Work patterns, socio-demographic characteristics and job satisfaction of the CRNA workforce - Findings from the 2019 AANA survey of CRNAs.

BACKGROUND: An ongoing shortage of anesthesia providers lends importance to the study of job satisfaction and retention among this critical workforce. Certified registered nurse anesthetists (CRNA) make up an increasing share of this workforce and the impact of factors affecting their satisfaction is not fully understood. PURPOSE: Understanding the job satisfaction of Certified Registered Nurse Anesthetists (CRNA) and its determinants. Methods We conduct a comprehensive survey in which we collect information on the job satisfaction of a nationally representative sample of CRNAs, along with information on factors related to their job satisfaction. We measure the impact of these characteristics on the CRNA's level of job satisfaction using a multivariate regression analysis. FINDINGS: Many CRNAs would prefer to pursue training opportunities on peripheral nerve blocks, epidural anesthesia and advanced airway management. Refreshing training on these procedures are factors that may enhance their job satisfaction, and potentially reduce unmet needs for anesthesia services. DISCUSSION: We find that most CRNAs are either very satisfied or somewhat satisfied with their job. Factors that significantly increase the probability of being very satisfied include greater autonomy in the delivery of anesthesia, and higher compensation.

Quality, Costs, and Policy: Factors Influencing Choice of Anesthesia Staffing Models.

EXECUTIVE SUMMARY: Certified registered nurse anesthetists (CRNAs) can practice independently or with varying degrees of supervision by physicians or anesthesiologists. Before 2001, the Centers for Medicare & Medicaid Services (CMS) conditions of participation required CRNAs to be supervised by a physician. Starting in November 2001, CMS implemented an opt-out policy to give states greater autonomy in determining how anesthesia services are delivered. The policy also provided a mechanism to increase access to anesthesia services.We sought to understand and describe surgical facility leaders' perceptions of CRNA quality, safety, and cost-effectiveness; the motivation and rationale for using different anesthesia staffing models; and facilitators and barriers to using CRNAs. We applied a mixed-methods approach to understand surgical facility leadership decision-making for staffing arrangements.The use of anesthesia staffing models differed by location and surgical facility type. For example, the predominantly CRNA model was used in only 10% of large urban hospitals but in 61% of rural ambulatory surgical centers. Interviews with surgical facility leaders revealed that geographic location, surgeon preference, and organizational inertia were powerful contributors to a facility's choice of staffing model. Other factors included the Medicare opt-out provision, facility experience, and cost considerations. Differences in quality and safety between models were not contributing factors for most facilities.

Advocacy, Research, and Anesthesia Practice Models: Key Studies of Safety and Cost-Effectiveness.

The practice of anesthesia includes multiple competing practice models, including services delivered by anesthesiologists, independent practice by certified registered nurse anesthetists (CRNAs), and team-based approaches incorporating anesthesiologist supervision or direction of CRNAs. Despite data demonstrating very low risk of death and complications associated with anesthesia, debate among professional societies and policymakers persists over the superiority or equivalence among these models. The American Society of Anesthesiologists uses published findings as evidence for claims that anesthesia is safer when anesthesiologists lead in providing care. The American Association of Nurse Anesthetists cites its own research on safety and cost-efficiency outcomes to defend against these claims. We review and critique studies of the safety outcomes and cost-effectiveness of anesthesia delivery that have been cited in the Federal Trade Commission comment letters related to competition in health care, where each profession has laid out their case for how they ought to be recognized in the market for anesthesia services. The Federal Trade Commission has a role in protecting consumers from anticompetitive conduct that has the potential to impact quality and cost in health care. Thus, it is important to evaluate the evidence used to make claims about these topics. We argue that while research in this area is imperfect, the strong safety record of anesthesia in general and CRNAs in particular suggest that politics and professional interests are the main drivers of supervision policy in anesthesia delivery.

Developing a Health Services Research Agenda in Nurse Anesthesia Using a Modified Delphi Method.

The authors sought to formalize a process and ascertain research priorities for nurse anesthesia, which resulted in a new Health Services Research (HSR) Agenda. After formation of an 8-member ad hoc committee (representing different stakeholders from the American Association of Nurse Anesthetists [AANA]), a modified Delphi technique was used to determine the top 3 HSR research priorities for the 2016 fiscal year. The committee identified 24 high-priority HSR questions/topics specific to policy, education, or practice. An anonymous, web-based survey was distributed to the committee to rank and prioritize the 24 identified research questions using a 5-point Likert scale. Two consensus meetings and a second anonymous, web-based survey were conducted to prioritize the top 3 HSR questions. Through this systematic method, an HSR agenda was created based on the research questions initially submitted by the committee. The method used ensured that the new research agenda is relevant and reflects the priorities of Certified Registered Nurse Anesthetists. This agenda was incorporated into the updated AANA and AANA Foundation Joint Research Program as suggested areas of research. This agenda is intended to focus investigators and funding organizations on highest priority areas in nurse anesthesia research.

The AANA Foundation Malpractice Closed Claims Study: A Descriptive Analysis.

The AANA Foundation Closed Claims Researchers evaluated 245 closed claims spanning from 2003-2012. The majority of claims comprised CRNA providers whom are mainly male, independent contractors, certified between 1980-1999, and with malpractice coverage limits of $1 million/$3 million. The median age for all claimants was 50 years old, and 63.7% of claimants were female. For those claims where race was known, 54% of claimants were Caucasian. Most adverse events occurred in a hospital with an outpatient admission status. The majority of adverse events were identified as intra-anesthesia. The top five surgical procedures associated with these claims were orthopedic general surgery, cosmetic, obstetric, and neurologic procedures. An adverse event leading to death occurred in 35.1% of claims. Regardless of severity of injury, reviewers determined that 45.5% of negative outcomes were preventable, 32.7% of the anesthesia treatment was inappropriate, and 29% of negative outcomes were caused by CRNAs' actions. Reviewers found that no AANA Standards were breached in 45.7% of claims; however, Standards 4, 5, and 3 were the most common standards breached. The most costly severity classification was major permanent injury (ie, paraplegia, blindness, loss of two limbs, or brain ddamage) with a median payment of $299,810.

Geographical Imbalance of Anesthesia Providers and its Impact On the Uninsured and Vulnerable Populations.

The purpose of this study was to determine if there is a relationship between socioeconomic factors related to geography and insurance type and the distribution of anesthesia provider type. Using the 2012 Area Resource File, the correlation analyses illustrates county median income is a key factor in distinguishing anesthesia provider distribution. Certified registered nurse anesthetists (CRNAs) correlated with lower-income populations where anesthesiologists correlated with higher-income populations. Furthermore, CRNAs correlated more with vulnerable populations such as the Medicaid-eligible population, uninsured population, and the unemployed. Access to health care is multifactorial; however, assuring the population has adequate insurance is one of the hallmark achievements of the Affordable Care Act. Removing barriers to CRNA scope of practice to maximize CRNA services will facilitate meeting the demand by vulnerable populations after full implementation of the Affordable Care Act.

Ouality and performance measurement: national efforts to improve quality of care through measurement development.

The US Department of Health and Human Services created the National Quality Strategy to provide a framework to focus providers and organizations in achieving greater impact around better care, healthy people and communites, and affordable care. Providing incentive programs around quality measurement is one mechanism used to achieve these aims. Certified Registered Nurse Anesthetists (CRNAs) should begin to familiarize themselves with the consensus development process used in measurement development and the importance of measurement endorsement through the National Quality Forum. Additionally, CRNAs should become familiar with what Physician Quality Reporting System (PORS) measures CRNAs are currently using in anesthesia and the 2015 payment adjustments one may face if not currently reporting to the PORS.

Human rhinovirus infection causes different DNA methylation changes in nasal epithelial cells from healthy and asthmatic subjects.

BACKGROUND: Mechanisms underlying the development of virus-induced asthma exacerbations remain unclear. To investigate if epigenetic mechanisms could be involved in virus-induced asthma exacerbations, we undertook DNA methylation profiling in asthmatic and healthy nasal epithelial cells (NECs) during Human Rhinovirus (HRV) infection in vitro. METHODS: Global and loci-specific methylation profiles were determined via Alu element and Infinium Human Methylation 450 K microarray, respectively. Principal components analysis identified the genomic loci influenced the most by disease-status and infection. Real-time PCR and pyrosequencing were used to confirm gene expression and DNA methylation, respectively. RESULTS: HRV infection significantly increased global DNA methylation in cells from asthmatic subjects only (43.6% to 44.1%, p = 0.04). Microarray analysis revealed 389 differentially methylated loci either based on disease status, or caused by virus infection. There were disease-associated DNA methylation patterns that were not affected by HRV infection as well as HRV-induced DNA methylation changes that were unique to each group. A common methylation locus stood out in response to HRV infection in both groups, where the small nucleolar RNA, H/ACA box 12 (SNORA12) is located. Further analysis indicated that a relationship existed between SNORA12 DNA methylation and gene expression in response to HRV infection. CONCLUSIONS: We describe for the first time that Human rhinovirus infection causes DNA methylation changes in airway epithelial cells that differ between asthmatic and healthy subjects. These epigenetic differences may possibly explain the mechanism by which respiratory viruses cause asthma exacerbations.

A closer look at the standards for nurse anesthesia practice.

As part of its ongoing work, the AANA's Practice Committee reviewed the Scope and Standards for Nurse Anesthesia Practice, particularly focusing on the Standards for Nurse Anesthesia Practice. Revisions and updates were made to the standards to ensure clarity and reflect current anesthesia practice. This article highlights several of the important revisions made to the Standards for Nurse Anesthesia Practice, specifically focusing on the importance of documentation, updates to Standard V-Patient Monitoring, and changes to other documents affected by the updates. This is not an exhaustive discussion of all changes made to the document. The updated Standards for Nurse Anesthesia Practice are presented in their entirety.

The National Practitioner Data Bank: what CRNAs need to know.

As a nationwide flagging system, the National Practitioner Data Bank (NPDB) allows state licensing boards, hospitals, and other registered healthcare entities the ability to monitor practitioners through reporting and inquiry about the qualifications and competency of healthcare practitioners seeking clinical privileges where incompetence or unprofessional conduct could adversely affect a patient's welfare. Certified Registered Nurse Anesthetists are not exempt from being reported on or queried by registered reporting and querying entities. The NPDB warehouses data pertaining to adverse actions or medical malpractice payments taken against a practitioner. Based on the updated federal ruling published in the Federal Register regarding the NPDB and Section 1921 of the Social Security Act, the NPDB has expanded the definition of healthcare practitioners to include all healthcare practitioners as a means of protecting beneficiaries of the Social Security Act's healthcare programs. As such, nurse anesthetists should be aware of the additional reportable information that may be collected or disseminated based on the updated ruling pertaining to the NPDB.

A highly specific algorithm for identifying asthma cases and controls for genome-wide association studies.

Our aim was to identify asthmatic patients as cases, and healthy patients as controls, for genome-wide association studies (GWAS), using readily available data from electronic medical records. For GWAS, high specificity is required to accurately identify genotype-phenotype correlations. We developed two algorithms using a combination of diagnoses, medications, and smoking history. By applying stringent criteria for source and specificity of the data we achieved a 95% positive predictive value and 96% negative predictive value for identification of asthma cases and controls compared against clinician review. We achieved a high specificity but at the loss of approximately 24% of the initial number of potential asthma cases we found. However, by standardizing and applying our algorithm across multiple sites, the high number of cases needed for a GWAS could be achieved.