Anesthesia E-ssential, May 15, 2013

Anesthesia E-ssential

May 15, 2013


Vital Signs

Anesthesia Professionals Question Safety of Non-experts Giving Propofol to Patients via New Sedasys™ Machine
Responding to a decision by the Food and Drug Administration (FDA) to approve a new machine that allows healthcare providers who are not anesthesia experts to give the powerful drug propofol to patients undergoing colonoscopies and other gastrointestinal procedures, the AANA stated that the safest option for any patient receiving propofol is still the hands-on care provided by CRNAs and physician anesthesiologists.
The pre-market approval of Johnson & Johnson’s Sedasys™ machine for administering propofol (Diprivan™) was announced on May 6 after three years of denial by the agency.
“Propofol is an effective anesthetic drug for colonoscopies and endoscopies because it is short acting and patients typically wake up quickly and feeling alert,” said AANA President Janice Izlar, CRNA, DNAP. “However, propofol is also a very powerful drug in that any patient receiving it can slip from a mildly sedated state into a state of general anesthesia requiring assistance with breathing. That’s why it is always best for propofol to be administered by a qualified anesthesia professional. Since a machine is not able to prevent or manage loss of consciousness, we have serious concerns.”
A 2004 joint position statement of the AANA and the American Society of Anesthesiologists (ASA) concurs, saying, “Whenever propofol is used for sedation/anesthesia, it should be administered only by persons trained in the administration of general anesthesia, who are not simultaneously involved in these surgical or diagnostic procedures.”
Even the FDA-approved labeling on propofol warns that the drug should only be provided by persons qualified in general anesthesia because the drug’s effects cannot be reversed.
According to Johnson & Johnson, facilities where the Sedasys machine is used should have an anesthesia professional immediately available for assistance or consultation, a vague requirement that generally limits the machine’s utility and cost-effectiveness. Johnson & Johnson also stresses the need for the propofol provider to be trained in dealing with the drug’s cardiorespiratory effects—abilities that CRNAs and anesthesiologists master during years of advanced education and clinical training.
“CRNAs are master’s prepared anesthesia experts educated and trained in the administration of general anesthesia and pain management,” said Izlar. “Numerous studies have demonstrated the cost effectiveness and high quality of CRNA care when personally provided to an individual patient. Substituting a machine for a dedicated anesthesia expert involves unknown costs and risks.”
Johnson & Johnson plans to conduct two studies to monitor use of the Sedasys machine in actual clinical practice after a limited rollout in 2014.


The Pulse

  • Negative Impact of Anesthesia Drug Shortages Lessened through Improved Communication Efforts, Survey Data Reveal
  • Be Sure to Vote in the AANA 2013 Election!
  • Online Forum for Board of Directors Candidates Open Now
  • AANA Seeks Senior Director of Finance
  • Great Workshop, Great Location, Reduced Price! Register Now!
  • Inspiring, Dynamic Keynote Speaker Slated for 2013 Annual Meeting
  • AANA Foundation Friends for Life Deadline is June 15
  • Register Now for AANA Foundation Event: Vegas - The Stars Come Out at Night
  • APRN License Required for CRNAs in West Virginia
  • Earn Six Free CE Credits: Take the AANA Journal Course Examination
  • Member Spotlight added to AANA Website
  • Administration Will Not Issue Regulations on ACA Provider Nondiscrimination Provision Before 2014
  • WPS Medicare Restores Coverage of CRNA Ultrasound Guidance Services
  • Lawmakers Reintroduce AMA-backed "Truth and Transparency" Bill with New Name
  • Congress Holds Hearings on Medicare SGR Fix
  • 27 Senators Sign in Support of Nursing Workforce Development
  • Are Your Reporting PQRS Quality Codes? If Not, You May Be Subject to Medicare Cuts
  • What CMS Said March 2012 About Medical Staffs and APRNs
  • CMS Issues Inpatient Hospital Rule, Requests Comment on Inpatient Hospital Anesthesia Quality and Efficiency Measures
  • AANA Participates in Institute of Medicine Innovation Collaborative
  • Tavenner's CMS Confirmation Delayed Over Funding Issue
  • Healthcare Cost Growth Continues Leveling Off, Says Health Affairs
  • Transitioning Away From Fee-for-Service Leads Recent Health Reform Plans

Healthcare Headlines

Healthcare Headlines is for informational purposes, and its content should not be interpreted as endorsements, standards of care, or position statements of the American Association of Nurse Anesthetists.

Inside the Association
Negative Impact of Anesthesia Drug Shortages Lessened through Improved Communication Efforts, Survey Data Reveal
While anesthesia drug shortages continue to disrupt patient access to healthcare by forcing the cancellation of surgical and other procedures, data from the AANA Drug Shortage Survey reveal that improved communication between drug manufacturers, pharmacists, anesthesia providers, and the U.S. Food and Drug Administration (FDA) would help mitigate the problem. Approximately 2,500 CRNAs responded to the survey. Respondents identified the following drug shortage information as most valuable to their practice: advance notice of a drug shortage (77 percent); anticipated duration of a shortage (76 percent); alternative drug choices and techniques (64 percent); medication inventory availability (53 percent); and source of the shortage (47 percent). Read the AANA press release here.
Be Sure to Vote in the AANA 2013 Election!
Voting Ends May 21, 12 Noon CDT
By now, active AANA members should have received their ballot materials, including their E-signature and voting instructions, electronically or in the mail from Survey & Ballot Systems (SBS), the AANA's election coordinator. The email with the voting credentials originates from Please make sure this email did not end up in your spam or junk mail folder. To access the AANA election site visit and enter your member number and the E-signature provided to you by SBS.
If you do not have your election login information, click on the “Need help logging in?” link on the login page and enter the email address on file with AANA, and your election login information will be emailed to you. SBS can be reached by phone at (952) 974-2339 (Monday through Friday, 8 a.m. to 5 p.m. CDT) or by email at If it’s more convenient, please feel free to contact or, and they will ask SBS to re-send you your voting credentials.
Online Forum for Board of Directors Candidates Open Now
Take advantage of this opportunity to become better acquainted with the candidates seeking election to the AANA Board of Directors. Available since April 15, this un-moderated forum is located in the members-only section of the AANA website at, along with the candidates’ speeches, photos, and position statements. The forum will be available until May 21 (the voting cut-off date).
AANA Seeks Senior Director of Finance
The AANA is conducting a search for a Senior Director of Finance to provide strategic leadership and guidance to the Association's Finance Division. This position reports directly to the AANA’s chief operating officer and supervises a professional staff for finance operations, accounting, financial management information systems, dues processing and member services. The Senior Director, Finance provides high-level financial advice, guidance, analysis and reports to the Chief Operating Officer, the President, the Board of Directors and the senior leadership team to help ensure the AANA’s success as one of the nation’s preeminent healthcare associations.
The ideal candidate for this role will bring the following qualifications: seven to ten years of senior-level financial management experience leading successful teams in finance, accounting and budgeting functions, ideally in a nonprofit organization or professional association, including 15 years or more of broad experience in finance and accounting in either a nonprofit or a corporate business setting; a bachelor's degree in accounting, finance or related field, and a current CPA designation is required; a master’s degree and/or MBA would be an advantage; must be a team-focused leader with a strong management ability to develop high-performing staff that produces quality results in a timely manner.
To be considered for this opportunity, send a cover letter and resume to: Colleen Rogers, Associate Consultant, Executive Search at
Great Workshop, Great Location, Reduced Price! Register Now!
AANA members and student registered nurse anesthetists now have the opportunity to attend the AANA Comprehensive Ultrasound Guided Peripheral Nerve Block and Vascular Access Workshop June 1-2, 2013, for a reduced registration fee and new special student rate! And the location can’t be matched: The AAA Five Diamond Grand America Hotel in Salt Lake City, Utah, surrounded by majestic mountains and within walking distance of vibrant downtown Salt Lake City. Much planning and preparation have gone into developing this workshop, which provides a comprehensive review of current practices related to peripheral nerve blocks and vascular access. Along with the basic sciences, current literature and latest techniques involving the use of ultrasound in anesthesia practice, this program helps CRNAs enhance their expertise, fill in knowledge gaps, and take their practice to the next level in these important areas. Register today for this stimulating and highly regarded workshop!
Inspiring, Dynamic Keynote Speaker Slated for 2013 Annual Meeting
The highly engaging motivational speaker J. R. Martinez will be the 2013 Annual Meeting Keynote speaker. A former U.S. Army soldier, Martinez suffered severe burns over 34 percent of his body in 2003, when his Humvee drove over a roadside explosive device, trapping him inside. Since his recovery, he has traveled around the country speaking about his experiences to corporations, veterans groups, schools, and other organizations. He devotes himself to showing others the true value of making the most of every situation. Fans of ABC’s “Dancing with the Stars” will recall that Martinez, along with his dance partner, Karina Smirnoff, took the season 13 coveted mirror ball trophy. He also starred on the daytime drama, “All My Children” and Lifetime’s “Army Wives.” Don’t miss his remarkable and inspiring presentation—Register today!

AANA Foundation Friends for Life Deadline is June 15
Friends for Life help support the future of the nurse anesthesia profession through meaningful, lasting gifts. Contributions through Friends for Life help fund and sustain programs that further research and education in anesthesia. Friends for Life receive a medallion at the Annual Meeting Opening Ceremonies, an engraved plaque in the AANA Park Ridge office and an invitation to the Annual Awards and Recognition Event. The minimum gift commitment to join Friends for Life is $25,000. Members may fulfill this commitment through a cash gift, but there are many other ways to meet the commitment through planned gifts. Some of the most popular planned gift options for becoming a Friend for Life include:
  • A gift (bequest) in the will for a specific amount or a percentage of the total estate
  • Gift of personal property or real estate
  • Including the Foundation as a beneficiary on a retirement plan or a whole life insurance policy
For further information, please contact Nat Carmichael at (847) 655-1175 or  The Friends for Life submission deadline for recognition at this year’s Annual Meeting in Las Vegas, Nevada is June 15, 2013.
Register Now for AANA Foundation Event: Vegas – The Stars Come Out at Night
If you’re planning to attend the Annual Meeting in Las Vegas and are looking to have a great time, watch fellow CRNAs and SRNAs compete in a talent competition with Kenan Thompson as emcee, and support a great cause, register today for… Vegas – The Stars Come Out At Night, Monday, Aug. 12, 2013 at 7:30 p.m. – Treasure Island Ballroom. To register, visit the Annual Meeting webpage and register online or via email or fax your registration to AANA. Once on the registration form, be sure to complete section 5 – Ticketed Events and register for the Monday Evening – AANA Foundation Fundraiser. Thank you in advance for your support. A portion of your registration fee for this event is tax-deductible and will support nurse anesthesia education and research. See you in Vegas!

APRN License Required for CRNAs in West Virginia
An Advanced Practice Registered Nurse (APRN) license is required in West Virginia beginning July 1, 2013, to continue or to begin practicing as a CRNA in that state. See the AANA website for more information and links to application forms. 

Earn Six Free CE Credits: Take the AANA Journal Course Examination
This member benefit will be available through July 31, 2013. Log in now!
Member Spotlight added to AANA Website
A new section has been added to the AANA website that aims to shine a light on CRNAs taking part in noteworthy endeavors. The Member Spotlight page will be filled with features stories, pictures and information about the hobbies, charities and second lives of anesthetists. It can be accessed by clicking on the News & Journal tab on the homepage or by clicking here. If you know someone you think should be profiled, contact Leland Humbertson at

Administration Will Not Issue Regulations on ACA Provider Nondiscrimination Provision Before 2014
The Obama Administration will not issue regulations interpreting the AANA-backed provider nondiscrimination provision of the Affordable Care Act before it takes effect Jan. 1, 2014, saying in an “FAQ” document issued this month that the provision is self-executing.
According to the FAQ document issued by the Medicare agency, IRS-Treasury and the Department of Labor, the administration said that until any further guidance is issued, non-grandfathered group health plans and health insurance issuers offering group or individual coverage are expected to implement the provision starting Jan. 1, 2014, using a good faith, reasonable interpretation of the law. The AANA supports provider nondiscrimination because it prohibits health plans from discriminating against qualified licensed health professionals, such as CRNAs, solely on the basis of licensure.
The FAQ document provides CRNAs some cause for concern, though, that the AANA has brought to the agencies’ attention. Namely, the document says that the provision “does not govern provider reimbursement rates,” and that it “does not require plans or issuers to accept all types of providers into a network.” The AANA has communicated to the agencies that the provision prohibits plans from discriminating solely on the basis of licensure, though market conditions and other factors may affect reimbursement. Further, the AANA has said if a plan covers anesthesia services, it may not exclude CRNA anesthesia services.
To view the FAQ document, see and scroll down to the provider nondiscrimination provision.
WPS Medicare Restores Coverage of CRNA Ultrasound Guidance Services
Wisconsin Physician Services Insurance Corporation (WPS), the Medicare Administrative Contractor (MAC) for Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, and Wisconsin, has informed the AANA that the carrier will no longer deny CRNA claims for ultrasound guidance (CPT 76942) as long as the procedure is within state scope of practice and is reasonable and necessary. This change will be retroactive to Jan. 1, 2013. The action by WPS Medicare came in response to concerns raised by AANA on behalf of its members whose ultrasound guidance services were being denied coverage by that MAC.
A mass adjustment will be done to pay claims that have been denied Jan. 1, 2013, to the present date for this issue, meaning that CRNAs will not need to compute and submit re-determinations for these claims. WPS states that this action should be completed within the next three weeks. Though the action does not affect states outside the WPS region, only CRNAs within the WPS region were subjected to denials in the first place.
The WPS contractor medical director offers the following guidance when billing for this service: “Please do note that CPT 76942 does state ‘imaging supervision and interpretation.’ We would therefore expect that there is documentation of a separate imaging report in the medical record to support the usage of this CPT code.”
Should you have any questions or concerns regarding this matter, please email with the subject line “WPS.”
Lawmakers Reintroduce AMA-backed “Truth and Transparency” Bill with New Name
The AMA-backed “truth and transparency” legislation has been reintroduced in the House by Reps. Larry Buschon (R-IN) and David Scott (D-GA) with the new name “Truth in Healthcare Marketing Act of 2013” (H.R. 1427), and was referred to the House Energy and Commerce Committee. But it is similar to legislation that former Rep. John Sullivan (R-OK) introduced in the last few Congresses before he was defeated in a primary election last summer.
The legislation would prohibit deceptive or misleading statements or acts that misrepresent whether a person holds a state healthcare license or misrepresents his or her education, degree, license, or clinical expertise. It requires healthcare professionals who advertise to disclose their licensure in their ads. It creates a federal course of action for the Federal Trade Commission (FTC) to prosecute violations, and orders the Federal Trade Commission to conduct a study and report which specific acts should be prosecutable under the legislation. The legislation also says it does not preempt state or local laws in this area.
A letter from the AMA and specialty groups supporting HR 1427 said, “Patients … are understandably confused by the increasing ambiguity of healthcare provider-related advertisements and marketing. Because of this uncertainty, patient-centered care and decision-making have been compromised,” reported Medscape Medical News April 24. However, the AMA did not explain the inconsistency between its support of FTC investigation of professional misrepresentations and its opposition to FTC letters to states and regulators when policy proposals impair patient access to care by qualified licensed providers.
While the AANA is reviewing the legislation, the AANA, APRN and allied health groups have expressed concerns about similar “truth and transparency” measures in the past, saying that they federalize commercial fraud and misrepresentation laws already on the books in the states, and they perpetuate the AMA’s “scope of practice partnership” agenda constraining competition and patient choice for services provided by physicians that can also be delivered by other healthcare professionals within their scope of practice.
Congress Holds Hearings on Medicare SGR Fix
Emboldened by slower healthcare spending growth reducing the cost of permanently fixing the annual Medicare Part B “sustainable growth rate” (SGR) funding formula cuts, committees in the House and Senate are newly holding hearings to examine the issue and seeking comments from the public.
The House Ways & Means Subcommittee on Health hosted its most recent hearing May 7, and the Senate Finance Committee has scheduled a hearing for May 14. “Using its new Medicare spending projections, CBO (the Congressional Budget Office) estimates that freezing Medicare physician payments at their current level over a 10-year period would cost $138 billion,” said subcommittee chair Rep. Kevin Brady (R-TX) in his opening statement. “This is a significant reduction from its $243 billion estimate for the same policy just a few months before.”
The AANA has been presenting Congress comments to its SGR funding formula proposals, focusing on the value and role of CRNAs, and the importance of APRNs to ensuring patient access to quality healthcare.
For further information, see the House Ways & Means Health Subcommittee hearing record, Chairman Kevin Brady’s (R-TX) opening statement, and the AANA’s most recent comments to Congress (requires AANA member login and password).
27 Senators Sign in Support of Nursing Workforce Development
Twenty-seven U.S. Senators wrote April 26 in support of the President’s 2014 budget request of $251 million for Title 8 nursing workforce development programs.
“We respectfully request that the Nursing Workforce Development Programs receive $251 million in Fiscal Year 2014,” they wrote to Senate Appropriations Labor-HHS-Education Subcommittee Chair Tom Harkin (D-IA) and Ranking Member Jerry Moran (R-KS). “Title VIII programs help to ensure that nursing care reaches our nation’s most vulnerable populations and underserved communities.”
The signers were Sens. Tammy Baldwin (D-WI), Richard Blumenthal (D-CT), Barbara Boxer (D-CA), Sherrod Brown (D-OH), Robert Casey (D-PA), Richard Durbin (D-IL), Al Franken (D-MN), Kirsten Gillibrand (D-NY), Kay Hagan (D-NC), Martin Heinrich (D-NM), Mazie Hirono (D-HI), Tim Johnson (D-SD), Amy Klobuchar (D-MN), Frank Lautenberg (D-NJ), Patrick Leahy (D-VT), Carl Levin (D-MI), Robert Menendez (D-NJ), Jeff Merkley (D-OR), Jack Reed (D-RI), John Rockefeller (D-WV), Bernard Sanders (I-VT), Brian Schatz (D-HI), Chuck Schumer (D-NY), Jeanne Shaheen (D-NH), Debbie Stabenow (D-MI), Jon Tester (D-MT), and Sheldon Whitehouse (D-RI).
Are You Reporting PQRS Quality Codes? If Not, You May Be Subject to Medicare Cuts
When you submit claims to Medicare, are you taking care to submit Physician Quality Reporting System (PQRS) quality measurements in as many cases as possible? You should, because successfully completing these reports in 50 percent or more of your Medicare cases in 2013 may make a 1.5 percent difference in your 2014 Medicare revenues.
Many CRNAs are already participating in PQRS. According to Medicare Chief Medical Officer Dr. Patrick Conway, 17,166 CRNAs were eligible participants in PQRS in 2011, and 38.9 percent of eligible CRNAs participated in the program that year. Further, 14,014 CRNAs received PQRS incentive payments for 2011, 81.6 percent of the total eligible, yielding a mean incentive amount of $202.16. Among APRN specialties, CRNAs had the highest level of participation in 2011.
Further, the most common measures that CRNAs reported in 2011 were, in order:
  • #30, perioperative care, timely administration of prophylactic parenteral antibiotics;
  • #193, perioperative temperature management;
  • #76, prevention of catheter-related bloodstram infections (CRBSI): central venous catheter (CVC) insertion protocol;
  • #20, perioperative care, timing of antibiotic prophylaxis—ordering physician, and;
  • #145, radiology, exposure time reported for procedures using fluoroscopy.
What CMS Said March 2012 About Medical Staffs and APRNs
Seven months after the Medicare agency finalized a rule encouraging hospital medical staffs to include advanced practice registered nurses (APRNs) such as CRNAs, the implementation of the rule is causing members to bring questions to the AANA. Here’s a recap of the final rule.
Medicare medical staff guidelines were changed to accommodate CRNAs and APRNs more thoroughly, according to a final rule published in the Federal Register May 16, 2012. The final rule for reform of Medicare and Medicaid Hospital and Critical Access Hospital Conditions of Participation was the subject of an AANA regulatory comment letter, as well as a nurse organization coalition comment coordinated by the AANA. The final rule addresses many of the issues raised by AANA and APRN colleagues.
Among other provisions, by its broadening the concept of “medical staff” to explicitly allow hospitals to use other practitioners as candidates for the medical staff with privileges to practice in the hospital according to state law, the agency said it would “clearly permit hospitals to use other practitioners (e.g. APRNs, PAs, pharmacists) to perform all functions within their scope of practice.” It also authorizes that “all practitioners will function under the medical staff.” Most CRNAs practice under medical staff, and the trend has been toward a greater number doing so.
For further information, read the final rule, specifically the portions on “medical staff,” the AANA comment letter, and the APRN comment letter. Access to the comment letters requires AANA member login and password.
CMS Issues Inpatient Hospital Rule, Requests Comment on Inpatient Hospital Anesthesia Quality and Efficiency Measures
The Medicare agency is proposing tying Medicare hospital payment incentives to achieving certain quality measures and proposing paying for reporting of other quality measures according to a notice of proposed rulemaking published May 10.
Among the hospital quality programs:
  • As part of development for measures for future years of the Hospital Inpatient Quality Reporting Program and the Hospital Value Based Purchasing Program, CMS is considering the addition of Medicare spending measures specific to such services as anesthesiology and is seeking input on how best to construct these measures. Note, however, that this request for information relates to hospital quality reporting and hospital value-based purchasing programs, and not directly to Medicare Part B anesthesia payments for CRNA services.
  • For the new Hospital-Acquired Condition Reduction Program, which is beginning in FY 2015, CMS is proposing to include two domains of measure sets. The first would include six patient safety indicator measures, including iatrogenic pneumothorax rate. The second domain would include the two healthcare-associated measures of central line-associated blood stream infections and catheter-associated urinary tract infections. Hospitals that are the lowest performing would receive a 1 percent reduction in what they would have received under the inpatient prospective payment system.
  • CMS is proposing to include among measures for the FY 2016 hospital value-based purchasing program, Surgical Care Improvement Project (SCIP) Measures, and Surgical Infection Measures restricted to colon and abdominal hysterectomy procedures. For the first time, the FY 2015 measures will include a Medicare spending per beneficiary measure, and CMS is proposing to include this as an FY 2016 measure as well.
The Medicare agency’s Hospital Inpatient Prospective Payment System Proposed Rule is under review by AANA, and subject to comment by June 25.
AANA Participates in Institute of Medicine Innovation Collaborative
On May 1, the AANA participated in the Institute of Medicine (IOM) Best Practices Innovation Collaborative, an ad hoc convening activity under the auspices of the IOM Roundtable on Value & Science-Driven Health Care. Here, professional organizations representing clinicians and government agencies actively involved in patient care programs gathered in Washington, D.C., to discuss identification and application of best practices.
Discussion at the Collaborative centered on team-based care and the patient’s role and responsibility as a member of the care team. What are the necessary conditions for successful partnering between patients and the surgical care team? What are the barriers that prevent patients from becoming active participants in their peri-operative care? What are the principles and expectations of patient-CRNA communication? These are just a few of the questions for CRNAs to consider as patient and family-centered care become more of a focus in healthcare policy development.
Tavenner’s CMS Confirmation Delayed Over Funding Issue
Senate confirmation of Marilyn Tavenner, RN, MHA, FACHE, to head the Medicare agency was delayed late April, as Sen. Tom Harkin (D-IA) placed a hold on her nomination to protest the Administration’s use of the Affordable Care Act’s Prevention and Public Health Fund. Two weeks later, Harkin relented, saying he had made his point, and a Senate confirmation vote for Tavenner was slated to take place.
During consideration of the Affordable Care Act in 2010, Sen. Harkin worked to ensure that the law included the Prevention and Public Health Fund to support initiatives for preventing illness and promoting health, so he watches over it closely. At a Senate hearing April 25, Harkin said he was disappointed that the fund was instead being used for other health reform initiatives inconsistent with what he felt was the fund’s original purpose. HHS Secretary Kathleen Sebelius responded that the Administration has tapped the fund to support expanding health insurance coverage and disease prevention education, and that congressional Republicans have blocked Administration requests for congressional funding of Affordable Care Act implementation.
Tavenner’s Senate confirmation, backed by AANA and many other healthcare organizations, was approved by the Senate Finance Committee April 23.
Read more from Kaiser Health News.
Healthcare Cost Growth Continues Leveling Off, Says Health Affairs
Healthcare cost growth in the United States has leveled off since 2004 to approximately the same growth as the economy, primarily because patients are having to pay more out-of-pocket in copays and deductibles, the effects of the 2008 financial crisis and following recession, and less use of new technology than expected. The findings appear in the May 2013 issue of Health Affairs, and represent a significant change from the historical pattern in which healthcare spending grew much faster than the U.S. economy.
What might this mean for CRNAs? Drawing reliable policy conclusions from the studies requires further time analysis than has been made available thus far. One question is whether this leveling-off of healthcare spending growth is a temporary or a permanent condition, knowing that the number of baby boomers retiring into Medicare is growing. One conclusion that the Congressional Budget Office has drawn is that reduced healthcare spending growth substantially reduces the cost of fixing the Medicare “sustainable growth rate” funding formula problem. Whether that reduction is enough to spur Congress to act remains another question.
Several of the studies used to draw these conclusions are available online at Blogs and abstracts are available free, articles require purchase or subscription.

Transitioning Away From Fee-for-Service Leads Recent Health Reform Plans
Two leading bipartisan policy organizations in Washington, D.C., have issued new proposals for further healthcare and entitlement program reforms. The note ringing through both, just as Congress is preparing to consider legislation replacing the flawed Medicare “sustainable growth rate” funding formula, is that fee-for-service reimbursement should be replaced by some type of coordinated or bundled payment system.
To the extent that legislators and regulators follow suit with recommendations released late April by the Bipartisan Policy Center and the Brookings Institution, such change portends opportunity for CRNAs as healthcare facilities and surgeons seek quality improvement and cost-consciousness at the same time. But it also portends risk for CRNAs as nurse anesthesia seeks direct reimbursement not from health plans, but from hospitals or surgeons as a share of the bundled payment that plans provide them.
Issued April 16, the Bipartisan Policy Center “Bipartisan Rx for Patient-centered Care and System-wide Cost Containment” introduces “Medicare Networks” as a concept to promote coordinated care delivery and cost savings. The Brookings plan released April 29 is titled “Bending the Curve: Person-centered Health Care Reform,” and it urges moving away from fee-for-service payment and toward modifications in Medicare payment systems and benefits. Both are worth a close review by CRNAs.
To learn more, read the Bipartisan Policy Center report and the Brookings report.
FEC-Required Legal Notification for CRNA-PAC
Gifts to political action committees are not tax deductible. Contributions to CRNA-PAC are for political purposes. All contributions to CRNA-PAC are voluntary. You may refuse to contribute without reprisal. The guidelines are merely suggestions. You are free to contribute more or less than the guidelines suggest and the association will not favor or disadvantage you by reason of the amount contributed or the decision not to contribute. Federal law requires CRNA-PAC to use its best efforts to collect and report the name, mailing address, occupation, and the name of the employer of individuals whose contributions exceed $200 in a calendar year. Each contributor must be a US citizen. 


Conscious sedation, rather than general anesthesia, may suffice during cryoablation procedures for atrial fibrillation, based on the findings of a small-scale study. Researchers at Memorial Leighton Heart and Vascular Center in South Bend, Ind., studied 88 patients undergoing cryoablation between mid-June 2011 and mid-November 2012. Among them, 14 received general anesthesia because of existing sleep apnea conditions that made moderate sedation risky for them; but the other 74 successfully underwent conscious sedation without needing to be converted over to general anesthesia. The team led by Patricia Gasper, RN, the center's electrophysiology coordinator, found that dexmedetomidine along with fentanyl and midazolam was able to keep patients comfortable. The day after their procedures, none of the conscious sedation patients could recall the phrenic nerve pacing that makes cryoablation so uncomfortable. Moreover, the approach saved more than $1,800 per patient just in medication costs. Although a larger, multi-center study is needed to verify the findings, the researchers determined, "Dexmedetomidine is a safe, efficacious, and cost-effective alternative to general anesthesia in the majority of patients undergoing balloon ablation for atrial fibrillation."
From "Cryoablation May Not Need Full Anesthesia"
MedPage Today (05/09/13) Phend, Crystal

General Anesthesia Not Linked to Raised Risk for Dementia
A new study published in the May 1 online edition of the journal Mayo Clinic Proceedings concluded that receiving general anesthesia does not place older people in more danger of developing long-term dementia or Alzheimer's disease. The research involved 900 patients aged 45 and older who had dementia—all residents of Olmsted County, Minn.—over a period of about 10 years. They were compared to individuals of similar ages, also living in the area, who did not develop dementia during that time frame. An estimated 70 percent of the study participants in both groups underwent surgery requiring general anesthesia. The Mayo investigators found that among those patients who had already been diagnosed with dementia, there were no indications that their symptoms worsened due to receiving general anesthesia. For those who did not have dementia, meanwhile, there was no evidence that they developed the disease after receiving general anesthesia. Based on the results, the researchers determined that administering general anesthesia does not increase elderly patients' long-term risk for developing dementia.
From "General Anesthesia Not Linked to Raised Risk for Dementia"
Doctors Lounge (05/01/2013)

Study Finds Survival From Cardiac Arrest Highest in the Operating Room or Post-Anesthesia Care Unit
According to a University of Michigan study published ahead of print in Anesthesiology, hospital patients who went into cardiac arrest were more likely to survive if they were in the operating room (OR) or post-anesthesia care unit (PACU) at the time. The survival rate in these areas was 25 percent to 65 percent higher than when cardiac arrest occurred in the intensive care unit (ICU) or general in-patient areas. Satya Krishna Ramachandran, MD, assistant anesthesiology professor at the University of Michigan, said, "The most surprising findings ... were that very sick patients in the ICU and postoperative low-risk patients in general inpatient areas had the poorest outcomes. We found outcomes were best when cardiac arrest occurred during or immediately after surgery and anesthesia. This [evidence] supports the view that the availability of anesthesia providers in the OR and PACU may contribute to better outcomes."
From "Study Finds Survival From Cardiac Arrest Highest in the Operating Room or Post-Anesthesia Care Unit"
Science Codex (05/01/13)

Anesthesia Selection Impacts Outcomes in Patients With Sleep Apnea Undergoing Joint Replacement
Researchers have concluded that the use of regional anesthesia in place of general anesthesia during total joint replacement improves outcomes in patients with sleep apnea, who tend to present complications more frequently than other patients. A team from New York City's Hospital for Special Surgery conducted a retrospective review of all hip and knee replacements performed nationwide on patients with sleep apnea between 2006 and 2010. Approximately 11 percent of the 30,024 patients had their procedure done under neuraxial anesthesia, a type of regional anesthesia; 15 percent under combined neuraxial/general anesthesia; and 74 percent under general anesthesia alone. Lead researcher Stavros Memtsoudis, MD, director of Critical Care Services at Hospital for Special Surgery, said "We wanted to know if regional anesthesia really makes a difference in this patient population and it seems to be doing that. Neuraxial anesthesia was associated with lower risk of complications" including gastrointestinal, infectious, and pulmonary complications; a reduced use of critical care services, mechanical ventilation, and transfusions; and "a [slight] decrease in the length of stay in the hospital." Reporting in Regional Anesthesia and Pain Medicine, the investigators suggested the results may apply to patients with sleep apnea undergoing surgeries such as prostatectomies and hysterectomies—an area currently being explored. "Before this study, the recommendation to use neuraxial anesthesia in sleep apnea patients was based on no scientific foundation," said Memtsoudis. The new study, presented at the annual Regional Anesthesiology and Acute Pain Medicine Meeting in Boston in early May, provides much needed support for the recommendation.
From "Anesthesia Selection Impacts Outcomes in Patients With Sleep Apnea Undergoing Joint Replacement"
Science Daily (05/03/2013) Memtsoudis, Stavros G.; Stundner, Ottokar; Rasul, Rehana; et al.
Choice of Anesthetic Technique on Plasma Concentrations of Interleukins and Cell Adhesion Molecules
To explore whether total intravenous anesthesia (TIVA) and volatile anesthesia provoke the same inflammatory responses during surgery, researchers studied 88 patients having laparoscopic cholecystectomies. Half were randomly assigned to undergo TIVA, with the other half receiving isoflurane anesthesia. Plasma concentrations of proinflammatory and anti-inflammatory interleukins (ILs) and cell adhesion molecules were measured in each patient before the procedure, prior to incision, at two hours after the surgery, and again at 24 hours postoperatively. Upon comparing the results, IL-6 was the only flagged biomarker that was not the same for both sets of patients. Two hours after surgery, concentrations of IL-6 were notably higher in the isoflurane group compared to the TIVA patients; however, levels between the two cohorts were equalized at baseline value within 24 hours post-operation. The researchers determined that the differences probably are not clinically relevant and called for additional studies.
From "Choice of Anesthetic Technique on Plasma Concentrations of Interleukins and Cell Adhesion Molecules"
7thSpace (05/02/13) Ionescu, Daniela; Sessler, Daniel; Miron, Nicolae; et al.
Enteral vs. Intravenous ICU Sedation Management: Study Protocol for a Randomized Controlled Trial
Italian researchers conducted a multi-center trial for the purpose of comparing enteral and intravenous sedative treatments in the intensive care unit (ICU). The study ran from Jan. 24-Dec. 31, 2012, with a total of 348 patients who were randomized to receive either intravenous propofol/midazolam or enteral melatonin/hydroxyzine/lorazepam. While not often used and incapable of producing deep sedation, the enteral approach effectively helps patients reach the 'conscious target,' where they are remain awake and adapted to the environment—even during the critical phases of illness. Moreover, enteral sedation accomplishes this with fewer side effects and lower costs. In addition to comparing the two sedative strategies, the "educational research" project sought to underscore the need for a cultural change in ICUs, based on the premise that outcomes can be improved by keeping critically ill patients awake.
From "Enteral vs. Intravenous ICU Sedation Management: Study Protocol for a Randomized Controlled Trial"
7thSpace (04/03/13) Mistraletti, Giovanni; Mantovani, Elena S.; Cadringher, Paolo; et al.

Effect of the Intraoperative Wake-Up Test in Sevoflurane-Sufentanil Combined Anesthesia During Adolescent Idiopathic Scoliosis Surgery
Sevoflurane-sufentanil anesthesia allows for fast recovery from adolescent idiopathic scoliosis (AIS) surgery; but researchers set out to determine what, if any, effect the intraoperative wake-up test for this approach has on outcomes. For the study, 30 AIS surgical patients were administered the combined anesthesia, then randomly assigned to undergo the wake-up test or not. The primary outcome was postoperative delirium, which occurred in one patient from each group. The researchers also calculated no statistically significant difference between the two sets of patients in terms of duration of anesthesia, duration of surgery, intraoperative blood loss and transfusion, average exposure of drugs administered, time to eye opening, extubation, and consciousness.
From "Effect of the Intraoperative Wake-Up Test in Sevoflurane-Sufentanil Combined Anesthesia During Adolescent Idiopathic Scoliosis Surgery"
Science Index (05/07/13)

Nubain Reduces Opioid-Related Itching
Pruritus, or itching, triggered by opioid use can be relieved with nalbuphine (Nubain), according to preliminary research presented at the American Pain Society's annual meeting. After reviewing 10 comparison trials, Rose Enricoso Jannuzzi, DNP, a nurse practitioner in pain control at Valley Health/Winchester Medical Center in Winchester, Va., found nalbuphine to be superior to propofol, diphenhydramine, naloxone, or placebo for treating pruritis in patients taking opioids for acute pain following surgery or labor. Not only did nalbuphine alleviate the itching more often than the other agents, it also reduced the incidence of nausea or vomiting and reversed respiratory depression. Jannuzzi additionally reported no attenuation of analgesia or deepening of sedation with low-dose nalbuphine. She noted that pruritis occurred most often in patients receiving neuraxial opioids.
From "Nubain Reduces Opioid-Related Itching"
MedPage Today (05/10/13) Susman, Ed
War Spawns New Approaches for Wounded Service Members' Pain Care
Battlefield injuries are challenging the medical community to come up with new and better ways to treat the unspeakable pain of soldiers who survive IED blasts and other wartime trauma. At the American Pain Society's annual scientific meeting recently, Defense Department scientists reported that strides are being made in treating military members who return from deployment with severe burns. Opioids have been the traditional approach in this scenario; however, with their extended use comes the risk of addiction and the increased potential for respiratory complications. According to Dayna Loyd Averitt, PhD, a DOD researcher at the U.S. Army Institute of Surgical Research, the Army is delving into innovative new treatment options, such as complementary drug therapy regimens, multidisciplinary pain management approaches, and even the use of virtual reality to alleviate pain to reduce pain during procedures. Specific projects include using tramadol—a synthetic analgesic—to treat pain or using resiniferatoxin—an injectable agent—to deactivate nerve endings for a period of time, which has shown in preclinical trials to significantly curb pain sensitivity from burns.
From "War Spawns New Approaches for Wounded Service Members' Pain Care"
Science Daily (05/11/2013)

Duloxetine May Ease Neuropathy From Chemo
A phase III trial recently published in the Journal of the American Medical Association has found that the depression and anxiety drug duloxetine is effective at treating peripheral neuropathy caused by chemotherapy. The study found that peripheral neuropathy patients who took duloxetine for five weeks experienced significantly larger decreases in pain as measured by the Brief Pain Inventory Short Form than did those in the placebo group. In addition, the study found that 59 percent of duloxetine patients experienced some degree of pain reduction, compared with 38 percent of patients given a placebo. However, patients who were given duloxetine and then given a placebo had a higher drop-out rate than patients who took the placebo before taking duloxetine.
From "Duloxetine May Ease Neuropathy From Chemo"
MedPage Today (04/02/13) Petrochko, Cole

Unmeltable, Uncrushable: The Holy Grail in Painkillers
The Food and Drug Administration's (FDA's) decision to prohibit the sale and manufacture of non-abuse-resistant OxyContin, which is made by Purdue Pharma, could prompt other drugmakers to start producing tamper-resistant painkillers of their own. The decision does not require all painkillers to have abuse-resistant technologies, but the FDA has said that it has the authority to take drugs off the market that do not include deterrents for abusers. As a result, drug companies that make tamper-resistant drugs could see less competition from generics that do not feature these technologies. As a result, drug companies such as Johnson & Johnson and Endo Pharmaceuticals—both of which are working on abuse-resistant drugs—could bring in billions of dollars in new revenue by entering the market for tamper-proof medications.
From "Unmeltable, Uncrushable: The Holy Grail in Painkillers"
Wall Street Journal (05/06/13) Martin, Timothy W.; Rockoff, Jonathan D.

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