4044 — A Description of the Landscape of Anesthesia Care in an Integrated National Healthcare System

Lead/Presenter: Ann Annis, COIN - Ann Arbor
All Authors: Annis AM (VA Ann Arbor Healthcare System) Rahman M (Kellogg Eye Center) Sales A (VA Ann Arbor Healthcare System, University of Michigan Medical School) Robinson C (VA Ann Arbor Healthcare System) Sullivan SC (Office of Nursing Services) Jensen PK (Office of Nursing Services) Hausman MS (VA Ann Arbor Healthcare System, University of Michigan Medical School)

Objectives:
The VA employs physician anesthesiologists, certified registered nurse anesthetists (CRNAs), and anesthesiology residents, to provide anesthesia care to Veterans nationwide, but little is known about the models of care utilized throughout the system. Our aim was to understand and describe the models of anesthesia care in VHA.

Methods:
Retrospective surgical data from 125 VHA facilities for an 18-month period (October 1, 2013-March 31, 2015) were analyzed. Three models of anesthesia care were identified based on the documented principal anesthetist and supervising anesthetist (if present): Model 1: physician anesthesiologist supervising a CRNA; Model 2: physician anesthesiologist practicing independently or supervising an anesthesiology resident; and Model 3: CRNA without a supervising anesthesiologist. Case volume and the prevalence of anesthesia care models were determined by surgical case complexity, patient health status, and facility complexity.

Results:
Over half (57%) of all surgical cases indicated a model of physician anesthesiologist supervising CRNA (Model 1), whereas 32% of cases were categorized as having a physician-driven model (Model 2: physician anesthesiologist practicing independently or physician anesthesiologist supervising resident), and 12% of cases indicated a CRNA without supervision model (Model 3). A higher proportion of highly complex cases were Model 2 (39%) than Model 3 (6%). Over half of surgical cases in the largest, most complex facilities utilized a supervisory approach to anesthesia care (Model 1), while the CRNA without supervision model (Model 3) was found almost exclusively among surgical cases in smaller facilities with lower complexity.

Implications:
Documentation of surgical cases in VHA facilities indicates that anesthesia care is delivered primarily by physician anesthesiologists supervising CRNAs. CRNA without supervision was most prevalent among lower complexity surgical cases and lower complexity facilities with less surgical volume.

Impacts:
Utilization of CRNAs in VHA is likely influenced by case- and facility-level factors, and by the surgical services and availability of physician anesthesiologists at facilities. CRNA practice without supervision may be a component of guaranteeing access to surgical services in VHA, particularly at smaller, rural facilities. Further efforts should evaluate how anesthesia care models best optimize care delivery, benefit anesthesia providers, and improve health outcomes for patients.