Personnel Shortage in Anesthesia: Estimating Demand and Supply

1. 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

2. 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

3. Assessing WorkForce Balance& (Carefully) Diffusing the Information • Credibility • Timeliness • Availability

4. 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

5. 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

6. 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)

7. AMG & IMG Anesthesia Residents by Year of Training Grogono A, ASA Newsletter November 2003

8. Cohort Attrition: Early vs. Late ‘90’s Grogono A, ASA Newsletters Modified by G. Eckhout, 2003

9. Tremper KK, et al. Advances in Anesthesia

11. 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

12. Tremper KK, et al. Advances in Anesthesia

13. 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%

14. =8-9% Facility growth annually

15. Surgical Demand Growth SMG Estimates 2003

16. Population 65 years of age and over: United States, 1950-2030 90 80 65 years and older 70 85 years and older 60 50 40 30 20 10 0 1950 1960 1970 1980 1990 2000 2010 2020 2030 Schubert et al, Mayo Clin Proc, 2001

17. Growth in Surgical Procedures: Carotid & Spine Schubert et al, Mayo Clin Proc 2001

18. Surgical Volume Trends Source: AHA, SMG

19. Surgical Workload 2001-2020Methods • 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

20. Surgical Workload 2001-2020Results • 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

21. Demand for Anesthesia Services Health Care Demands of the US Population • Growth in Surgical Procedures (next 5 years) Outpatient, hospital (3-4%) Inpatient (-1%) Outpatient-freestanding (4.5-6%) Office-based (1.5-3.5%) • Geriatric procedures tripled • Chronic pain (5%), obesity, critical care AHA - CDC/NCHS - SMG US Census Bureau - HRSA

22. Other Considerations • CRNA’s • DO’s • Historical Resident Production • Malpractice Environment • Nurses & Propofol Administration • Robotic Technology • Etc.

23. CRNA Trainee Output Courtesy: A Grogono, Oct 2003

24. CRNA Age Distribution Courtesy: A Grogono, Oct 2003

25. TOTAL RESIDENTS - PGY1-4 Data Courtesy: A Grogono, Oct 2003

26. Surveys • ASA-Tarrance Group • Ohio Society of Anesthesiologists • ASA On-line Membership Survey • Recruiting Firms & Position Ads • SAAC-AAPD

27. August: SAAC/AAPD Survey = 568 open positions; If 20% of Workforce is academic, shortage estimate=2800 Courtesy of K. Tremper, MD, PhD. In 2003, 67% of programs have OPEN CRNA positions

28. 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

29. OHIO Society of Anesthesiologists Membership Surveys Pos Vac 2001 2003 1 22% 22% MD>1 39% 35% avg 1.7 1.6 CRNA1 10% 12% >1 45% 44% avg 2.3 1.8 37 groups  60 pos; extrapolated to US  2200 vacant

30. 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 = 10% Shortage 1.5% demand growth = Shortage stops • 15% annually in residency positions to achieve equilibrium by 2010

31. 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 • Trainee growth slower than originally predicted; fewer IMGs • Demand growth was higher than assumed “No Change”

32. 2003 Update Despite resident entry ’g to 1600, shortage continues, if somewhat less severe. • 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: 2600 2005: 2300 2008: 1900

33. Workforce Model

34. Predicted Anesthesiologist Shortfall - Original

35. Predicted Anesthesiologist Shortfall - New

36. 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” • 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 • Kindig, JAMA v.270,1993 • Meyer et al, JAMA v. 276, 1996

37. 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

38. 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…..??

39. ASA Committee on Physician ResourcesDATA 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

40. ASA Committee on Physician Resources - DATA Repository for Anesthesia Workforce (DRAW)

41. ASA Committee on Physician Resources - DATA Repository for Anesthesia Workforce (DRAW)

42. Population Growth Vs. Anesthesia Graduates Courtesy: A Grogono, Oct 2003

43. Thank You ! Cleveland Clinic Foundation Division of Anesthesiology & Critical Care