Practice Model Trends in Medicare Payments Across States and Regions.

Anesthesia delivery models have long been shaped by workforce trends, state and federal regulations, economic incentives driven by reimbursement, and the normative preferences of provider and facility organizations. In recent years, there has been a significant shift toward greater use of more efficient certified registered nurse anesthetist (CRNA)-oriented delivery models observed at the national level Medicare data. However, given the wide range of these factors across states and regions, this shift has likely occurred at an uneven pace. This study analyzes the influence of provider workforce composition and CRNA scope of practice (SOP) regulations on usage of competing types of anesthesia delivery models, including anesthesiologist alone, care team, and undirected CRNA models. Results show that over the period from 2010-2019, anesthesia delivery models utilized under Medicare Part B have become increasingly oriented around the use of CRNAs. However, increases in the care team vs undirected CRNA model are highly uneven and inconsistent across states, even after adjusting for workforce and SOP. Speculation on additional normative or organization-driven reasons for persistent use of inefficient delivery models in some places is offered.

Impact of COVID-19 Pandemic on Certified Registered Nurse Anesthetist Practice.

The coronavirus disease 2019 (COVID-19) pandemic prompted profound shifts in the delivery of critical healthcare services. A mixed-methods study was conducted to explore the impact of the pandemic on Certified Registered Nurse Anesthetist (CRNA) practice. The quantitative component involved a survey of CRNAs during the initial period of the pandemic to determine changes in practice and any relationship to removal of state and federal barriers. Approximately 16% of 2,202 responding CRNAs reported practice expansion beyond their normal responsibilities, primarily outside the operating room and involving tracheal intubation, ventilator management, arterial line placement, and central line placement. CRNAs were more likely to experience an expansion of practice in states affected by removal of regulatory barriers. However, respondents also reported missed opportunities to use the full expertise of CRNAs because of state and institutional restrictions. Findings from the qualitative component of this study are reported in a separate article.

Work patterns, socio-demographic characteristics and job satisfaction of the CRNA workforce - Findings from the 2019 AANA survey of CRNAs.

BACKGROUND: An ongoing shortage of anesthesia providers lends importance to the study of job satisfaction and retention among this critical workforce. Certified registered nurse anesthetists (CRNA) make up an increasing share of this workforce and the impact of factors affecting their satisfaction is not fully understood. PURPOSE: Understanding the job satisfaction of Certified Registered Nurse Anesthetists (CRNA) and its determinants. Methods We conduct a comprehensive survey in which we collect information on the job satisfaction of a nationally representative sample of CRNAs, along with information on factors related to their job satisfaction. We measure the impact of these characteristics on the CRNA's level of job satisfaction using a multivariate regression analysis. FINDINGS: Many CRNAs would prefer to pursue training opportunities on peripheral nerve blocks, epidural anesthesia and advanced airway management. Refreshing training on these procedures are factors that may enhance their job satisfaction, and potentially reduce unmet needs for anesthesia services. DISCUSSION: We find that most CRNAs are either very satisfied or somewhat satisfied with their job. Factors that significantly increase the probability of being very satisfied include greater autonomy in the delivery of anesthesia, and higher compensation.

Mindfulness Training to Improve Nurse Clinical Performance: A Pilot Study.

Health care errors are a national concern. Although considerable attention has been placed on reducing errors since a 2000 Institute of Medicine report, adverse events persist. The purpose of this pilot study was to evaluate the effect of mindfulness training, employing the standardized approach of an eight-week mindfulness-based, stress reduction program on reduction of nurse errors in simulated clinical scenarios. An experimental, pre- and post-test control group design was employed with 20 staff nurses and senior nursing students. Although not statistically significant, there were numerical differences in clinical performance scores from baseline when comparing mindfulness and control groups immediately following mindfulness training and after three months. A number of benefits of mindfulness training, such as improved listening skills, were identified. This pilot study supports the benefits of mindfulness training in improving nurse clinical performance and illustrates a novel approach to employ in future research.

Advocacy, Research, and Anesthesia Practice Models: Key Studies of Safety and Cost-Effectiveness.

The practice of anesthesia includes multiple competing practice models, including services delivered by anesthesiologists, independent practice by certified registered nurse anesthetists (CRNAs), and team-based approaches incorporating anesthesiologist supervision or direction of CRNAs. Despite data demonstrating very low risk of death and complications associated with anesthesia, debate among professional societies and policymakers persists over the superiority or equivalence among these models. The American Society of Anesthesiologists uses published findings as evidence for claims that anesthesia is safer when anesthesiologists lead in providing care. The American Association of Nurse Anesthetists cites its own research on safety and cost-efficiency outcomes to defend against these claims. We review and critique studies of the safety outcomes and cost-effectiveness of anesthesia delivery that have been cited in the Federal Trade Commission comment letters related to competition in health care, where each profession has laid out their case for how they ought to be recognized in the market for anesthesia services. The Federal Trade Commission has a role in protecting consumers from anticompetitive conduct that has the potential to impact quality and cost in health care. Thus, it is important to evaluate the evidence used to make claims about these topics. We argue that while research in this area is imperfect, the strong safety record of anesthesia in general and CRNAs in particular suggest that politics and professional interests are the main drivers of supervision policy in anesthesia delivery.

A chronic grief intervention for dementia family caregivers in long-term care.

Dementia caregivers do not relinquish their role after placing family members in long-term care and they experience increased chronic grief. The Chronic Grief Management Intervention (CGMI) is a12-week group-based program that uses guided discussion to deliver knowledge of Alzheimer's or a related dementia and teach skills in communication, conflict resolution, and chronic grief management in dementia caregivers who placed their family members in long-term care. Using a quasi-experimental design, 83 caregivers from 15 long-term care facilities received either the CGMI (n = 34) or a comparison condition consisting of two check-in calls (n = 49). In this pilot study, we examined the feasibility of implementing the CGMI and evaluated the effects of the intervention on caregivers' knowledge and skill and their chronic grief and depression. The intervention was feasible and resulted in significant improvement in caregivers' heartfelt sadness and longing at 3 months and a significant drop in their guilt at the 6-month follow-up.

The relationship between physical activity and cognition in older Latinos.

OBJECTIVES: The purpose of this study was to explore the relationship between minutes spent participating in light and moderate/vigorous-intensity physical activity (PA) and cognition in older Latinos, controlling for demographics, chronic health problems, and acculturation. METHOD: A cross-sectional study design was used. Participants were self-identified Latinos, without disability, who had a score less than 14 on a 21-point Mini-Mental State Examination. Participants were recruited from predominantly Latino communities in Chicago at health fairs, senior centers, and community centers. PA was measured with an accelerometer, worn for 7 days. Episodic memory and executive function (inference control, inattention, and word fluency) were measured with validated cognitive tests. RESULTS: Participants were 174 Latino men (n = 46) and women (n = 128) aged 50-84 years (M = 66 years). After adjusting for control variables (demographics, chronic health problems) and other cognitive measures, regression analyses revealed that minutes per day of light-intensity PA (r = -.51), moderate/vigorous PA (r = -.56), and counts per minute (r=-.62) were negatively associated with lower word fluency. DISCUSSION: Findings suggest that the cognitive benefits of both light-intensity PA and moderate/vigorous PA may be domain-specific.

Physical activity of urban community-dwelling older Latino adults.

BACKGROUND: To date, little is known about the physical activity (PA) levels and commonly reported modes of PA of older Latinos, and this information is critical to developing interventions for this population. The purpose of the current study was to examine PA assessed by self-report and accelerometer and to assess the influence of acculturation, gender, and age on the PA of urban community-dwelling older Latino adults. METHODS: Participants were self-identified Latinos, primarily women (73%), and individuals aged 50 to 59 (31%), 60 to 69 (30%), and 70+ (39%). PA was measured with an accelerometer and the Community Healthy Activity Model Program for Seniors (CHAMPS) PA questionnaire. RESULTS: Men reported engaging in, and objectively participated in, significantly more minutes of moderate/vigorous PA than women, but women reported greater light intensity household PA. Latinos aged 50 to 59 engaged in significantly more accelerometer-assessed PA than Latinos aged 60 to 69 and 70+, respectively. The majority of participants did not meet the PA Guidelines for Americans. No differences in PA were demonstrated by acculturation level. Older Latino men and women reported walking and dancing as modes of leisure PA. CONCLUSIONS: These findings suggest PA interventions should be targeted toward older Latinos, taking into account gender and age.

Physical Activity of Urban Community-Dwelling Older Latino Adults.

BACKGROUND: To date, little is known about the physical activity (PA) levels and commonly reported modes of PA of older Latinos, and this information is critical to developing interventions for this population. The purpose of the current study was to examine PA assessed by self-report and accelerometer and to assess the influence of acculturation, gender, and age on the PA of urban community-dwelling older Latino adults. METHODS: Participants were self-identified Latinos, primarily women (73%), and individuals aged 50 to 59 (31%), 60 to 69 (30%), and 70+ (39%). PA was measured with an accelerometer and the Community Healthy Activity Model Program for Seniors (CHAMPS) PA questionnaire. RESULTS: Men reported engaging in, and objectively participated in, significantly more minutes of moderate/vigorous PA than women, but women reported greater light intensity household PA. Latinos aged 50 to 59 engaged in significantly more accelerometer-assessed PA than Latinos aged 60 to 69 and 70+, respectively. The majority of participants did not meet the PA Guidelines for Americans. No differences in PA were demonstrated by acculturation level. Older Latino men and women reported walking and dancing as modes of leisure PA. CONCLUSIONS: These findings suggest PA interventions should be targeted toward older Latinos, taking into account gender and age.

Place of death among older Americans: does state spending on home- and community-based services promote home death?

BACKGROUND: The majority of Americans die in institutions although most prefer to die at home. States vary greatly in their proportion of home deaths. Although individuals' circumstances largely determine where they die, health policies may affect the range of options available to them. OBJECTIVE: To examine whether states' spending on home- and community-based services (HCBS) affects place of death, taking into consideration county health care resources and individuals' family, sociodemographic, and health factors. METHODS: Using exit interview data from respondents in the Health and Retirement Study born in 1923 or earlier who died between 1993 and 2002 (N = 3362), we conducted discrete-time survival analysis of the risk of end-of-life nursing home relocation to examine whether states' HCBS spending would delay or prevent end-of-life nursing home admission. Then we ran logistic regression analysis to investigate the HCBS effects on place of death separately for those who relocated to a nursing home and those who remained in the community. RESULTS: Living in a state with higher HCBS spending was associated with lower risk of end-of-life nursing home relocation, especially among people who had Medicaid. However, state HCBS support was not directly associated with place of death. CONCLUSIONS: States' generosity for HCBS increases the chance of dying at home via lowering the risk of end-of-life nursing home relocation. State-to-state variation in HCBS spending may partly explain variation in home deaths. Our findings add to the emerging encouraging evidence for continued efforts to enhance support for HCBS.

Risk of nursing home admission among older americans: does states' spending on home- and community-based services matter?

OBJECTIVE: States vary greatly in their support for home- and community-based services (HCBS) that are intended to help disabled seniors live in the community. This article examines how states' generosity in providing HCBS affects the risk of nursing home admission among older Americans and how family availability moderates such effects. METHODS: We conducted discrete time survival analysis of first long-term (90 or more days) nursing home admissions that occurred between 1995 and 2002, using Health and Retirement Study panel data from respondents born in 1923 or earlier. RESULT: State HCBS effects were conditional on child availability among older Americans. Living in a state with higher HCBS expenditures was associated with lower risk of nursing home admission among childless seniors (p <.001). However, the association was not statistically significant among seniors with living children. Doubling state HCBS expenditures per person aged 65 or older would reduce the risk of nursing home admission among childless seniors by 35%. DISCUSSION: Results provided modest but important evidence supportive of increasing state investment in HCBS. Within-state allocation of HCBS resources, however, requires further research and careful consideration about fairness for individual seniors and their families as well as cost effectiveness.