Transcript The Future of Manpower in Anesthesiology

Personnel Shortage in Anesthesia:
Estimating Demand and Supply
Armin Schubert,MD,MBA
Chair, Department of General Anesthesiology
Professor of Anesthesiology
Cleveland Clinic Lerner College of Medicine
The Cleveland Clinic Foundation
ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH
SECTION EDITOR
RONALD D. MILLER
An Updated View of the National Anesthesia
Personnel Shortfall
Armin Schubert, MD, MBA*, Gifford Eckhout, Jr., MD*, and Kevin Tremper, MD,
PhD†
*Department of General Anesthesiology, The Cleveland Clinic Foundation, Cleveland, Ohio; and
†Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
ANESTH ANALG
SCHUBERT ET AL.
2003;96:207–14
Assessing WorkForce Balance
& (Carefully) Diffusing the Information
•Credibility
•Timeliness
•Availability
WorkForce Balance Assessment
Surveys, vacancies, anecdotes
……..MODEL Construction
 Supply Factors
Additions
Losses
 Demand Factors
Locations, facilities, procedures
Population age & health demographics
 Special Factors
to be used sparingly
Anesthesia “Trend” Model Construction
Vs. “needs” (social construction - what “ought to” occur)
Uses established historical supply/demand trends
• Predicts near term from residency enrollment trends
• Predicts future demand based on…..
– immediate past history
– estimated disease & population growth
• Calculates present and predicted workforce balance
• Deals with growth uncertainty: 2 scenarios
* Snyderman, Health Affairs, Jan/Feb2002
* Cooper, Health Affairs, Mar/Apr 2002
Model Assumptions- Supply
• Starting Point: In - balance: 1994
• Supply information from Grogono/ABA
– Graduates (minus J-visa losses)
– Projected attrition
– Fellowship losses (assume constancy)
• Losses:
– Retirement (ASA membership age distribution)
– 90% workforce participation by women
– Other part-time & non-clinical (assume constancy)
AMG & IMG Anesthesia Residents by Year of Training
1,500
AMG(PG1)
IMG(PG1)
AMG(CA1)
IMG(CA1)
AMG(CA2)
IMG(CA2)
AMG(CA3)
IMG(CA3)
AMG(Grad)
IMG(Grad)
1,000
500
0
1985
1990
1995
2000
2005
Grogono A, ASA Newsletter November 2003
Cohort Attrition: Early vs. Late ‘90’s
Cohort Attrition: Early vs Present
105%
100%
86 to 93
95%
94 to 98
90%
99 to 03
85%
80%
CA-1
CA-2
CA-3
Grad
Grogono A, ASA Newsletters
Modified by G. Eckhout, 2003
Tremper KK, et al. Advances in Anesthesia
Winter 2001 SAAC/AAPD Survey of 138 US Anesthesiology Residency Training Programs**
Number
Percent
J-1 visa
holders
138
100
-
# of non-responders
1
0.7
-
# of responders with
incomplete data
2*
1.4
-
Complete data
135
97.8
-
Total CA-1 residents
1456
87
6.0
Total CA-2 residents
1355
120
8.9
Total CA-3 residents
1290
142
11.0
Trainees in ACGME
accredited fellowships
352
105
29.8
Trainees in non-ACGME
accredited fellowships
178
68
38.2
Total fellows
530
173
32.6
Total CA-3 residents &
Fellows (PGY-5 & higher)
1820
-
315
17.3
Total residents & fellows
4631
-
522
11.3
# of programs surveyed
Percent
Retirement
•
•
•
ASA commissioned survey in 2002 (Tarrance Group;
hospitals with >100 beds)
34% response rate (2363 US hospitals)
Assume: - related to anesthesiologists only
- only one group served each hospital
• Estimated retirements/yr = 800
•
ASA Retirements/yr = 400; total < 600
Tremper KK, et al. Advances in Anesthesia
Model Assumptions - Demand
• No change in care model (ratios)
• Growth:
1994 -2001:
2.0 vs. 3.0%
2002- 2003:
1.5 vs. 2.0%
2004- 2007:
1.5%
Freestanding Outpatient Surgery Centers &
Operating Rooms 1993-2002.
Year
# of FOSC’s
# of FOSC OR’s
1993
N/A
N/A
1994
1890
N/A
1995
N/A
N/A
1996
2314
5525
1997
2425
5545
1998
2665
5758
1999
2726
5839
2000
2755
5930
2002
3383
6180
=8-9%
Facility
growth
annually
Surgical Demand Growth SMG
Estimates 2003
Total Hospital
Based
Surgies
FOSC
Surgeries
18%
16%
14%
12%
10%
4%
2%
20
06
20
04
20
02
20
00
0%
19
98
Total Surgical
Volume
6%
19
96
Total
Outpatient
Surgeries
8%
19
94
POBS
Surgeries
Population 65 years of age and over:
United States, 1950-2030
90
80
65 years and older
85 years and older
70
60
50
40
30
20
10
0
1950
1960
1970
1980
1990
2000
2010
2020
2030
Schubert et al, Mayo Clin Proc, 2001
Growth in Surgical Procedures: Carotid & Spine
Schubert et al, Mayo Clin Proc 2001
Surgical Volume Trends
60000
50000
40000
30000
Total Surg
Office Surg
FOSC Surg
20000
Hosp Based Surg
10000
07
20
05
20
03
20
01
20
99
19
97
19
95
19
93
19
91
19
89
19
87
19
85
19
83
19
19
81
0
Source:
AHA, SMG
Surgical Workload 2001-2020
Methods
•
•
•
•
•
•
2001-2020 US Census data
1996 NHDS and NSAS
7 specialties
214 representative procedures
Physician work component of RVU
Age specific incidence rates for each
procedure multiplied by RVU
Etzioni et al, Ann Surg 238:170,2003
Surgical Workload 2001-2020
Results
• Each specialty accounted for 13-15% of total
workload
• 58% of procedures associated with age>65
• Workload increase 30-35%
• Annually 1.3-1.5%
• Surgeons to operate more, train more
• All of the above will  anesthesia demand
Etzioni et al, Ann Surg 238:170,2003
Demand for Anesthesia Services
Health Care Demands of the US Population
• Growth in Surgical Procedures (next 5 years)
Outpatient, hospital (3-4%)
Outpatient-freestanding (4.5-6%)
Inpatient (-1%)
Office-based (1.5-3.5%)
• Geriatric procedures tripled
• Chronic pain (5%), obesity, critical care
AHA - CDC/NCHS - SMG
US Census Bureau -
HRSA
Other Considerations
•
•
•
•
•
•
•
CRNA’s
DO’s
Historical Resident Production
Malpractice Environment
Nurses & Propofol Administration
Robotic Technology
Etc.
CRNA Trainee Output
1400
1200
1000
800
600
Grad
Cert
400
200
0
89
91
93
95
97
99
01
Courtesy: A Grogono, Oct 2003
CRNA Age Distribution
25%
CRNAs
20%
15%
10%
5%
Over 64
60-64
55-59
50-54
45-49
40-44
35-39
30-34
Under 30
0%
Courtesy: A Grogono, Oct 2003
TOTAL RESIDENTS - PGY1-4
7000
6000
5000
PGY4
4000
PGY3
3000
PGY2
PGY1
2000
1000
03
20
01
20
99
19
97
19
95
19
93
19
91
19
89
19
87
19
19
85
0
Data Courtesy: A Grogono, Oct 2003
Surveys
• ASA-Tarrance Group
• Ohio Society of Anesthesiologists
• ASA On-line Membership Survey
• Recruiting Firms & Position Ads
• SAAC-AAPD
August: SAAC/AAPD Survey
4.5
4
3.8
4
3.9
= 568 open
positions;
3.4
3.5
3
2.5
2
1.5
1
91.50%
83.50%
78.40%
77%
0.5
0
2000
2001
2002
If 20% of
Workforce
is
academic,
shortage
estimate
= 2800
2003
Courtesy of K. Tremper, MD, PhD.
In 2003, 67% of programs have OPEN CRNA positions
Tarrance Group ASA Hospital (>100 bed)
Administrator Surveys
•
•
•
•
43% limited ORs due to shortage
43% said their hosp has too few anesthesiologists
59% said they were currently recruiting
If vacancy/hosp is 1.6, shortage estimates =
1600-2200 vacancies
• If avg 3 rural hosp. Served by one group, add at least 100
more to shortage estimate
• Shortage estimate of 1700-2300
The Tarrance Group, August 2002
Abenstein et al, Anesthesiology, A-1131, 2002
OHIO Society of Anesthesiologists
Membership Surveys
Pos Vac
MD
CRNA
2001
2003
1
22%
22%
>1
39%
35%
avg
1.7
1
10%
12%
>1
avg
45%
2.3
44%
1.8
1.6
37 groups  60 pos; extrapolated to US  2200 vacant
Summary of Model Predictions
•
•
•
•
2001 shortage 3.6-10.9% of supply
1200-3800 full time positions
Similar shortfall will persist until 2005
Thereafter, prediction is dependent on annual
demand growth
2% demand growth
1.5% demand growth
=
=
10% Shortage
Shortage stops
• 15%  annually in residency positions to
achieve equilibrium by 2010
Updated Assessment 2002
• Surveys: OSA, Tarrance Grp; SAAC/AAPD
• SAAC-AAPD (no change from 2001)
• Our 2003 “best estimate” of shortage:
1100 - 3800 in 2002
700 - 3900 in 2005
“No Change”
• Trainee growth slower than originally
predicted; fewer IMGs
• Demand growth was higher than assumed
2003 Update
• New data from AMA, HRSA, ABA
• Trainee growth slower than
originally predicted; fewer IMGs
• Demand data from SMG (> than orig.)
• Model points to mild oversupply in 1994
• Our current “best estimate” of shortage:
2003:
2005:
2008:
2600
2300
1900
Despite
resident entry
’g to 1600,
shortage
continues, if
somewhat less
severe.
Workforce Model
AMG Grads
IMG Grads
Percent
IMG Grads
J-1 visa
Attrition
Total Grads
2002
649
614
11%
546
34
2003
783
550
9%
501
25
1,229
1,308
a
ASA Active Membership
23,608
b
All active US Anesthesiologists
37,418
38,100
c
% female ASA members
22
22
d
ASA retirements
410
425
e
Estimated non-ASA retirements
216
261
Estimated
626
686
Estimated
8,232
8,382
10% FTE
823
838
1.82%
Total MD
36,594
37,262
Demand
37,135
37,618
Demand
39,136
39,724
Excess
(541)
(356)
Excess
(2,542)
(2,461)
2004
876
418
6%
393
13
39
1,281
2005
1,101
372
5%
353
9
44
1,464
2006
1,258
238
5%
226
6
45
1,490
2007
1,300
200
5%
190
5
45
1,495
2008
1,400
200
5%
190
5
48
1,595
24,249
38,696
22
460
168
628
8,513
851
24,981
39,532
23
470
176
646
9,045
904
25,726
40,376
23
590
217
807
9,286
929
26,473
41,064
23
600
211
811
9,445
944
27,271
41,848
24
610
207
817
10,010
1,001
37,845
38,107
40,319
(262)
(2,475)
38,627
38,602
40,924
25
(2,297)
39,447
39,104
41,538
343
(2,091)
40,119
39,613
42,161
507
(2,042)
40,847
40,127
42,794
719
(1,947)
Predicted Anesthesiologist Shortfall - Original
45,000
40,000
Old Supply
Old Demand 1.5%
Old Demand 2%
35,000
10
20
08
20
06
20
04
20
02
20
00
20
98
19
96
19
19
94
30,000
Predicted Anesthesiologist Shortfall - New
45,000
40,000
New Supply
New Demand
3% /1.3%
35,000
10
20
08
20
06
20
04
20
02
20
00
20
98
19
96
19
94
30,000
19
New Demand
80% SMG/1.5%
How Many To Train?
Centralized Management
Formulas: underestimate MD workforce needs
•
Haase, Ann Emerg Med 1996
• ABT Report: underestimated AN need
• DGME Cap: 3468 (= 900/year: dbls shortage by 2010)
Market Forces
“Education Pipeline”
•
•
Kindig, JAMA v.270,1993
Meyer et al, JAMA v. 276, 1996
Recent Match Data: Continuing high interest but numbers
similar to 1994, despite  demand and 7 years of drought;
5-6 year “pipeline”
Our Personnel Model:
1.5% growth: need 1600/yr to 2010
•
In a 2002 survey of medical students attending
the AMSA Annual Meeting…..
14% (16/112) still reported being
discouraged from entering anesthesia because of



“too many people in the field”
“shortage of positions”
“potential for forced primary care”
Curry & Bralliar, Anesthesiology A1101, Oct 2002
Market forces can be expected to
work well only with
timely & accurate information.
•
•
•
•
•
•
Annual workforce supply and demand review
Credible, impartial, competent
Input from academia, practice & government
Assessment of present & future
Widely publicized: Medical students, advisors
ASA, AMA, AAMC, COGME, GMENAC…..??
ASA Committee on Physician Resources
DATA Repository for Anesthesia Workforce
(DRAW)
• ASA supported
• Accessible, up-datable resources
Supply - Demand - Balance
• Reviewed by committee members
• Assembled into model
• To be available on dedicated web space
• Access for students, advisors, flex personnel
ASA Committee on Physician Resources DATA Repository for Anesthesia Workforce (DRAW)
WORKFORCE SUPPLY FACTOR
GENERAL RESOURCES
American Society of Anesthesiologists
WEB ADDRESS / SOURCE
ASA <http://www.asahq.org/>
American Medical Association
AMA <http://www.ama-assn.org/>
Association of Anesthesia Clinical Directors
AACD <http://aacdhq.org/>
Medical Group Management Association
MGMA <http://www.mgma.org/>
Society of Academic Anesthesiology Chairs/ Association
of Anesthesiology Program Directors
AAPD-SAAC <http://www.asahq.org/aapd-saac/>
ANESTHESIOLOGISTS
ASA Membership Demographics
ASA membership database and on-line surveys
U.S. Anesthesiologists Demographics
AMA Physician Characteristics & Distribution in the US
2003-04
Physician Resources Committee Annual Report 2002
Osteopathic Anesthesiologists
All Anesthesiologists Demographics
Retirement and FTE factors
Immigration of anesthesiologists
Total Physician Supply (FTE)
AMA Physician Socioeconomic Statistics
National Center for Health Workforce Analysis reports
Federal Sources
Federal NA diversity targets
CRNA education issues
Carrie Hankett
Julia Pollock
Greg Unruh
(resources to be identified)
and the
Physician
Work force in The United
USGlobalization
Health Workforce
Reports
Factbook
States
<http://bhpr.hrsa.gov/>
AMA Physician Characteristics & Distribution in the US
2003-04
Health workforce reports
Social Statistics Briefing Room
AANA <http://www.aana.com/>
COA <http://www.aana.com/coa/quality.asp>
(resources to be identified)
HRSA FY2003 Performance Plan
CANA Education Programs 2002 Annual Report
General Nursing Demographics
National Center for Health Workforce Analysis
Projected Supply, Demand, Shortages of Registered Nurses
2000-2020
American Association of Colleges of Nursing
AACN <http://www.aacn.nche.edu/>
Faculty
Shortages in Baccalaureate & Graduate Nursing
Prgms
Nursing faculty shortages
Armin Schubert
(resources to be identified)
NURSE ANESTHETISTS
American Association Nurse Anesthetists
Council on Accreditation of Nurse Anesthesia Education
Programs
CRNA Workforce Factors
LIAISON
Mary Dale Peterson
Armin Schubert
Susan Goelzer
ASA Committee on Physician Resources DATA Repository for Anesthesia Workforce (DRAW)
SERVICE DEMAND FACTORS
OPERATIVE & DIAGNOSTIC ANESTHESIA
Kenneth Freese
Agency for Healthcare Research & Quality
AHRQ <http://www.ahcpr.gov/>
National Center for Health Statistics
NCHS <http://www.cdc.gov/nchs/default.htm>
Healthcare Cost & Utilization Project
HCUPnet <http://www.ahcpr.gov/data/hcup/hcupnet.htm>
Position vacancies
Gifford Eckhout
T arrance Group Survey
Carrie Hankett
State Anesth. Society Surveys
Gifford Eckhout
FACILITIES DISPERSION
Patricia Davidson
Hospital-based Statistics
AHA Annual Hospital Survey from AHAdata.com
Ambulatory/FOSC Statistics
MGMA Ambulatory Surgery Center Performance Survey Report
The National Hospital Ambulatory Medical Care Survey
VA-based Statistics
VA Health Economics Resource Center
ANNUAL VOLUME
Arm in Schubert
Hospital-based Statistics
AHA Annual Hospital Survey from AHAdata.com
Ambulatory/FOSC Statistics
MGMA Ambulatory Surgery Center Performance Survey Report
The National Hospital Ambulatory Medical Care Survey
VA-based Statistics
VA Health Economics Resource Center
INTENSIVE CARE
(resources to be identified)
PAIN MANAGEMENT
American Academy of Pain Management
AAPM <http://www.aapainmanage.org/>
Fiscal & educational issues for practitioners
(resources to be identified)
Service demand
(resources to be identified)
Population Growth Vs. Anesthesia Graduates
Popn.
400
360
Grads
2000
Popn. (millions)
Anes Grads
1800
320
1600
280
1400
240
1200
200
1000
160
800
120
1980
1985
1990
1995
2000
600
2005
Courtesy: A Grogono, Oct 2003
Thank You !
Cleveland Clinic Foundation
Division of Anesthesiology & Critical Care