a Q:
is there data showing that CRNA unsupervised are just as safe as the ACT, or is there merely an absence of good data showing harm with CRNA out of teh ACT.
I think an important difference.
there's neither, really. just
post hoc comparison based on limited available outcomes data. and, a lot of convention and assumption was used in both studies to make the comparison.
what such studies do not show, but what would be important in my opinion, prospectively are:
1) rate/incidence of prolonged post-op hospitalization and/or increased level of care (ie. SICU vs. intermediate vs. floor) when an anesthesiologist is not directing care
2) peri-operative morbidity (not mortality), to include (among others) softer endpoints such as poorly controlled pain, uncontrolled hyper-/hypotension, acute renal failure - and this should be stratified to a equal case-to-case comparison (ie. unfair to compare the outcome of a healthy 25-y.o. female undergoing Essure placement to a 82-y.o. poly-morbid patient undergoing a Whipple) that do not end-up (necessarily) in permanent morbidity/mortality
3) total peri-operative cost, again stratified to maintain parity among case mix, of anesthesiologist vs. non-anesthesiologist directed care
4) time spent in PACU when anesthesiologist vs. non-anesthesiologist directs care
these are just a few ideas. the problem is, you have to do this prospectively and intra-institutionally if you want to get the best results. likewise, you have to inform people that they are being studied, which may result in people bringing their "a-game" (which would be okay... you should always bring your a-game) even to the chip shot cases.
the reality is that it would be incredibly difficult to find 1) willing participants (from either camp) and 2) a practice milieu that would allow such a study to be run prospectively.
what will likely happen is that there will be long-term outcomes, again post-hoc, measurement in those systems where there is parity. for example, in an "opt-out" state where a crna-only group operates a similar case mix to a anesthesiologist group. then, you could do a similar side-by-side comparison.
generally, i agree with others that it is an unfair comparison, though, to make between the advanced and extensive training we get in comparison to those a nurse gets. i just understand what's going on inside a patient much better than my crna colleagues, and most of them know this and admit this. where their hubris shows is the belief that this ultimately doesn't matter. of course, we know better intuitively. and, no study will ever be able to prove that.
