Mia Zeller, RN, DNP, CRNA

DNP Nurse Anesthesia 

Improving Veteran Health Administration Anesthesia Cost, Quality, and Access Synthesis Project

Project Category: Evidence Synthesis

Project Team: Mia Zeller, DNP, CRNA, Natalia Walat, DNP, CRNA, Peter Kallio, DNP, CRNA (Advisor)

Abstract

Background: Veterans Health Administration (VHA) anesthesia practice models are inconsistent with the research on patient outcomes, costs, or access to care. No universal practice model exists throughout the VHA, and models vary greatly among sites. It was necessary to combine current studies and synthesize literature to identify VHA anesthetic care gaps and redundancies. Based on evidence, the project aimed to inform VHA about the impact of current anesthesia staffing models on cost, quality of care, and barriers to anesthesia care access compared to military entities.

Methods: As the United States’ largest healthcare system, the Veterans Health Administration (VHA) provides surgical care in 110 hospitals and 27 ambulatory care centers nationwide (Annis et al., 2018). The vision of this organization is to provide exemplary care that is patient-centered and evidence-based while being delivered by a collaborative team of healthcare professionals. However, the anesthesia practice models currently utilized do not align with evidence-based literature recommendations regarding patient outcomes, cost of care, or access to care. There is currently no universal practice model used throughout the VHA system, and practices vary widely among facilities.

Results: The majority of rural anesthesia is provided by the CRNAs due their strong and diverse skill set (Cohen et al. (2021). In addition, during the COVID-19 pandemic, when APRNs were granted increased autonomy, 36% of their care was provided in rural settings, compared to 28% prior to the waiver (Martin, Buck & Zong, 2023). Within the VHA, the independent CRNA practice model was mostly utilized in rural areas and made up for 11.6% of cases (Annis et al. (2018). Physician anesthesiologists practicing independently made up for 31.6% of cases whereas physician anesthesiologist supervising a CRNA made up for 56.8% of cases (Annis et al. (2018). According to the VHA directory, there are currently 822 CRNAs and 892 physician anesthesiologists working within the system (Veterans Affairs, 2023). These metrics can provide insight into VHA staffing ratios and inefficiencies in allocation of anesthesia providers. In contrast, in their analysis of 6,440 private sector institutions regarding anesthesia staffing, Mills et al. (2020) were able to identify staffing arrangements as 30% CRNA only, 26% physician anesthesiologist only, and 44% as anesthesia care team.

Conclusion: Existing literature synthesis suggested that the quality of care provided by CRNAs is on par with that of physician anesthesiologists. There is no significant difference in patient outcomes following an anesthetic administered by either provider, making CRNA services a reliable option for patients in need of anesthesia care. Additionally, CRNA services are beneficial in terms of cost effectiveness and access to care, particularly in underserved and rural communities. Thus, CRNAs are essential in providing safe, high quality, and cost-effective anesthetic care to a wide range of patients. The results are consistent with the six dimensions of health care quality identified by the Institute of Medicine: Healthcare should be safe, timely, equitable, effective, efficient, and patient-centered (Institute of Medicine, 2001). CRNA scope of practice policies vary among government organizations. The vast majority of them permit full scope of practice, but the few that do not, defer to state regulations. Rather than implement change, project leaders sought to inform key stakeholders by disseminating evidence-based recommendations that reflect current VHA and military policies. 

Full Manuscript