title: The Effect of "Opt-Out" Regulation on Access to Surgical Care for Urgent Cases in the United States: Evidence from the National Inpatient Sample.
abstract: In 2001, the Center for Medicare and Medicaid Services issued a rule permitting states to "opt-out" of federal regulations requiring physician supervision of nurse anesthetists. We examined the extent to which this rule increased access to anesthesia care for urgent cases.
  
  
  
  Using data from a national sample of inpatient discharges, we examined whether opt-out was associated with an increase in the percentage of patients receiving a therapeutic procedure among patients admitted for appendicitis, bowel obstruction, choledocholithiasis, or hip fracture. We chose these 4 diagnoses because they represent instances where urgent access to a procedure requiring anesthesia is often indicated. In addition, we examined whether opt-out was associated with a reduction in the number of appendicitis patients who presented with a ruptured appendix. In addition to controlling for patient morbidities and demographics, our analysis incorporated a difference-in-differences approach, with additional controls for state-year trends, to reduce confounding.
  
  
  
  Across all 4 diagnoses, opt-out was not associated with a statistically significant change in the percentage of patients who received a procedure (0.0315 percentage point increase, 95% confidence interval [CI] -0.843 to 0.906 percentage point increase). When broken down by diagnosis, opt-out was also not associated with statistically significant changes in the percentage of patients who received a procedure for bowel obstruction (0.511 percentage point decrease, 95% CI -2.28 to 1.26), choledocholithiasis (2.78 percentage point decrease, 95% CI -6.12 to 0.565), and hip fracture (0.291 percentage point increase, 95% CI -1.76 to 2.94). Opt-out was associated with a small but statistically significant increase in the percentage of appendicitis patients receiving an appendectomy (0.876 percentage point increase, 95% CI 0.194 to 1.56); however, there was no significant change in the percentage of patients presenting with a ruptured appendix (-0.914 percentage point decrease, 95% CI -2.41 to 0.582). Subanalyses showed that the effects of opt-out did not differ in rural versus urban areas.
  
  
  
  Based on 2 measures of access, opt-out does not appear to have significantly increased access to anesthesia for urgent inpatient conditions.
authors.affiliation: From the *Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, California; †Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, Iowa; and ‡American Society of Anesthesiologists, Schaumburg, Illinois.
authors.forename: Eric
authors.initials: E
authors.lastname: Sun
authors.forename: Franklin
authors.initials: F
authors.lastname: Dexter
authors.forename: Thomas R
authors.initials: TR
authors.lastname: Miller
mesh_terms: D000072080:Anesthesiologists / Q000331:legislation & jurisprudence* / Q000639:trends; D001064:Appendicitis / Q000175:diagnosis / Q000601:surgery; D014487:Centers for Medicare and Medicaid Services, U.S. / Q000331:legislation & jurisprudence* / Q000639:trends; D042883:Choledocholithiasis / Q000175:diagnosis / Q000601:surgery; D016208:Databases, Factual; D013505:Digestive System Surgical Procedures / Q000379:methods* / Q000639:trends; D005592:Fracture Fixation / Q000379:methods* / Q000639:trends; D033161:Government Regulation; D006291:Health Policy / Q000331:legislation & jurisprudence* / Q000639:trends; D006297:Health Services Accessibility / Q000331:legislation & jurisprudence* / Q000639:trends; D006620:Hip Fractures / Q000175:diagnosis / Q000601:surgery; D006801:Humans; D007297:Inpatients; D007415:Intestinal Obstruction / Q000175:diagnosis / Q000601:surgery; D009719:Nurse Anesthetists / Q000331:legislation & jurisprudence* / Q000639:trends; D024802:Nurse's Role; D010819:Physician's Role; D057184:Practice Patterns, Nurses' / Q000639:trends; D010818:Practice Patterns, Physicians' / Q000639:trends; D017064:Process Assessment, Health Care / Q000331:legislation & jurisprudence* / Q000639:trends; D019984:Quality Indicators, Health Care / Q000331:legislation & jurisprudence; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States