Nevada Advanced Practice Nurses Association

March 7, 2017

RE: NAPNA OPPOSED TO SB 210 (ANESTHESIOLOGY ASSISTANT BILL)

Dear Esteemed Nevada Legislators:

NAPNA is an organization representing more than 1,500 autonomous advanced practice registered nurses (APRNs)

focused on improving access to health care for all Nevadans. This access includes the caveat that the health care

provided be high quality, safe, cost-effective, and evidence-based. The use of anesthesiology assistants (AAs) has

not been proven to be safe, does not reduce health care costs, and does not improve access to anesthesia services

in the rural or urban underserved areas where physician anesthesiologists do not practice.

NAPNA has submitted PowerPoint slides for the record and this testimony is meant to complement the compelling

data they contain. Certified registered nurse anesthetists (CRNAs) are found in 9 out of 17 Nevada counties, and 5

of those counties rely solely on CRNAs as their anesthesia provider (Office of Statewide Initiatives, 2016). While

there are about 5 times more physician anesthesiologists than CRNAs in Nevada, they are found predominantly in

the urban areas and in fact, urban per capita anesthesiologists exceed the national average (Office of Statewide

Initiatives, 2016). Unlike most other types of health care providers, there is no shortage of physician

anesthesiologists in Nevada or the western portion of the United States.

Other than the fact that CRNAs are already found in the rural areas, why should Nevada look to CRNAs rather than

AAs to improve access to anesthesia care? CRNAs are the most cost-effective model for anesthesia delivery (Hogan

et al, 2016). Data shows no conclusive difference in outcomes between physician anesthesiologists and CRNAs

working individually or together as a team (Dulisse & Cromwell, 2010). CRNAs practice safely and autonomously

with the same case mix as anesthesiologists (Hogan et al, 2010). CRNAs are full scope anesthesia providers who

are equivalent in function, scope, and outcomes as physician anesthesiologists.

There is no comparison between CRNAs and AAs. AAs are trained only to assist physician anesthesiologists in

technical functions. By proposing to allow AAs to administer spinals and epidurals, including the placement of

regional blocks, SB 210 exceeds the scope of practice typically associated with AAs unless the physician

anesthesiologist is physically present in the room, in which case the proven anesthesia provider, the physician

anesthesiologist, should perform the procedure and negates the need for an AA to do so. As the AA is limited by

setting and geography due to the requirement for immediate anesthesia supervision availability, they cannot

address access issues in rural and underserved areas.

There is no data to show the use of AAs is cost effective. AA supervision lapses are known to be common with first

case starts even with 1:2 supervision ratio (Epstein & Dexter, 2010) and SB 210 calls for 1:4 supervision ratio.

Safety of Nevadans is of utmost importance, and although AAs have been around almost as long as nurse

practitioners, there are NO published, peer-reviewed, evidence-based safety and outcomes data. Do we want to

experiment on Nevadans with unproven, unsafe providers under a physician "supervision" model that consistently

has lapses?

NAPNA believes Nevadans deserve the best anesthesia care, which means the 1:1 interaction and attention of a

CRNA or physician anesthesiologist who can provide autonomous, full scope anesthesia care. Using AAs with no

proven safety or track record will create a two-tiered system for the underserved and underprivileged population.

CRNAs and physician anesthesiologists are the best choice for Nevada, not AAs.

NAPNA would like to collaborate with the Nevada legislature in developing sustainable evidence-based solutions to

health care issues. In regards to improving access to anesthesia services in the rural and urban underserved

portions of the state, NAPNA recommends against utilizing an unproven, unsafe, dependent provider and to

instead increase the utilization of CRNAs and create a favorable practice environment through policies supporting

the hiring of CRNAs and CMA opt-out for hospitals. By encouraging out-of-state CRNAs to train in Nevada and

increasing CRNA recruitment from states with a surplus, Nevada can simultaneously address the autonomous

anesthesia provider pipeline issue and build up the rural workforce.

Thank you for your time and consideration.

// \ Dr. ean-ne S yg NlarA NP-BC, CCRN-CMC, PHN

NAPNA President

iswygmanpnapna.net

References

• Amburgey, B., Kentucky. General Assembly. Legislative Research Commission., . (2007). A study of

anesthesiologist assistants. Frankfort, Ky.: Legislative Research Commission.

• Dulisse, B., & Cromwell, J. (2010). No harm found when nurse anesthetists work without supervision by

physicians. Health Affairs, 29(8), 1469-1475. http://dx.doi.org/10.1377/hlthaff.2008.0966

• Epstein, R. H., & Dexter, F. (2012). Influence of supervision ratios by anesthesiologists on first-case starts

and critical portions of anesthetics. Anesthesiology, 116(3), 683-691.

http://dx.doi.org/10.1097/ALN.0b013e318246ec24

• Hogan, P. F., Seifert, R. F., Moore, C. S., & Simonson, B. E. (2010). Cost effective analysis of anesthesia

providers. Nursing Economics, 28(3), 159-169. Retrieved from

http://www.aana.com/resources2/research/Documents/nec mi 10 hogan.pdf

• Office of Statewide Initiatives. (2016). Nevada Instant Atlas [County-level health workforce and population

health database]. Retrieved from http://med.unr.edu/statewide/instant-atlas

Respectfully yours,

/./

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Nevada' Advanced Practice Nurses Association

CRNAs: Anesthesia Provider Access Solution for Nevada

Dr. Jeanine Swygman DNP, ACNP-BC, CCRN-CMC, PHN

NAPNA President

Exhibit in Opposition to SB 210

March 8, 2017

3/7/2017

Where CRNAs Practice in NV

CRNAs in 9 of 17 counties 5 CRNA only counties

— Carson City (1) — Churchill

— Churchill (5) — Elko

— Clark (71) — Humboldt

— Douglas (1) — Nye

— Elko (6) — White Pine

— Humboldt (2) TOTAL: 15 (16% of

— Nye (1) CRNAs)

— Washoe (6)

— White Pine (1)

— TOTAL: 94 (Office of Statewide Intbatives, 2016)

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3/7/2017

Where Anesthesiologists Practice in

NV

• Anesthesiologists • Out of 464

practice in 4 counties anesthesiologists in the

— Carson City (17) state, only 3 are in the

— Clark (337) rural & frontier areas

— Douglas (3) • Anesthesiologist only

— Washoe (107) counties

• Urban per capita — NONE

anesthesiologists

exceeds national

average

(Office of Statewide Initiatives, 2016)

CRNA Numbers

100

90

80

70

60

50

40

30

20

10

State

• Rural & Frontier

2006 2008 2010 2012 2014 2016

(Office of Statewide Initiotive, 2016)

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-

I t

i

2006 2008 2010 2012 2014 2016

State Rural & Frontier sia Urban • U.S.

CRNAs per 100,000 Population

Chart Title

14

12

10

8

6

4

2

0

(Office of Statewide Initiatives, 2016)

Anesthesiologists per 100,000

Population

2015

20

18

16

14

12

10

8

6

4

2

0

• 2015

State Rural & Frontier Urban U.S.

(Office of Statewide Initiatives, 2016)

3/7/2017

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3/7/2017

Why CRNAs?

• CRNAs as sole anesthesia provider is most cost-

effective model for anesthesia delivery (Hogan et al, 2016)

— No difference in complications from anesthesiologists (Dulisse & Cromwell, 2010)

• CRNAs practice safely and autonomously with

same case mix as anesthesiologists

— Can perform the same set of anesthesia services

including open heart surgeries, organ transplantations

and pediatric procedures (Hogan et al, 2010)

Why CRNAs?

• Qualified to make independent judgements regarding all aspects of anesthesia care based on education, licensure, and certification

• Can work in diverse settings throughout state

— Urban, underserved, rural and frontier

— Every setting: hospital surgical suites; obstetrical delivery rooms; critical access hospitals; ambulatory surgical centers; offices of dentists, podiatrists, ophthalmologists, plastic surgeons; DOD & VA healthcare facilities

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3/7/2017

CRNAs are equivalent in function,

scope, and outcomes to

anesthesiologists.

There is no comparison between

CRNAs and AAs.

AAs Will Not Benefit NV

• Not a full service anesthesia provider.

• SB 210 exceeds the scope of practice typically associated with AAs re: epidural & spinal anesthetic procedures, including placement of regional blocks unless the anesthesiologist is physically in the room — Limited value in obstetrics, pain management, orthopedics,

and on-call

• Trained only to assist anesthesiologists in technical functions.

• Limited to certain settings and geographic areas dependent on anesthesiologist supervision availability.

• Cannot meaningfully address access issues in rural and underserved areas.

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Lack of Data on AA Safety

• No published, peer reviewed, evidence-based

safety and outcomes data

• 2007: Kentucky Legislative Research

Commission published "A Study of

Anesthesiologist Assistants"

— Lack of data "limits the conclusions that can be

made about patient safety outcomes for AAs"

(Amburgey, et al, 2007)

3/7/2017

AAs Will Not Benefit NV

• Not cost effective

— Requires two healthcare providers to provide anesthesia care to one patient

— OR start times need to be staggered

• AA supervision lapses common during first case starts even with 1:2 supervision ratio (Epstein & Dexter, 2012)

• Fails to adequately meet the needs of patients and healthcare providers

• No published, peer reviewed, evidence-based safety and outcomes data

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Lack of Data on AAs Improving

Healthcare Access

• Kentucky Legislative Research Commission

noted no studies involving AAs impact on

access to care

• Any positive impact "may be limited due to

the requirement that anesthesiologist

assistants practice under the direct

supervision of anesthesiologists"

(Amburgey, et al, 2007)

3/7/2017

Closed Claims Malpractice Data on AAs

• Suggested as a way to assess safety of AAs

• Closed claims malpractice data is used to identify safety concerns in anesthesia, patterns of injury, and develop strategies of prevention to improve patient safety

• Data is from malpractice insurance organization claim files

• Not appropriate data source for and has not been used to demonstrate AA safety

(AANA Foundation Closed Malpractice Claims Database; www.asaclosedclaims.org)

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3/7/2017

Efficacy

• Argument for AAs: "Lack of data does not

mean lack of efficacy"

• Merriam-Webster definition: the power to

produce an effect

• NO DATA on AA's safety, outcomes, impact on

healthcare access since 1969

• LACK OF DATA = LACK OF EFFICACY OF AAs

Choice

• Anesthesiologists want a choice in providers

like surgical colleagues

— Surgeons have choice between APRNs and PAs

— Anesthesiologists have CRNAs, want AAs instead

• Why?

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3/7/2017

How AAs Fit Into a Business Model

• One anesthesiologist = 1 case = $100 (example)

• One anesthesiologist supervises 4 AAs = $100 x 4 = $400

— Assume 50% from each AA = $200

• Benefits to practice

— Need less expensive anesthesiologists to take care of 4 times as many patients

— Increases profit

Nevadans Deserve the Best in

Anesthesia Care

• 1:1 interaction and attention of CRNA or

anesthesiologist who can provide safe, full

scope anesthesiology care autonomously

— AAs with no proven safety or outcomes track

record will create two-tier system for underserved

and underprivileged population

— Best choice for Nevadans is anesthesiologist and

CRNAs, not AAs

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VA Final Rule

• Main argument against VA CRNAs was full

practice authority would eliminate team

based concept of care

— Established in VHA Handbook 1123, Anesthesia

Service

— Full practice authority does not eliminate team

based care

(Federal Register § 38 CFR Part 17, 2016)

3/7/2017

VA Final Rule

• Effective 1/13/2017 NPs, CNS, CNM practicing

under the auspices of the VA will be granted

full practice authority

— CRNA exclusion "does not stem from the CRNAs

inability to practice to the full extent of their

professional competence, but rather from VA's

lack of access problems in the area of

anesthesiology"

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VA Final Rule

• Second argument: "No shortage of physician

anesthesiologists in VA and the current system

allows for sufficient flexibility to address the

needs of all VA hospitals"

— Noted that most of comments "not substantiated

by evidence" however "VA believes evidence

exists there is not currently a shortage of

anesthesiologists that critically impacts access to

care"

(Federal Register § 38 CFR Part 17, 2016)

3/7/2017

Workforce Shortage Myth

• Per capita anesthesiologists exceeds national

average

• September 2016: 13 CRNAs fired from large

anesthesiology practice in Las Vegas

— Almost 15% of the state's CRNAs

— Almost 20% of Clark county CRNAs

• AAs will displace not only CRNAs but

anesthesiologists

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Anesthesia Provider Demand

• National (as of 12/22/2016)

— Anesthesiologists: 1664

—CRNAs: 2298

— AAs: 45

• Nevada

— Anesthesiologist: 17

— CRNA: 4

(Ga,vorLcon-4

3/7/2017

Workforce Shortage Myth

• Monopolistic anesthesia employment marketplace does not allow flexibility to address Nevada's anesthesia access needs

• Most CRNAs un- and underemployed

— Interest from CRNAs to move to NV if jobs available

• Need to maximize use of currently available CRNAs to the fullest extent of their education, training and certification

• No evidence of need for AAs with an unproven track record

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3/7/2017

Anesthesia Workforce Solutions

• Improve access to care by increasing utilization of CRNAs in urban underserved and rural/frontier areas

• Address autonomous anesthesiology provider pipeline issue and build up rural workforce

— Encourage training of CRNAs (instead of AAs) from out-of-state

— Increase recruitment from states with CRNA surplus (i.e. OR)

• Create favorable practice environment through policies encouraging hiring CRNAs & CMS opt-out

References

• Advanced Practice Registered Nurses, 81 Federal Register§ 38 CFR Part 17 (2016). Department of Veterans Affairs

• Amburgey, B., Kentucky. General Assembly. Legislative Research Commission.,. (2007). A study of anesthesiologist assistants. Frankfort, Ky.: Legislative Research Commission.

• Dulisse, B., & Cromwell, J. (2010). No harm found when nurse anesthetists work without supervision by physicians. Health Affairs, 29(8), 1469-1475.

• Epstein, R. H., & Dexter, F. (2012). Influence of supervision ratios by anesthesiologists on first-case starts and critical portions of anesthetics. Anesthesiology,11.6(3), 683-691.

• Hogan, P. F., Seifert, R. F., Moore, C. S., & Simonson, B. E. (2010). Cost effective analysis of anesthesia providers. Nursing Economics, 28(3), 159-169. Retrieved from

• Office of Statewide Initiatives. (2016). Nevada Instant Atlas [County-level health workforce and population health database). Retrieved from

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