Nurse anesthetists are winning the trust of more politicians, physicians and patients.

Fourteen states no longer require physicians to supervise certified registered nurse anesthetists (CRNAs). These states have chosen to take advantage of a November 2001 anesthesia care rule published by the Centers for Medicare & Medicaid Services.

The rule allows states to opt out from the physician-supervision requirement through a gubernatorial request. Alaska, Idaho, Iowa, Kansas, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, South Dakota, Washington and Wisconsin have opted out.

"The fact that [this many] states have opted out in such a short time period is a remarkable victory for nurse anesthetists," says Mitchell Tobin, director of state government affairs for the American Association of Nurse Anesthetists (AANA).

Results Are Encouraging

The decision and its consequences are encouraging to CRNAs such as William Miller and Sharon Hensley.

"The opt-out has opened up more opportunity for us," says Miller, CRNA, CFNP, MS, and director of AANA Region 4. "Now we can provide anesthesia services in a dental office or a plastic surgeon's office without the stigma of having to be supervised by a physician."

Hensley, CRNA, MS, is pleased that the decision has benefited patients in her New Mexico community. She says that without advanced practice nurses, many facilities serving rural areas such as hers would be unable to maintain surgical, obstetric and trauma stabilization services.

"In New Mexico, more than half of all hospitals depend solely on CRNAs for their anesthesia services," says Hensley, who is president of the New Mexico Association of Nurse Anesthetists. "The opt-out gives hospitals in rural areas much more flexibility in providing anesthesia services, and itinerant surgeons are now comfortable working with CRNAs."

And Tobin says the change is helping hospitals in opt-out states recruit and retain CRNAs at a time when the profession is facing a shortage of qualified personnel.

Some Opposition Remains

Despite the seemingly positive results so far, the American Society of Anesthesiologists formally opposes opt-outs, claiming "there are no outcomes studies on the practice of unsupervised nurse anesthetists."

In 1990, the US Centers for Disease Control and Prevention examined anesthesia outcomes and concluded that morbidity and mortality rates due to anesthesia were too low to warrant a multimillion-dollar national study.

There are, however, objective studies on anesthesia care. In 1994, a legislatively mandated report by the Minnesota Department of Health determined that there are no studies that conclusively show a difference in patient outcomes by type of anesthesia provider.

In addition, according to an Institute of Medicine report published in October 1999, anesthesia care today is nearly 50 times safer than it was 20 years ago. CRNAs administer 65 percent of the anesthetics given each year in the United States and are the predominant anesthesia providers in rural and other medically underserved areas.

Will more states opt out? Tobin says some states are considering it, but he does not anticipate the same "fast and furious" adoption rate the industry witnessed over the past two years.

"To the extent that there's a message that [these] opt-outs carry, the message is that no harm is done by removing safeguards initiated by organized medicine," Tobin says. "There are no reports of any ill effects or adverse consequences in any of the opt-out states."