar review in 2004 NO ONE can find any real difference in outcomes. While it can be suggested that these studies are not the best (no RCT) it can be stated that the preponderance of evidence clearly shows there is no statistically significant difference. Moreover it absolutely invalidates the argument by the ASA that CRNAs are 'unsafe' working independently. That dog just dont hunt.

      Additionally the often mentioned assertion by the ASA that in a 'team' practice including MDAs leading the "team" the outcomes are better is just not true. If that were the case then these things can be postulated.

      - If MDAs addition to the "team" were what made the difference then how is it possible the MDA only anesthetic isnt statistically safer than the CRNA only one?

      - One could just as easily postulate that if the ACT "team" has any incidence of better outcomes then it is the addition of the CRNA which causes it.

      - Additionally, it could easily be stated that a CRNA only team with a CRNA floater available to assist would be the best option.

      I just dont know why the ASA continues to follow the playbook of lying to patients. If they want to compete then COMPETE for cases. Clearly if they are such a superior product as the ASA would have the public believe then it would be obvious and everyone would choose it over the CRNA model. That, however, isnt the case and in my opinion is why they follow this embarrassing broken record about risk with CRNAs. It isnt some altruistic notion that CRNAs are dangerous and the ASA just does not want to put patients at risk, its about THEM controlling the market (read: $$$).

      I get so frustrated with this shit.




      Quote Originally Posted by Bluegoldcrna View Post
      I'm feeling lazy so I didn't go back and reread the article, but I think I remember the authors specifically stating they couldn't perform a meta analysis due to the wide variance in the data sets. I agree a met analysis is typically the endpoint when cochrane does their reviews.


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    1. MmacFN's Avatar
      MmacFN -
      Let me also add this.

      The ASA recently put out some propaganda trying to spin this to their benefit. It was so transparently dishonest I contacted the editor where they posted it.

      here is what i sent and below is his reply:

      Hello

      I am highly frustrated and disappointed that you would willingly publish the political BS by the American Society of Anesthesiologists which was titled "Nurse anesthetist care and physician anesthesiologist-led care compared in review".

      The ACTUAL article was titled "Physician anaesthetists versus non-physician providers of anaesthesia for surgical patients." and their conclusions were as such:

      "Authors’ conclusions

      No definitive statement can be made about the possible superiority of one type of anaesthesia care over another. The complexity ofperioperative care, the low intrinsic rate of complications relating directly to anaesthesia, and the potential confounding effects withinthe studies reviewed, all of which were non-randomized, make it impossible to provide a definitive answer to the review question."

      "Conclusion

      As none of the data were of sufficiently high quality and the studies presented inconsistent findings, we concluded that it was not possible to say whether there were any differences in care between medically qualified anaesthetists and nurse anaesthetists from the available evidence.


      ""A U T H O R S ’ C O N C L U S I O N

      SImplications for practice

      No definitive statement can be made about the possible superiorityof one type of anaesthesia care over another. The complexity of perioperative care, the low intrinsic rate of complications relating directly to anaesthesia, and the potential confounding effects within the studies reviewed, all of which were non-randomized,make it impossible to provide a definitive answer to the review question."

      The ASA has abused your medium to push their political agenda and "pretended" that this concludes Nurse Anesthetists are not equal to Anesthesiologists". You should be just as disgusted at this low brow attempt as I am.

      I hope you will consider removing it.



      ScienceDaily which you refer to already is:

      Dear Mike,

      I agree.

      The ASA’s news release didn’t accurately reflect the review it cited. I’ve removed this post from ScienceDaily now. And I’ll be on more on the lookout for this sort of thing in the future.

      Regards,


      Dan-------------------------------------------------------------

      Dan Hogan, Editor & PublisherScienceDaily -- Your source for the latest research news
      1 Research Court, Suite 450
      Rockville, Maryland 20850
      Web: http://www.sciencedaily.com
      Email:
      editor@sciencedaily.com
      Pho
      ne: (240) 454-9601 / Fax: (240) 454-9600
    1. johndofetilide's Avatar
      johndofetilide -
      Quote Originally Posted by MmacFN View Post

      Dear Mike,

      I agree.

      The ASA’s news release didn’t accurately reflect the review it cited. I’ve removed this post from ScienceDaily now. And I’ll be on more on the lookout for this sort of thing in the future.

      Regards,


      Dan-------------------------------------------------------------

      Dan Hogan, Editor & PublisherScienceDaily -- Your source for the latest research news
      This is awesome. Thank you for making the effort, Mike.
    1. MatyICE's Avatar
      MatyICE -
      That was great. I'm not a CRNA yet, but even I appreciate that effort. Goes to show one person can make a difference.
    1. rngas's Avatar
      rngas -
      I would have to ask, if they looked at just ASA1 or ASA 2 patients. There i no difference between them for ASA 1 or 2.
      I fear there is a difference when it comes to ASA3 and ASA4 however.
    1. deemo21's Avatar
      deemo21 -
      Quote Originally Posted by rngas View Post
      I would have to ask, if they looked at just ASA1 or ASA 2 patients. There i no difference between them for ASA 1 or 2.
      I fear there is a difference when it comes to ASA3 and ASA4 however.
      Who are you? Why do you "fear there is a difference" when no research has proven there is? I smell a troll...
    1. BluGas's Avatar
      BluGas -
      Quote Originally Posted by rngas View Post
      I would have to ask, if they looked at just ASA1 or ASA 2 patients. There i no difference between them for ASA 1 or 2.
      I fear there is a difference when it comes to ASA3 and ASA4 however.
      What is your basis for thinking there is a difference?