The anesthesia human resources crisis in Canada

May combine two claims.

Only 8% of physicians serve the rural population, who comprise 18% of all Canadians.

“Only 8% of physicians serve the rural population, who comprise 18% of all Canadians.7”

• cites [7] Orser BA, Wilson CR. Canada needs a national strategy for anesthesia services in rural and remote regions. CMAJ 2020; 192: e861–3. https://doi.org/10.1503/cmaj.200215 sourceSupported

May combine two claims.

A recent analysis showed that although the absolute physician-to-population ratio has improved over time, the additional increase in physicians per capita between the 1980s and 2020 is 50% less when adjusted for population aging.

“A recent analysis showed that, although the absolute physician-to-population ratio has improved over time, the additional increase in physicians per capita between the 1980s and 2020 is 50% less when adjusted for population aging.23”

• cites [23] Islam R, Kralj B, Sweetman A. Physician workforce planning in Canada: the importance of accounting for population aging and changing physician hours of work. CMAJ 2023; 195: E335–40. https://doi.org/10.1503/cmaj.221239 sourceSupported

Classified as probably not a substantial claim.

The authors of that systematic review concluded that volume-to-outcomes associations are variable and inconclusive with regards to safety.

“The authors concluded that volume-tooutcomes associations are variable and inconclusive with regards to safety.31”

• cites [31] Kornelsen J, McCartney K, Williams K. Centralized or decentralized perinatal surgical care for rural women: a realist review of the evidence on safety. BMC Health Serv Res 2016; 16: 381. https://doi.org/10.1186/s12913-016-1629-6 sourceSupported

May combine two claims.

Although female physicians' work hours have remained relatively stable, male physicians' work hours declined significantly after 1997.

“Although female physicians' work hours have remained relatively stable, male physicians' work hours declined significantly after 1997.”

• cites [23] Islam R, Kralj B, Sweetman A. Physician workforce planning in Canada: the importance of accounting for population aging and changing physician hours of work. CMAJ 2023; 195: E335–40. https://doi.org/10.1503/cmaj.221239 sourcePartly supported

  In “What is the trend in physician hours of work?” (page unavailable), the paper says female physicians’ average hours were relatively stable from 1987 to 2020, while male physicians’ hours declined. It does not identify 1997 as the start of the male decline or describe that decline as statistically significant. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

May combine two claims.

Many physicians do not work full-time and the gap between the full-time equivalent supply of physicians and absolute count has been increasing since the 1980s, worsening significantly after 2020.

“Many physicians do not work full-time and the gap between the full-time equivalent supply of physicians and absolute count has been increasing since the 1980 s.This worsened significantly after 2020.”

• cites [23] Islam R, Kralj B, Sweetman A. Physician workforce planning in Canada: the importance of accounting for population aging and changing physician hours of work. CMAJ 2023; 195: E335–40. https://doi.org/10.1503/cmaj.221239 sourcePartly supported

  The section on population aging and physician hours reports that the full-time-equivalent supply was below the physician count and that the gap opened in the mid-1990s, not the 1980s. The paper analyzes data only through 2020 and cautions against interpreting that pandemic year; it does not establish significant worsening after 2020. Its findings on average hours also do not establish how many physicians worked part-time. (LLM, conf=0.90)

  Experimental — accuracy not yet measured

May combine two claims.

Between 1996 and 2018, the total number of nerve blocks and total payments for anesthesia services increased by seven-fold and five-fold, respectively.

“Similarly, between 1996 and 2018, the total number of nerve blocks and total payments for anesthesia services increased by seven-fold and five-fold, respectively.20”

• cites [20] Simkin S, Orser BA, Wilson CR, McVicar JA, Crozier M, Bourgeault IL. The physician anesthesia workforce in Canada from 1996 to 2018: a longitudinal analysis of health administration data. Anesth Analg 2023; 137: 1128–34. https://doi.org/10.1213/ane.0000000000006650 sourcePartly supported

  The Abstract Results report a seven-fold increase in nerve block services from 1996 to 2018 and a five-fold increase in payments for *other anesthesia services*. The citing sentence broadens the latter to total payments for anesthesia services; the Results passage and Figure 4 caption do not establish that the five-fold figure applies to all anesthesia-service payments. (LLM, conf=0.82)

  Experimental — accuracy not yet measured

May combine two claims.

A disadvantage of centralization is that it ties specialist physician anesthesiologists to urban centres and adds logistical and financial challenges of bringing patients to them.

“A disadvantage, however, is that this ties specialist physician anesthesiologists to urban centres, and adds logistical and financial challenges of bringing patients to them.29”

• cites [29] Aggarwal A, Han L, van der Geest S, et al. Health services planning to assess the expected impact of centralising specialist cancer services on travel times, equity and outcomes: a national population-based modelling study. Lancet Oncol 2022; 23: 1211–20. https://doi.org/10.1016/s1470-2045(22)00398-9 sourcePartly supported

  The Introduction (page not supplied) says centralising complex cancer surgery can require patients to travel farther, and the Results (page not supplied) report increased travel time in the modelled scenarios. The paper does not establish that centralisation ties specialist physician anesthesiologists to urban centres or document the claimed financial challenges. (LLM, conf=0.87)

  Experimental — accuracy not yet measured

May combine two claims.

Physician anesthesiologists must supervise all resident and ancillary personnel activities and, per guidelines, only administer general anesthesia, major regional anesthesia or deep sedation for one patient at a time.

“Physician anesthesiologists must supervise all resident and ancillary personnel activities and, per guidelines, only administer general anesthesia, major regional anesthesia or deep sedation for one patient at a time.38”

• cites [38] Dobson G, Chau A, Denomme J, et al. Guidelines to the Practice of Anesthesia: Revised Edition 2023. Can J Anesth 2023; 70: 16–55. https://doi.org/10.1007/s12630-022-02368-0 sourcePartly supported

  Section 2.4 (p. 7) requires an attending anesthesiologist to supervise all resident activities, and section 5.3 (p. 13) prohibits one anesthesiologist from administering the listed forms of anesthesia or sedation to more than one patient simultaneously. Sections 2.5 (p. 7) and 5.3 (p. 13) address supervision and responsibility for delegated ancillary care, but do not require anesthesiologists to supervise all ancillary personnel activities. (LLM, conf=0.87)

  Experimental — accuracy not yet measured

May combine two claims.

In 2018, FPAs contributed 75% of the Yukon's, 15-18% of Alberta's, British Columbia's, and Ontario's, and close to 10% of Saskatchewan's and Manitoba's anesthesia workforce.

“In a recent longitudinal analysis by Bourgeault's group and the Canadian Health Workforce Network, it is reported that, in 2018, FPAs contributed 75% of the Yukon's, 15-18% of Alberta's, British Columbia's, and Ontario's, and close to 10% of Saskatchewan's and Manitoba's anesthesia workforce.20”

• cites [20] Simkin S, Orser BA, Wilson CR, McVicar JA, Crozier M, Bourgeault IL. The physician anesthesia workforce in Canada from 1996 to 2018: a longitudinal analysis of health administration data. Anesth Analg 2023; 137: 1128–34. https://doi.org/10.1213/ane.0000000000006650 sourceCould not verify

  The Results report 536 FPAs among 3,681 Canadian anesthesia providers in 2018, but give no province- or territory-specific workforce shares. Searches for Yukon and the named provinces, as well as the claimed percentages, found no passage in our copy that verifies those figures. (LLM, conf=0.74)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Anaesthesia Associates were introduced in the UK in 2004 and work under the direction and supervision of an anesthesiologist at all times.

“Anaesthesia Associates were introduced in 2004 and work under the direction and supervision of an anesthesiologist at all times.”

• cites [54] Massey S. NHS long term workforce plan; 2023. Available from URL: https://anaesthesiaassociates.org/news/nhs-long-term-workforce-plan-published/ (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [55] Marks R. Why anaesthetists are calling for an extraordinary meeting on anaesthesia associates. BMJ 2023; 383: 2369. https://doi.org/10.1136/bmj.p2369 sourcePartly supported

  The Abstract says anaesthesia associates theoretically always worked under supervision, but the author had heard that this restriction was being breached. Our copy does not give 2004 as their introduction date or establish that they are supervised by an anaesthesiologist at all times. (LLM, conf=0.88)

  Experimental — accuracy not yet measured

May combine two claims.

A significant proportion of anesthesia in rural Canada is provided by FPAs and has remained a relatively small workforce not exceeding 200 physicians as of 2018.

“Currently, a significant proportion of anesthesia in rural Canada is provided by FPAs and has remained a relatively small workforce not exceeding 200 physicians as of 2018.20”

• cites [20] Simkin S, Orser BA, Wilson CR, McVicar JA, Crozier M, Bourgeault IL. The physician anesthesia workforce in Canada from 1996 to 2018: a longitudinal analysis of health administration data. Anesth Analg 2023; 137: 1128–34. https://doi.org/10.1213/ane.0000000000006650 sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

There remains significant inequity in access to anesthesia provision across Latin America.

“There remains significant inequity in access to anesthesia provision across Latin America.”

• cites [51] Ibarra P, Bagatini A, Salgueiro C, Osorio A. Safety in anesthesia: Latin American perspective. Curr Anesthesiol Rep 2018; 8: 448–55. https://doi.org/10.1007/s40140-018-0288-z sourceNot checked — no full text of the source
• cites [52] Eslava-Schmalbach J. Colombian Journal of Anesthesiology, present and future challenges, in its 50th volume. Colombian J Anesthesiol 2022; 50: e1032. https://doi.org/10.5554/22562087.e1032 sourcePartly supported

  The paper reports unequal access to surgical and anesthetic services in Colombia (p. 2), including the absence of surgical, obstetric and anesthesia providers in its most disadvantaged municipalities (p. 1). It mentions inequalities affecting Colombia and the region, but does not establish the claim about anesthesia provision across Latin America. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Although the Anaesthesia Associates supervised model of care remains a significant minority in the UK, Anaesthesia Associates have been targeted for expansion in a recent NHS long term workforce plan.

“Although the Anaesthesia Associates supervised model of care remains a significant minority in the UK, Anaesthesia Associates have been targeted for expansion in a recent NHS long term workforce plan.55”

• cites [55] Marks R. Why anaesthetists are calling for an extraordinary meeting on anaesthesia associates. BMJ 2023; 383: 2369. https://doi.org/10.1136/bmj.p2369 sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

Anaesthesia Associates provide perioperative care in either a 1:1 or 2:1 model depending on patient acuity.

“Anaesthesia Associates provide perioperative care in either a 1:1 or 2:1 model depending on patient acuity.54,55”

• cites [54] Massey S. NHS long term workforce plan; 2023. Available from URL: https://anaesthesiaassociates.org/news/nhs-long-term-workforce-plan-published/ (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [55] Marks R. Why anaesthetists are calling for an extraordinary meeting on anaesthesia associates. BMJ 2023; 383: 2369. https://doi.org/10.1136/bmj.p2369 sourcePartly supported

  The Abstract says anaesthesia associates provide anaesthetic care, theoretically under supervision and within a restricted scope of practice. Neither that passage nor the discussion of supervision in “A question of professional identity” (p. 2) specifies 1:1 or 2:1 models or says the model depends on patient acuity. (LLM, conf=0.82)

  Experimental — accuracy not yet measured

May combine two claims.

In several countries such as India and Korea, the legal standing of NPAPs is not secure, and they are not recognized by national anesthesia societies despite providing anesthesia in the country.

“In several countries such as India (4.3 PAPs per 100,000) and Korea (22.4 PAPs per 100,000), the legal standing of NPAPs is not secure, and they are not recognized by national anesthesia societies despite providing anesthesia in the country.71”

• cites [71] Kapoor M. ‘Safe anesthesia care for all’ in India—challenges. Indian J Anaesth 2019; 63: 963–4. https://doi.org/10.4103/ija.IJA_882_19 sourcePartly supported

  The paper states that NPAPs have no legal status in India and describes acceptance by the medical community as a hurdle. It does not discuss Korea or the cited workforce densities, and it does not specifically say that national anaesthesia societies refuse to recognize NPAPs. (LLM, conf=0.88)

  Experimental — accuracy not yet measured

May combine two claims.

In Africa, most anesthesia providers are nonphysician providers, including 93% in Uganda, 83% in Kenya, 95% in Rwanda, 95% in Tanzania, and 99% in Burundi.

“In Africa, most anesthesia providers are nonphysician providers; including 93% in Uganda (0.16 PAPs per 100,000), 83% in Kenya (0.37 PAPs per 100,000), 95% in Rwanda (0.22 PAPs per 100,000), 95% in Tanzania (2.5 PAPs per 100,000), and 99% in Burundi (0.03 PAPs per 100,000).68”

• cites [68] Epiu I, Tindimwebwa JV, Mijumbi C, et al. Challenges of anesthesia in low- and middle-income countries: a cross-sectional survey of access to safe obstetric anesthesia in East Africa. Anesth Analg 2017; 124: 290–9. https://doi.org/10.1213/ane.0000000000001690 sourcePartly supported

  The Results state that nonphysician anesthetists provide most anesthesia in the five-country East African region. The passages in our copy do not give the claimed country-by-country percentages or the PAP densities in the citing sentence; the Discussion instead lists anesthesiologist densities. The evidence also concerns East Africa, not Africa as a whole. (LLM, conf=0.85)

  Experimental — accuracy not yet measured

Classified as probably not a substantial claim.

A systematic review by the Cochrane Collaboration in 2014 concluded that there was insufficient evidence to draw any firm conclusions because of potential confounders and bias within the studies reviewed.

“A systematic review by the Cochrane Collaboration in 2014 concluded that there was insufficient evidence to draw any firm conclusions because of potential confounders and bias within the studies reviewed.”

• cites [94] Lewis SR, Nicholson A, Smith AF, Alderson P. Physician anaesthetists versus non-physician providers of anaesthesia for surgical patients. Cochrane Database Syst Rev 2014; 11: CD010357. https://doi.org/10.1002/14651858.cd010357.pub2 sourceSupported

May combine two claims.

Increasing the number of FPAs has been a significant goal of ''The Rural Road Map for Action'' and part of the strategic plans developed by the 2021 national symposium for ''Improving anesthesia care and pain medicine in rural Canada.''

“Increasing the number of FPAs has been a significant goal of ''The Rural Road Map for Action,'' a taskforce to improve the health of rural Canadians, 87 as well as part of the strategic plans developed by the 2021 national symposium for ''Improving anesthesia care and pain medicine in rural Canada.''88”

• cites [87] Advancing Rural Family Medicine: The Canadian Collaborative Taskforce. Rural road map for action—directions; 2017. Available from URL: https://www.cfpc.ca/CFPC/media/Resources/Rural-Practice/Rural-Road-Map-Directions-ENG.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [88] Orser BA, Wilson CR, Bainbridge D. Improving anesthesia care and pain medicine in rural Canada: nothing about us without us. Can J Anesth 2021; 68: 1731–7. https://doi.org/10.1007/s12630-021-02098-9 sourcePartly supported

  The paper’s symposium recommendations (Abstract; page not supplied) call for educating enough specialist and nonspecialist anesthesia providers, and the authors explicitly advocate more family-practice-anesthesia training positions. However, it says a team will create a work plan based on those recommendations; it does not establish that the symposium had already developed the strategic plans described in the claim. The separate Rural Road Map assertion is attached to citation 87, not this source. (LLM, conf=0.84)

  Experimental — accuracy not yet measured

May combine two claims.

Canada's specialist anesthesiologist density increased from 8.9/100,000 in 2016 to 9.5/100,000 in 2021, a 14.9% increase in absolute numbers and a 6.5% increase when population increase is accounted for.

“This has actually increased from 8.9/100,000 based on data collected in 2016 (when trainees and family practice anesthetists are excluded)-a 14.9% increase in absolute numbers and a 6.5% increase when population increase is accounted for.10”

• cites [10] Kempthorne P, Morriss WW, Mellin-Olsen J, Gore-Booth J. The WFSA Global Anesthesia Workforce survey. Anesth Analg 2017; 125: 981–90. https://doi.org/10.1213/ane.0000000000002258 (https://wfsahq.org/resources/workforce-map/). sourceNot checked — no full text of the source

May combine two claims.

The number of specialist anesthesiologists in Canada seems to be increasing ahead of population increase, while the increase in total PAPs remains more static.

“In summary, the number of specialist anesthesiologists seems to be increasing ahead of the increase in population, while the increase in total PAPs remains more static.”

May combine two claims.

CIHI data support an increase in anesthesiologists in Canada (excluding Quebec) from 2,905 in 2016 to 3,797 in 2022, a 30.7% increase and a 20.8% population-adjusted increase from 10.5 to 12.7/100,000.

“Data from the Canadian Institute for Health Information (CIHI) support there having been an increase in anesthesiologists in Canada (although Quebec is excluded from these data) with 2,905 anesthesiologists in 2016 increasing to 3,797 in 2022-an increase of 30.7% (and an increase of 20.8% when population is accounted for, increasing from 10.5 to 12.7/100,000 population).”

May combine two claims.

CIHI data indicate that the number of physician anesthesia providers peaked in 2016 with a density of 13.1 PAPs/100,000 population, with a slight fall when accounting for population over subsequent years.

“CIHI data indicate that the number of physician anesthesia providers (PAPs-defined as a specialist anesthesiologist or a physician with additional training in anesthesia such as a family practice anesthetist) peaked in 2016 with a density of 13.1 PAPs/100,000 population with a slight fall when accounting for population over subsequent years.”

May combine two claims.

Recent media headlines have featured vacant physician anesthesiologist positions, closure of maternity units, and postponement of elective surgeries because of a shortage of anesthesiologists.

“Recent media headlines have featured vacant physician anesthesiologist positions remaining unfilled, closure of maternity units, and postponement of elective surgeries because of a shortage of anesthesiologists.5,6”

• cites [5] Cooke A. What an anesthesiologist shortage means for pregnant women in Yarmouth; 2019. Available from URL: https://www.cbc.ca/news/canada/nova-scotia/anesthesiologist-shortage-pregnant-women-in-yarmouth-drive-out-of-town-1.5109707 (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [6] Bergen R. At least 300 Winnipeg surgeries in September postponed over anesthesia staff shortages; 2022. https://www.cbc.ca/news/canada/manitoba/wrha-surgeries-cancelled-september-memo-1.6542611 (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Canada's health care spending is 12.2% of GDP, above the OECD median of 9.1%, yet its PAP density is below the OECD median of 17.3 PAP per 100,000.

“Canada's health care spending of 12.2% (as a proportion of gross domestic product [GDP]) is well above the median for other OECD countries (9.1%), yet our PAP density is well below the median (17.3 PAP per 100,000).”

• cites [12] Organisation for Economic Co-operation and Development. Health expenditure and financing. Available from URL: https://stats.oecd.org/Index.aspx?DataSetCode=SHA (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

The number of common surgical procedures performed in Canada has increased over the past decade, with the greatest increase seen in orthopedic surgery procedures such as total knee and hip replacements.

“The number of common surgical procedures performed in Canada has increased over the past decade, with the greatest increase seen in orthopedic surgery procedures such as total knee and hip replacements.11”

• cites [11] Organisation for Economic Co-operation and Development. Hip and knee replacement; 2021. Available from URL: https://www.oecd-ilibrary.org/sites/8b492d7a-en/index.html?itemId=/content/component/8b492d7a-en (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Centralization of all breast cancer surgical consultations in Vancouver, BC, reduced median wait and case completion times as well as need for neoadjuvant therapy.

“The centralization of all breast cancer surgical consultations in Vancouver, BC, reduced median wait and case completion times as well as need for neoadjuvant therapy.27”

• cites [27] Cha J, McKevitt E, Pao JS, Dingee C, Bazzarelli A, Warburton R. Access to surgery following centralization of breast cancer surgical consultations. Am J Surg 2020; 219: 831–5. https://doi.org/10.1016/j.amjsurg.2020.01.050 sourceNot checked — no full text of the source

May combine two claims.

Resident numbers doubled between 1992 and 2008, but plateaued with trainee numbers increasing by less than 10% from 2010 to 2021, in line with a population increase of 11% in that decade.

“Resident numbers doubled between 1992 and 2008, but plateaued with trainee numbers increasing by less than 10% from 2010 to 2021 (Fig. 2) 16 in line with a population increase of 11% in that decade.15”

• cites [16] CAPER. Canadian Post-MD Education Registry 2021–2022: specialty report. Available from URL: https://caper.ca/sites/default/files/pdf/specialty/2021-22_Individual_Specialty_Tables.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [15] Statistics Canada. Population projections for Canada, provinces and territories, 2021 to 2068, 2022. Available from URL: https://www150.statcan.gc.ca/n1/daily-quotidien/220822/dq220822b-eng.htm (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Statistics Canada projects the Canadian population to reach between 42.9 and 52.5 million by 2043.

“Statistics Canada projects the Canadian population to reach between 42.9 and 52.5 million by 2043.15”

• cites [15] Statistics Canada. Population projections for Canada, provinces and territories, 2021 to 2068, 2022. Available from URL: https://www150.statcan.gc.ca/n1/daily-quotidien/220822/dq220822b-eng.htm (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The Canadian population is aging; the number of Canadians over 85 more than doubled between the 2001 and 2021 Censuses and is one of the fastest growing age groups.

“Of further note, the Canadian population is aging, the number of Canadians over 85 has more than doubled between the 2001 and 2021 Censuses and is one of the fastest growing age groups.”

Probably not a substantial claim: may not pass S3 (load-bearing).

By 2040, the proportion of health care resources used by individuals over 65 yr of age is predicted to rise to 71.4%.

“By 2040, the proportion of health care resources used by individuals over 65 yr of age is predicted to rise to 71.4%.22”

• cites [22] Globerman S. Aging and expenditures on health care; 2021. Available from URL: https://www.jstor.org/stable/pdf/resrep30194.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The USA has the highest health care budget of all OECD nations yet has one of the worst maternal mortality rates, which has been increasing over the past two decades.

“The USA has by far the highest health care budget of all the OECD nations yet has one of the worst maternal mortality rates, which has been increasing over the past two decades.14”

• cites [14] Gunja MZ, Gumas ED, Williams RD II. The U.S. maternal mortality crisis continues to worsen: an international comparison; 2022. Available from URL: https://www.commonwealthfund.org/blog/2022/us-maternal-mortality-crisis-continues-worsen-international-comparison (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Statistics Canada predicts that by 2046 the population over 85 could triple to almost 2.5 million people.

“Statistics Canada predicts that by 2046, this demographic could triple to almost 2.5 million people.21”

• cites [21] Statistics Canada. A portrait of Canada’s growing population aged 85 and older from the 2021 Census; 2022. Available from URL: https://www12.statcan.gc.ca/census-recensement/2021/as-sa/98-200-X/2021004/98-200-x2021004-eng.cfm (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

According to the December 2019 CMA Anesthesiology Profile, 40% of specialist trained anesthesiologists are over age 55 and 29% are in the 45-54 yr age bracket.

“According to the December 2019 Canadian Medical Association (CMA) Anesthesiology Profile, 40% of the specialist trained anesthesiologists are over the age of 55 and 29% are in the 45-54 yr age bracket.8”

• cites [8] Canadian Medical Association. Anesthesiology Profile; updated December 2019. Available from URL: https://www.cma.ca/sites/default/files/2020-10/anesthesiology-e.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Individuals over 65 yr of age accounted for 45.7% of total health care expenditures in 2019.

“Older patients use more health care resources with individuals over 65 yr of age accounting for 45.7% of total health care expenditures in 2019.”

• cites [22] Globerman S. Aging and expenditures on health care; 2021. Available from URL: https://www.jstor.org/stable/pdf/resrep30194.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Canada has a relatively low PAP density yet high health care funding compared with the other 37 OECD nations.

“Canada has a relatively low PAP density yet high health care funding when compared with the other 37 Organisation for Economic Co-operation and Development (OECD) nations.11”

• cites [11] Organisation for Economic Co-operation and Development. Hip and knee replacement; 2021. Available from URL: https://www.oecd-ilibrary.org/sites/8b492d7a-en/index.html?itemId=/content/component/8b492d7a-en (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

In Europe, there are several different models for anesthesia provision.

“In Europe, there are several different models for anesthesia provision.”

Probably not a substantial claim: may not pass S3 (load-bearing).

CLASA represents 19 national anesthesiology societies in the Latin American region.

“The Confederacio ´n Latinoamericana de Sociedades de Anestesiologı ´a (CLASA) represents 19 national anesthesiology societies in the Latin American region.”

May combine two claims.

Quebec and the Atlantic provinces have no FPA training programs and very few practicing FPAs.

“Quebec and the Atlantic provinces have no FPA training programs and very few practicing FPAs.”

May combine two claims.

There is much variation among the use of AAs throughout Canada and not all employers require a CCAA certification to work as an AA.

“Again, there is much variation among the use of AAs throughout Canada (Table 1) and not all employers require a CCAA certification to work as an AA.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The South African Society of Anaesthesiologists reports an anesthesia skills shortage, which is impacting the number of patients receiving surgery, especially in the public sector.

“The South African Society of Anaesthesiologists (SASA) also reports an anesthesia skills shortage, which is impacting the number of patients receiving surgery, especially in the public sector.49”

• cites [49] South African Society of Anaesthesiologists. Practice guidelines 2018 revision; 2018. Available from URL: www.sasaweb.com/wp-content/uploads/2022/07/SASA-Practice-Guidelines-2018.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Nova Scotia, with the highest PAP density of all the provinces, recently launched a pilot for FPAs at the Yarmouth Regional Hospital to augment the anesthesia workforce.

“Nova Scotia, with the highest PAP density of all the provinces (Table 1), recently launched a pilot for FPAs at the Yarmouth Regional Hospital to augment the anesthesia workforce.39”

• cites [39] Nova Scotia Health. Nova Scotia Health launches pilot for family practice anesthesiology in Yarmouth to help address surgery backlogs and anesthetist shortages; 2023. Available from URL: https://physicians.nshealth.ca/news/nova-scotia-health-launches-pilot-family-practice-anesthesiology-yarmouth-help-address-surgery#:~:text=To%20help%20address%20the%20national,at%20the%20Yarmouth%20Regional%20Hospital (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

An Australia-wide shortage of GPs has impacted communities that rely on GP anesthetists for anesthesia coverage.

“Furthermore, the Australia-wide shortage of GPs has impacted communities that rely on GP anesthetists for anesthesia coverage.”

• cites [46] Australia Department of Health. Australia’s future health workforce—anaesthesia; 2016. Available from URL: https://www.health.gov.au/sites/default/files/documents/2021/03/anaesthesia-australia-s-future-health-workforce-report.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [47] Australian Society of Anaesthetists. Australia’s health workforce September 2005. Available from URL: https://www.pc.gov.au/inquiries/completed/health-workforce/submissions/subpp195/subpp195.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

In the UK (14.2 PAPs per 100,000), all anesthesia provision must be led by a physician with most patients being looked after directly by an anesthesiologist.

“In the UK (14.2 PAPs per 100,000), all anesthesia provision must be led by a physician with most patients being looked after directly by an anesthesiologist (Table 2).”

• cites [53] Royal College of Anaesthetists. Chapter 2: Guidelines for the provision of anaesthesia services for the perioperative care of elective and urgent care patients 2024; 2023. Available from URL: https://www.rcoa.ac.uk/gpas/chapter-2 (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

International approaches to anesthesia workforce composition have both differences and similarities with respect to Canada and to each other.

“International approaches to anesthesia workforce composition have both differences and similarities with respect to Canada and to each other (Table 2).”

May combine two claims.

South Africa has a PAP density of 2.9 per 100,000 and anesthesia provision is based on a physician-only model.

“South Africa has a PAP density of 2.9 per 100, 000 and anesthesia provision is based on a physician-only model (Table 2).9”

• cites [9] Law TJ, Lipnick MS, Morriss W, et al. The Global Anesthesia Workforce survey: updates and trends in the anesthesia workforce. Anesth Analg 2024; https://doi.org/10.1213/ane.0000000000006836 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

As of 2014, there were 276 GP anesthetists who provided 6.3% of anesthesia services across Australia.

“As of 2014, there were 276 GP anesthetists who provided 6.3% of anesthesia services across Australia.46”

• cites [46] Australia Department of Health. Australia’s future health workforce—anaesthesia; 2016. Available from URL: https://www.health.gov.au/sites/default/files/documents/2021/03/anaesthesia-australia-s-future-health-workforce-report.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Japan has reported a relative shortage of practicing anesthesiologists to be a national issue.

“Japan has also reported a relative shortage of practicing anesthesiologists to be a national issue.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The Australian Society of Anaesthetists' workforce projections report a maldistribution, as well as administrative and financial issues, rather than an overall shortage of anesthetists as the cause for the anesthesia workforce deficit in Australia.

“The Australian Society of Anaesthetists' workforce projections report a maldistribution, as well as administrative and financial issues, rather than an overall shortage of anesthetists as the cause for the anesthesia workforce deficit in Australia.”

• cites [46] Australia Department of Health. Australia’s future health workforce—anaesthesia; 2016. Available from URL: https://www.health.gov.au/sites/default/files/documents/2021/03/anaesthesia-australia-s-future-health-workforce-report.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [47] Australian Society of Anaesthetists. Australia’s health workforce September 2005. Available from URL: https://www.pc.gov.au/inquiries/completed/health-workforce/submissions/subpp195/subpp195.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Upon completion of training, GP anesthetists in Australia can provide anesthesia services to ASA Physical Status classification level I-III patients and to children five years and older and be certified epidural-competent in obstetrics.

“Upon completion of training, GP anesthetists can provide anesthesia services to ASA Physical Status classification level I-III patients and to children five years and older and be certified epiduralcompetent in obstetrics.45”

• cites [45] Australia and New Zealand College of Anaesthetists. Rural generalist anaesthesia training program. Available from URL: https://www.anzca.edu.au/education-training/rural-generalist-anaesthesia#:~:text=Launched%20in%202023%2C%20the%20Rural,rural%20general%20practitioners%20and%20rural (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The Government of Ontario has announced plans to remove registration requirements for out-of-province health care workers as well as allowing licencing of USA-trained physicians in a bid to fill staffing vacancies across the health care professions.

“The Government of Ontario has announced plans to remove registration requirements for out-of-province health care workers as well as allowing licencing of USA-trained physicians in a bid to fill staffing vacancies across the health care professions.41”

• cites [41] Cook D. Ontario to remove registration requirements for out-of-province health care workers; 2023. Available from URL: https://www.theglobeandmail.com/canada/article-ontario-doctors-nurses-credentials/ (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

As of 2021, the anesthesia workforce consisted of 3,709 specialist anesthesiologists, 398 FPAs, and 545 certified clinical AAs.

“As of 2021, the anesthesia workforce consisted of 3,709 specialist anesthesiologists, 398 FPAs, and 545 certified clinical AAs (Table 1).”

May combine two claims.

As recently as 2016, an estimated 20% of anesthesia care in Japan was delivered by surgeons, with obstetricians administering anesthesia in 40% of operative deliveries and providing 80% of labour analgesic techniques.

“As recently as 2016, an estimated 20% of anesthesia care was delivered by surgeons, with obstetricians administering anesthesia in 40% of operative deliveries and providing 80% of labour analgesic techniques.43”

• cites [43] Bishop DG, Fernandes NL, Dyer RA, et al. Global issues in obstetric anesthesia: perspectives from South Africa, Japan, China, Latin America and North America. Int J Obst Anesth 2023; 54: 103648. https://doi.org/10.1016/j.ijoa.2023.103648 sourceNot checked — no full text of the source

May combine two claims.

In Japan (11.7 PAPs per 100,000), only physicians are legally allowed to administer anesthesia and the majority of anesthesia care is provided by board-certified physician anesthesiologists.

“In Japan (11.7 PAPs per 100,000), only physicians are legally allowed to administer anesthesia and the majority of anesthesia care is provided by board-certified physician anesthesiologists (Table 2).42”

• cites [42] Miyasaka K. A Japanese perspective on patient safety; 2016. Available from URL: https://www.apsf.org/wp-content/uploads/newsletters/2016/June/pdf/APSF201606.pdf#page=18 (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

It is mandatory in the UK to have a second anesthesia provider at induction, either in the form of a second anesthesiologist or an operating department practitioner.

“It is mandatory in the UK to have a second anesthesia provider at induction, either in the form of a second anesthesiologist or an operating department practitioner (an anesthesia-trained technician).53”

• cites [53] Royal College of Anaesthetists. Chapter 2: Guidelines for the provision of anaesthesia services for the perioperative care of elective and urgent care patients 2024; 2023. Available from URL: https://www.rcoa.ac.uk/gpas/chapter-2 (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

An updated Rural Generalist Anaesthesia training program for GP anesthetists was launched in 2023 as a joint initiative between ANZCA, the Royal Australian College of General Practitioners, and the Australian College of Rural and Remote Medicine and consists of 12 months of clinical training and success in the RGA examination.

“An updated Rural Generalist Anaesthesia (RGA) training program for GP anesthetists was launched in 2023 as a joint initiative between the ANZCA, the Royal Australian College of General Practitioners, and the Australian College of Rural and Remote Medicine and consists of 12 months of clinical training and success in the RGA examination.”

• cites [45] Australia and New Zealand College of Anaesthetists. Rural generalist anaesthesia training program. Available from URL: https://www.anzca.edu.au/education-training/rural-generalist-anaesthesia#:~:text=Launched%20in%202023%2C%20the%20Rural,rural%20general%20practitioners%20and%20rural (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In Quebec, with the lowest PAP density, a trained assistant (RT/AA) must be present for every anesthesiologist-administered anesthetic.

“For example, in Quebec, with the lowest PAP density, a trained assistant (RT/AA) must be present for every anesthesiologist-administered anesthetic.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

In the USA, independent anesthesia providers include physician specialists as well as nurse anesthetists.

“In the USA (15.9 PAPs per 100,000), independent anesthesia providers include physician specialists as well as nurse anesthetists (Table 2).”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Physician-led anesthesia care teams are widely used in Europe.

“Physician-led anesthesia care teams are widely used in Europe.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

While no European country allows nurse anesthetists to provide anesthesia independently, some countries use nurse anesthetists in a supervised role.

“While no European country allows nurse anesthetists to provide anesthesia independently, some countries use nurse anesthetists in a supervised role.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Recent UK media has featured headlines such as ''Shortage of anaesthetists endangers NHS recovery'' and ''NHS faces ticking time bomb over shortage of anaesthetists.''

“Recent UK media has featured headlines such as ''Shortage of anaesthetists endangers NHS recovery'' 56 and ''NHS faces ticking time bomb over shortage of anaesthetists.''57”

• cites [56] Goodhand S. Shortage of anaesthetists endangers NHS recovery; 2022. Available from URL: https://www.ft.com/content/7f2676a2-9a6a-443f-b7b6-88644553c8b1 (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [57] Thomas R. NHS faces ticking ‘time bomb’ of 8m cancelled or delayed operations due to anaesthetist shortage; 2022. Available from URL: www.independent.co.uk/news/health/nhs-time-bomb-shortage-anaesthetists-b2020737.html (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

In 2021, the number of CCAAs in Yukon was 0.

“| Yukon | 1 | 6 | 2 | 16 | 0 | 0 |”

Probably not a substantial claim: may not pass S3 (load-bearing).

In 2021, the PAP density per 100,000 population in Yukon was 16.

“| Yukon | 1 | 6 | 2 | 16 | 0 | 0 |”

Classified as probably not a substantial claim.

Canadians in every province and territory face significant challenges in accessing timely surgery.

“A recent position statement by the Canadian Anesthesiologists' Society (CAS) notes that ''Canadians in every province and territory are facing significant challenges in accessing timely surgery.''4”

• cites [4] Canadian Anesthesiologists’ Society. Strategies to address the surgical backlog and health human resource issues in anesthesia; 2023. Available from URL: https://www.cas.ca/CASAssets/Documents/Practice-Resources/Reports-Position-Papers/CAS-HHR-Surgical-Backlog-Position-Statement_FINAL.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

According to the Canadian Anesthesiologists' Society, the shortage is beginning to impact larger towns and cities and is predicted to worsen as the current workforce ages and retires.

“According to the CAS, this shortage is beginning to impact larger towns and cities and is predicted to worsen as the current workforce ages and retires.3”

• cites [3] Canadian Anesthesiologists’ Society Press Release. Shortage of anesthesiologists impacts delivery of surgical, acute and chronic pain services; 2019. Available from URL: https://www.cas.ca/CASAssets/Documents/About-Us/88_20-19-May-PressReleasePhysicianShortage-v2.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Classified as probably not a substantial claim. May combine two claims.

The productivity of the anesthesia workforce is dependent on where anesthesiologists work, how much they work, the efficiency of institutions in which they work, what services are provided, and the wellness of the workforce.

“The productivity of the workforce is also dependent on where the anesthesiologists are working, how much they work, the efficiency of institutions in which they work, what services are provided, as well as the wellness of the workforce.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

The geography and population dispersion in Canada cannot be overlooked as a challenge to anesthesia access.

“The geography and population dispersion in Canada cannot be overlooked as a challenge to anesthesia access.”

May combine two claims.

Reasons for the anesthesia human resources crisis may include increasing involvement of anesthesiologists in diagnostic and therapeutic interventions outside the operating room, an increasing burden of disease amenable to surgical care, an increase in available surgical options for disease, and/or changing societal expectations.

“Reasons for this crisis may include an increasing involvement of anesthesiologists in diagnostic and therapeutic interventions outside the operating room, 4 an increasing burden of disease that is amenable to surgical care, an increase in available surgical options for disease, and/or changing societal expectations.”

• cites [4] Canadian Anesthesiologists’ Society. Strategies to address the surgical backlog and health human resource issues in anesthesia; 2023. Available from URL: https://www.cas.ca/CASAssets/Documents/Practice-Resources/Reports-Position-Papers/CAS-HHR-Surgical-Backlog-Position-Statement_FINAL.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

The position of ANZCA is that anesthesia should only be practiced by specialist or general practitioner anesthetists.

“The position of the Australia and New Zealand College of Anaesthetists (ANZCA) is that anesthesia should only be practiced by specialist or general practitioner (GP) anesthetists (Table 2).45”

• cites [45] Australia and New Zealand College of Anaesthetists. Rural generalist anaesthesia training program. Available from URL: https://www.anzca.edu.au/education-training/rural-generalist-anaesthesia#:~:text=Launched%20in%202023%2C%20the%20Rural,rural%20general%20practitioners%20and%20rural (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Different approaches to the anesthesia workforce are taken across Canada, and differences in care models will likely continue as the health needs of geographic areas continue to differ.

“Different approaches to the anesthesia workforce are taken across Canada, and it is likely that differences in care models will continue as the health needs of geographic areas continue to differ.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The goals of CLASA are for anesthesia to only be delivered by physician anesthesiologists in the countries associated with CLASA and that decisions about anesthesia workforce development can only be made with the involvement and leadership of physician anesthesiologists.

“The goals of CLASA are for anesthesia to only be delivered by physician anesthesiologists in the countries associated with CLASA and that decisions about anesthesia workforce development can only be made with the involvement and leadership of physician anesthesiologists (Table 2).43,50”

• cites [43] Bishop DG, Fernandes NL, Dyer RA, et al. Global issues in obstetric anesthesia: perspectives from South Africa, Japan, China, Latin America and North America. Int J Obst Anesth 2023; 54: 103648. https://doi.org/10.1016/j.ijoa.2023.103648 sourceNot checked — no full text of the source
• cites [50] CLASA-WFSA. Joint statement on provision of safe anesthesia care; 2022. Available from URL: https://wfsahq.org/wp-content/uploads/Final-CLASA-WFSA-Joint-Statement-on-Provision-of-Safe-Anesthesia-Care.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Australia (20.6 PAPs per 100,000) has similar challenges to Canada in anesthesia provision with regards to a vast geography and widely dispersed rural population.

“Australia (20.6 PAPs per 100,000) has similar challenges to Canada in anesthesia provision with regards to a vast geography and widely dispersed rural population.”

• cites [45] Australia and New Zealand College of Anaesthetists. Rural generalist anaesthesia training program. Available from URL: https://www.anzca.edu.au/education-training/rural-generalist-anaesthesia#:~:text=Launched%20in%202023%2C%20the%20Rural,rural%20general%20practitioners%20and%20rural (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Estimates from 2016 in Papua New Guinea indicate that 70% of anesthesia providers are nonphysicians who administer over 90% of all anesthetics.

“Estimates from 2016 in Papua New Guinea (1.1 PAPs per 100,000) indicate that 70% of anesthesia providers are nonphysicians who administer over 90% of all anesthetics.70”

• cites [70] Loughnan TE, Cooper MG, Wake PB, Aigeeleng H. History of non-physician anaesthesia providers in Papua New Guinea: from heil tultuls to anaesthetic scientific officers. Anaesth Intensive Care 2021; 49: 29–40. https://doi.org/10.1177/0310057x211027872 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The geographic distribution of physician anesthesiologists is an issue in many parts of the world but most severely impacts low- and lower-middle-income countries.

“The geographic distribution of physician anesthesiologists is an issue in many parts of the world but most severely impacts low-and lower-middle-income countries.67”

• cites [67] Morriss WW, Enright AC. The anesthesia workforce crisis revisited. Anesth Analg 2023; 136: 227–9. https://doi.org/10.1213/ane.0000000000006189 sourceNot checked — no full text of the source

May combine two claims.

Both the CAS and ACUDA have requested an increase in the number of residency training positions in anesthesiology.

“This is supported by both the CAS and ACUDA, who have both requested an increase in the number of residency training positions in anesthesiology.3”

• cites [3] Canadian Anesthesiologists’ Society Press Release. Shortage of anesthesiologists impacts delivery of surgical, acute and chronic pain services; 2019. Available from URL: https://www.cas.ca/CASAssets/Documents/About-Us/88_20-19-May-PressReleasePhysicianShortage-v2.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Certified Registered Nurse Anesthetists provide over 50 million anesthetics each year in the USA.

“Certified Registered Nurse Anesthetists provide over 50 million anesthetics each year 60 in the USA”

• cites [60] American Association of Nurse Anesthesiology. Certified registered nurse anesthetists fact sheet; 2022. Available from URL: https://njana.com/wp-content/uploads/2022/03/crna-fact-sheet.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Despite the USA having one of the highest PAP densities (15.9 PAPs per 100,000) and over 56,000 CRNAs, there is a predicted shortage of both physician anesthesiologists (deficit of 12,500 by 2033) and CRNAs, which has been further aggravated by the COVID-19 pandemic.

“Despite the USA having one of the highest PAP densities (15.9 PAPs per 100,000) 9 and over 56,000 CRNAs, there is a predicted shortage of both physician anesthesiologists (deficit of 12,500 by 2033) and CRNAs, which has been further aggravated by the COVID-19 pandemic.63,64”

• cites [9] Law TJ, Lipnick MS, Morriss W, et al. The Global Anesthesia Workforce survey: updates and trends in the anesthesia workforce. Anesth Analg 2024; https://doi.org/10.1213/ane.0000000000006836 sourceNot checked — no full text of the source
• cites [63] Simoneaux R. Are we facing an anesthesiologist shortage? ASA Monitor 2022; 86: 1–5. https://doi.org/10.1097/01.ASM.0000805968.27980.7c sourceNot checked — no full text of the source
• cites [64] Medical Business Management. The future of anesthesiology: how anesthesiologist and CRNA shortages are making an impact; 2021. Available from URL: www.mbmps.com/the-future-of-anesthesiology-how-anesthesiologist-and-crna-shortages-are-making-an-impact/ (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Between 2010 and 2019, the CaRMS anesthesiology residency training quota ranged from 100 to 109 annual positions for CMGs and from eight to 11 annual positions for IMGs.

“Between 2010 and 2019, the Canadian Resident Matching Service (CaRMS) anesthesiology residency training quota ranged from 100 to 109 annual positions for Canadian medical graduates (CMGs) and from eight to 11 annual positions for international medical graduates (IMGs).73”

• cites [73] Canadian Residency Matching Service. R-1 data and reports. Available from URL: https://www.carms.ca/data-reports/r1-data-reports/ (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In Europe, anesthesia human resources appear more fluctuant partly because of the relative freedom of labour movement within the European Union.

“In Europe, anesthesia human resources appear to be more fluctuant in part because of the relative freedom of labour movement within the European Union.”

• AssumptionRests on an assumption: Skilled labour, such as anesthesiologists, migrate to countries with more competitive salaries and better working conditions.

May combine two claims.

With the Ontario ACT model implementation, there was no increase in serious adverse events and a reduction in postanesthesia care unit time and overall hospital length of stay.

“With this implementation, there was no increase in serious adverse events and a reduction in postanesthesia care unit time and overall hospital length of stay.85”

• cites [85] ACT Implementation Advisory Committee. A plan to evolve the anesthesia care team model in Ontario; 2009. Available from URL: https://www.crto.on.ca/pdf/Misc/Anesthesia_Care_Team_Ontario.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Seventy-three percent of physicians in Canada are CMGs.

“Seventy-three percent of physicians in Canada are CMGs.75”

• cites [75] Canadian Institute for Health Information. A profile for physicians in Canada; 2021. Available from URL: https://www.cihi.ca/en/a-profile-of-physicians-in-canada (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

The intervention to increase training positions has begun with an increase in CMG positions from 117 in 2020 to 139 in 2023, while the IMG quota has remained unchanged.

“This intervention has begun to be enacted with an increase in CMG positions of 117 in 2020 to 139 in 2023.Nevertheless, the IMG quota has remained unchanged.73”

• cites [73] Canadian Residency Matching Service. R-1 data and reports. Available from URL: https://www.carms.ca/data-reports/r1-data-reports/ (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Certified Registered Nurse Anesthetists are highly involved in the provision of anesthesia care in rural areas of the USA.

“Certified Registered Nurse Anesthetists are highly involved in the provision of anesthesia care in rural areas of the USA.60,61”

• cites [60] American Association of Nurse Anesthesiology. Certified registered nurse anesthetists fact sheet; 2022. Available from URL: https://njana.com/wp-content/uploads/2022/03/crna-fact-sheet.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [61] U.S. Bureau of Labor Statistics. Occupational employment and wages, May 2023. Available from URL: https://www.bls.gov/oes/current/oes291151.htm#nat (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

An Africa-wide survey in 2019 identified 30 distinct training pathways to become an anesthesia provider in Africa, with the majority for nonphysician anesthesia providers.

“An Africa-wide survey was conducted in 2019 on anesthesia provider training and practice models.Thirty distinct training pathways to become an anesthesia provider in Africa were identified with the majority for nonphysician anesthesia providers (NPAPs).”

• cites [69] Law TJ, Bulamba F, Ochieng JP, et al. Anesthesia provider training and practice models: a survey of Africa. Anesth Analg 2019; 129: 839–46. https://doi.org/10.1213/ane.0000000000004302 sourceNot checked — no full text of the source

May combine two claims.

In Sweden, nonphysician providers outnumber anesthesiologists, with a 4:1 ratio of nurse anesthetists to physician anesthesiologists.

“and in Sweden (18.6 PAPs per 100,000), nonphysician providers outnumber anesthesiologists where there is a 4:1 ratio of nurse anesthetists (who require indirect supervision) to physician anesthesiologists (Table 2).”

• cites [58] Meeusen V, van Zundert A, Hoekman J, Kumar C, Rawal N, Knape H. Composition of the anaesthesia team: a European survey. Eur J Anaesthesiol 2010; 27: 773–9. https://doi.org/10.1097/eja.0b013e32833d925b sourceNot checked — no full text of the source

May combine two claims.

Family practice anesthesia graduates have a shorter time period to independent practice and are already providing a significant proportion of rural anesthesia care including elective and emergent cases as well as resuscitative assistance in emergency departments and critical care units.

“Family practice anesthesia graduates have a shorter time period to independent practice and are already providing a significant proportion of rural anesthesia care including elective and emergent cases as well as resuscitative assistance in emergency departments and critical care units.86”

• cites [86] Orser BA, Wilson CR, Rotstein AJ, et al. Improving access to safe anesthetic care in rural and remote communities in affluent countries. Anesth Analg 2019; 129: 294–300. https://doi.org/10.1213/ane.0000000000004083 sourceNot checked — no full text of the source

May combine two claims.

To date, 22 states have opted out of the federal rule requiring anesthesiologist supervision of nurse anesthetists, although many still require physician involvement.

“To date, 22 states have opted out, although many still require physician involvement.60”

• cites [60] American Association of Nurse Anesthesiology. Certified registered nurse anesthetists fact sheet; 2022. Available from URL: https://njana.com/wp-content/uploads/2022/03/crna-fact-sheet.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

In the 2022 CaRMS match, only ten positions were open to IMGs, with 287 applicants.

“In the 2022 CaRMS match, only ten positions were open to IMGs, with 287 applicants.73”

• cites [73] Canadian Residency Matching Service. R-1 data and reports. Available from URL: https://www.carms.ca/data-reports/r1-data-reports/ (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Shortages have been predicted in some European countries because of an aging physician workforce.

“Nevertheless, shortages have been predicted in some European countries because of an aging physician workforce.59”

• cites [59] Halbeis CB, Cvachovec K, Scherpereel P, Mellin-Olsen J, Brobnik L, Sondore A. Anaesthesia workforce in Europe. Eur J Anaesthesiol 2007; 24: 991–1007. https://doi.org/10.1017/s0265021507000762 sourceNot checked — no full text of the source

May combine two claims.

Task sharing has been used safely in many jurisdictions, including the European model where anesthesiologists supervise nurse anesthetists, and Europe is one of the only regions of the world to have very limited reports of anesthesia shortages.

“This has been used safely in many jurisdictions, including the European model where anesthesiologists supervise nurse anesthetists and is one of the only regions of the world to have very limited reports of anesthesia shortages.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Independent CRNA care models have been reported to be the most cost-effective given their salaried status and lower training costs, followed by physician anesthesiologist-led ACTs, with physician anesthesiologists working alone being the least cost effective.

“Independent CRNA care models have been reported to be the most cost-effective given their salaried status and lower training costs.This is followed by physician anesthesiologist-led ACTs and physician anesthesiologists working alone being the least cost effective.95”

• cites [95] Hogan P, Seifert RF, Moore CS, Simonson BE. Cost effectiveness analysis of anesthesia providers. Nurs Econ 2010; 28: 159–69.Not checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The Government of British Columbia has proposed introducing an entirely new group of anesthesia providers such as CRNAs either as part of the ACT or as independent practitioners as a solution to improving perioperative access in the province.

“The latter has been proposed by the Government of British Columbia as a solution to improving perioperative access in the province.93”

• cites [93] Canadian Anesthesiologists’ Society. Advocacy: certified registered nurse anesthetists (CRNAS). Available from URL: https://www.cas.ca/en/about-cas/advocacy (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S1 (asserted), S2 (checkable), S3 (load-bearing). May combine two claims.

A private system still must work within the constraints of the limited pool of human resources in a province; therefore, it is debatable whether this would improve access to care for all and has the potential to draw resources away from the public system.

“The counter-argument to this had been that a private system still must work within the constraints of the limited pool of human resources in a province; therefore, it is debatable whether this would improve access to care for all and has the potential to draw resources away from the public system.104”

• cites [104] Australian Government Department of Health and Aged Care. The Australian health system. Available from URL: https://www.health.gov.au/about-us/the-australian-health-system#private-health-insurance (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

The CAS is only supportive of physician-led anesthesia (either specialty-trained FRCPC anesthesiologists or FPAs) with the support of the ACT using the principle of delegation but firmly rejects the adoption of independent CRNAs in Canada.

“The CAS is also only supportive of physician-led anesthesia (either specialty-trained FRCPC anesthesiologists or FPAs) with the support of the ACT using the principle of delegation but firmly rejects the adoption of independent CRNAs in Canada.4,40”

• cites [4] Canadian Anesthesiologists’ Society. Strategies to address the surgical backlog and health human resource issues in anesthesia; 2023. Available from URL: https://www.cas.ca/CASAssets/Documents/Practice-Resources/Reports-Position-Papers/CAS-HHR-Surgical-Backlog-Position-Statement_FINAL.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [40] Canadian Anesthesiologists’ Society. Position statement: certified registered nurse anesthetists (CRNAS) in Canada; 2022. Available from URL: https://www.cas.ca/CASAssets/Documents/Advocacy/CRNA-Position-Statement-FINAL-08-22_1.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

The private vs public health care system debate is becoming increasingly prominent in Canadian politics as a solution to improving access to surgical care.

“The private vs public health care system debate is also becoming increasingly prominent in Canadian politics as a solution to improving access to surgical care.103”

• cites [103] Angus Reid Institute. Public purists, privatization proponents and the curious: Canada’s three health-care mindsets; 2023. Available from URL: https://angusreid.org/health-care-privatization-perspectives/ (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Other solutions to improving the surgical backlog endorsed by the CAS include improving efficiency, facilitating anesthesiologists moving between provinces to the area of greatest need, and reducing burnout and attrition in anesthesiologists by better supporting them.

“In addition to increasing the number of anesthesia providers in the Canadian workforce, other solutions to improving the surgical backlog that have been endorsed by the CAS include improving efficiency, facilitating anesthesiologists moving between provinces to the area of greatest need, and reducing burnout and attrition in anesthesiologists by better supporting them.102”

• cites [102] Canadian Anesthesiologists’ Society. Strategies to address the surgical backlog and health human resources issues in anesthesia; 2023. Available from URL: https://www.cas.ca/CASAssets/Documents/Practice-Resources/Reports-Position-Papers/CAS-HHR-Surgical-Backlog-Position-Statement_FINAL.pdf (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

In Quebec, following the 2005 Supreme Court ruling allowing Quebec residents to have private medical insurance, there are now private clinics providing a significant part of the province's care.

“In Quebec, following the 2005 Supreme Court ruling allowing Quebec residents to have private medical insurance, there are now private clinics providing a significant part of the province's care.105”

• cites [105] Shingler B, Hendry L. Privatizing health care isn’t the taboo it once was. But would it help Quebec’s ailing system? 2022. Available from URL: https://www.cbc.ca/news/canada/montreal/quebec-private-health-care-caq-qs-1.6583776 (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The Australian Government provides means-tested rebate to help cover the cost of private health insurance, which can cover the costs of hospital treatment as a private patient.

“For example, the Australian Government provides means-tested rebate to help cover the cost of private health insurance, which can cover the costs of hospital treatment as a private patient.104”

• cites [104] Australian Government Department of Health and Aged Care. The Australian health system. Available from URL: https://www.health.gov.au/about-us/the-australian-health-system#private-health-insurance (accessed May 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Another study showed increased cost-effectiveness ratios associated with physician-directed anesthesia relative to the nurse anesthetist care model.

“Another study showed increased cost-effectiveness ratios associated with physician-directed anesthesia relative to the nurse anesthetist care model.”

• cites [100] Abenstein JP, Long KH, McGlinch BP, Dietz NM. Is physician anesthesia cost-effective? Anesth Analg 2004; 98: 750–7. https://doi.org/10.1213/01.ane.0000100945.56081.ac sourceNot checked — no full text of the source