The Global Anesthesia Workforce Survey: Updates and Trends in the Anesthesia Workforce.

BACKGROUND: There is a large global deficit of anesthesia providers. In 2016, the World Federation of Societies of Anaesthesiologists (WFSA) conducted a survey to count the number of anesthesia providers worldwide. Much work has taken place since then to strengthen the anesthesia health workforce. This study updates the global count of anesthesia providers. METHODS: Between 2021 and 2023, an electronic survey was sent to national professional societies of physician anesthesia providers (PAPs), nurse anesthetists, and other nonphysician anesthesia providers (NPAPs). Data included number of providers and trainees, proportion of females, and limited intensive care unit (ICU) capacity data. Descriptive statistics were calculated by country, World Bank income group, and World Health Organization (WHO) region. Provider density is reported as the number of providers per 100,000 population. RESULTS: Responses were obtained for 172 of 193 United Nations (UN) member countries. The global provider density was 8.8 (PAP 6.6 NPAP 2.3). Seventy-six countries had a PAP density <5, whereas 66 countries had a total provider density <5. PAP density increased everywhere except for high- and low-income countries and the African region. CONCLUSIONS: The overall size of the global anesthesia workforce has increased over time, although some countries have experienced a decrease. Population growth and differences in which provider types that are counted can have an important impact on provider density. More work is needed to define appropriate metrics for measuring changes in density, to describe anesthesia cadres, and to improve workforce data collection processes. Effort to scale up anesthesia provider training must urgently continue.

Relationship between rural hospital closures and the supply of nurse practitioners and certified registered nurse anesthetists.

BACKGROUND: Reductions in primary care and specialist physicians follow rural hospital closures. As the supply of physicians declines, rural healthcare systems increasingly rely on nurse practitioners (NPs) and certified registered nurse anesthetists (CRNAs) to deliver care. PURPOSE: We sought to examine the extent to which rural hospital closures are associated with changes in the NP and CRNA workforce. METHOD: Using Area Health Resources Files (AHRF) data from 2010-2017, we used an event-study design to estimate the relationship between rural hospital closures and changes in the supply of NPs and CRNAs. FINDINGS: Among 1,544 rural counties, we observed 151 hospital closures. After controlling for local market characteristics, we did not find a significant relationship between hospital closure and the supply of NPs and CRNAs. DISCUSSION: We do not find evidence that NPs and CRNAs respond to rural hospital closures by leaving the healthcare market.

Maternity Units in Rural Hospitals in North Carolina: Successful Models for Staffing and Structure.

OBJECTIVES: Almost 15% of all US births occur in rural hospitals, yet rural hospitals are closing at an alarming rate because of shortages of delivering clinicians, nurses, and anesthesia support. We describe maternity staffing patterns in successful rural hospitals across North Carolina. METHODS: All of the hospitals in the state with ≤200 beds and active maternity units were surveyed. Hospitals were categorized into three sizes: critical access hospitals (CAHs) had ≤25 acute staffed hospital beds, small rural hospitals had ≤100 beds without being defined as CAHs, and intermediate rural hospitals had 101 to 200 beds. Qualitative data were collected at a selection of study hospitals during site visits. Eighteen hospitals were surveyed. Site visits were completed at 8 of the surveyed hospitals. RESULTS: Nurses in CAHs were more likely to float to other units when Labor and Delivery did not have patients and nursing management was more likely to assist on Labor and Delivery when patient census was high. Anesthesia staffing patterns varied but certified nurse anesthetists were highly used. CAHs were almost twice as likely to accept patients choosing a trial of labor after cesarean section (CS) than larger hospitals, but CS rates were similar across all hospital types. Hospitals with only obstetricians as delivering providers had the highest CS rate (32%). The types of hospitals with the lowest CS rates were the hospitals with only family physicians (24%) or high proportions of certified nurse midwives (22%). CONCLUSIONS: Innovative staffing models, including family physicians, nurse midwives, and nurse anesthetists, are critical for the survival of rural hospitals that provide vital maternity services in underserved areas.

Relationship Between State Policy and Anesthesia Provider Supply in Rural Communities.

BACKGROUND: There is a significant geographic variation in anesthesia provider supply. Lower supply in rural communities raises concerns about access to procedures that require anesthesia in rural areas. State policies related to certified registered nurse anesthetist (CRNA) practice may help to alleviate rural supply concerns. OBJECTIVES: To estimate the association between state CRNA policy and anesthesia provider supply especially in rural communities. RESEARCH DESIGN: Repeated cross-sectional design using ordinary least squares and 2-stage least squares regressions. SUBJECTS: All counties in the United States from 2010 to 2015. MEASURES: Dependent variables include anesthesia provider counts per 100,000 people, calculated separately for anesthesiologists, CRNAs, and their sum. Key variables of interest include state-level CRNA policy based on scope of practice (SOP) regulations and Medicare opt-out status. RESULTS: Opt-out status and less restrictive SOP regulations were consistently correlated with a greater supply of CRNAs, especially in rural counties. Furthermore, we found that anesthesiologists and CRNAs tend to be complements to each other, but less restrictive SOP and opt-out status tend to weaken the importance of this relationship. CONCLUSIONS: State regulations may lead to increased supply of CRNAs in rural communities. However, the design of our study makes causality difficult to assert. So, it is also possible that states set CRNA policy as a response to counts of anesthesia providers in rural areas. Furthermore, given supply of anesthesiologists and CRNAs are complementary to one another, improving access to anesthesia services may require addressing issues pertaining to the supply of all anesthesia provider types.

Obstetric Anesthesia Workforce Survey: A 30-Year Update.

BACKGROUND: Obstetric Anesthesia Workforce Surveys were conducted in 1981, 1992, and 2001, and the 10-year update was conducted in 2012. Anesthesia providers from US hospitals were surveyed to identify the methods used to provide obstetric anesthesia. Our primary hypothesis was that the provision of obstetric anesthesia services has changed in the past 10 years. METHODS: A sample of hospitals was generated based on the number of births per year and US census region. Strata were defined as follows: I ≥ 1500 annual births (n = 341), II ≥ 500 to 1499 annual births (n = 438), and III < 500 annual births (n = 414). Contact email information for the anesthesia provider in charge of obstetric services was obtained by phone call. Electronic questionnaires were sent through email. RESULTS: Administration of neuraxial (referred to as "regional" in previous surveys) labor analgesia was available 24 hours per day in all stratum I hospitals responding to the survey. Respondents across all strata reported high rates of in-house coverage, with 86.3% (95% confidence interval [CI] = 82.7%-90%) of stratum I providers reporting that they provided in-house anesthesiology services for obstetrics. The use of patient-controlled epidural analgesia in stratum I hospitals was reported to be 35% in 2001 and 77.6% (95% CI = 73.2%-82.1%) in this survey. Independent Certified Registered Nurse Anesthetists were reported to provide obstetric anesthesia services in 68% (95% CI = 57.9%-77.0%) of stratum III hospitals. Although 76% (95% CI = 71.2%-80.3%) of responding stratum I hospitals allow postpartum tubal ligations, 14% report inadequate staffing to provide anesthesia either always or at off-hours. CONCLUSIONS: Since 2001, there have been significant changes in how responding hospitals provide obstetric anesthesia care and staff the labor and delivery ward. Obstetric anesthesia surveys, updated every 10 years, continue to provide information about changes in obstetric anesthesia practice.

Preparing the health workforce in Ethiopia: A Cross-sectional study of competence of anesthesia graduating students.

BACKGROUND: Efforts to address shortages of health workers in low-resource settings have focused on rapidly increasing the number of higher education programs for health workers. This study examines selected competencies achieved by graduating Bachelor of Science and nurse anesthetist students in Ethiopia, a country facing a critical shortage of anesthesia professionals. METHODS: The study, conducted in June and July 2013, assessed skills and knowledge of 122 students graduating from anesthetist training programs at six public universities and colleges in Ethiopia; these students comprise 80% of graduates from these institutions in the 2013 academic year. Data was collected from direct observations of student performance, using an objective structured clinical examination approach, and from structured interviews regarding the adequacy of the learning environment. RESULTS: Student performance varied, with mean percentage scores highest for spinal anesthesia (80%), neonatal resuscitation (74%), endotracheal intubation (73%), and laryngeal mask airway insertion check (71%). Average scores were lowest for routine anesthesia machine check (37%) and preoperative screening assessment (48%). Male graduates outscored female graduates (63.2% versus 56.9%, P = 0.014), and university graduates outscored regional health science college graduates (64.5% versus 55.5%, P = 0.023). Multivariate linear regression found that competence was associated with being male and attending a university training program. Less than 10% of the students believed that skills labs had adequate staff and resources, and only 57.4% had performed at least 200 endotracheal intubations at clinical practicum sites, as required by national standards. DISCUSSION: Ethiopia has successfully expanded higher education for anesthetists, but a focus on quality of training and assessment of learners is required to ensure that graduates have mastered basic skills and are able to offer safe services.

Geographical Imbalance of Anesthesia Providers and its Impact On the Uninsured and Vulnerable Populations.

The purpose of this study was to determine if there is a relationship between socioeconomic factors related to geography and insurance type and the distribution of anesthesia provider type. Using the 2012 Area Resource File, the correlation analyses illustrates county median income is a key factor in distinguishing anesthesia provider distribution. Certified registered nurse anesthetists (CRNAs) correlated with lower-income populations where anesthesiologists correlated with higher-income populations. Furthermore, CRNAs correlated more with vulnerable populations such as the Medicaid-eligible population, uninsured population, and the unemployed. Access to health care is multifactorial; however, assuring the population has adequate insurance is one of the hallmark achievements of the Affordable Care Act. Removing barriers to CRNA scope of practice to maximize CRNA services will facilitate meeting the demand by vulnerable populations after full implementation of the Affordable Care Act.

Training rotations at hospitals as a recruitment tool for Certified Registered Nurse Anesthetists.

Recruiting newly graduating Certified Registered Nurse Anesthetists (CRNAs) is expensive. Recruitment into rural areas is especially challenging. We analyzed the first jobs of all 95 graduates of the University of Iowa's CRNA training program, from the initial graduating class of 1997 through the class of 2009. We compared the location of the student's first job to where the student lived at the time of application to the program. Hospitals enhanced recruitment of CRNAs by having student rotations (P = .001). Most students who joined a practice offering an outside rotation were not from the county or contiguous counties of the hospital they joined (P < .001). In years that hospitals with rotations hired more than the median number of students, significantly more students had rotated through the hospital (P = .02). Offering a CRNA training program did not facilitate the university's retention of nurses already living in its county or contiguous counties (P = 0.58). Consequently, rural hospitals can view sponsoring rotations as a recruitment tool for graduating CRNAs. The university sponsoring the training program did not retain an advantage, however, in hiring its own graduates. Because this case study provided valuable insights, other programs should consider performing similar analyses.

Status of the anesthesia workforce in 2011: evolution during the last decade and future outlook.

The purpose of this review is to present a comprehensive assessment of the anesthesia workforce during the past decade and attempt forecasting the future based on present knowledge. The supply of anesthesiologists has gradually recovered from a deficit in the mid to late 1990 s. Current entry rates into our specialty are the highest in more than a decade, but are still below the level they were in 1993. These factors along with slower surgical growth and less capital available for expanding anesthetizing locations have resulted in greater availability of anesthesiologists in the labor market. Despite these recent events, the intermediate-term outlook of a rapidly aging population and greater access of previously uninsured patients portends the need to accommodate increasing medical and surgical procedures requiring anesthesia, barring disruptive industry innovations. Late in the decade, nationwide surveys found shortages of anesthesiologists and certified registered nurse anesthetists to persist. In response to increasing training program output with stagnant surgical growth, compensation increases for these allied health professionals have moderated in the present. Future projections anticipate increased personnel availability and, possibly, less compensation for this group. It is important to understand that many of the factors constraining current demand for anesthesia personnel are temporary. Anesthesiologist supply constrained by small graduation growth combined with generation- and gender-based decrements in workforce contribution is unlikely to keep pace with the substantial population and public policy-generated growth in demand for service, even in the face of productivity improvements and innovation.

Swiss healthcare cost containment policies and their impact on anaesthetists' density and satisfaction.

INTRODUCTION: To control healthcare costs, Federal and Cantonal states have introduced policies to limit expenses and the number of practising physicians. It is unclear to date whether these policies have had a real impact on anaesthetists in Switzerland. The aim of the current study was to assess the density, characteristics and satisfaction of anaesthetists in Latin Switzerland and to compare the results with data collected before the introduction of cost containment policies in 2002. METHOD: We performed a cross-sectional study between March and July 2009 and included all practicing anaesthetists in Latin Switzerland. A questionnaire consisting of 103 items analysing demographics, activity and job satisfaction was used. The results were analysed and compared to a previous survey conducted in 2002. RESULTS: Compared to 2002, there was an overall 12% increase in the number of practising anaesthetists who were older and more often females (42% versus 35% in 2002 (p = 0.06)). The number of non-Swiss anaesthetists significantly increased to 19% compared to 11% in 2002 (p <0.05). In contrast, working hours in public hospitals decreased from 59 to 53 hours/week (p <0.001). The majority of anaesthetists considered that their overall personal situation was better than in the previous 10 years and 87.7% considered that these measures had no impact on their future plans. CONCLUSIONS: Implicit rationing policies introduced in Switzerland to limit healthcare costs and the number of physicians has had no impact on anaesthetists' workforce density, working conditions and overall satisfaction in Latin Switzerland. This opens the question of the real usefulness of these policies, at least for anaesthetists.

The role of Certified Registered Nurse Anesthetists in the United States.

Certified Registered Nurse Anesthetists (CRNAs) have been providing anesthesia care in the United States (US) for nearly 150 years. Historically, anesthesia care for surgical patients was mainly provided by trained nurses under the supervision of surgeons until the establishment of anesthesiology as a medical specialty in the US. Currently, all 50 US states utilize CRNAs to perform various kinds of anesthesia care, either under the medical supervision of anesthesiologists in most states, or independently without medical supervision in 16 states; the latter has become an on-going source of conflict between anesthesiologists and CRNAs. Understanding the history and current conditions of anesthesia practice in the US is crucial for countries in which the shortage of anesthesia care providers has become a national issue.

Studies support removing CRNA supervision rule to maximize anesthesia workforce and ensure patient access to care.

Recent research reaffirms that Certified Registered Nurse Anesthetists (CRNAs) are critical to the delivery of anesthesia in the United States and argues persuasively for the removal of barriers-including supervision requirements--that prevent CRNAs and other advanced practice registered nurses (APRNs) from practicing to the full extent of their education and training. As we as a nation strive to make healthcare accessible, ever safer, and affordable, the health system must use anesthesia professionals as efficiently as possible. Repealing the federal Medicare physician supervision requirement for nurse anesthetists is an important step toward achieving this goal.

Cooperation and conflict between very similar occupations: the case of anesthesia.

This article examines the features of a labor market in which there are two professional groups that both cooperate and directly compete with each other: certified registered nurse anesthetists (CRNAs) and anesthesiologists (MDAs). We examine how the relative numbers of these two types of anesthesia providers, and differences in regulation, affect the earnings of CRNAs, and the extent of supervision of CRNAs by MDAs. We find that both the earnings, and the likelihood of medical supervision of CRNAs, are closely determined by their market share. As the market share of CRNAs increases from 0% to 50%, the gains to MDAs from restricting competition increase; over this range the likelihood that CRNAs are supervised increases and their expected earnings decline. However, as the CRNAs' market share increases beyond 50%, the costs to MDAs of anticompetitive measures become too large, therefore, the probability of supervision declines, and the earnings of CRNAs increase.

Assessment of surgical and obstetrical care at 10 district hospitals in Ghana using on-site interviews.

BACKGROUND: For most of the population in Africa, district hospitals represent the first level of access for emergency and essential surgical services. The present study documents the number and availability of surgical and obstetrical care providers as well as the types of surgical and obstetrical procedures being performed at 10 first-referral district hospitals in Ghana. MATERIALS AND METHODS: After institutional review board and governmental approval, a study team composed of Ghanaian and American surgeons performed on-site surveys at 10 district hospitals in 10 different regions of Ghana in August 2009. Face-to-face interviews were conducted documenting the numbers and availability of surgical and obstetrical personnel as well as gathering data relating to the number and types of procedures being performed at the facilities. RESULTS: A total of 68 surgical and obstetrical providers were interviewed. Surgical and obstetrical care providers consisted of Medical Officers (8.5%), nurse anesthetists (6%), theatre nurses (33%), midwives (50.7%), and others (4.5%). Major surgical cases represented 37% of overall case volumes with cesarean section as the most common type of major surgical procedure performed. The most common minor surgical procedures performed were suturing of lacerations or episiotomies. CONCLUSIONS: The present study demonstrates that there is a substantial shortage of adequately trained surgeons who can perform surgical and obstetrical procedures at first-referral facilities. Addressing human resource needs and further defining practice constraints at the district hospital level are important facets of future planning and policy implementation.