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Department of Anesthesiology, Mayo Clinic, Rochester, MN, weis.marilyn@mayo.edu
To the Editor:
As a CRNA currently working in a team anesthesia setting, I feel obliged to write regarding "Is Physician Anesthesia Cost Effective?" (1) This is the most recent attempt to prove anesthesia outcomes by quoting outdated studies (2,3) with significant limitations. By basing their findings on an obsolete study on perioperative mortality, and stating a 600% increase in anesthesiologists as the reason that patient outcomes have dramatically improved, the authors disregard the advancements made both in pharmacology and monitoring. The elegant 2003 study of surgical mortality and type of anesthesia provider by Pine et al. (4) found similar risk-adjusted mortality rates between hospitals without anesthesiologists and hospitals where anesthesiologists provided or directed care. This study also has double the amount of participants than the studies quoted by Abenstein et al (1). Abenstein et al. stated that anesthesia conversion factors are the same for CRNAs and physicians. If that is true, and differences in mortality cannot be shown, then it should be a simple matter to prove true cost-effectiveness. The study should include salary, cost of office space, support staff, computers, business trips, and benefits. If one compared the true cost per hour versus the amount of revenue generated, one would surely see which anesthesia model is most cost-effective.
References
Department of Anesthesiology and Division of Health Care Policy and Research, Mayo Clinic College of Medicine, Rochester, MN, abenstein.john@mayo.edu
In Response:
We appreciated Ms. Weis’s feedback to our recent article (1). It is important to understand that our ad hoc cost-effectiveness model was designed from the payer’s, not employer’s, perspective. Specifically, the question we tried to answer was whether there was a difference in cost to payers between physician and nurse anesthesia. If there was increased cost associated with physician anesthesia, we also determined whether this was cost-effective from a societal perspective. We did not examine the cost to employers (i.e., salary, benefits, productivity, hours-per-week, and so on).
Our survey of anesthesia practices throughout the United States clearly showed that the anesthesia conversion factor paid by private payers was the same for physicians and nurses (i.e., $49.02 ± 13.63 vs $47.27 ± 14.44 per anesthesia unit, P = 0.595, respectively). Medicare pays the same fee no matter how the anesthetic is delivered. Considering the fact that the average anesthetic generates 13 anesthesia units, private payers, on average, see a $23.79 per anesthetic increased cost for physician anesthesia as compared with nurse anesthesia.
Whether physician anesthesia is a cost-effective practice model is dependent on the difference, if any, in patient outcomes. To answer this question we incorporated the results of Silber et al. (2), not Bechtoldt (3) or Forest (4). This study of more than 200,000 patients showed an improved 30-day postoperative mortality rate of 1 patient per 400 anesthetics when anesthesia was delivered with physician anesthesia, P < 0.04. The avoided incremental cost of perioperative death was also incorporated into the model. Considering an actuarial life expectancy of 20 years, the calculated fiscal impact of physician anesthesia, as compared with nurse anesthesia, was a reduction in net health care costs of (–$2,600) per year-of-life-saved. Pine et al.’s study was published after our manuscript was submitted, but it is worth noting that this investigation showed a more frequent inpatient mortality rate with nurse anesthesia as compared with anesthesia care team practices, 0.46% vs 0.34%, respectively, or an excess inpatient death rate of 1 per 800 anesthetics (5).
We recognized that the data used in our ad hoc model was potentially biased in favor of physicians. Therefore, we recalculated the dollars-per-years-of-life-saved when cost differences between physicians and nurses were far larger than reported, when outcome differences were far smaller, and when the cost of avoidable deaths were far less. Under both univariate and multivariate scenarios, the cost to payers fell well below the societal threshold of $50–$80,000 per year-of-life-saved.
While Ms. Weis’s concerns are well taken, we believe our survey data are reliable and consistent with public sources. In addition, the methodology and results of Silber et al. (2) are comparable with those of similar investigations, such as Needleman et al.’s study (6) of hospital outcomes related to the proportion of register nurses involved inpatient care. Our ad hoc model was validated by a sensitivity analysis that adjusted for potential physician bias. Finally, although we recognize the concerns expressed with the difference between physician and nursing compensation, but as pointed out above, the purpose of this study was to determine the cost-effectiveness of physician anesthesia from a payer, not an employer, perspective. We note, however, that employers who offer only nurse anesthesia appear to charge physician fees, pay nursing salaries, retain the difference, and leave patients to bear the consequences.
References
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