Supply and Demand of Nurse Anesthetists. Ongoing Literature Review. - Prepared July, 2002

Transcription

1 1 Supply and Demand of Nurse Anesthetists Ongoing Literature Review Prepared by Mei Xue, RN,MSN with direction from Elizabeth Merwin, PhD, RN - Prepared July, 2002 Do you have additional relevant reports/documents/citations that should be included? If so, Elizabeth Merwin, qhcseim@aol.com

2 2 AUTHOR/ ORGANIZ ATION AANA TITLE MAIN GOAL DATA SOURCE DESIGN MAJOR FINDINGS KEYWORDS POLICY RESEARCH Quality of Care in Using different research studies to illustrate that CRNAs provide the same quality of care compared to that of AANA None To demonstrate CRNA s general practice in U.S. AANA State Governmen t Affairs Department AANA Fact Sheet Concerning November 13, 2001 CMS Rule Pennsylva nia Study examines Post- Operative Physician Care To list the requirements from CMS if the state chooses not to follow the rule (CRNAs must be supervised by physician) To suggest that the study actually focused on postoperative physician care instead of anesthesia outcomes done by 1.Bechtoldt study 2.Forrest Study 3.Minnesota Department of Health Study 4.CDC pilot Study 5.National Academy of Sciences Study 6.St.Paul Data 7.Silber Study 8.Abenstein & Warner Article 9. Wiklund & Rosenbaum Article Council on Accreditation of Nurse Educational Program data, AANA 2000 member Survey, Centers for Medicare & Medicaid Services 1. Bechtoldt study 2.Forrest Study 3. Memorandum from Dr. Longnecker to CRNAs in University of Pennsylvania Health System s Department of Summarize, compare and criticize various studies PowerPoint Slides printout Summarize major point from the November 13, 2001 Rule Utilize different sources to demonstrate that the Pennsylvania study misleads the public with its data sets in order to prove that Patient outcomes are not significantly different between the different qualifications of anesthesia care provider. CRNAs has the same safe practices as (p.19) Nursing shortage in general and the need to increase CRNA programs in order to increase graduates outcomes are statistically insignificant different whether CRNAs are under Medical direction or working independently (p.4) Quality of care, patient outcomes, safety, data, measures, anesthesia care, qualification, CRNAs,, morbidity, mortality, weighted outcome scales, difference, CRNAs general distribution, scope of practice, medium income, nursing shortage, CRNA education program Supervision requirement, quality of anesthesia service, Opt-out, state law, governor, consultation, regulation, authority, anesthesia outcomes, specifications, participation, Quality of care, measures, anesthesia outcomes, safety, data, death rate, anesthesia care, qualification, As long as the state meets all the requirements and consistent with the current law, CMS agree that the state to be exempted from the federal supervision requirement

3 3 AANA AANA Report on the Developme nt of a Medicare Part B Fee Schedule National Commissio n on Nurse Education (Final Report of the Task Force) nurse anesthetists patients have better outcomes if their anesthesia are under the direction of To assist the American Association of Nurse Anesthetist in developing a fair fee schedule and reimbursement system for CRNA services across the country Nationwide CRNA shortage pushes AANA to understand the problem and try to relieve it by expanding of existing programs and developing new CRNA programs. (p. 5) 2. Funding and adequate supply of academic faculties for CRNA program are also critical in alleviating CRNA shortage. The The country is divided into 5 regions and 8 out of 180 hospitals in which CRNAs practice have 5000 usable procedure data. There are three main categories: cost data, case specific data from anesthesia log, services performed by CRNAs at the hospital and average CRNA salaries. Membership surveys performed by AANA AANA Enrollment Expansion Survey, AANA Hospital Administrator Survey, Faculty survey, Funding sources for nurse anesthesia program questionnaire, CRNA degree completion survey, Scholarship survey, The anesthesia manpower study mandated by the U.S. Congress and performed by Health Economic Research Inc., Hearings conducted by Commission members A sampling survey was conducted to develop the average number of base, modifier units per cases and the average number of time units per case. All the cases have to be treated in a fiscal year ending on or before Sept 30, An analysis was performed and results were then combined to calculate a payment rate, which will be budget neutral. Collecting and analyzing background information from data source while directing the project goals into multiple strategies in order to increase CRNA manpower supply. The study duration on nurse anesthesia education was nine months. The average number of minutes: 92.0, time unit: 6.44, and base units per case (p.11). The calculation resulted in a rate per unit of $ for CRNAs where medical direction fees are also paid (p.15). The shrink of CRNA education programs is a major cause of the short supply of CRNAs nationwide. The utilization of CRNAs is not only cost saving but also consistent with the evolving environment of health care reform, which focuses on increasing professional utilization and decrease cost. (p.9) mortality, morbidity, post- 0perative physician care, controversy, Law, Omnibus Budget Reconciliation Act of 1987 (OBRA 87), Reimbursement system for CRNAs, budget neutral, payments, relative value guide, modifier units per case, average number of case, time units per case, sampling survey, analysis, practice mode, inflation, technology, legislation, Medicare, Health Care Financing Administration, CRNA shortage, hospital education programs, nurse anesthesia education, worker s compensation, Federal Funding, foundations, National Commission on Nurse education, grant writing, grants, CRNA innovative graduate program, CRNA outreach, faculty workload, In the policy approval process, a broad regulatory approach and strategy is necessary in conjunction with AANA. Lists of important individuals within the HCFA who will be in charge to direct reimbursement of CRNAs are also presented in the study.

4 4 AANA Standards for Accreditati on of Nurse Educational Program Draft #2 commission makes recommendations on these issues. To set up standards for CRNA education program so that the quality of education programs are maintained through U.S. and the safety of CRNA practice is warranted. at the AANA Assembly of States meetings, letters, and papers on topics regarding education of nurse anesthetists, Council on Accreditation of Nurse Educational Programs, Public hearings at November 10, 2001, February 22, 2002 (cover page). time/activity ratio, recruitment, health care reform, community involvement, effective leadership, Governance, Program effectiveness, accreditation, efficient operation, policies, procedures, standards, evaluations, resources, funding, budget, Accountability, patient safety, curriculum, federal mandated requirements, Standard: 1.The structure integrity of the institution is important to the efficient operation of CRNA program, which means to achieve its goals and objectives in the best interest of public (p.3) 2.Program policies, procedures and evaluation process is on going to achieve effectiveness and excellence (p.5). 3.Program of study is competitive nation wide in terms of relevance, currency, and standards (p.7). 4.Different kind of resources is available to ensure the quality of CRNA program in the institution (p.11). 5.The program is trustable in different areas of

5 5 AANA Allied Consulting Inc. Fact Sheet Regarding Anesthesiol ogist Assistants (AA) Summary Report 2001: Review of Allied Health Care Professiona l Recruitmen t Incentives Based on 2000 Data Introduce two major education programs for AAs in U.S., different state laws regarding legality of AA s practice and the differentiation between an AA and a physician assistant. To review the recruitment incentives offered by different types of employers such as hospitals so that the incentive standard can be developed in health care professional recruitment market (p.1) State laws, Outlines of two educational programs for AAs: Emory University and Case Western Reserve University, ASA news letters, and different web sites related to AAs. Data are from Allied search assignment from 2000 List information that related to AA education and practice, to inform readers about this medical specialty. Uses facts, numbers and analysis. Data are stratified into 16 categories in order to provide readers different comparisons There are less than 1000 AAs who are practicing in U.S. (p. 2) The major difference between an AA and a PA is that an AA is only trained to deliver anesthesia with anesthesiologist s supervision (p.2). A PA is trained in a broader area. State laws are different in classify AA and PA, and different supervision ratio. (p.5) ASA seems put efforts in AA s obtaining licensure and their reimbursement under supervision (p.7). The health care professional market put strong demands on certain specialties such as pharmacists, CRNAs and imaging technologists. The flourishing of new drugs on the market, cost-effective management from HMO, and the aging U.S. population etc are all the driving Educational program, anesthesiologist assistant, physician assistant, Emory University, Case Western University, laws, status, ASA, qualification, supervision ratios (p.5), Delegatory (p.6), reimbursement, salaries (p.7) Search assignment, recruitment incentives, benchmark, recruitment market, specialties, demand, CRNAs, imaging technologists, pharmacists, salary, bonus, academic activities such as grading, student recruitment and tuition and fees etc (p.12).

6 6 Abt Associates Inc. Estimation of Physician work Force Requireme nts in Anesthesiol ogy (prepared for ASA) To estimate the manpower requirement for the in the year 2010, so that their future training and workforce distribution in different anesthesia service are forecasted in a reasonable way (p.iv) 1991National Hospital Discharge Survey (NHDS), ASA manpower database, panel discussion include seven, three CRNAs, a surgeon, and a cardiologist, Graduate Medical Education National Advisory Committee Summary Report Vol. 1, U.S. department of Health and Human Services publication no. (HRA) , and Council on Graduate Medical Education First Report of the Council, AMA masterfile, AANA membership survey, Medicare part B annual data, 1993 Projection of the population of the United States by age, sex, and race. American Hospital Association annual survey, 1991data (p.28) Data from different sources were analyzed to develop baseline estimates of the volume of services that currently consumes most of the anesthesia providers time. Then the authors forecasted the total amount of time required providing these different services. Combining all of these time requirements, a total number of needed for services in 2010 were calculated based on a full-time equivalent basis per year (62 hours/week, 46 weeks/year or 50 hours/week, 46 weeks/year). Four different staffing models were also used to estimates the manpower needs (p.vii). forces of this trend (p.7). PAs and nurse practitioners recruitment does not seem to increase in year 2000 (p.8). Internal and external factors will affect the estimates of 2010 manpower such as aging population, staffing pattern in a facility, and time requirements to deliver anesthesia care (p.51). The total number of required is presented in the table under four models (p. 52). Future training needs for in the next 15 years is likely to decline after analyzing the ASA man power survey. Estimates, workforce requirements,, CRNA, assumptions, Physicianintensive model, first team model, second team model, CRNA intensive model, surgical anesthesia, obstetric deliveries, pain management, critical care, teaching, research, administration, full-time equivalent, ICD-9 procedure codes, staffing ratio, Barondess, J.A. Specializati on and the physician workforce Drivers and Determinan To explore the reason of the growth of specialists in physician workforce and the effect on general Journal articles from JAMA, Annual of Internal Medicine N/A The rising in specialization has started since World War II. The primary force of the trend is the fast development of modern Specialization, physician workforce, trend, board, subspecialization, expertise, complex disease, patient

7 7 Bingham, R. Adams, B. ts Leaving Nursing Accountabl e and Powerless public and the medical profession itself. A real life story tells about a NICU nurse s struggle between short staffing in the unit and his desire to provide adequate care to sick infants. Real life nursing experience concerned a nurse and what he did to break the silence to protect his patients and his profession The author s own experiences in his nursing career The author s own experiences in his nursing career Narrative form Narrative form technology, increase productivity of biomedical research and a general view in medical profession that generalist would not be able to manage complex disease (p. 1300). Managed care and consumer advocacy put pressure to limit access to subspecialties. Patient and public needs should be the objectives in relate to structuring of the health care system (p.1301). Nursing is a profession that emphasizes on caring and human touch. But it is caught between the cost reduction by institution and providing high quality care to patients (p.211). With increasing patient load, increasing medication Error, and rising patient complaints, the nurse decided to speak out. But this process has been long and difficult and eventually the nurse has to go through the tumbles such as losing his job, go to court without the outcome, fragmentation, managed care, regulation, funding, medical graduates, residents, fellows, generalists, Managed care, cost cutting, nurse layoffs, staffing cutbacks, ECMO, workload, patient safety, adverse outcomes, honesty, humanity, caring, bedside, powerless, High-quality care, law, authoritative voice, medication errors, staffing, JCAHO, National Labor Relations Board, Nursing Board, legislation,

8 8 Brotherton, S.E., Simon, F.A., & Tomany, S.C. Buerhaus, P., Stiger, D., & Auerbach, D. US Graduate Medical Education, Implication of an Aging RN Workforce To demonstrate the trends in medical education by comparing the data from different sources and the effect on physician workforce distribution particularly in subspecialties and among ethnic group To state the fact that RN workforce is aging and there is an urgent need to take actions to prevent future nursing shortage American Medical Association Annual Survey of Graduate Medical Education Program for , and the similar data collected in the past several years (p.1121) U.S Census Bureau, Current Population surveys The survey was electronically mailed to all programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) and to combined specialty programs (p.1122). Data was collected in a six-month period. It is an abstract form of the article support from the State Board of Nursing. But all is worthy when it comes to benefit patients and the nursing profession (p.223). Since the overall control of numbers of physicians in the workforce is absent, there is increased number of residents and programs to deliver more MDs into the market. More IMGs are going into subspecialty program and with more additional training. Increasing numbers in primary care training programs especially blacks and Hispanic residents, while Asian are more likely to go into internal medicine. Other trends varied and did not consistent through the years. In the past decade, RN workforce is aging rapidly comparing to other occupation. By 2010, working RNs will start to retire and the number will fall 20% below requirements. Better wages, better use of RNs, and more gender diversity in Graduate Medical Education, US citizen, permanent resident, specialty program, international medical school graduates (IMGs), osteopathic medical school (USDOs), physician workforce, subspecialty, citizenship status, primary care trainee, ethnicity, race, ambulatory setting, Aging RN workforce, baby boom years, retire, options, social problems, women s movement, career choices, ergonomics, retention, respect

9 9 Buerhaus, P., Stiger, D., & Auerbach, D. Buerhaus, P. I. & Staoger, D. O. Chambers, D. A. Policy Responses to an Aging Registered Nurse workforce Trouble in the Nurse Labor Market? Recent Trends And Future Outlook Comments of The AANA on the Proposed Rule Several important strategies and actions are presented for the policy makers, nurse educators, hospital administrators, and the public to deal with RN shortage and aging RN workforce in the near future (p.278). To understand the driving forces that changes the nursing labor market and to predict the trend in RN workforce in the near future according to data (p.214) To argue that Centers for Medicare and Medicaid Services (CMS) should adapt the final rule Enrollment and graduations in baccalaureate and graduate programs in nursing by American Associate of Colleges of Nursing (p.284), and authors own publications U.S. Bureau of the Census, Current Population Survey , HCFA proposed rules Dec 19, 1997, January 18, 2001, and July 5, 2001 (p.2). NRHA March 2, 2001 letter to President Bush Provide different evidences regarding the aging RN workforce and give recommendations. Data is compared from 1983 to 1997 and combined with other sources to draw conclusions about nurse labor market List the main points of argument and give facts so that AANA s comments to HCFA s final rule is reasonable and RN preparation need to be considered. The wide spread of managed care across the country slows down RN employment growth in hospitals and home health sector (p.217). Nursing still remains a good public image and is a good career option for many people (p.221). Aging RN workforce, baby boom years, nursing education, options, image of nursing, social problems, women s movement, career choices, retention, foreign-educated nurses, patient outcomes, confidence, quality of care, Nurse labor market, trends, future outlook, empirical data, nursing workforce, managed care, HMO, home health sector, health care system, health care consumers, public confidence, work satisfaction, morale, CMS, HCFA, AANA, AHA, CRNA, anesthesiologist, Medicare, Medicaid, JAMA, One action is to increase the competence and the use of unlicensed assistive personnel. Hospitals need to maintain certain staffing level to meet the requirement of legislation. The issue has to be raised onto social policy agenda so that the Congress will request AHRQ or IOM to do research projects related to nursing workforce (p.284). HCFA should adapt the Jan 18, 2001 final rule because First there are 31 states that do not

10 10 Charles Pearson Associates Medicare &Medicaid Programs Hospital Conditions of Participatio n Services Rationale, Assumptio ns and Calculation s Used in Estimating The on Jan.18, 2001made by HCFA, and CRNA supervision issue should be deferred to state law instead of mandated by federal government (p.1). To develop costeffective alternatives for anesthesia services, especially focus on the cost savings in different anesthesia (p.7), state law, 1998 JAMA article by Cooper, Henderson and Dietrich (p.8). AANA comments to HCFA Based on the company s own anesthesia services consulting projects, journal articles, legitimate Using assumptions and calculations Since patients anesthesia outcomes are not significantly different based on the type of anesthesia provider (p.2), eliminating certain proposed rule, Supervision requirement, quality of anesthesia service, federal requirement, political decision, policy issue, Optout process, state law, governor, consultation, regulation, authority, anesthesia outcomes, specifications, participation, state licensing, Consultant, assumption, calculations, CRNA, anesthesiologist, anesthesia services, staffing require CRNAs to be supervised by. Second, there are no scientific evidences and valid studies to show that CRNAs has better patient outcomes if supervised by. 3. If the July 5, 2001 rule is adapted, then an opt-out should be granted to states that do not require CRNAs to be supervised by with a minimum of 1 year validation and the state governor should make his own independent decision instead of consulting other parties especially from State Board of Medicine other than State Board of Nursing.

11 11 Conte, A.T. & Delgado, E. Cooper, R.A., Getzen, T.E., McKee, H. J., & Laud, P. potential Annual Cost- Savings by Restructuri ng Care Teams Based on the Acuity of Patients and The Required Levels of Care Survey of ASA Resident Delegates: Residents Attitudes Toward Choosing a Residency and the Outlook on the Future of Anesthesiol ogy, vs Economic and Demograph ic Trends Signal An Impending Physician Shortage staffing models. To compare residents attitudes toward choosing their residency program in to those from a previous similar data conducted in (p.20) To predict the future physician shortage using a new model Surveys were distributed to members of the 1997 ASA Resident Component; and with the same survey conducted in Bureau of the Census, Bureau of Economic Analysis, Public Health Reports 75, Comparison was made between these two data set using 5- point Likert scale with 1 being strongly disagreed and 5 being strongly agreed (p.20). Statistical methods was also being used to calculate the standard error of the mean at p< A model is developed to help explain the physician workforce. The trend model is based on four assumptions: First is economic expansion, Second is population growth, Third is the work effort of percent of will save health care $5 to $ 7 billion per year (p.1) depending on the percentage and the anesthesia care model. Residents choose the anesthesia program based on the reputation of the institution or personal needs such as benefits, family obligations etc. Residents in do not worry about the career opportunities because the market has been good. They demand more education exposure to the business side of practice setting (p.21). The trend model estimates a growth in the demand for physician workforce about percent annually based on a prediction of an increase in MD supply of 0.75 percent for each 1 model, quality of care, cost, savings, Medicare, patient outcome, supervision, medial direction, patients acuity, reimbursement, HCFA, health systems, ASA residents, attitudes, survey, reputation of the program, benefits, geographical location, employment prospects, current market, ambulatory care setting, Shortage, physician supply, physician workforce, Council on Graduate Medical Education, the Trend Model, macrotrends, nonphysician

12 12 Cromwell, J., & Snyder, K. Alternative Cost- Effective Care Teams To study some of the various organizational anesthesia delivery models in order to find the most costeffective way using and CRNAs. Four hospitals around the country (a large high-end tertiary academic teaching hospital in the Northeast, a large tertiary private community hospital in Southeast, a mediumsized tertiary private community hospital in Midwest, and a small secondary community HMO hospital in the West) serves as case study models to illustrate anesthesia team arrangements. physicians and the fourth are the services provided by non-md clinicians (p.142). Comparison of four anesthesia practice models percent increase in GDP (p.148). The magnitude of this statement is that the manpower shortages will be worse than that existed in 1960s. The ambiguity of the assumptions is largely affected by the demand for physician services and the economic growth that underlies it (p.149). Using all in one hospital is very costly. Team anesthesia is very cost-effective. CRNAs cost less than half as much as but are trained to provide all kinds of anesthesia procedures in high quality. Hospital administrators are pressured to decrease cost in a managed care environment and they can use these four models to deliver anesthesia service to achieve financial competition (last page). clinician, population growth, GDP, health care labor force, correlation, physician work efforts, productivity, managed care, medical schools, Cost effective, care team, organizational model, Medicare, DRG, workforce arrangement, CRNAs, resident, supervision, scope of practice, managed care, third-party payers, salary, FTE, labor costs, Eckhout, G., & Schubert, A. Where Have All the Anesthesiol ogists Gone? To clarify the myth from certain research articles that there will be a surplus of in Health demographic data from federal agencies and AMA as well as membership data from ASA (p.16), a survey conducted by the Using figure and data to convey the point The cumulative shortage of is now depending on the growth of the Anesthesiologists, residents, shortage, economic climate, health care environment, data,

13 13 Fallacaro, M.D. Fallacaro, M.D. Fallacaro, M.D. Analysis of the National Worker Shortage The Practice and Distributio n of Certified Registered Nurse Anesthetist s in Federally Designated Nurse Shortage Areas A Look at Workforce Projections The national distribution the next decade To compare and explain the distribution of CRNAs in nurse shortage counties vs. non-nurse shortage counties across America (p.56) To predict the nurse Anesthetists workforce and workforce To describe the distribution of CRNA across the Massachusetts Society of Anesthesiologists (p.18), a survey of academic departments by the Society of Academic Anesthesiology Chairs and the Association of Anesthesiology Program Directors (p.18), 1. A list of Counties in the United States with a Shortage of Nurses from the Office of Shortage Designation, Bureau of Primary Health Care 2. United States Department of Agriculture entitled Rural-Urban Continuum codes for Metro and Nonmetro Counties. 3. Membership and Information Systems Department of the AANA (p.56) AANA 1989 Commission on Nurse Education, 1990 Department of Health and Human Services study of CRNA manpower, AANA Membership and Information System Department to locate Combine the three data sets and calculate the CRNA to 100,000 population ratios in urban and rural area, gender distribution, education level for both nurse shortage and nonshortage counties. Summary of article Analyze CRNA population ratio according to rural- surgical procedure (p.18). The current shortage of manpower will continue to last into next decade. What needs to be done is to systemically assess the overall situation and to plan and prepare for the future (p.19). There are fewer CRNA per 100,000 population in nonmetropolitan settings than in metropolitan settings (p.59). Economic environment plays a big role in CRNAs distribution across the country. More male CRNAs work in rural nurse shortage areas maybe related to the fact that more autonomous role is required than that in nonshortage area (p.60). It is predicted that by the year 2020 there is going to be a ratio of 8.9 CRNA to 100,000 U.S. population. There will be an oversupply of in the next decade predicted by ASA manpower projection. 81.3% of CRNAs reside in metropolitan counties recruitment, labor supply, surgical procedure, limiting, demand, elderly population trend, extenders, nurse anesthetists, workforce, ruralurban continuum, nurse shortage area, nurse anesthetists, metropolitan, nonmetropolitan, gender, economic environment, independence, autonomy, workforce, CRNA,, education program, anesthesia resident, surgical procedures, ASA, workforce, ruralurban continuum,

14 14 Garde, J.F. Graham, S. (with supporting articles one by Atkinson and the other anonymous ) Grogono, A. W. of Certified Registered Nurse Anesthetist s across metropolita n and nonmetrop olitan settings Report of the AANA Executive Director Nurse Win Reprieve on Legislation National Residency Matching Program 1998: A Further Increase for Anesthesiol ogy, United States in metropolitan and nonmetropolitan area The changing phases of AANA from 1983 to 2000, including service departments, strategic plan, and also the nurse anesthesia profession itself. To demonstrate that the withdrawn of H.B. 986 bill is both benefit to the hospital and the patients To report the trend in Anesthesiology graduates in 1998 and to compare the data from previous years CRNA place of residency by county, U.S. Department of Agriculture, entitled Rural-Urban Continuum Codes for Metro and Nonmetro Counties, AANA history, AANA membership survey 1984, 1990, 1994, 1995, 1996, 1997, 1998, 2000 Data from 12 hospitals in Maryland were obtained from HSCRC for the most recently completed fiscal year National Residency Matching Program data urban continuum codes with 0 being Metropolitan area over 1 million population and 9 being completely rural less than Report form with graphs to demonstrate Using various quotes from experts to support the main idea, John D. Klein s model is used to calculate the cost of various staffing patterns Using figures and tables while 18.7% reside in nonmetropolitan counties. Higher percentage of male CRNAs work in rural areas than in urban area. CRNAs in metropolitan area have higher education degree than those in nonmetropolitan area. Most CRNAs work in clinical settings with rising median income in recent years. There is still a need to campaign for new education program and raising public role of CRNAs. There is an increase in U.S. graduates recruited in 1998 but the percentage of IMGs (international medical graduates) fall now with less percentage than U.S. graduates (p.22). nurse anesthetists, metropolitan, nonmetropolitan, gender, economic environment, independence, autonomy, age distribution, CRNA, AANA, profession, median income, employment, membership, practice setting, research, educator, rural and urban communities, Maryland, supervision, legislation,, cost-effective, quality of care, HMO, Medicare, staffing patterns, CRNA, HSCRC, National Residency Matching Program, U.S. medical graduate, International medical graduates, recruitment, regional The withdrawn of the bill (requires a nurse anesthetist to collaborate with MDs in order to administer anesthesia) not only benefit rural Maryland hospitals but also save Maryland hospitals $2 million to $ 2.5 million per year.

15 15 Grogono, A. W. Grogono, A. W. Grogono, A. W. Grogono, A. W. Especially From U.S. Graduates Update on Residents and Their Prospects in 1997 National Residency Matching Program (NRMP) 1997: An Increase for Anesthesiol ogy National Residency Matching Program Results for Update on Residency Compositio n To analyze the trend in the residents job searching and the comparison of the number of graduates from previous years To present the trend of graduate recruitment and matching into in 1997 To present the trend of graduate recruitment and matching into in 1999 To present the composition of residents from 1960 to 1998 by Survey by the Association of Anesthesiology Program Directors and the Society of Academic Anesthesiology Chairs (p.17), Data from the American Board of Anesthesiology regarding the size and composition of all four years in residency training (p.18). Data are from National Residency Matching Program, Data from the American Board of Anesthesiology Data are from National Residency Matching Program, Data from the American Board of Anesthesiology Data from the American Board of Anesthesiology (p.26), Using figures and tables Using figures and tables Using figures and tables Using figures and tables The public demand for ensures the market place for this specialty will be continually strong. The unemployment rate for graduates is 2.0%, which was down compared to last year. There is an increase in AMGs this year with a large increase in the number of IMGs. More percentage of AMG fellows enter into academic practice full-time this year. NRMP has found a decline in recruitment since 1993 especially in U.S. graduates (p.26). There is an increase of graduates entering into with an increase number in IMGs in 1997 (p.27). There is an increase in number of graduate seniors into (p.21). The two largest recruitment cities are California and New York. The number of residents in training, which peaked at 1994, was five times higher than 1960s distribution, specialty, Residents, fellows, survey, data, U.S. medical graduate, International medical graduates, recruitment, unemployment, Residents, Match, trends, data, U.S. medical graduate, International medical graduates, recruitment, unemployment, Residents, Match, trends, data, U.S. medical graduate, International medical graduates, recruitment, unemployment, Residents, Match, composition, data, U.S. medical graduate, International

16 16 Grogono, A. W. Grogono, A. W. Grogono, A. W. Grogono, A. W. Update on Residency Compositio n National Resident Matching Program results for 2000: Anesthesiol ogy More Popular than Again Update on residency Compositio n, Residency Compositio AMGs and IMGs To present the composition of residents from 1960 to 1999 by AMGs and IMGs To present To present the trend of graduate recruitment and matching into residency in 2000 To present the composition of residents from 1960 to 2000 by AMGs and IMGs To present the composition of Data from the American Board of Anesthesiology (p.19) Data are from National Residency Matching Program, Data from the American Board of Anesthesiology (p.16) Data from the American Board of Using figures and tables Using figures and tables Using figures and tables Using figures and tables (p.26). There is a decline in recruitment of AMGs in recent years because of the increase of IMGs recruitment (p.28). The number of residents in training increases this year compared to previous six years (p.17). There is also an increase in the number of AMGs into residency training. The number of U.S. citizen IMGs and osteopathic medical graduates into have both increased from 1996 to The two largest recruitment cities are still California and New York. The improvement in job market attracts strong U.S. candidates. An increasing number of CA-1 residents this year with increased number of AMGs and decreased number of IMGs (p.17). The availability of job opportunities stimulates the recruitment growth in residency (p.19). There is a 17% increase in residents medical graduates, recruitment, training, Residents, Match, composition, data, U.S. medical graduate, International medical graduates, recruitment, training, attrition, Residents, Match, trends, data, U.S. medical graduate, International medical graduates, recruitment, osteopathic medical school, Residents, Match, composition, data, U.S. medical graduate, International medical graduates, recruitment, training, attrition, Residents, Match, composition, data,

17 17 Gunn, I. P. The Policy Futures Panel Horton, B.J. n and Numbers Graduating From Residencies and Nurse Schools Anesthesiol ogist Data Concerning Certificatio n and IMG Graduates (1996), From AMA Sources Nursing Supply/De mand issue Brief from the Policy Futures Panel Focus Team On Education - residents from 1960 to 2001 by AMGs and IMGs, and with additional information on nurse anethestists To list the number of and the percentage of being certified from 1986 to 1996, percentage of IMGs, and the number in active practicing and retiring from 1996to To discuss the potential issues and regulatory resolutions for nursing shortage To develop strategies to help programs facing Anesthesiology and from AANA (p.19) AMA Center for Health Policy Research, ASA newsletter, Listing of numbers and percentages graduating and a decrease number of IMGs and increase number of AMGs in residency program 2001 (p.19). Number of nurse anesthetists graduating and being certified varies from low in 1989 to high in 1996 (p.20). U.S. medical graduate, International medical graduates, recruitment, training, attrition, nurse anesthetists, certification, workforce, Specialty of practice, certification, residents, fellows, ABA, N/A Narrative form Nursing shortage, regulatory policy, standard, unlicensed assistive personnel, Board of Nursing, quality of data, public protection, supply and demand, health care system, List provided by AACN (p.2), Council on Accreditation of Nurse Listing the projects and their results Programs, AACN, funding, nurse anesthesia There were 45.9% who were not being certified in 1986 compared to 29.1% in There are about 27% of were IMGs in More people came into active practicing from 1996 to 1998 than the number retired in three years. The shortage of nurses will affect regulatory policies in using unlicensed assistive personnel, in the scope of practice for various types of nurses, and in the quality of data collected by Board of Nursing. Major projects developed by focus team

18 18 Joseph, A.M. & Melick, J. R. -Report To AANA Board of Directors Health Care staffing Shortage financial difficulties and to relief manpower shortage To analyze the present health care staffing shortage especially nursing shortage and possible solutions Education Program data (p.10), Authors did not specify the data sources except mentioned American Hospital Association, Using figures and tables program, financial pressure, CRNA manpower shortage, closure, Nursing shortage, temporary agency nurses, Balanced Budget Act of 1997, supply, demand, aging, managed care, Medicare, HMOs, ICU, bonuses, foreign nurses, agency nurses, professional development, personal expense, salaries, wages, fees, and benefits expenses (SWFB), operating margin, operating revenue, utilization, include first develop new programs, second help at risk programs and third address financial issues with new programs and with CRNA faculty. Other projects include advertise CRNA manpower shortage through press media and software. The nursing shortage is because supply does not meet demand, more career opportunities for women, aging of nursing workforce, etc (p.2). The longterm solution may involve a root change in the nature of this profession, promote professional development, and increase enrollment in nursing program

19 19 Kruckemey er, M. Lema, M.J. How VA Health Care Works for all Americans In Case You Haven t Heard Th ere Are No Available Providers To provide information and evidences regarding Veterans Affairs Health Care s contribution to the American s future health care needs and cost savings. To inform anesthesia professionals and medical society that there is a shortages for and nurse anesthetists. Nurses Organization of Veterans Affairs, VHA survey on Potential Shortage of Registered Nurses Summary of Responses June 1999, Narrative form VA health care takes care of 3,600,000 very sick veterans in the nation with considerable lower cost than Medicare recipients do. VHA offers largest training resources for health professionals in the country and conducts medical research for all Americans. Therefore the government needs to put money in support of country s patriots under the environment of managed care. N/A Narrative form There is a tendency for to join more profitable private groups other than working in academic medical centers because of dropping in managed care reimbursement system. Certainly nursing career is no longer an only career choice for women. A 75% VA health care, patient, veterans, Medicare, managed care, nursing home, education training, public officials, Anesthesiologists, nurse anesthetists, salary, operating room, reimbursement, pain specialist, assistants, workload, expectation, (p.3). The short-term solution may be offering sign on bonuses, encourage retention, and recruit foreign nurses (p.3).

20 20 decrease in residents entering program in 1990s will cause a devastating consequence later on. Longnecker, D.E. Mastropietr o, C.A., Horton, B.J., Ouellette, S.M., & Callahan, M. F. Navigation in Uncharted Waters Is Anesthesiol ogy on Course for the 21 st century? The National Commissio n On Nurse Education 10 years Later Part 1: The Commissio n Years (1989- To demonstrate the present problems facing, the possible resolutions to a better visible specialty and make effective changes to the profession To introduce the function and the background of NCNAE and the goals the commission needs to accomplish. National Resident Matching Program data since 1990 (p.737), Council on Accreditation of Nurse Educational Programs 1999 (p.379), Council on Certification of Nurse Anesthetists and 1999 (p.379), Council on Certification of Nurse Anesthetists and 1989 (p.381), Council on Certification of Nurse Anesthetists Speech form Goal setting and the results Anesthesiologists have to go out the operating rooms, to expand their care to pre and post-op patients, to work more closely with the surgical colleagues, and to participate in health care reform and public health care issues. Pain research, mechanisms of drug therapy and the root of perioperative medicine are areas of research for in the future. Quality of care and patient outcomes also need to be studied by our specialty in order to have a leading role in workforce issues. The shortfall of nurse anesthesia program from 1975 to 2000 causes great concerns from AANA and NCNAE was formed to achieve 8 goals to meet the needs of health care system. The main target for the goals is to increase the supply of Anesthesiology, education, providers, research, workforce, graduate medical school, health care delivery, perioperative medicine, cost containment, quality of service, Certified registered nurse anesthetist shortage, faculty, National Commission on Nurse Education, nurse anesthesia, AANA,, funding, supply

21 21 Moorefield, J.A., Hall, J.M., & Hussey, L. Pine, M. 1994) and 1993 (p.382), Enrollment expansion survey, Hospital Administrators Survey, Certified Registered Nurse Anesthetist Position Availability in North Carolina Annotated Bibliograph y of Selected References On the Quality of Care by Anesthesiol ogists and Nurse Anesthetist s To conduct a research study in NC region regarding nurse anesthetist vacancies and future five year CRNA manpower prediction (p.2) To examine a series of studies in order to understand the quality of care by different anesthesia providers A survey was sent to 144 chief CRNAs at ASCs and hospitals in NC (p.6). Studies from Annuals of Surgery, British Journal of, Anesthesiology, Journal of the American Medical Association, North Carolina Medical Journal, Health Affairs, Medical Care, New England Journal of Medicine, Data collection lasted four weeks with a return rate of 53% (p.7). A descriptive study design was implemented using the Statistical Package for the Social Service (SPSS) for analyzing the data. Descriptive statistics were obtained to include totals, percentages and means as need to quantify data (p.7). Graphs were used to give visual effect to certain numerical data (p.7). Briefly explain the studies, the conclusion of the studies and the author s own opinion nurse anesthetists by increasing new programs in state level, increasing clinical site, developing funding to assist faculties and schools, marketing nurse anesthesia and education. Thirty-nine percent facilities of 76 return of the surveys indicated 82.5 position vacancies in NC (p.7). Sixty vacancies due to facility growth and new CRNA positions (p.8). Thirty-six vacancies due to CRNA retirement and attrition (p.7). There will be vacancies in 2004 in NC (Figure 6). From the entire classic American study listed, it is not conclusive that the quality of care different significantly among different anesthesia care providers. Also the patients death directly related to anesthesia procedure were so low (around.00066%), (p.3) some wonder if it is necessary to do and demand, research, CRNA, North Carolina, shortage, vacancies, research, study, retirement, attrition, facility, health care, clinical access, anesthesia curriculum, survey, workforce, position creation, recruitment, CRNA, workforce, provider,, mortality, surgery, death rate, perioperative deaths, morbidity, ASA physical status, risk adjustment, costeffective,

22 22 Rathmell, J.P. Revak, G. R. & Jaffe, J.M. Reves, J.G. Are We Training Too Many Pain Specialists? CRNA Retirement Final Report Annual Survey of Training Programs Highlights Committee on Subspecialt ies To examine the demand and supply in the market for pain specialists To develop a model of CRNA retirement patterns in order to predict the future manpower needs for newly certified CRNAs To examine the trend and numbers of residents in subspecialty training American Society of Anesthesiologists, American Board of Anesthesiology, AANA membership database from 1993 to 1997, ASA Committee on Subspecialties annual survey, Using figures and tables The research uses a number of computer and computation tools. Data analysis was performed using SPSS 8.0, Lotus release 5 and Microsoft Excel 97 (p.3). Using figures and tables expensive studies on mortality audit in anesthesia. The demand for pain management is growing and so does physicians seeking fellowship training in the specialty in the last decade. (p.10). But the future demand for pain specialists is not available from the market analysis data. Three models were developed: baseline (flat inflows), high inflow with 5% increase, and low inflows with 2% decrease in the year (p.8). According to baseline model, the increase of CRNAs begins to taper off around 2007, with high inflow model the number begin to accelerate in 2004, with low inflow mode the number peak at 2007 and then begin to decline (p.10). There are about 60% of finishing residents entering into fellowship training in subspecialty (p.23). The number in subspecialty education in pain management has Pain specialists, ASA, ABA, workforce, board exam, certification, pain management, anesthesiologist, subspecialists, fellowship, AANA, CRNA, retirement, age, practice, database, inflows, outflows, practitioner, net termination rate, certification, projections, model, anesthetic procedures, demand, baseline, ASA, survey, fellowship, residents, subspecialty, trends, pain management,

23 23 Reves, J.G., Rogers, M.C., & Smith, L.R. Schubert, A., Gifford, E., Cooperider, T., & Kuhel, A. Activities Resident Workforce in a Time of U.S. Health- Care System Transition Evidence of a Current and Lasting National Personnel Shortfall: Scope and Implication To forecast the future need for and the strategies to achieve the balance between demand and supply To give the evidence of current shortage, to predict the future needs and demands for service and to provide new ways to resolve the ASA, U.S. Census Bureau, National Residency Match Program, Accreditation Committee for Graduate Medical Education (ACGME), Duke University Medical Center, Published health personnel data from federal agencies and the American Medical Association, as well as membership data from American Society of Anesthesiologists (p. 995) Narrative form using figures and tables For current supply, authors uses ASA and AMA data in 2001based on the number of graduating residents and fellows. For future supply, authors based on their estimates on 5% growth of AMGs been increasing over the years. A substantial shortage of and anesthesia ancillary personnel such as CRNAs will persist for a few years due to multiple facts such as changing health care environment, Anesthesiology workforce predictions, education, residents, managed care, HMO, Medicare, Congress, CRNAs, physician assistants, quality, federal laws, National Residency Matching Program, financial compensation, Anesthesiology workforce shortage, manpower, demand, supply, education, residents, fellowship, managed care, The changing health-care delivery system demands U.S. medical schools to produce more generalists over specialists. Anesthesiology residents are facing a market that will have a surplus of in the next decade. Using Duke University Medical Center as an example, a reduction in the number of residents either voluntarily or involuntarily will attract only the brightest into residency program and increase the overall quality of anesthesia program and the service they provide.

24 24 s workforce issues annually. The demand for anesthesia services was based on surveys as well as statistics on population elements. managed care, Medicare reimbursement system, aging population, increasing surgical interventions, increasing demands for pain management etc. The ways to relieve the shortage are to train more personnel, lobbying legislators and regulatory agencies, and allow diversity in training program (p.1008). HMO, Medicare, Congress, surgery, pain management, aging population, AMGs, IMGs, nurse anesthetists, anesthesiologist assistant,

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26 References: 1. American Association of Nurse Anesthetists. (1998). Quality of care in anesthesia. Professional Liability Services Inc American Association of Nurse Anesthetists State Government Affairs Department. (2001). Fact sheet concerning November 13, 2001 CMS rule. Park Ridge, IL: American Association of Nurse Anesthetists. 4. American Association of Nurse Anesthetists. (2001). Pennsylvania study examines post-operative physician care. Park Ridge, IL: American Association of Nurse Anesthetists. 5. Touche Ross International. (1989). Request on the development of a Medicare part B fee schedule. Park Ridge, IL: American Association of Nurse Anesthetists. 6. National Commission on Nurse Education. (1994). Final report of the task force. Park Ridge, IL: American Association of Nurse Anesthetists. 7. American Association of Nurse Anesthetists Education Committee. (2001). Call for comments on draft 32 of the proposed accreditation standards. Park Ridge, IL: American Association of Nurse Anesthetists. 8. American Association of Nurse Anesthetists Members. (2001). Fact sheet regarding anesthesiologist assistant. Park Ridge, IL: American Association of Nurse Anesthetists Nurse Anesthetists. 9. Allied Consulting Inc. (2001). Summary Report 2001 review of Allied Health Care professional recruitment incentives. Irving, TX: Allied Consulting Inc. 10. Abt Associates Inc. (1994, September). Estimation of physician workforce requirements in anesthesiologist. Bethesda, Maryland: Abt Associates Inc. 11. Barondess, J. A. (2000). Specialization and the physician workforce. JAMA, 284 (10), Bingham, R. (2002, January/February). Leaving nursing. Health Affairs, 21(1), Adams, B. (2002, January/February). Accountable but powerless. Health Affairs, 21(1), Brontherton, S. E., Simon, F.A., & Tomany, S.C. (2000). US graduate medical education, JAMA, 284 (9), Buerhaus, P., Staiger, D., & Auerbach, D. (2000). Implications of an aging RN workforce. JAMA, 283(22), Buerhaus, P., Staiger, D., & Auerbach, D. (2000). Policy responses to an aging registered nurse workforce. Nursing Economics, 18(6), Buerhaus, P., & Staiger, D. (2000). Trouble in the nurse labor market? Recent trends and future outlook. Health Affairs, 18(1), Chambers, D. A. (2001). Comments of the AANA regarding HCFA/CMS proposed rule. Park Ridge, IL: American Association of Nurse Anesthetists. 19. Pearson, C. (2000). Rational, assumptions and calculations used in estimating the potential annual cost savings by restructuring anesthesia care teams based on the acuity of patients and the required levels of anesthesia care. Seattle, Washington: Charles Pearson Associates. 20. Conte, A.T., & Delgado, E. (1998, August). Survey of ASA resident delegates: residents attitudes toward choosing a residency and the outlook on the future of, vs American Society of Anesthesiologists Newsletter, 62, Cooper, R.A., Getzen, T.E., McKee, H.J., & Laud, P. (2002). Economic and demographic trends signal an impending physician shortage. Health Affairs, 21(1), Cromwell, J. (1999). Barriers to achieving a cost-effective workforce mix: lessons from. Journal of Health Politics, Policy and Law, 24 (6), Cromwell, J., & Snyder, K. (2000). Alternative cost-effective anesthesia care teams. Nursing Economics, 18 (4). 26