Nurse anesthetists acting alone are more cost effective than anesthesiologists acting solo or CRNAs supervised by anesthesiologists, according to a new study comparing the costs and quality of various anesthesia delivery models.

"CRNAs acting independently provide anesthesia services at the lowest economic cost," write the authors of the study, published in the Journal of Nursing Economics.

While the supervisory model is the next lowest model, the authors note that the 1:1 medical direction model "is almost always the least efficient." In facilities with high demand, the authors found the 1:4 medical direction model to be about as cost-efficient as the solo CRNA model, but in areas of low demand, "CRNAs acting independently are the only model likely to have positive net revenue."

Conducted by the Lewin Group, a health care and human resources consulting company, the analysis is based on simulation modeling of 3 types of anesthesia models: anesthesiologists working alone, CRNAs as sole providers and 1 to 6 CRNAs supervised by a single anesthesiologist. The authors compared the cost of training and education for CRNAs and physician anesthesiologists, as well as the costs associated with the various anesthesia delivery models based on CMS, private and self-pay billing structures.

Based on a comprehensive review of 9 published studies, the Lewin Group also found the quality of care among CRNAs and anesthesiologists to be "interchangeable." "As the demand for health care continues to grow," conclude the authors, "increasing the number of CRNAs and permitting them to practice in the most efficient delivery models will be a key to containing costs while maintaining quality care."

"The data confirm that CRNAs deliver anesthesia safely and cost-effectively," said James Walker, CRNA, DNP, president of the American Association of Nurse Anesthetists in a statement touting the findings. "With growing demands on the healthcare system nationwide, we must do all we can to make sure the nation's healthcare professionals are used as effectively and efficiently as possible."

But John P. Abenstein, MD, associate professor of anesthesiology at the Mayo Clinic in Rochester, Minn., and speaker of the American Society of Anesthesiologists' House of Delegates, cautions that the analysis appears "fatally flawed in a number of ways," both in how it assesses quality and cost differences between the various anesthesia models.

"This analysis doesn't take into account the differences between how many cases per year an anesthesiologist may do as compared to a nurse anesthetists," that "anesthesiologists have other sources of income generation" and that "physicians are uncommonly employees of the medical facility," says Dr. Abenstein. "There's no surprise that this scenario shows that if a physician or a nurse do the exactly the same thing, bill exactly the same but are paid differently, and assuming that nothing at all changes, that the facility will make more money utilizing a nurse. I'd expect the same result of a similar analysis comparing the cost-effectiveness of teachers' aides as compared to teachers, or legal assistants as compared to lawyers."

Irene Tsikitas

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