Autism and Vaccinations: Is There Evidential Strength to Link the Two?

Written By - Dr. Kim Riviello, DNP, MBA, CRNA

Autism is a developmental disability that comes from a neurological disorder affecting the brain. It is characterized by abnormal communication, social, and reasoning skills. The symptoms are usually not present until approximately 30 months of age at which time the child will start to exhibit fixation on inanimate objects, inability to communicate normally, and resistance to change in daily activities. They are unable to hold eye contact, display unmotivated temper tantrums, insensitivity to pain, and repetition of words and phrases. The degree of these symptoms can vary widely. One-quarter of these children develop seizures and two-thirds are diagnosed as mentally retarded ("Autism," 2011). 

Autism has no known single cause. There are no two children with autism alike, which makes scientists believe that it is a variety of factors that cause autism. The genetic disposition of the child has been determined a primary factor. Specifically what occurs with the genes is unknown but it appears to be related to gene mutation or genetic variants. Environmental factors such as viral infections and pollutants have also been suggested as triggering agents for autism ("Autism-Mayo," 2012). 

From mid-1980 to mid-1990 the incidence of autism increased from 1 in approximately 2500 to 1 in approximately 300 children, respectively. This increase coincided with the increase in the number of childhood vaccines being administered (Novella, 2008). This supposed association was investigated by Wakefield in 1998 when twelve children presented with pervasive developmental disorder, gastrointestinal symptoms and developmental regression. Eight of the twelve children had behavioral changes associated with the MMR vaccine according to retrospective accounts by the parents and physicians. This study by Wakefield did not have substantial evidence to prove his hypothesis linking the MMR vaccine to autism. 

The validity of the study was questionable due to the insufficient number of children and a lack of a control group. Potential bias was instilled with the data collection being dependent on retrospective memory of the parents and physicians concerning the actual symptoms of the children. The report itself refuted any connection between the MMR vaccine and the behavioral changes that the children exhibited (Wakefield et al., 1998). The one thing that Wakefield did accomplish was to introduce a possible cause for autism that left people wondering.

The increase in number of autistic cases still continues to rise. 1 in 150 children are now estimated to be diagnosed with autism (Novella, 2008). The question still remains, what is the cause and is it still possibly related to vaccines? 

Since Wakefield’s study in 1998 there have been several other studies addressing the relationship of vaccines to autism. In 2001 Dewild and his colleagues conducted a case-control study of children in the United Kingdom to examine a sequential association between the MMR vaccine and autism. Dewild hypothesized that the onset of developmental regression following the MMR vaccine would be revealed in an increase in consultations with the children’s physicians. A general practice databank was employed to examine whether children who were later diagnosed with autism had more frequent consults following the MMR vaccine than children who were not vaccinated. Dewild’s study matched seventy-one children with autism and 284 matched controls during 1989 to 2000. They matched for age, sex month of MMR vaccination, and physician. The study showed no significant difference in consultations between the children with autism and the control group. During the time period, only one case of autism was diagnosed within six months of the MMR vaccination. This study being a matched-control with over 300 children being examined makes the validity of the study far more conclusive than 

the Wakefield study. The only limitation found within Dewild’s research is that it included all consults not just consults specific to autism (Dewild, Carey, Richards, Hilton, & Cook, 2001).

An even stronger study rebutting the association of MMR vaccines and autism was conducted in Denmark in 2002. Madsen and his colleagues piloted a population-based retrospective study comparing the rates of autism among children who were vaccinated with MMR and those who were not. The Danish Civil Registration system was used to collect data on children born between 1991 and 1998. A total of 537, 303 children were in the cohort and followed for 2,129,864 person-years. The Danish vaccine program vaccinated children with MMR at fifteen months and twelve years of age. The data only included those children at age 15 months due to the relevance to the study. The diagnosis of autism was retrieved from the Danish Psychiatric Central Register based on ICD codes and included all children with autism. A total of 440,655 children (82 percent) received the MMR vaccine for a total of 1,647,504 person-years of follow up, compared with 482,360 person-years of follow up of children who did not receive the vaccine. A total of 316 children were diagnosed with an autistic disorder and 422 diagnosed with some other type of development disorder. The relative risk of autistic disorder among vaccinated children compared to unvaccinated children was 0.92% with a relative risk for another developmental disorder was 0.83%. Madsen and his colleagues showed that the risk of autism was comparable both in vaccinated and unvaccinated children with no sequential clustering of autism cases following immunizations, thus they concluded that the MMR vaccine was not associated with autism (Madsen et al., 2002).

Numerous other studies have been conducted repudiating the link between MMR vaccines and autism however the preservative Thimerosal, mercury based preservative contained in vaccines, has been questioned as a contributory factor. In 2004 the Institute of Medicine

(IOM) released a statement that there was no association between Thimerosal and autism based on studies they reviewed. The IOM did state that children with autism do have difficulty with excreting mercury from their systems but Thimerosal was not an influential element in the root cause of autism ("IOM Safety Review," 2004).

Due to the continued upsurge in autistic cases the CDC decided to conduct their own study on Thimerosal. They expanded their study to include impact of maternal exposure to Thimerosal while pregnant, evaluation of exposure in association with the three autism spectrum disorder subtypes, and a more rigorous approach to evaluating autism diagnosis and Thimerosal exposure. A total of 1,008 children were studied with 256 having autism and 752 did not. The study found that children with autism and those without had similar exposures to Thimerosal from pregnancy to twenty months of age. There was also no association to autism with maternal exposure to Thimerosal during pregnancy (prenatally) or as a young child. The CDC found the same results to be in male and females and the final conclusion being that Thimerosal-containing immunizations did not increase the risk of any of the autistic outcomes (Price et al., 2010). 

Based on the above studies, and the numerous others not mentioned, the evidence is strong to support that there is no link concerning childhood vaccines and autism. This information needs to be conveyed to parents in order to continue the necessary vaccinations against childhood diseases. 

References

Autism. (2012). Mayo-Clinic. Retrieved from http://www.mayoclinic.com/health/autism/DS00348/DSECTION=causes 

Dewild, S., Carey, I. M., Richards, N., Hilton, S. R., & Cook, D. G. (2001). Do children who become autistic consult more often after MMR vaccination? []. British Journal of General Practicioners, 51(464), 226-7. 

Immunization safety review: autism and vaccines. (2004). Institute of Medicine . Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK25349/ 

Madsen, K. M., Lauritsen, M. B., Vestergaard, M., Schendel, D., Wohlfahrt, J., Thorsen, P.,...Melbye, M. (2002). A population-based study of measles, mumps, and rubella vaccination and autism. New England Journal of Medicine, 347(19), 1477-82. 

Novella, S. (2008, April 16). The increase in autism diagnosis: two hypotheses []. Science-Based Medicine. Retrieved from http://www.sciencebasedmedicine.org/index.php/the-increase-in-autism-diagnoses-two-hypotheses/ 

Price, C. S., Thompson, W. W., Goodson, B., Weintraub, E. S., Croen, L. A., Hinrichsen, V. L.,...DeStefano, F. (2010, September 13). Prenatal and infant exposure to Thimerosal from vaccines and immunoglobulins and risk of autism. Pediatrics, 126(4), 656-654. doi:10.1542/peds.2012-0309 

Wakefield, A. J., Murch, S. H., Anthony, A., Linnell, J., Casson, D. M., Malik, M.,...Walker-Smith, J. A. (1998). Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet, 351, 637-41. 

What is autism? (2011). Autism. Retrieved from http://www.autism-pdd.net/what-is-autism.html 

CRNAs, Access and Medicaid

CRNAs & Medicaid

State medicaid programs do reimburse hospitals for anesthesia services provided by a CRNA; however some regulations vary by state. 

In some states, Medicaid will pay for CRNA services only when they are "medically directed" by an anesthesiologist. Such a policy causes hospitals to bear the burden of higher‐cost anesthesia services that are underpaid by the state’s Medicaid program.

Access to CRNAs

CRNAs are crucial to rural areas. Rural areas are in need of access to Anesthetists for various reasons: few anesthesiologists practice in rural areas, and without anesthesia present there can be no surgical procedures, labor and delivery, trauma stabilization, or pain management care. Without those services, local rural hospitals would not exist. And without rural hospitals, the health of local communities are at greater risk.

With the aging population, there is high demand for both CRNAs and Anesthesiologists. However, more procedures are being done in facilities other than traditional hospital settings, such as ambulatory surgical centers and physicians’ offices.

Additionally, the implementation of the Affordable Care Act has caused millions of previously uninsured Americans to enter the healthcare system for the first time, many of whom will need procedures requiring anesthesia care. With this in mind, CRNAs can be seen as a more cost effective solution for these non-traditional facilities and growing number of patients.

For more information contact us or visit www.aana.com.

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Supervision of CRNAs

Does Medicare Require CRNAs to be Supervised by an Anesthesiologist? 

No. Medicare only requires a physician to be present, this does NOT mean "supervision by an anesthesiologist." An anesthesiologist is only one type of physician that can supervise a CRNA. Currently, there is NO federal requirement stating that CRNAs must be supervised by anesthesiologists. Since 2001 the federal government has allowed states to opt out of the Medicare physician supervision requirement, meaning that CRNAs don't have to be supervised by any type of physician to be reimbursed by Medicare.

Why Supervision at All?

Physician supervision of CRNAs is required for facility reimbursement of anesthesia services by Medicare; it is not required for safety reasons. Under current Medicare rules, CRNAs must be supervised by a physician when delivering anesthesia services unless a state has opted out of this federal requirement and allows CRNAs to work without physician supervision. 

What does "opt out" mean exactly and why have states chosen this option?

To "opt out" of the Medicare physician supervision requirement means that a state is no longer required to have CRNAs supervised by physicians during the administration of anesthesia. This allows CRNAs to provide safe, cost-effective anesthesia care in any healthcare settings. This also provides the facilities a greater flexibility to deliver anesthesia services more tailored to the patients needs.

Opting Out Increases Access to Care

Opting out helps hospitals and ambulatory (out patient) surgery centers, typically in underserved areas, easily recruit certified and capable anesthesia providers without the high cost of an anesthesiologist or the misconception of safety concerns. This also gives medical facilities the ability to make their own decisions on how to best staff their anesthesia department, increasing access to care and keeping costs at bay.

Safety of CRNA v. Anesthesiologist

A study of anesthesia patient outcomes in opt‐out states and non opt‐out states conducted by RTI and published in the journal Health Affairs shows that nurse anesthesia care in the opt-out states is as safe as ever. 

This landmark study (and many others) confirms that there are no measurable differences in the quality or safety of anesthesia services delivered by CRNAs, by anesthesiologists, or by CRNAs being supervised by anesthesiologists. In fact, the RTI results show that, all other things being equal, anesthesia delivered only by CRNAs is as safe as – and in some cases safer than – anesthesia delivered only by anesthesiologists or by CRNAs supervised by anesthesiologists.

Why should nurse anesthetists be allowed to practice without a physician supervision?

In most situations, CRNAs practice with a surgeon or operating practitioner. In some cases such as, obstetrics or pain management, CRNAs practice without any physician supervision. Due to their extensive training and recent correlating data, CRNAs are perfectly capable and should be trusted to provide anesthesia services safely. Nurse anesthetists provide a cost effective solution to anesthesia services, leading to less waste and outstanding patient safety outcomes in our healthcare system.

Can it really hurt to have supervision?

Requiring supervise can be an unnecessary cost that is neither effective or efficient. CRNAs are able to provide safe and effective care without breaking the facilities budgetary restraints.

For more information on CRNA supervision please visit www.future-of-anesthesia-care-today.com.

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Education and Work Environment of CRNAs

What are the Prerequisites for Anesthesia School?

While individual nurse anesthesia educational programs may have additional requirements, the general entrance requirements to a program are:

• A Bachelor of Science in Nursing (BSN) or other appropriate baccalaureate degree.

• A license as a registered nurse (RN).

• At least one year of experience as an RN in an acute care setting. 

Is a master's degree Required to become a CRNA?

Yes. To become a CRNA today, one must graduate with a master’s degree from a nurse anesthesia educational program accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA).However, nurse anesthesia educational requirements are transitioning to the doctoral level by 2025, and many educational programs already offer doctoral degrees.

Where do CRNAs work?

CRNAs practice in every healthcare setting in which anesthesia is delivered, including traditional hospital surgical suites and obstetrical delivery rooms, ambulatory surgery centers, pain clinics and physicians' offices.CRNAs are the hands‐on providers of more than 34 million anesthetics delivered each year in the United States. They provide the majority of anesthesia care in the Veterans Administration and U.S. Military.

CRNAs are the primary anesthesia providers in rural America, enabling healthcare facilities in these medically underserved areas to offer obstetrical, surgical, trauma stabilization, and pain management services. In some states, CRNAs are the sole anesthesia providers in nearly 100 percent of the rural hospitals.

How long does it take to become a CRNA?

It typically takes seven to eight years of education, training, and experience to become a nurse anesthetist: four years to earn a bachelor’s degree in nursing (or other appropriate baccalaureate degree) and become licensed as a registered nurse; a minimum of one year practicing as an RN in an acute care setting; and two to three more years of graduate-level education and training culminating in a master’s or doctoral degree from an accredited nurse anesthesia educational program. To become certified to practice as a nurse anesthetist, the graduate must pass the National Certification Examination.

What is included in the curriculum for student registered nurse anesthetists?

The nurse anesthesia classroom curriculum emphasizes anesthesia, pain management, anatomy, physiology, pathophysiology, biochemistry, chemistry, physics and pharmacology. The clinical component provides case experience in all anesthesia techniques.

CRNAs receive extensive clinical experience in basic, advanced and subspecialty anesthesia and related services.

What is the average salary of a CRNA?

Reflecting the level of responsibility they assume on a daily basis, CRNAs are the highest paid advanced practice registered nurses. According to the American Association of Nurse Anesthetists, the median annual total compensation in 2012 was $165,000.

Continuing Education

In order to be recertified, CRNAs must obtain a minimum of 40 hours of approved continuing education every two years, document substantial anesthesia practice, maintain current state licensure, and certify that they have not developed any conditions that could adversely affect their ability to practice anesthesia.

CRNA's Comprable to Physician Anesthesiologist

CRNAs and anesthesiologists undergo similar education and training, and research shows that CRNAs deliver anesthesia care that is the same high quality as that of anesthesiologists. The focus should be on outcomes, not titles.

CRNAs are highly educated advanced practice registered nurses who specialize in anesthesia, have extensive experience in acute care settings, and hold advanced degrees in addition to their undergraduate nursing education and training. America’s 45,000 CRNAs administer approximately 34 million anesthetics to patients each year in the United States. CRNAs are the primary anesthesia providers in rural America, the military and the VA. Additionally, CRNAs practice in collaboration with other healthcare professionals in every setting where anesthesia is delivered.

Source: AANA.com

CRNAs: The Basics

The Definition of A CRNA

Certified Registered Nurse Anesthetists (CRNAs) are highly skilled advanced practice registered nurses who specialize in the field of anesthesiology and pain management. As licensed independent practitioners, CRNAs undergo significant post-graduate education and training averaging 30 months in duration and resulting in a master’s or doctoral degree in nurse anesthesia. They are required to pass the National Certification Examination in order to practice. CRNAs provide the same anesthesia services as physician anesthesiologists, based on a foundation of acute care nursing and graduate education. CRNAs practice in all 50 states and safely administer more than 34 million anesthetics to patients each year in the United States.

What do CRNA's Do?

CRNAs are responsible for the safety of patients before, during and after surgery. They administer every type of anesthesia to all types of patients in any healthcare setting where anesthesia is required. CRNAs provide continuous pain relief and sustain patients’ critical life functions throughout surgical, obstetrical and other medical procedures.

In addition to anesthetic agents, CRNAs select and administer adjunct drugs to preserve life functions; they also use technologically advanced monitoring equipment and interpret a vast array of diagnostic information throughout the course of the anesthetic process. CRNAs are qualified to provide pain care services such as acute pain management after a surgical procedure and chronic pain management in primary care settings within their communities.

A CRNA's Role During Surgery

As anesthesia professionals, CRNAs stay with their patients throughout the entire procedure, administering their anesthesia and monitoring their vital signs to ensure maximum safety and comfort. 

During surgery, the patient’s life often rests in the hands of the nurse anesthetist. This awesome responsibility requires CRNAs to fully utilize every aspect of their anesthesia education and training, nursing skills, and scientific knowledge. In addition to vigilantly monitoring the patient’s vital signs and modifying the anesthesia as needed, CRNAs also analyze situations, make decisions, communicate clearly with the other members of the surgical team, and respond quickly and appropriately in an emergency.

Collaboration with Physicians

Like all anesthesia professionals CRNAs collaborate with other members of the surgical team including surgeons, endoscopists, radiologists, podiatrists, obstetricians and other physician specialists. State laws and regulations vary on requiring CRNAs to be supervised by a physician;

well over half of all states do not require physician supervision.

In any case, nurse anesthetists are always independently responsible for their own actions. Surgeons quite properly defer to nurse anesthetists as the experts in anesthesia care. Under state nurse practice acts or board of nursing rules, CRNAs deliver comprehensive anesthesia care consisting of all accepted anesthetic techniques including general, regional (e.g., epidural, spinal, peripheral nerve block), sedation, local, and pain management.

What's the Difference? CRNA vs. Physician Anesthesiologist.

Like anesthesiologists, CRNAs provide the full range of anesthesia services in collaboration with surgeons, endoscopists, radiologists, podiatrists, obstetricians, and other physician specialists. When anesthesia is administered by a nurse anesthetist, it is recognized as the practice of nursing; when administered by an anesthesiologist, it is recognized as the practice of medicine. Regardless of whether their educational background is in nursing or medicine, all anesthesia professionals provide anesthesia using the same state of the art techniques and leading edge equipment, resulting in an exemplary safety record.

Numerous studies have demonstrated that there is no difference in outcomes when anesthesia is administered by a CRNA or by an anesthesiologist.

The Safety of Anesthesia

Advances in pharmaceuticals, technology and training for nurse anesthetists and anesthesiologists have contributed significantly to improvements in patient safety.

According to the Institute of Medicine (IOM), AANA, and the American Society of Anesthesiologists, anesthesia care is nearly 50 times safer than it was just 30 years ago, and in a 1999 report the IOM identified anesthesia as one of the safest healthcare specialties. Today, perioperative deaths attributed to anesthesia occur approximately once for every 250,000-300,000 anesthetics provided, representing a dramatic increase in patient safety despite an aging U.S. population and older, sicker patients being treated in operating rooms nationwide. 

CRNAs and the Future of Healthcare

CRNAs are the primary providers of anesthesia care in rural America, affording 10s of millions of rural Americans access to surgical, obstetrical, trauma stabilization, and pain management services without having to travel long distances to receive needed care.

In some states, CRNAs are the sole anesthesia professionals in nearly 100 percent of rural hospitals.

CRNAs also provide a significant amount of anesthesia and related care in urban and suburban healthcare facilities, and are the primary anesthesia professionals in many medically underserved inner‐city areas.

Are CRNAs Accepted by Insurance?

The importance of access to CRNA care has been recognized by the inclusion of “non-discriminatory” language in the Affordable Care Act.

This provision ensures that a group health plan or an insurance issuer will support a competitive, high-quality healthcare marketplace by recognizing CRNAs who provide covered services within their scope of practice. 

Managed care plans recognize CRNAs for providing high‐quality anesthesia care with reduced expense to patients and insurance companies.

The cost‐efficiency of CRNAs helps control escalating healthcare costs. 

Medical Liability

Nurse anesthetists are responsible for securing their own liability coverage, just as physicians are. In part because the care delivered by CRNAs is getting safer all the time, nurse anesthetist professional liability premiums are 33 percent lower today than 25 years ago (or 62 percent lower when adjusted for inflation). 

The same legal principles that govern the liability of surgeons working with nurse anesthetists apply to surgeons working with anesthesiologists. An examination of relevant case law supports the fact that surgeons are no more liable when working with a CRNA than with an anesthesiologist.

What is the Cost Differential Between A CRNA and a Physician Anesthesiologist?

Yes, there is a cost differential between an anesthesiologist and a CRNA.

The mean annual compensation for an anesthesiologist is about $400,000, nearly two and one-half times that of a CRNA whose median total compensation is about $165,000.

Because Medicare pays the same fee for an anesthesia service whether it is provided by a CRNA, an anesthesiologist, or both working together, the higher cost of the anesthesiologist is borne by someone – the hospital, the healthcare facility, or the patient.

Source: http://www.future-of-anesthesia-care-today.com