Feyereisen Scott, McConnell William, Puro Neeraj
Department of Management Programs, College of Business, Florida Atlantic University, Boca Raton, Florida, USA.
Department of Sociology, Schmidt College of Arts & Letters, Florida Atlantic University, Boca Raton, Florida, USA.
J Rural Health. 2025 Mar;41(2):e12879. doi: 10.1111/jrh.12879. Epub 2024 Sep 30.
Rural hospitals in the United States often rely on nonphysician providers such as advanced practice nurses to care for their patients. One important role that is served by advanced practice nurses is that of anesthesia provider (certified registered nurse anesthetist or CRNA). In 2001, Centers for Medicare & Medicaid Services (CMS) passed an opt-out law affording state governors the right to loosen physician supervision requirements on CRNAs in their respective states, thus potentially improving access in targeted areas. Since then, 24 states have adopted these opt-out provisions. We aim to understand the extent to which the CMS opt-out law has resulted in increased CRNA service provision in hospitals, especially in rural areas.
The study used a longitudinal design. We compiled 2010-2021 American Hospital Association data, which includes 4,464 unique U.S. hospitals observed an average of 8 times annually (35,863 total hospital-year observations).
We model CRNA services provision at the hospital level using longitudinal mixed effects generalized linear models that incorporate state, county, and hospital control variables.
Using descriptive statistics and mixed effects generalized linear models, we discovered that adopting opt-out provisions does not universally result in increased CRNA service provision in U.S. hospitals. Notably, opt-out provisions do not improve access in rural counties. However, in supplemental analysis, we discover some of the conditions under which the likelihood of CRNA service provision is influenced.
Hospitals often utilize CRNAs to staff their hospitals. However, many hospitals use both CRNAs and physician anesthesiologists; this can be a potential source of contention and confusion, given the lack of uniformity in the scope of practice policies. We offer some suggestions with regard to the effects of state interventions into the field, and how they might impact this dispute. Lastly, policymakers should consider additional measures to address rural access limitations, as the opt-out policy does not seem to be working as intended.
美国的乡村医院通常依靠非医师医疗服务提供者，如高级执业护士来照顾患者。高级执业护士所发挥的一个重要作用是担任麻醉服务提供者（注册护士麻醉师或CRNA）。2001年，医疗保险和医疗补助服务中心（CMS）通过了一项选择退出法，赋予州长放宽各自州对CRNA医师监督要求的权利，从而有可能改善目标地区的医疗服务可及性。自那时以来，已有24个州采用了这些选择退出条款。我们旨在了解CMS选择退出法在多大程度上导致医院，尤其是农村地区CRNA服务提供的增加。
该研究采用纵向设计。我们汇编了2010 - 2021年美国医院协会的数据，其中包括4464家不同的美国医院，平均每年观察8次（总计35863次医院年度观察）。
我们使用纵向混合效应广义线性模型，在医院层面模拟CRNA服务的提供情况，该模型纳入了州、县和医院控制变量。
通过描述性统计和混合效应广义线性模型，我们发现采用选择退出条款并不会普遍导致美国医院CRNA服务提供的增加。值得注意的是，选择退出条款并未改善农村县的医疗服务可及性。然而，在补充分析中，我们发现了一些影响CRNA服务提供可能性的条件。
医院经常利用CRNA为其医院配备人员。然而，许多医院同时使用CRNA和麻醉医师；鉴于执业范围政策缺乏统一性，这可能是潜在的争议和混乱来源。我们就州对该领域干预的影响以及它们可能如何影响这一争议提供了一些建议。最后，政策制定者应考虑采取额外措施来解决农村地区医疗服务可及性的限制，因为选择退出政策似乎并未按预期发挥作用。
