The AANA response DOES seem to have had a lot more thought put into it than the ASA response, though i suspect that the ASA response was not actually contained in that link given above. It seems to summary to me.
In any event, from the AANA response we have the following on death rates:
"Death Rates. The Pennsylvania study cites death rates that were many times more than the anesthesia-related death rates commonly reported in recent years, again leading one to conclude that the increase was almost certainly due to nonanesthesia factors."
The conclusion here is suspect (and goes to the heart of the matter). The "accepted" rate of death associated with Anesthesia administration prior to the study (1/240,000) is associated with MDA administration, NOT CRNA administration. Hence, IF the study suggests a death rate "several multiples" higher than the "accepted rate" it does NOT necessarily following that the higher rate is due to non-anesthetic post-operative care, as the AANA claim, but in fact may very well be the conclusion of the study itself, which is that non-MDA administration leads to death rates several multiples higher than MDA administration.
On TimeFraim, the AANA says:
"However, if one considered the study?s sample size (217,440) in relation to the widely accepted anesthesia mortality rate of one death in approximately 240,000 anesthetics given, which is recognized by ASA, AANA and cited in the Institute of Medicine report, To Err is Human: Building a Safer Health System (Kohn LT, Corrigan JM, Donaldson MS. Washington, DC: National Academy Press. 1999.), logic would dictate that less than a single individual in the entire database is likely to have died as the direct result of an anesthesia mishap!
What that leaves is this: Based on the 30-day time frame, it is clear that the study actually evaluates postoperative physician care, not anesthesia care."
Again, this conclusion does not follow. If the accepted death rate is 1/240,000 patients, and this study shows a death rate several multiples of that, the mere fact that it includes death rates after long post-operative care times does not mean that the type of provider is irrelevant UNLESS post-operative death rates are also elevated for MDA providers. After all, presumably the patient receives the same level of post-operative care over the following 30 days whether the provider was an MDA or a CRNA. True, the study asks this question outright (ie, whether non-MDA providers experienced, for whatever reason, lesser post-opperative care for thier patients than MDA providers did) - but assuming the post-operative care was the same, the ONLY variable in the study is MDA versus non-MDA provider in the OR.
And then from AANA:
"In a June 2000 press release about the Pennsylvania study, the ASA stated "that patient safety has greatly improved from one [death] in 10,000 anesthetics to one in 250,000 anesthetics." (This amounts to four deaths in one million.) In the same press release, the ASA stated that, "Dr. Silber?s findings show that for every 10,000 patients who had surgery, there were 25 more deaths if an anesthesiologist did not direct the anesthesia care." (The difference translates to 8,000 deaths in one million.) Thus, the difference in mortality rates that the ASA cited is 2,000 times the mortality rate ever attributed (including by the ASA) in the last decade to the administration of anesthesia. To attribute a difference of this magnitude solely to the supervision of CRNAs is ridiculous. In actuality, the large differences in mortality and failure-to-rescue are due to differences unrelated to the administration of anesthesia and outside the scope of practice of CRNAs, whether unsupervised, supervised by anesthesiologists, or supervised by other physicians."
ISN'T it possible that the study DID suggest a death rate 2000 times higher for non-MDA administration? After all, non-MDA administration acounts for a much larger percentage of administration than non-MDA, right? Still, the study would have to compare death rates for MDA's after a similar post-opperative period in order to make these numbers meaningful. I'm not sure the study does this. Still, one cannot ignore the "failure to rescue" factor. Presumably, a failure to rescue occurs in the OR, NOT during the post-operative period. Accordingly a difference in "failure to rescue" rates among MDA's and non-MDA' IS significant and CANNOT be dismissed by references to the long post-operative period.
THIS, however, is where the ASA needs to get on board:
"Failure to Rescue. For the most part, failure to rescue occurs when a physician is unable to save a patient who develops nonanesthesia complications following surgery. Therefore, it is not a relevant measure of the quality of anesthesia care provided by nurse anesthetists. It is a relevant measure of postoperative physician care, however."
Whoa whoa whoa. . .correct me if I am wrong, but, (1) don't failures to rescue occur in the OR or immedietly after surgery, and (2) isn't the anesthesia provider IN FACT and (presumably) necessarily the principle physician responsible for rescues (or failures to rescue)? As I understand it, the MDA is the only "internal medicine" doctor in the room, trained in airway management, crashing, etc. Defining "rescue" as outside the scope of anesthesia administration rather begs the question - IF the anesthesia provider is not responsible for rescue, just WHO exactly IS responsible for rescue in the OR (or immedietly after)?
And that's just the point, isn't it? an MDA is trained in quite a bit more than the mere "administration" of anesthetic. And while mere administration by CRNA's is as good as that by MDA's, the reality is that without an MDA in the room, death rates will necessarily rise due to a lack of care (in relation to rescue, etc.) as a result of the absence of the other skills that would normally be provided by an MDA OUTSIDE of his experitise in the mere administration of anesthetic.
That said, from what I can tell of the critique, the study has some gaping holes, particularly related to whether the patient was put in the MDA group or non-MDA group. The AANA did a MUCH better job than the ASA did in the critiques.
In any event, this issue is RIPE for some better studies on M&M rates. I think cardiologist mentioned in the critique is probably right - death rates associated with gas care will be much lower than complications. That is where the studies should focus. I would have though schools of public health would be all over this issue - not sure why it has not ben studied.
Judd
You mean to tell me you don't accept Mac's random statements as divine truth. 
