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Nurse anesthetists strike back at anesthesiologists over VA rule change

JEFFERSON CITY, Mo. – Missouri nurse anesthetists are fighting back against anesthesiologists to support a proposed rule change by the Veterans Administration designed to give veterans greater access to care.

The Missouri Association of Nurse Anesthetists (MOANA) have voiced their support for the rule, which would mandate independent practice for nurses with advanced training to practice their speciality without the oversight of a doctor. Nurse anesthetists easily fit that description and the rule change would allow them to practice anesthesia outside the purview of anesthesiologists, who usually monitor and manage anesthesia in Missouri hospitals.

Last month, the Missouri Times published an article regarding the Missouri Society of Anesthesiologists’ (MSA) opposition to the new rule. The anesthesiologists claimed that the new rule would lead to a lesser quality of care for patients inside the VA system, but Rob Walsh, a past president of MOANA and a certified registered nurse anesthetist, says there is no evidence that care would drop off for the nation’s veterans.

“The level of care which would be measured by patient safety outcomes, those outcomes have been studied quite extensively… what we’ve seen is there are no differences in safety outcomes,” Walsh said. “We would argue that argument does not hold any weight at all.”

National nurse anesthetist groups have pointed to multiple studies (here and here, among others) that show there is either negligible difference in the care received by patients treated by nurse anesthetists, physician anesthesiologists, or anesthetists overseen by anesthesiologists or that a difference cannot be found.

Walsh explains that the level of expertise practiced by both anesthetists and anesthesiologists means that regardless of who is providing the service, it will be done well. After physicians finish medical school, they do a four-year residency to specialize in anesthesia to become anesthesiologists with the option to become certified by a national certifying board with an exam. The exam is not required for anesthesiologists.

Anesthetists also go through rigorous training. After becoming a registered nurse and working as a critical care nurse for anywhere from two to five years , he or she can begin nurse anesthesia classes at an anesthesia school, a graduate program which takes roughly three years. The board exam is required for nurse anesthetists.

Both require a four-year undergraduate degree prior to entering graduate school.

“Suffice to say, both professions are highly educated and highly trained,” Walsh said.

Walsh and MOANA both say that the implication the quality of care would drop simply because anesthesiologists would not be managing capable nurse anesthetists is untrue.

“They say it is more complicated caring for veterans because they are older and sicker, which is why vets need an anesthesiologist to participate in their care,” MOANA wrote in a letter to the Missouri Times. “The argument defies logic and is an insult to all veterans and their families, especially those who were cared for by CRNAs during combat.”

MOANA also disputes that veterans have been as dismissive of the rule change as the anesthesiologists say. The American Association of Nurse Anesthetists, the national advocacy organization for nurse anesthetists, has found that early analysis on the comment period for the rule change has garnered mostly supportive comments from veterans. In addition to those comments, the new rule also has the backing of several high profile advocacy and lobbying groups that work with and represent veterans like the Paralyzed Veterans for America, Iraq and Afghanistan Veterans of America, and the AARP (which represents millions of veteran households).

Walsh also says the rule change is not revolutionary by any means. Over half of the states in the union do not require physician supervision for nurse anesthetists and 17 states have received what they call a federal opt-out that eliminates federal Medicare physician supervision for nurse anesthetists.

Missouri, however, is not one of those states.