{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T11:17:12Z","timestamp":1790248632111,"version":"4.1.0"},"reference-count":17,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2020,7,2]],"date-time":"2020-07-02T00:00:00Z","timestamp":1593648000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["The Journal of Rural Health"],"published-print":{"date-parts":[[2021,9]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Background<\/jats:title><jats:p>Shortages of anesthesia providers in rural areas have long resulted in access limitations in many US states. This situation prompted federal legislation designed to promote increased usage of certified registered nurse anesthetists (CRNAs) in hospitals. Starting in 2001, state governors were afforded the option to adopt \u201copt\u2010out\u201d provisions, giving facilities in their states flexibility in utilizing CRNAs; specifically, adopting the opt\u2010out policy removes physician oversight requirements for Medicare billing purposes.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>We used mixed effects generalized linear models to identify predictors of CRNA service provision in hospitals from 2011\u20102015.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>We found that being located in an opt\u2010out state does not result in increased odds of CRNA service provision in US hospitals. Higher levels of deprivation in counties, being located in rural geographic areas, and being a teaching hospital all influenced CRNA service provision.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Given that we found no evidence that being in an opt\u2010out state increases the odds of using CRNAs in hospitals, we contribute to the growing literature suggesting that states adopting the opt\u2010out policy have not realized increased health care access or reduced health care costs. As a result of other contextual restrictions on hospitals\u2019 decision\u2010making, simply adopting the opt\u2010out policy has not been enough to address anesthesia provider shortages.<\/jats:p><\/jats:sec>","DOI":"10.1111\/jrh.12487","type":"journal-article","created":{"date-parts":[[2020,7,2]],"date-time":"2020-07-02T08:47:55Z","timestamp":1593679675000},"page":"684-691","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":12,"title":["Addressing Provider Shortages in Rural America: The Role of State Opt\u2010Out Policy Adoptions in Promoting Hospital Anesthesia Provision"],"prefix":"10.1111","volume":"37","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8327-3749","authenticated-orcid":false,"given":"Scott L.","family":"Feyereisen","sequence":"first","affiliation":[{"name":"College of Business Florida Atlantic University  Boca Raton Florida"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8893-2317","authenticated-orcid":false,"given":"Neeraj","family":"Puro","sequence":"additional","affiliation":[{"name":"College of Business Florida Atlantic University  Boca Raton Florida"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"William","family":"McConnell","sequence":"additional","affiliation":[{"name":"Dorothy F. Schmidt College of Arts and Letters Florida Atlantic University  Boca Raton Florida"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2020,7,2]]},"reference":[{"key":"e_1_2_5_2_1","doi-asserted-by":"publisher","DOI":"10.1213\/ANE.0000000000000228"},{"key":"e_1_2_5_3_1","doi-asserted-by":"publisher","DOI":"10.1177\/1077558716687889"},{"issue":"3","key":"e_1_2_5_4_1","first-page":"159","article-title":"Cost effectiveness analysis of anesthesia providers","volume":"28","author":"Hogan PF","year":"2010","journal-title":"Nurs Econ"},{"key":"e_1_2_5_5_1","unstructured":"Fact Sheet Concerning State Opt\u2010Outs and November 13 2001 CMS Rule.Park Ridge IL:American Association of Nurse Anesthetists;2018.https:\/\/www.aana.com\/advocacy\/state-government-affairs\/federal-supervision-rule-opt-out-information\/fact-sheet-concerning-state-opt-outs. Accessed June 16 2020."},{"key":"e_1_2_5_6_1","doi-asserted-by":"publisher","DOI":"10.1097\/MLR.0000000000001106"},{"key":"e_1_2_5_7_1","doi-asserted-by":"publisher","DOI":"10.1213\/ANE.0000000000001154"},{"issue":"9","key":"e_1_2_5_8_1","first-page":"283","article-title":"In the United States,\u201copt\u2010out\u201d States Show no increase in access to anesthesia services for Medicare beneficiaries compared with non\u2014\u201copt\u2010out\u201d states","volume":"6","author":"Sun EC","year":"2016","journal-title":"A&A Pract"},{"key":"e_1_2_5_9_1","doi-asserted-by":"publisher","DOI":"10.1111\/jrh.12417"},{"key":"e_1_2_5_10_1","doi-asserted-by":"publisher","DOI":"10.1186\/s13561-017-0146-6"},{"key":"e_1_2_5_11_1","doi-asserted-by":"publisher","DOI":"10.7326\/M13-2946"},{"key":"e_1_2_5_12_1","volume-title":"Hierarchical Linear Models: Applications and Data Analysis Methods","author":"Raudenbush SW","year":"2002"},{"key":"e_1_2_5_13_1","doi-asserted-by":"publisher","DOI":"10.1093\/aje\/kwh090"},{"key":"e_1_2_5_14_1","doi-asserted-by":"publisher","DOI":"10.1177\/0962280211427759"},{"key":"e_1_2_5_15_1","doi-asserted-by":"publisher","DOI":"10.1097\/MLR.0000000000000554"},{"key":"e_1_2_5_16_1","doi-asserted-by":"publisher","DOI":"10.2105\/AJPH.93.7.1137"},{"issue":"5","key":"e_1_2_5_17_1","first-page":"263","article-title":"Geographical imbalance of anesthesia providers and its impact on the uninsured and vulnerable populations","volume":"33","author":"Liao CJ","year":"2015","journal-title":"Nurs Econ"},{"key":"e_1_2_5_18_1","doi-asserted-by":"publisher","DOI":"10.1097\/JHM-D-18-00186"}],"container-title":["The Journal of Rural Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/api.wiley.com\/onlinelibrary\/tdm\/v1\/articles\/10.1111%2Fjrh.12487","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/jrh.12487","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1111\/jrh.12487","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/jrh.12487","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,8,30]],"date-time":"2023-08-30T00:50:56Z","timestamp":1693356656000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/jrh.12487"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,7,2]]},"references-count":17,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2021,9]]}},"alternative-id":["10.1111\/jrh.12487"],"URL":"https:\/\/doi.org\/10.1111\/jrh.12487","archive":["Portico"],"relation":{},"ISSN":["0890-765X","1748-0361"],"issn-type":[{"value":"0890-765X","type":"print"},{"value":"1748-0361","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,7,2]]},"assertion":[{"value":"2020-07-02","order":2,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}