Did duty hour reform lead to better outcomes among the highest risk patients?

Work Where You Live or Live Where You Work? Resident Work and Sleep Patterns While on "Home Call"

Background

Unlike in-house call, the Accreditation Council for Graduate Medical Education (ACGME) does not require a postcall day for "home call" shifts. Despite this, we hypothesize that on-call residents are still in the hospital for the majority of their shift despite having the luxury of home call and, thus, are not protected by ACGME postcall duty hour regulations.

Methods

A prospective single center survey study was conducted by surveying junior and senior residents who completed overnight call shifts from January 2023 to April 2023 at one of the busiest level 1 trauma centers in the United States. Data include number of trips into the hospital, hours spent in the hospital, and hours of sleep.

Results

Response rate was 195 of 200 (97.5%) total call shifts from 7 pm to 7 am the next morning. Junior residents reported an average of 3.25, 3.92, and 0.73 hours of sleep when on hand call, face call, and triple call (hand + face + general), respectively. Senior residents reported an average of 4.18 and 4.75 hours of sleep for hand and face call, respectively.

Conclusions

Hours of sleep when taking home call varies widely based on type of call. Junior residents reported significantly decreased sleep and more time in the hospital when taking hand, face, and triple call compared with general call alone. Senior residents reported that both hand and face call result in significantly decreased hours of sleep compared with general call alone. These results highlight the need to discuss ACGME protection for residents taking home call.

Systematic Review of the Impact of Physician Work Schedules on Patient Safety with Meta-Analyses of Mortality Risk

Resident physician work hour limits continue to be controversial. Numerous trials have come to conflicting conclusions about the impact on patient safety of eliminating extended duration work shifts. We conducted meta-analyses to evaluate the impact of work hour policies and work schedules on patient safety. After identifying 8,362 potentially relevant studies and reviewing 688 full-text articles, 132 studies were retained and graded on quality of evidence. Of these, 68 studies provided enough information for consideration in meta-analyses. We found that patient safety improved following implementation of the Accreditation Council for Graduate Medical Education's 2003 and 2011 resident physicians work hour guidelines. Limiting all resident physicians to 80-hour work weeks and 28-hour shifts in 2003 was associated with an 11% reduction in mortality (p < 0.001). Limited shift durations and shorter work weeks were also associated with improved patient safety in clinical trials and observational studies not specifically tied to policy changes. Given the preponderance of evidence showing that patient and physician safety is negatively affected by long work hours, efforts to improve physician schedules should be prioritized. Policies that enable extended-duration shifts and long work weeks should be reexamined. Further research should expand beyond resident physicians to additional study populations, including attending physicians and other health care workers.

Resilience in Residency and Beyond

» Distinct from the burnout and wellness continuum, resilience is a developed and refined characteristic that propels an individual toward personal and professional success.» We propose a clinical resilience triangle consisting of 3 components that define resilience: grit, competence, and hope.» Resilience is a dynamic trait that should be built during residency and constantly fortified in independent practice so that orthopaedic surgeons may acquire and hone the skills and mental fortitude required to take on the overwhelming challenges that we all inevitably face.

Does work time limit for resident physician affect short-term treatment outcome and hospital length of stay in patients with spontaneous intracerebral hemorrhage?: a two-year experience at a single training hospital in South Korea

Objective

To compare short-term treatment outcomes at hospital discharge and hospital length of stay (LOS) in patients with spontaneous intracerebral hemorrhage (sICH) before and after introduction of resident physician work time limit (WTL).

Methods

We retrospectively reviewed consecutive patients treated for sICH at our institution between 2016 and 2019. Then we dichotomized these patients into two groups, pre-WTL and post-WTL. We analyzed demographic elements and clinical features, and hospital length of stay (LOS). We evaluated short-term outcome using modified Rankin scale score at hospital discharge and then divided it into “good” and “poor” outcome groups. We subsequently, compared short-term treatment outcome and hospital LOS between the pre-WTL and post-WTL groups.

Results

Out of 779 patients, 420 patients (53.9%) were included in the pre-WTL group, and 359 (46.1%) in post-WTL. The mortality rate in sICH patients was higher in the post-WTL group (pre-WTL; 13.6% vs. post-WTL; 17.3%), but there was no statistically significant difference in short-term outcome including mortality (p=0.332) between the groups. The LOS also, was not significantly different between the two groups (pre-WTL; 19.0 days vs. post-WTL; 20.2 days) (p=0.341). The initial Glasgow Coma Scale score, personal stroke history, and mean age were the only independent outcome predicting factors for patients with sICH.

Conclusions

Some neurosurgeons may expect poorer outcome for sICH after implementation of the WTL of the K-MHW for resident physician however, enforcement of the WTL did not significantly influence the short-term outcome and hospital LOS for sICH in our hospital. Further well-designed multi-institutional prospective studies on the effects of WTL in sICH patient outcome, are anticipated.

Physicians' working time restriction and its impact on patient safety: an integrative review

BACKGROUND

Although shift work is a part of the physicians' routine, there is controversy on the length of shifts and adequate rest for safe professional practice. If on the one hand long working hours might have negative impact on patient safety by interfering with the psychological and physical functioning of physicians, on the other shorter working hours might impair the safety of patients due to interference with the continuity of care.

OBJECTIVE

To analyze the impact of restrictions to physicians' working hours on patient safety.

METHOD

Integrative literature review in which we surveyed studies on restriction to physicians' working time and patient safety included in databases National Library of Medicine (PubMed) and Scientific Electronic Library Online (SciELO) until May 2018. Thirty-five studies which met the inclusion criteria were included.

RESULTS

Patient safety outcomes analyzed in the included studies were mortality, adverse events, continuity of care, in-hospital complications, readmission rate and length of stay at hospital. Restriction to working time was associated with variable impact on patient safety indicators, but often did not modify their performance.

CONCLUSION

Restrictions to physicians' working time did not always improved patient safety indicators. Focusing on interventions which only seek to limit the workload of physicians might be insufficient to bring consistent improvement to patient care.

Association of residency work hour reform with long term quality and costs of care of US physicians: observational study

OBJECTIVE

To determine whether 30 day mortality, 30 day readmissions, and inpatient spending vary according to whether physicians were exposed to work hour reforms during their residency.

DESIGN

Retrospective observational study.

SETTING

US Medicare.

PARTICIPANTS

20% random sample (n=485 685) of Medicare beneficiaries aged 65 years or more admitted to hospital and treated by a general internist during 2000-12.

MAIN OUTCOME MEASURES

30 day mortality, 30 day readmissions, and inpatient Medicare Part B spending among patients treated by first year internists who were fully exposed to the 2003 Accreditation Council for Graduate Medical Education (ACGME) work hour reforms during their residency (completed residency after 2006) compared with first year internists with partial or no exposure to reforms (completed residency before 2006). Senior internists not exposed to reforms during their residency served as a control group (10th year internists) for general trends in hospital care: a difference-in-difference analysis.

RESULTS

Exposure of physicians to work hour reforms during their residency was not associated with statistically significant differences in 30 day mortality, 30 day readmissions, or inpatient spending. Among 485 685 hospital admissions, 30 day mortality rates during 2000-06 and 2007-12 for patients of first year internists were 10.6% (12 567 deaths/118 014 hospital admissions) and 9.6% (13 521/140 529), respectively, and for 10th year internists were 11.2% (11 018/98 811) and 10.6% (13 602/128 331), for an adjusted difference-in-difference effect of -0.1 percentage points (95% confidence interval -0.8% to 0.6%, P=0.68). 30 day readmission rates for first year internists during 2000-06 and 2007-12 were 20.4% (24 074/118 014) and 20.4% (28 689/140 529), respectively, and for 10th year internists were 20.1% (19 840/98 811) and 20.5% (26 277/128 331), for an adjusted difference-in-difference effect of 0.1 percentage points (-0.9% to 1.1%, P=0.87). Medicare Part B inpatient spending for first year internists during 2000-06 and 2007-12 was $1161 (£911; €1024) and $1267 per hospital admission, respectively, and for 10th year internists was $1331 and $1599, for an adjusted difference-in-difference effect of -$46 (95% confidence interval -$94 to $2, P=0.06).

CONCLUSIONS

Exposure of internists to work hour reforms during their residency was not associated with post-training differences in patient mortality, readmissions, or costs of care.

Patient Safety Outcomes under Flexible and Standard Resident Duty-Hour Rules

BACKGROUND

Concern persists that extended shifts in medical residency programs may adversely affect patient safety.

METHODS

We conducted a cluster-randomized noninferiority trial in 63 internal-medicine residency programs during the 2015-2016 academic year. Programs underwent randomization to a group with standard duty hours, as adopted by the Accreditation Council for Graduate Medical Education (ACGME) in July 2011, or to a group with more flexible duty-hour rules that did not specify limits on shift length or mandatory time off between shifts. The primary outcome for each program was the change in unadjusted 30-day mortality from the pretrial year to the trial year, as ascertained from Medicare claims. We hypothesized that the change in 30-day mortality in the flexible programs would not be worse than the change in the standard programs (difference-in-difference analysis) by more than 1 percentage point (noninferiority margin). Secondary outcomes were changes in five other patient safety measures and risk-adjusted outcomes for all measures.

RESULTS

The change in 30-day mortality (primary outcome) among the patients in the flexible programs (12.5% in the trial year vs. 12.6% in the pretrial year) was noninferior to that in the standard programs (12.2% in the trial year vs. 12.7% in the pretrial year). The test for noninferiority was significant (P = 0.03), with an estimate of the upper limit of the one-sided 95% confidence interval (0.93%) for a between-group difference in the change in mortality that was less than the prespecified noninferiority margin of 1 percentage point. Differences in changes between the flexible programs and the standard programs in the unadjusted rate of readmission at 7 days, patient safety indicators, and Medicare payments were also below 1 percentage point; the noninferiority criterion was not met for 30-day readmissions or prolonged length of hospital stay. Risk-adjusted measures generally showed similar findings.

CONCLUSIONS

Allowing program directors flexibility in adjusting duty-hour schedules for trainees did not adversely affect 30-day mortality or several other measured outcomes of patient safety. (Funded by the National Heart, Lung, and Blood Institute and Accreditation Council for Graduate Medical Education; iCOMPARE ClinicalTrials.gov number, NCT02274818.).

Development of the individualised Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial: a protocol summary of a national cluster-randomised trial of resident duty hour policies in internal medicine

INTRODUCTION

Medical trainees' duty hours have received attention globally; restrictions in Europe, New Zealand and some Canadian provinces are much lower than the 80 hours per week enforced in USA. In USA, resident duty hours have been implemented without evidence simultaneously reflecting competing concerns about patient safety and physician education. The objective is to prospectively evaluate the implications of alternative resident duty hour rules for patient safety, trainee education and intern sleep and alertness.

METHODS AND ANALYSIS

63 US internal medicine training programmes were randomly assigned 1:1 to the 2011 Accreditation Council for Graduate Medical Education resident duty hour rules or to rules more flexible in intern shift length and number of hours off between shifts for academic year 2015-2016. The primary outcome is calculated for each programme as the difference in 30-day mortality rate among Medicare beneficiaries with any of several prespecified principal diagnoses in the intervention year minus 30-day mortality in the preintervention year among Medicare beneficiaries with any of several prespecified principal diagnoses. Additional safety outcomes include readmission rates, prolonged length of stay and costs. Measures derived from trainees' and faculty responses to surveys and from time-motion studies of interns compare the educational experiences of residents. Measures derived from wrist actigraphy, subjective ratings and psychomotor vigilance testing compare the sleep and alertness of interns. Differences between duty hour groups in outcomes will be assessed by intention-to-treat analyses.

ETHICS AND DISSEMINATION

The University of Pennsylvania Institutional Review Board (IRB) approved the protocol and served as the IRB of record for 40 programmes that agreed to sign an Institutional Affiliation Agreement. Twenty-three programmes opted for a local review process.

TRIAL REGISTRATION NUMBER

NCT02274818; Pre-results.

Implementation of 2011 Duty Hours Regulations through a Workload Reduction Strategy and Impact on Residency Training

BACKGROUND

Training programs have implemented the 2011 ACGME duty hour regulations (DHR) using "workload compression" (WLC) strategies, attempting to fit similar clinical responsibilities into fewer working hours, or workload reduction (WLR) approaches, reducing the number of patient encounters per trainee. Many have expressed concern that these strategies could negatively impact patient care and learner outcomes.

OBJECTIVE

This study evaluates the medical knowledge and clinical impact of a WLR intervention in a single institution.

DESIGN & PARTICIPANTS

Nonrandomized intervention study with comparison to a historical control study among 58 PGY-1 internal medicine trainees in the 2 years after duty hour implementation [exposure cohort (EC), 7/1/2011-6/30/2013], compared to 2 years before implementation [comparison cohort (CC), 7/1/2009-6/30/2011].

MAIN MEASURES

Process outcomes were average inpatient encounters, average new inpatient admissions, and average scheduled outpatient encounters per PGY-1 year. Performance outcomes included trainee inpatient and outpatient days on service, In-Training Examination (ITE) scores as an objective surrogate of medical knowledge, Case-Mix Index (CMI), and quality of care measures (30-day readmission rate, 30-day mortality rate, and average length of stay).

KEY RESULTS

Baseline characteristics and average numbers of inpatient encounters per PGY-1 class were similar between the EC and CC. However, the EC experienced fewer new inpatient admissions (157.47 ± 40.47 vs. 181.72 ± 25.45; p < 0.01), more outpatient encounters (64.80 ± 10.85 vs. 56.98 ± 6.59; p < 0.01), and had similar ITE percentiles (p = 0.58). Patients of similar complexity cared for by the EC also had a greater reduction in readmissions (21.21 % to 19.08 %; p < 0.01) than the hospital baseline (12.07 to 11.14 %; p < 0.01).

CONCLUSIONS

Our WLR resulted in a small decrease in the average number of new inpatient admissions and an increase in outpatient encounters. ITE and care quality outcomes were maintained or improved. While there is theoretical concern that reducing PGY-1 inpatient admissions volumes may negatively impact education and clinical care measures, this study found no evidence of such a trade-off.

Exposing physicians to reduced residency work hours did not adversely affect patient outcomes after residency

In 2003, work hours for physicians-in-training (residents) were capped by regulation at eighty hours per week, leading to the hotly debated but unexplored issue of whether physicians today are less well trained as a result of these work-hour reforms. Using a unique database of nearly all hospitalizations in Florida during 2000-09 that were linked to detailed information on the medical training history of the physician of record for each hospitalization, we studied whether hospital mortality and patients' length-of-stay varied according to the number of years a physician was exposed to the 2003 duty-hour regulations during his or her residency. We examined this database of practicing Florida physicians, using a difference-in-differences analysis that compared trends in outcomes of junior physicians (those with one-year post-residency experience) pre- and post-2003 to a control group of senior physicians (those with ten or more years of post-residency experience) who were not exposed to these reforms during their residency. We found that the duty-hour reforms did not adversely affect hospital mortality and length-of-stay of patients cared for by new attending physicians who were partly or fully exposed to reduced duty hours during their own residency. However, assessment of the impact of the duty-hour reforms on other clinical outcomes is needed.

Patient Outcomes when Housestaff Exceed 80 Hours per Week

BACKGROUND

It has been posited that high workload and long work hours for trainees could affect the quality and efficiency of patient care. Duty hour restrictions seek to balance patient care and resident education by limiting resident work hours. Through a retrospective cohort study, we investigated whether patient care on an inpatient general medicine service at a large academic medical center is impacted when housestaff work more than 80 hours per week.

METHODS

We identified all admissions to a housestaff-run general medicine service between June 25, 2013 and June 29, 2014. Each hospitalization was classified by whether the patient was admitted by housestaff who have worked more than 80 hours per week during their hospitalization. Housestaff computer activity and duty hours were calculated by institutional electronic heath record audit, as well as length of stay and a composite of in-hospital mortality, intensive care unit (ICU) transfer rate, and 30-day readmission rate.

RESULTS

We identified 4767 hospitalizations by 3450 unique patients; of which 40.9% of hospitalizations were managed by housestaff who worked more than 80 hours that week during their hospitalization. There was a significantly higher rate of the composite outcome (19.2% vs 16.7%, P = .031) for patients admitted by housestaff working more than 80 hours per week during their hospitalization. We found a statistically significant higher length of stay (5.12 vs 4.66 days, P = .048) and rate of ICU transfer (3.53% vs 2.38%, P = .029). There was no statistically significant difference in 30-day readmission rate (13.7% vs 12.8%, P = .395) or in-hospital mortality rate (3.18% vs 2.42%, P = .115). There was no correlation with team census on admission and patient outcomes.

CONCLUSIONS

Patients taken care of by housestaff working more than 80 hours per week had increased length of stay and number of ICU transfers. There was no association between resident work-hours and patient in-hospital mortality or 30-day readmission rate.

The Impact of the 2011 Accreditation Council for Graduate Medical Education Duty Hour Reform on Quality and Safety in Trauma Care

BACKGROUND

In 2011, the ACGME limited duty hours for residents. Although studies evaluating the 2011 policy have not shown improvements in general measures of morbidity or mortality, these outcomes might not reflect changes in specialty-specific practice patterns and secondary quality measures.

STUDY DESIGN

All trauma admissions from July 2009 through June 2013 at an academic Level I trauma center were evaluated for 5 primary outcomes (eg, mortality and length of stay), and 10 secondary quality measures and practice patterns (eg, operating room [OR] visits). All variables were compared before and after the reform (July 1, 2011). Piecewise regression was used to study temporal trends in quality.

RESULTS

There were 11,740 admissions studied. The reform was not strongly associated with changes in any primary outcomes except length of stay (7.98 to 7.36 days; p = 0.01). However, many secondary quality metrics changed. The total number of OR and bedside procedures per admission (6.72 to 7.34; p < 0.001) and OR visits per admission (0.76 to 0.91; p < 0.001) were higher in the post-reform group, representing an additional 9,559 procedures and 1,584 OR visits. Use of minor bedside procedures, such as laboratory and imaging studies, increased most significantly.

CONCLUSIONS

Although most major outcomes were unaffected, quality of care might have changed after the reform. Indeed, a consistent change in resource use patterns was manifested by substantial post-reform increases in measures such as bedside procedures and OR visits. No secondary quality measures exhibited improvements strongly associated with the reform. Several factors, including attending oversight, might have insulated major outcomes from change. Our findings show that some less-commonly studied quality metrics related to costs of care changed after the 2011 reform at our institution.

National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training

BACKGROUND

Concerns persist regarding the effect of current surgical resident duty-hour policies on patient outcomes, resident education, and resident well-being.

METHODS

We conducted a national, cluster-randomized, pragmatic, noninferiority trial involving 117 general surgery residency programs in the United States (2014-2015 academic year). Programs were randomly assigned to current Accreditation Council for Graduate Medical Education (ACGME) duty-hour policies (standard-policy group) or more flexible policies that waived rules on maximum shift lengths and time off between shifts (flexible-policy group). Outcomes included the 30-day rate of postoperative death or serious complications (primary outcome), other postoperative complications, and resident perceptions and satisfaction regarding their well-being, education, and patient care.

RESULTS

In an analysis of data from 138,691 patients, flexible, less-restrictive duty-hour policies were not associated with an increased rate of death or serious complications (9.1% in the flexible-policy group and 9.0% in the standard-policy group, P=0.92; unadjusted odds ratio for the flexible-policy group, 0.96; 92% confidence interval, 0.87 to 1.06; P=0.44; noninferiority criteria satisfied) or of any secondary postoperative outcomes studied. Among 4330 residents, those in programs assigned to flexible policies did not report significantly greater dissatisfaction with overall education quality (11.0% in the flexible-policy group and 10.7% in the standard-policy group, P=0.86) or well-being (14.9% and 12.0%, respectively; P=0.10). Residents under flexible policies were less likely than those under standard policies to perceive negative effects of duty-hour policies on multiple aspects of patient safety, continuity of care, professionalism, and resident education but were more likely to perceive negative effects on personal activities. There were no significant differences between study groups in resident-reported perception of the effect of fatigue on personal or patient safety. Residents in the flexible-policy group were less likely than those in the standard-policy group to report leaving during an operation (7.0% vs. 13.2%, P<0.001) or handing off active patient issues (32.0% vs. 46.3%, P<0.001).

CONCLUSIONS

As compared with standard duty-hour policies, flexible, less-restrictive duty-hour policies for surgical residents were associated with noninferior patient outcomes and no significant difference in residents' satisfaction with overall well-being and education quality. (FIRST ClinicalTrials.gov number, NCT02050789.).

Association of Medical Comorbidities, Surgical Outcomes, and Failure to Rescue: An Analysis of the Rhode Island Hospital NSQIP Database

BACKGROUND

Failure to rescue (FTR) is a key metric of perioperative morbidity and mortality. We review perioperative medical comorbidities (MCMs) to determine what factors are associated with complications and rates of FTR.

STUDY DESIGN

A retrospective review of a NSQIP database including general, vascular, and surgical subspecialty patients from a tertiary referral center between March 2008 and March 2013 was performed. Demographics, MCMs, complications, 30-day mortality, and risk of FTR associated with specific complications and MCM were evaluated.

RESULTS

A total of 7,763 patients were included; 52.6% had MCMs and 14% (n = 1,099) experienced a complication. Patients with complications were older (64.9 vs 55 years; p < 0.001), more likely male (54% vs 44%; p < 0.001), and had more MCMs per patient (1.6 vs 1.4; p < 0.001). Complications were also associated with renal failure (odds ratio [OR] = 1.4; 95% CI, 1.0-2.0), steroid use (OR = 1.9; 95% CI, 1.4-2.5), CHF (OR = 2.5; 95% CI, 1.2-5.1), and ascites (OR = 9.1; 95% CI, 3.7-21.7), but not diabetes, hypertension, or COPD. There were 117 (11%) deaths among patients with complications. Adjusting for age, sex, American Society of Anesthesiologists class, and number of comorbidities, FTR was associated with postoperative respiratory failure, sepsis, and renal failure, as well as comorbid CHF, renal failure, ascites, and disseminated cancer.

CONCLUSIONS

Specific comorbidities are associated with higher rates of complications and FTR. Preoperative CHF, renal failure, and ascites, which were associated with FTR, can reflect a physiologic inability to tolerate complication-induced fluid shifts. Postoperative mortality was associated with signs of end organ damage, including sepsis, respiratory failure, and renal failure. Earlier recognition of these complications in at-risk patients should improve rates of FTR.

Assessing the utility of ICU readmissions as a quality metric: an analysis of changes mediated by residency work-hour reforms

BACKGROUND

ICU readmissions are associated with increased mortality and costs; however, it is unclear whether these outcomes are caused by readmissions or by residual confounding by illness severity. An assessment of temporal changes in ICU readmission in response to a specific policy change could help disentangle these possibilities. We sought to determine whether ICU readmission rates changed after 2003 Accreditation Council for Graduate Medical Education Resident Duty Hours reform ("reform") and whether there were temporally corresponding changes in other ICU outcomes.

METHODS

We used a difference-in-differences approach using Project IMPACT (Improved Methods of Patient Information Access of Core Clinical Tasks). Piecewise regression models estimated changes in outcomes immediately before and after reform in 274,491 critically ill medical and surgical patients in 151 community and academic US ICUs. Outcome measures included ICU readmission, ICU mortality, and in-hospital post-ICU-discharge mortality.

RESULTS

In ICUs with residents, ICU readmissions increased before reform (OR, 1.5; 95% CI, 1.22-1.84; P < .01), and decreased after (OR, 0.85; 95% CI, 0.73-0.98; P = .03). This abrupt decline in ICU readmissions after reform differed significantly from an increase in readmissions observed in ICUs without residents at this time (difference-in-differences P < .01). No comparable changes in mortality were observed between ICUs with vs without residents.

CONCLUSIONS

The changes in ICU readmission rates after reform, without corresponding changes in mortality, suggest that ICU readmissions are not causally related to other untoward patient outcomes. Instead, ICU readmission rates likely reflect operational aspects of care that are not patient-centered, making them less useful indicators of ICU quality.

Sink or Night Float: University of British Columbia Radiology Residents' Experience with Overnight Call

Purpose

In July 2012, in response to residents' concerns regarding the impact of the traditional 24-hour call system on their personal well-being and educational experience, the University of British Columbia Radiology residency program adopted a 12-hour night float system. This shift takes place in the context of increasing concerns, both across Canada and internationally, about resident well-being and the impact of prolonged duty hours on patient care.

Methods

An anonymous survey was distributed to all 25 postgraduate years 2-5 University of British Columbia radiology residents 12 months after the introduction of night float. This study sought to solicit residents' feedback about these changes and to identify potential future changes to optimize the call system.

Results

The response rate was 100%; 96% of residents were in favor of continuing with night float rather than the traditional call system; 72% of residents reported that their judgement was affected secondary to being on night float. Although most residents described varying degrees of impairment, the rate of acute discrepancies between resident preliminary and attending radiologist final reports decreased by more than half, from 2% to less than 1%.

Conclusions

The vast majority of our residents were in favor of maintaining the night float call system. Night float had a beneficial effect on the resident educational experience: by eliminating the pre-call morning and post-call day off rotation, residents gained an additional 24 days per year on other clinical rotations.

The impact of 2011 ACGME duty hour restrictions on internal medicine resident workload and education

The Accreditation Council for Graduate Medical Education (ACGME) implemented work hour restrictions for physicians in training in 2003 that were revised July 1, 2011. Current published data are insufficient to assess whether such work hour restrictions will have long-term impact on residents' education. We searched computer-generated reports of hospital in-patient census, continuity clinic census, in-training exam scores and first-year resident attendance at educational conferences for the academic years 2010-2011 (August 1, 2010-May 31, 2011) and 2011-2013 (August 1, 2011-May 31, 2013). During the first year of the study period, the residents' inpatient internal medicine services admitted 1,754 patients; during this same period for academic years 2011-2012 and 2012-2013, the teaching services admitted 1,539 and 1,428 patients respectively, yielding a decrease of 16.4%. Monthly, these services cared for a mean of 27.1 (27.1/175.4 [15.4%]) fewer patients and 9.7 (9.7/34.4 [28.2%]) fewer patients per intern than in the previous year. No statistical difference was observed regarding continuity clinic attendance and in-training exam scores. Residents in the years following work hours restrictions attended more educational conferences. Implementation of 2011 ACGME work hour regulations resulted in fewer patients seen by first-year residents in hospital, but did not affect in-training exam scores. Whether these findings will translate into differences in patient outcomes, and quality of care remains to be seen.

Mortality and treatment patterns among patients hospitalized with acute cardiovascular conditions during dates of national cardiology meetings

IMPORTANCE

Thousands of physicians attend scientific meetings annually. Although hospital physician staffing and composition may be affected by meetings, patient outcomes and treatment patterns during meeting dates are unknown.

OBJECTIVE

To analyze mortality and treatment differences among patients admitted with acute cardiovascular conditions during dates of national cardiology meetings compared with nonmeeting dates.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of 30-day mortality among Medicare beneficiaries hospitalized with acute myocardial infarction (AMI), heart failure, or cardiac arrest from 2002 through 2011 during dates of 2 national cardiology meetings compared with identical nonmeeting days in the 3 weeks before and after conferences (AMI, 8570 hospitalizations during 82 meeting days and 57,471 during 492 nonmeeting days; heart failure, 19,282 during meeting days and 11,4591 during nonmeeting days; cardiac arrest, 1564 during meeting days and 9580 during nonmeeting days). Multivariable analyses were conducted separately for major teaching hospitals and nonteaching hospitals and for low- and high-risk patients. Differences in treatment utilization were assessed.

EXPOSURES

Hospitalization during cardiology meeting dates.

MAIN OUTCOMES AND MEASURES

Thirty-day mortality, procedure rates, charges, length of stay.

RESULTS

Patient characteristics were similar between meeting and nonmeeting dates. In teaching hospitals, adjusted 30-day mortality was lower among high-risk patients with heart failure or cardiac arrest admitted during meeting vs nonmeeting dates (heart failure, 17.5% [95% CI, 13.7%-21.2%] vs 24.8% [95% CI, 22.9%-26.6%]; P < .001; cardiac arrest, 59.1% [95% CI, 51.4%-66.8%] vs 69.4% [95% CI, 66.2%-72.6%]; P = .01). Adjusted mortality for high-risk AMI in teaching hospitals was similar between meeting and nonmeeting dates (39.2% [95% CI, 31.8%-46.6%] vs 38.5% [95% CI, 35.0%-42.0%]; P = .86), although adjusted percutaneous coronary intervention (PCI) rates were lower during meetings (20.8% vs 28.2%; P = .02). No mortality or utilization differences existed for low-risk patients in teaching hospitals or high- or low-risk patients in nonteaching hospitals. In sensitivity analyses, cardiac mortality was not affected by hospitalization during oncology, gastroenterology, and orthopedics meetings, nor was gastrointestinal hemorrhage or hip fracture mortality affected by hospitalization during cardiology meetings.

CONCLUSIONS AND RELEVANCE

High-risk patients with heart failure and cardiac arrest hospitalized in teaching hospitals had lower 30-day mortality when admitted during dates of national cardiology meetings. High-risk patients with AMI admitted to teaching hospitals during meetings were less likely to receive PCI, without any mortality effect.

Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients

IMPORTANCE

Patient outcomes associated with the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms have not been evaluated at a national level.

OBJECTIVE

To evaluate the association of the 2011 ACGME duty hour reforms with mortality and readmissions.

DESIGN, SETTING, AND PARTICIPANTS

Observational study of Medicare patient admissions (6,384,273 admissions from 2,790,356 patients) to short-term, acute care, nonfederal hospitals (n = 3104) with principal medical diagnoses of acute myocardial infarction, stroke, gastrointestinal bleeding, or congestive heart failure or a Diagnosis Related Group classification of general, orthopedic, or vascular surgery. Of the hospitals, 96 (3.1%) were very major teaching, 138 (4.4%) major teaching, 442 (14.2%) minor teaching, 443 (14.3%) very minor teaching, and 1985 (64.0%) nonteaching.

EXPOSURE

Resident-to-bed ratio as a continuous measure of hospital teaching intensity.

MAIN OUTCOMES AND MEASURES

Change in 30-day all-location mortality and 30-day all-cause readmission, comparing patients in more intensive relative to less intensive teaching hospitals before (July 1, 2009-June 30, 2011) and after (July 1, 2011-June 30, 2012) duty hour reforms, adjusting for patient comorbidities, time trends, and hospital site.

RESULTS

In the 2 years before duty hour reforms, there were 4,325,854 admissions with 288,422 deaths and 602,380 readmissions. In the first year after the reforms, accounting for teaching hospital intensity, there were 2,058,419 admissions with 133,547 deaths and 272,938 readmissions. There were no significant postreform differences in mortality accounting for teaching hospital intensity for combined medical conditions (odds ratio [OR], 1.00; 95% CI, 0.96-1.03), combined surgical categories (OR, 0.99; 95% CI, 0.94-1.04), or any of the individual medical conditions or surgical categories. There were no significant postreform differences in readmissions for combined medical conditions (OR, 1.00; 95% CI, 0.97-1.02) or combined surgical categories (OR, 1.00; 95% CI, 0.98-1.03). For the medical condition of stroke, there were higher odds of readmissions in the postreform period (OR, 1.06; 95% CI, 1.001-1.13). However, this finding was not supported by sensitivity analyses and there were no significant postreform differences for readmissions for any other individual medical condition or surgical category.

CONCLUSIONS AND RELEVANCE

Among Medicare beneficiaries, there were no significant differences in the change in 30-day mortality rates or 30-day all-cause readmission rates for those hospitalized in more intensive relative to less intensive teaching hospitals in the year after implementation of the 2011 ACGME duty hour reforms compared with those hospitalized in the 2 years before implementation.

Morbidity, mortality, and health care costs for patients undergoing spine surgery following the ACGME resident duty-hour reform

Object

The Accreditation Council for Graduate Medical Education (ACGME) implemented resident duty-hour restrictions on July 1, 2003, in concern for patient and resident safety. Whereas studies have shown that duty-hour restrictions have increased resident quality of life, there have been mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay (LOS), and charges in patients who underwent spine surgery.

Methods

The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, LOS, and charges by comparing the prereform (2000–2002) and postreform (2005–2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method.

Results

A total of 693,058 patients were included in the study. The overall complication rate was 8.6%, with patients in the postreform era having a significantly higher rate than those in the pre–duty-hour restriction era (8.7% vs 8.4%, p < 0.0001). Examination of hospital teaching status revealed complication rates to decrease in nonteaching hospitals (8.2% vs 7.6%, p < 0.0001) while increasing in teaching institutions (8.6% vs 9.6%, p < 0.0001) in the duty-hour reform era. The DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching institutions to had a significantly greater increase in complications during the postreform era (p = 0.0002). The overall mortality rate was 0.37%, with no significant difference between the pre– and post–duty-hour eras (0.39% vs 0.36%, p = 0.12). However, the mortality rate significantly decreased in nonteaching hospitals in the postreform era (0.30% vs 0.23%, p = 0.0008), while remaining the same in teaching institutions (0.46% vs 0.46%, p = 0.75). The DID analysis to compare the changes in mortality between groups revealed that the difference between the effects approached significance (p = 0.069). The mean LOS for all patients was 4.2 days, with hospital stay decreasing in nonteaching hospitals (3.7 vs 3.5 days, p < 0.0001) while significantly increasing in teaching institutions (4.7 vs 4.8 days, p < 0.0001). The DID analysis did not demonstrate the magnitude of change for each group to differ significantly (p = 0.26). Total patient charges were seen to rise significantly in the post–duty-hour reform era, increasing from $40,000 in the prereform era to $69,000 in the postreform era. The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.55).

Conclusions

The implementation of duty-hour restrictions was associated with an increased risk of postoperative complications for patients undergoing spine surgery. Therefore, contrary to its intended purpose, duty-hour reform may have resulted in worse patient outcomes. Additional studies are needed to evaluate strategies to mitigate these effects and assist in the development of future health care policy.

Patient safety in the era of the 80-hour workweek

OBJECTIVE

In 2003, duty-hour regulations (DHR) were initially implemented for residents in the United States to improve patient safety and protect resident's well-being. The effect of DHR on patient safety remains unclear. The study objective was to evaluate the effect of DHR on patient safety.

DESIGN

Using an interrupted time series analysis, we analyzed selected patient safety indicators (PSIs) for 376 million discharges in teaching (T) vs nonteaching (NT) hospitals before and after implementation of DHR in 2003 that restricted resident work hours to 80 hours per week. The PSIs evaluated were postoperative pulmonary embolus or deep venous thrombosis (PEDVT), iatrogenic pneumothorax (PTx), accidental puncture or laceration, postoperative wound dehiscence (WD), postoperative hemorrhage or hematoma, and postoperative physiologic or metabolic derangement. Propensity scores were used to adjust for differences in patient comorbidities between T and NT hospitals and between discharge quarters. The primary outcomes were differences in the PSI rates before and after DHR implementation. The PSI differences between T and NT institutions were the secondary outcome.

SETTING

T and NT hospitals in the United States.

PARTICIPANTS

Participants were 376 million patient discharges from 1998 to 2007 in the Nationwide Inpatient Sample.

RESULTS

Declining rates of PTx in both T and NT hospitals preintervention slowed only in T hospitals postintervention (p = 0.04). Increasing PEDVT rates in both T and NT hospitals increased further only in NT hospitals (p = 0.01). There were no differences in the PSI rates over time for hemorrhage or hematoma, physiologic or metabolic derangement, accidental puncture or laceration, or WD. T hospitals had higher rates than NT hospitals both preintervention and postintervention for all the PSIs except WD.

CONCLUSIONS

Trends in rates for 2 of the 6 PSIs changed significantly after DHR implementation, with PTx rates worsening in T hospitals and PEDVT rates worsening in NT hospitals. Lack of consistent patterns of change suggests no measurable effect of the policy change on these PSIs.

Worse outcomes for patients undergoing brain tumor and cerebrovascular procedures following the ACGME resident duty-hour restrictions

OBJECT

On July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions for resident physicians due to concerns for patient and resident safety. Though duty-hour restrictions have increased resident quality of life, studies have shown mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay, and charges in patients who underwent brain tumor and cerebrovascular procedures.

METHODS

The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, length of stay, and charges by comparing the pre-reform (2000-2002) and post-reform (2005-2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method.

RESULTS

A total of 90,648 patients were included in the analysis. The overall complication rate was 11.7%, with the rates not significantly differing between the pre- and post-duty hour eras (p = 0.26). Examination of hospital teaching status revealed that complication rates decreased in nonteaching hospitals (12.1% vs 10.4%, p = 0.0004) and remained stable in teaching institutions (11.8% vs 11.9%, p = 0.73) in the post-reform era. Multivariate analysis demonstrated a significantly higher complication risk in teaching institutions (OR 1.33 [95% CI 1.11-1.59], p = 0.0022), with no significant change in nonteaching hospitals (OR 1.11 [95% CI 0.91-1.37], p = 0.31). A DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching hospitals had a significantly greater increase in complications during the post-reform era than nonteaching hospitals (p = 0.040). The overall mortality rate was 3.0%, with a significant decrease occurring in the post-reform era in both nonteaching (5.0% vs 3.2%, p < 0.0001) and teaching (3.2% vs 2.3%, p < 0.0001) hospitals. DID analysis to compare the changes in mortality between groups did not reveal a significant difference (p = 0.40). The mean length of stay for all patients was 8.7 days, with hospital stay decreasing from 9.2 days to 8.3 days in the post-reform era (p < 0.0001). The DID analysis revealed a greater length of stay decrease in nonteaching hospitals than teaching institutions, which approached significance (p = 0.055). Patient charges significantly increased in the post-reform era for all patients, increasing from $70,900 to $96,100 (p < 0.0001). The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.17).

CONCLUSIONS

The implementation of duty-hour restrictions correlated with an increased risk of postoperative complications for patients undergoing brain tumor and cerebrovascular neurosurgical procedures. Duty-hour reform may therefore be associated with worse patient outcomes, contrary to its intended purpose. Due to the critical condition of many neurosurgical patients, this patient population is most sensitive and likely to be negatively affected by proposed future increased restrictions.

A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes

BACKGROUND

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated 80-hour resident duty limits. In 2011 the ACGME mandated 16-hour duty maximums for PGY1 (post graduate year) residents. The stated goals were to improve patient safety, resident well-being, and education. A systematic review and meta-analysis were performed to evaluate the impact of resident duty hours (RDH) on clinical and educational outcomes in surgery.

METHODS

A systematic review (1980-2013) was executed on CINAHL, Cochrane Database, Embase, Medline, and Scopus. Quality of articles was assessed using the GRADE guidelines. Sixteen-hour shifts and night float systems were analyzed separately. Articles that examined mortality data were combined in a random-effects meta-analysis to evaluate the impact of RDH on patient mortality.

RESULTS

A total of 135 articles met the inclusion criteria. Among these, 42% (N = 57) were considered moderate-high quality. There was no overall improvement in patient outcomes as a result of RDH; however, some studies suggest increased complication rates in high-acuity patients. There was no improvement in education related to RDH restrictions, and performance on certification examinations has declined in some specialties. Survey studies revealed a perception of worsened education and patient safety. There were improvements in resident wellness after the 80-hour workweek, but there was little improvement or negative effects on wellness after 16-hour duty maximums were implemented.

CONCLUSIONS

Recent RDH changes are not consistently associated with improvements in resident well-being, and have negative impacts on patient outcomes and performance on certification examinations. Greater flexibility to accommodate resident training needs is required. Further erosion of training time should be considered with great caution.

Assessing the effects of the 2003 resident duty hours reform on internal medicine board scores

PURPOSE

To determine whether the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty hours reform affected medical knowledge as reflected by written board scores for internal medicine (IM) residents.

METHOD

The authors conducted a retrospective cohort analysis of postgraduate year 1 (PGY-1) Internal Medicine residents who started training before and after the 2003 duty hour reform using a merged data set of American Board of Internal Medicine (ABIM) Board examination and the National Board of Medical Examiners (NMBE) United States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge test scores. Specifically, using four regression models, the authors compared IM residents beginning PGY-1 training in 2000 and completing training unexposed to the 2003 duty hours reform (PGY-1 2000 cohort, n = 5,475) to PGY-1 cohorts starting in 2001 through 2005 (n = 28,008), all with some exposure to the reform.

RESULTS

The mean ABIM board score for the unexposed PGY-1 2000 cohort (n = 5,475) was 491, SD = 85. Adjusting for demographics, program, and USMLE Step 2 exam score, the mean differences (95% CI) in ABIM board scores between the PGY-1 2001, 2002, 2003, 2004 and 2005 cohorts minus the PGY-1 2000 cohort were -5.43 (-7.63, -3.23), -3.44 (-5.65, -1.24), 2.58 (0.36, 4.79), 11.10 (8.88, 13.33) and 11.28 (8.98, 13.58) points respectively. None of these differences exceeded one-fifth of an SD in ABIM board scores.

CONCLUSIONS

The duty hours reforms of 2003 did not meaningfully affect medical knowledge as measured by scores on the ABIM board examinations.

Internal medicine residents' perspectives on effects of 2011 ACGME work hour regulations on patient care

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) introduced new work hour limitations in July 2011.

PURPOSES

The aim is to assess internal medicine residents' perspectives on the impact of these limitations on their ability to discharge patient care duties.

METHODS

An anonymous survey was administered to 158 medicine residents in an urban university-affiliated internal medicine residency program. Residents' perspectives on various aspects of patient care were recorded on a 5-point Likert-type scale.

RESULTS

The response rate was 62%. The majority of residents (80%) agreed that patients had adequate continuity of care. Most residents agreed that they had enough time to follow up on consult notes (64% agreed) and investigations (80% agreed) daily. Most PGY-1 residents (59%) reported having enough time to prepare sign-outs. Most (60%) residents felt that reducing handoffs would improve patient care.

CONCLUSIONS

Most residents believe that the new work hour limitations would continue to uphold patient safety, but handoffs in care must be restricted.

Approval and perceived impact of duty hour regulations: survey of pediatric program directors

OBJECTIVES

To determine pediatric program director (PD) approval and perception of changes to resident training and patient care resulting from 2011 Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements.

METHODS

All US pediatric PDs (n = 181) were identified from the ACGME. Functional e-mail addresses were identified for 164 (90.6%). Three individualized e-mail requests were sent to each PD to complete an anonymous 32-question Web-based survey.

RESULTS

A total of 151 responses were obtained (83.4%). Pediatrics PDs reported approval for nearly all of the 2011 ACGME duty hour regulations except for 16-hour intern shift limits (72.2% disapprove). Regarding the perceived impact of the new standards, many areas were reportedly unchanged, but most PDs reported negative effects on resident education (74.7%), preparation for senior roles (79.9%), resident ownership of patients (76.8%), and continuity of care (78.8%). There was a reported increase in PD workload (67.6%) and use of physician extenders (62.7%). Finally, only 48.3% of PDs reported that their residents are "always" compliant with 2011 requirements.

CONCLUSIONS

Pediatric PDs think there have been numerous negative consequences of the 2011 Common Program Requirements. These include declines in resident education and preparation to take on more senior roles, as well as diminished resident accountability and continuity of care. Although they support individual aspects of duty hour regulation, almost three-quarters of pediatric PDs say there should be fewer regulations. The opinions expressed by PDs in this study should prompt research using quantitative metrics to assess the true impact of duty hour regulations.

The effect of the 16-hour intern workday restriction on surgical residents' in-hospital activities

OBJECTIVE

To observe the effects of the 2011 Accreditation Council on Graduate Medical Education 16-hour intern workday restrictions on surgical residents' clinical and educational activities.

DESIGN

All the residents recorded the following weekly in-hospital activities during February and March 2011 (year before intern work restrictions) and 2012 (first year under new requirements): operating room (OR) and clinic; bedside procedures; rounds and ward work; on-call duties in hospital; communication (e.g., checkouts and family and patient discussions); education (conferences and study); and personal (rest and meals). Descriptive statistics were calculated in 3 resident groups (interns, first postgraduate year [PGY1]; junior, PGY2 and 3; and senior, PGY4 and 5). The unpaired t test was used to compare data between 2011 and 2012; significance was set at p< 0.05.

SETTING

Medical school affiliated hospital.

PARTICIPANTS

Categorical resident trainees in surgery, PGY1-5, 4 residents per level, with all 20 residents participating in the study.

RESULTS

From 2011 to 2012, time spent in the hospital by the intern did not change (all results in h/wk, mean±standard deviation: 68.5±13.8 to 72.8±15.8, respectively) but the time devoted to specific activities changed significantly. In-hospital personal time decreased by 50% (5.3±4.6 to 2.6±2.0, p = 0.004). Interns spent less time placing central lines (2.1±2.2 to 0.9±1.2, p = 0.006) and more on rounds (8.8±8.8 to 14.2±9.8, p = 0.027), which included supervision with upper level residents. There was no change in the total time spent in the OR, the clinic, performing bedside procedures, and educational activities. Changes in intern work did not affect the time junior and senior residents spent on bedside procedures, time spent in the clinic, and total time spent in the hospital. In 2012, junior residents spent less time in educational activities (11.4±8.5 to 7.0±4.5, p = 0.0007) and the seniors spent more time in the OR (13.7±7.5 to 20.6±10.7, p = 0.0002).

CONCLUSIONS

The 16-hour restriction preserved interns' educational activities and time spent in the OR and clinic, but changed resident work activities at all levels. The time spent on rounds increased, time spent by the juniors on conferences decreased, and time spent by senior residents in the OR increased. Duty restrictions in general and intern supervision requirements demand ongoing adjustments in resident work schedules.

Mortality among high-risk patients with acute myocardial infarction admitted to U.S. teaching-intensive hospitals in July: a retrospective observational study

BACKGROUND

Studies of whether inpatient mortality in US teaching hospitals rises in July as a result of organizational disruption and relative inexperience of new physicians (July effect) find small and mixed results, perhaps because study populations primarily include low-risk inpatients whose mortality outcomes are unlikely to exhibit a July effect.

METHODS AND RESULTS

Using the US Nationwide Inpatient sample, we estimated difference-in-difference models of mortality, percutaneous coronary intervention rates, and bleeding complication rates, for high- and low-risk patients with acute myocardial infarction admitted to 98 teaching-intensive and 1353 non-teaching-intensive hospitals during May and July 2002 to 2008. Among patients in the top quartile of predicted acute myocardial infarction mortality (high risk), adjusted mortality was lower in May than July in teaching-intensive hospitals (18.8% in May, 22.7% in July, P<0.01), but similar in non-teaching-intensive hospitals (22.5% in May, 22.8% in July, P=0.70). Among patients in the lowest three quartiles of predicted acute myocardial infarction mortality (low risk), adjusted mortality was similar in May and July in both teaching-intensive hospitals (2.1% in May, 1.9% in July, P=0.45) and non-teaching-intensive hospitals (2.7% in May, 2.8% in July, P=0.21). Differences in percutaneous coronary intervention and bleeding complication rates could not explain the observed July mortality effect among high risk patients.

CONCLUSIONS

High-risk acute myocardial infarction patients experience similar mortality in teaching- and non-teaching-intensive hospitals in July, but lower mortality in teaching-intensive hospitals in May. Low-risk patients experience no such July effect in teaching-intensive hospitals.

Teaching and Assessing Colorectal Surgery Residents in the Age of ACGME Competencies: Pieces of the Whole

Educators have struggled with teaching and evaluation of the six Accreditation Council for Graduate Medical Education (ACGME) core competencies since their introduction in 1999. In addition, many authors have questioned the construct validity of the competencies. Concern has also arisen regarding the educational effects of the competencies and the subsequent limitation of resident duty hours, the combination of which have forced unprecedented changes in American graduate medical education. This article attempts to present an understanding of how these events have had direct and indirect effects on the education of residents in colon and rectal surgery, and to provide a framework for educators in colon and rectal surgery to adapt in their curricula.

Follow-up on a national survey: american neurosurgery resident opinions on the 2011 accreditation council for graduate medical education-implemented duty hours

OBJECTIVE

We previously performed a nationwide survey of American neurosurgical residents before the initiation of the 2011 Accreditation Council for Graduate Medical Education regulations, in which more than 70% indicated the proposed changes would negatively impact residency training. We sought to resurvey the resident population as to the actual changes that occurred to their programs after the 2011 standards went into effect.

METHODS

Surveys were mailed to every neurosurgery training program in the United States and Puerto Rico. Program directors and coordinators were asked to distribute surveys to their residents.

RESULTS

A total of 253 neurosurgery residents responded. Reported duty-hour violations were largely unchanged after the 2011 duty-hour changes. Sixty-percent of residents reported that they had underreported duty hours, with nearly 25% of respondents doing so on a weekly or daily basis. Most reported that the 2011 changes had not affected operative caseload, academic productivity, quality of life, or resident fatigue. The majority of residents disagreed or strongly disagreed that the PGY-1 16-hour limitation had a positive impact on first-year resident training (69%) or had improved patient safety (62%). Overall, the majority of respondents reported that the 2011 changes had a negative (35%) or negligible (33%) effect on residency training at their institution.

CONCLUSION

Respondents indicated that the 2011 Accreditation Council for Graduate Medical Education regulations have had a smaller perceived effect on neurosurgical training programs than previously predicted. However, the majority of residents admitted to underreporting duty hours, with a quarter doing so on a regular basis. The 16-hour rule for interns remains unpopular.

Teaching hospital five-year mortality trends in the wake of duty hour reforms

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour regulations for residents in 2003 and again in 2011. While previous studies showed no systematic impacts in the first 2 years post-reform, the impact on mortality in subsequent years has not been examined.

OBJECTIVE

To determine whether duty hour regulations were associated with changes in mortality among Medicare patients in hospitals of different teaching intensity after the first 2 years post-reform.

DESIGN

Observational study using interrupted time series analysis with data from July 1, 2000 to June 30, 2008. Logistic regression was used to examine the change in mortality for patients in more versus less teaching-intensive hospitals before (2000-2003) and after (2003-2008) duty hour reform, adjusting for patient comorbidities, time trends, and hospital site.

PATIENTS

Medicare patients (n = 13,678,956) admitted to short-term acute care non-federal hospitals with principal diagnoses of acute myocardial infarction (AMI), gastrointestinal bleeding, or congestive heart failure (CHF); or a diagnosis-related group (DRG) classification of general, orthopedic, or vascular surgery.

MAIN MEASURE

All-location mortality within 30 days of hospital admission.

KEY RESULTS

In medical and surgical patients, there were no consistent changes in the odds of mortality at more vs. less teaching intensive hospitals in post-reform years 1-3. However, there were significant relative improvements in mortality for medical patients in the fourth and fifth years post-reform: Post4 (OR 0.88, 95 % CI [0.93-0.94]); Post5 (OR 0.87, [0.82-0.92]) and for surgical patients in the fifth year post-reform: Post5 (OR 0.91, [0.85-0.96]).

CONCLUSIONS

Duty hour reform was associated with no significant change in mortality in the early years after implementation, and with a trend toward improved mortality among medical patients in the fourth and fifth years. It is unclear whether improvements in outcomes long after implementation can be attributed to the reform, but concerns about worsening outcomes seem unfounded.

Twenty-year route of prevalence of risk factors, treatment patterns, complications, and mortality rate of acute myocardial infarction in Iran

OBJECTIVES

Coronary artery diseases are regarded as the main cause of mortality in most countries. The present study aims at evaluating variations and studying its complications in Iranian patients within past 20 years.

METHODS

This cross-sectional analytical-descriptive study retrospectively evaluated the files of 600 patients with acute myocardial infarction during a 20-year period. Basic data and laboratory information, chemotherapies and intervention treatments of patients were registered in special forms and compared regarding the mentioned time intervals.

RESULTS

There were 440 (73.3%) male and 160 (26.7%) female patients and mean age of the patients was 60.03 ± 11.61 years. Mean duration of hospitalization (p < 0.001) and prevalence of smoking (p < 0.001) had significantly decreased in the past two decades. There was no meaningful difference when considering mortality rate (p = 0.533) and cardiac insufficiency (p = 0.403).

CONCLUSION

The results indicate prominent improvement in the management process of patients suffering from acute myocardial infarction within the past 20 years.

Does admission to a teaching hospital affect acute myocardial infarction survival?

PURPOSE

Previous studies have found that teaching hospitals produce better acute myocardial infarction (AMI) outcomes than nonteaching hospitals. However, these analyses generally excluded patients transferred out of nonteaching hospitals and did not study outcomes by patient risk level. The objective of this study was to determine whether admission to a teaching hospital was associated with greater survival after accounting for patient transfers and patient severity.

METHOD

This observational study used logistic models to examine the association between hospital teaching status and 30-day mortality of AMI patients, adjusting for patient comorbidities and common time trends. The sample included 1,309,554 Medicare patients admitted from 1996 to 2004 to 3,761 acute care hospitals for AMI. The primary outcome was 30-day all-cause, all-location mortality.

RESULTS

Mortality was slightly lower in minor teaching hospitals compared with nonteaching hospitals (odds ratio [OR] 0.97; 95% confidence interval [CI] 0.95-0.99) but not different between major teaching and nonteaching hospitals (OR 1.01; 95% CI 0.96-1.03). The odds of mortality in minor teaching hospitals decreased 4.2% relative to nonteaching hospitals during the seven-year period (OR from 0.98 to 0.94). There was no consistent pattern of association between teaching status and patient severity.

CONCLUSIONS

After correctly accounting for the ability of nonteaching hospitals to appropriately transfer patients in need of different care, there was no survival benefit on average for initial admission to a teaching hospital for AMI. Further more, higher-risk patients did not benefit from initial admission to teaching hospitals.

Teaching hospital financial status and patient outcomes following ACGME duty hour reform

OBJECTIVE

To examine whether hospital financial health was associated with differential changes in outcomes after implementation of 2003 ACGME duty hour regulations.

DATA SOURCES/STUDY SETTING

Observational study of 3,614,174 Medicare patients admitted to 869 teaching hospitals from July 1, 2000 to June 30, 2005.

STUDY DESIGN

Interrupted time series analysis using logistic regression to adjust for patient comorbidities, secular trends, and hospital site. Outcomes included 30-day mortality, AHRQ Patient Safety Indicators (PSIs), failure-to-rescue (FTR) rates, and prolonged length of stay (PLOS).

PRINCIPAL FINDINGS

All eight analyses measuring the impact of duty hour reform on mortality by hospital financial health quartile, in postreform year 1 ("Post 1") or year 2 ("Post 2") versus the prereform period, were insignificant: Post 1 OR range 1.00-1.02 and Post 2 OR range 0.99-1.02. For PSIs, all six tests showed clinically insignificant effect sizes. The FTR rate analysis demonstrated nonsignificance in both postreform years (OR 1.00 for both). The PLOS outcomes varied significantly only for the combined surgical sample in Post 2, but this effect was very small, OR 1.03 (95% CI 1.02, 1.04).

CONCLUSIONS

The impact of 2003 ACGME duty hour reform on patient outcomes did not differ by hospital financial health. This finding is somewhat reassuring, given additional financial pressure on teaching hospitals from 2011 duty hour regulations.

Recent family medicine residency graduates' perceptions of resident duty hour restrictions

BACKGROUND

Resident duty hour limits, new requirements for supervision, and an enhanced focus on patient safety have shown mixed effects on resident quality of life, patient safety, and resident competency. Few studies have assessed how recent graduates feel these changes have affected their education.

OBJECTIVE

We assessed recent graduates' perceptions about the effects of duty hour and supervision requirements on their education.

METHODS

We conducted a cross-sectional survey of graduates from South Carolina Area Health Education Consortium-affiliated family medicine residency programs from 2005 to 2009 by using logistic regression to determine associations between participant characteristics and survey responses.

RESULTS

Graduates (N  =  136) completed the survey with a 51.3% response rate. Nearly all (96%) reported that residency prepared them for their current work hours; 97% reported they felt adequately supervised; 81% worked fewer hours in practice than in residency; 20% believed the limits had restricted their clinical experience; and 3% felt duty hour limits were more important than supervision. Graduates who practiced in a mid-sized communities were more likely to report duty hour limits restricted their clinical experience than individuals practicing in communities of <10 000 (OR  =  6.30; 95% CI, 1.38-28.72).

CONCLUSIONS

Most graduates who responded to the survey felt supervision was equally or more important than limits on resident duty hours. However, 20% of respondents felt that the duty hour standards limited their education. The duty hour and supervision requirements challenge educators to ensure quality education.

Increased error rates in preliminary reports issued by radiology residents working more than 10 consecutive hours overnight

RATIONALE AND OBJECTIVES

To determine if the rate of major discrepancies between resident preliminary reports and faculty final reports increases during the final hours of consecutive 12-hour overnight call shifts.

MATERIALS AND METHODS

Institutional review board exemption status was obtained for this study. All overnight radiology reports interpreted by residents on-call between January 2010 and June 2010 were reviewed by board-certified faculty and categorized as major discrepancies if they contained a change in interpretation with the potential to impact patient management or outcome. Initial determination of a major discrepancy was at the discretion of individual faculty radiologists based on this general definition. Studies categorized as major discrepancies were secondarily reviewed by the residency program director (M.H.S.) to ensure consistent application of the major discrepancy designation. Multiple variables associated with each report were collected and analyzed, including the time of preliminary interpretation, time into shift study was interpreted, volume of studies interpreted during each shift, day of the week, patient location (inpatient or emergency department), block of shift (2-hour blocks for 12-hour shifts), imaging modality, patient age and gender, resident identification, and faculty identification. Univariate risk factor analysis was performed to determine the optimal data format of each variable (ie, continuous versus categorical). A multivariate logistic regression model was then constructed to account for confounding between variables and identify independent risk factors for major discrepancies.

RESULTS

We analyzed 8062 preliminary resident reports with 79 major discrepancies (1.0%). There was a statistically significant increase in major discrepancy rate during the final 2 hours of consecutive 12-hour call shifts. Multivariate analysis confirmed that interpretation during the last 2 hours of 12-hour call shifts (odds ratio (OR) 1.94, 95% confidence interval (CI) 1.18-3.21), cross-sectional imaging modality (OR 5.38, 95% CI 3.22-8.98), and inpatient location (OR 1.81, 95% CI 1.02-3.20) were independent risk factors for major discrepancy.

CONCLUSIONS

In a single academic medical center, major discrepancies in resident preliminary reports increased significantly during the final 2 hours of consecutive 12-hour overnight call shifts. This finding could be related to either fatigue or circadian desynchronization. Discrimination of these two potential etiologies requires additional investigation as major discrepancies in resident reports have the potential to negatively impact patient care/outcome. Cross-sectional imaging modalities including computed tomography and ultrasound (versus conventional radiography), as well as inpatient location (versus Emergency Department location), were also associated with significantly higher major discrepancy rates.

Effect of a protected sleep period on hours slept during extended overnight in-hospital duty hours among medical interns: a randomized trial

CONTEXT

A 2009 Institute of Medicine report recommended protected sleep periods for medicine trainees on extended overnight shifts, a position reinforced by new Accreditation Council for Graduate Medical Education requirements.

OBJECTIVE

To evaluate the feasibility and consequences of protected sleep periods during extended duty.

DESIGN, SETTING, AND PARTICIPANTS

Randomized controlled trial conducted at the Philadelphia VA Medical Center medical service and Oncology Unit of the Hospital of the University of Pennsylvania (2009-2010). Of the 106 interns and senior medical students who consented, 3 were not scheduled on any study rotations. Among the others, 44 worked at the VA center, 16 at the university hospital, and 43 at both.

INTERVENTION

Twelve 4-week blocks were randomly assigned to either a standard intern schedule (extended duty overnight shifts of up to 30 hours; equivalent to 1200 overnight intern shifts at each site), or a protected sleep period (protected time from 12:30 AM to 5:30 AM with handover of work cell phone; equivalent to 1200 overnight intern shifts at each site). Participants were asked to wear wrist actigraphs and complete sleep diaries.

MAIN OUTCOME MEASURES

Primary outcome was hours slept during the protected period on extended duty overnight shifts. Secondary outcome measures included hours slept during a 24-hour period (noon to noon) by day of call cycle and Karolinska sleepiness scale.

RESULTS

For 98.3% of on-call nights, cell phones were signed out as designed. At the VA center, participants with protected sleep had a mean 2.86 hours (95% CI, 2.57-3.10 hours) of sleep vs 1.98 hours (95% CI, 1.68-2.28 hours) among those who did not have protected hours of sleep (P < .001). At the university hospital, participants with protected sleep had a mean 3.04 hours (95% CI, 2.77-3.45 hours) of sleep vs 2.04 hours (95% CI, 1.79-2.24) among those who did not have protected sleep (P < .001). Participants with protected sleep were significantly less likely to have call nights with no sleep: 5.8% (95% CI, 3.0%-8.5%) vs 18.6% (95% CI, 13.9%-23.2%) at the VA center (P < .001) and 5.9% (95% CI, 3.1%-8.7%) vs 14.2% (95% CI, 9.9%-18.4%) at the university hospital (P = .001). Participants felt less sleepy after on-call nights in the intervention group, with Karolinska sleepiness scale scores of 6.65 (95% CI, 6.35-6.97) vs 7.10 (95% CI, 6.85-7.33; P = .01) at the VA center and 5.91 (95% CI, 5.64-6.16) vs 6.79 (95% CI, 6.57-7.04; P < .001) at the university hospital.

CONCLUSIONS

For internal medicine services at 2 hospitals, implementation of a protected sleep period while on call resulted in an increase in overnight sleep duration and improved alertness the next morning.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00874510.

Impact of resident duty hour limits on safety in the intensive care unit: a national survey of pediatric and neonatal intensivists

OBJECTIVE

Resident duty-hour regulations potentially shift the workload from resident to attending physicians. We sought to understand how current or future regulatory changes might impact safety in academic pediatric and neonatal intensive care units.

DESIGN

Web-based survey.

SETTING

U.S. academic pediatric and neonatal intensive care units.

SUBJECTS

Attending pediatric and neonatal intensivists.

INTERVENTIONS

We evaluated perceptions on four intensive care unit safety-related risk measures potentially affected by current duty-hour regulations: 1) attending physician and resident fatigue; 2) attending physician workload; 3) errors (self-reported rates by attending physicians or perceived resident error rates); and 4) safety culture. We also evaluated perceptions of how these risks would change with further duty-hour restrictions.

MEASUREMENTS AND MAIN RESULTS

We administered our survey between February and April 2010 to 688 eligible physicians, of whom 360 (52.3%) responded. Most believed that resident error rates were unchanged or worse (91.9%) and safety culture was unchanged or worse (84.4%) with current duty-hour regulations. Of respondents, 61.9% believed their own work-hours providing direct patient care increased and 55.8% believed they were more fatigued while providing direct patient care. Most (85.3%) perceived no increase in their own error rates currently, but in the scenario of further reduction in resident duty-hours, over half (53.3%) believed that safety culture would worsen and a significant proportion (40.3%) believed that their own error rates would increase.

CONCLUSIONS

Pediatric intensivists do not perceive improved patient safety from current resident duty-hour restrictions. Policies to further restrict resident duty-hours should consider unintended consequences of worsening certain aspects of intensive care unit safety.

Pediatric residents' perspectives on reducing work hours and lengthening residency: a national survey

OBJECTIVE

In 2011, the Accreditation Council on Graduate Medical Education increased restrictions on resident duty-hours. Additional changes have been considered, including greater work-hours restrictions and lengthening residency. Program directors tend to oppose further restrictions; however, residents' views are unclear. We sought to determine whether residents support these proposals, and if so why.

METHODS

We surveyed US pediatric residents from a probability sample of 58 residency programs. We used multivariate logistic regression to determine predictors of support for (1) a 56-hour workweek and (2) the addition of 1 year to residency to achieve a 56-hour week.

RESULTS

Fifty-seven percent of sampled residents participated (n = 1469). Forty-one percent of respondents supported a 56-hour week, with 28% neutral and 31% opposed. Twenty-three percent of all residents would be willing to lengthen training to reduce hours. The primary predictors of support for a 56-hour week were beliefs that it would improve education (odds ratio [OR] 8.6, P < .001) and quality of life (OR 8.7, P < .001); those who believed patient care would suffer were less likely to support it (OR 0.10, P < .001). Believing in benefits to education without decrement to patient care also predicted support for a 56-hour-week/4-year program.

CONCLUSIONS

Pediatric residents who support further reductions in work-hours believe reductions have positive effects on patient care, education, and quality of life. Most would not lengthen training to reduce hours, but a minority prefers this schedule. If evidence mounts showing that reducing work-hours benefits education and patient care, pediatric residents' support for the additional year may grow.

Limiting PGY 1 residents to 16 hours of duty: review and report of a workshop

BACKGROUND

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted limits on duty hours. Residents were restricted to working 80 hours/week and limited to 24 hours of continuous patient care. Effective July 2011, an additional restriction will be instituted for PGY 1 residents limiting continuous duty to 16 hours maximum.

OBJECTIVE

Prospective evaluation of the impact of the upcoming work shift limitations for PGY 1 residents.

DESIGN/SETTING/PARTICIPANTS

Review of literature and discussions among program directors, program coordinators, and residents on the effects of prior limitations of duty hours, as a point of reference, to manage the changes of duty hours for PGY 1 residents during a workshop at the Association of Program Directors in Surgery Annual Meeting.

RESULTS

Work-hour restrictions necessitate a change from the traditional 24-hour on-duty call schedule for PGY 1 residents. The benefits to patients of being treated by less tired doctors working in shifts may be offset by communication failures from poor handoffs, rendering the system prone to adverse events/near misses. With additional work-hour restrictions, it is imperative to anticipate problems and deal with them effectively. Continued reevaluation of the handoff system and efforts made to decrease the number of preventable adverse events that typically occur during periods of cross coverage should be undertaken. Labor costs to carry out these new restrictions are predictably high but can be made budget neutral if improvement in patient care leads to reduction in the costs of corrective actions.

CONCLUSIONS

Residency programs have adapted to the 2003 work-hour restrictions without apparent ill effect. We must study the effects of the July 2011 requirements prospectively as the traditional frontline physicians (PGY 1 residents) will no longer be available for 24-hour duty shifts.

A longitudinal analysis of the impact of hospital service line profitability on the likelihood of readmission

Quality of care may be linked to the profitability of admissions in addition to level of reimbursement. Prior policy reforms reduced payments that differentially affected the average profitability of various admission types. The authors estimated a Cox competing risks model, controlling for the simultaneous risk of mortality post discharge, to determine whether the average profitability of hospital service lines to which a patient was admitted was associated with the likelihood of readmission within 30 days. The sample included 12,705,933 Medicare Fee for Service discharges from 2,438 general acute care hospitals during 1997, 2001, and 2005. There was no evidence of an association between changes in average service line profitability and changes in readmission risk, even when controlling for risk of mortality. These findings are reassuring in that the profitability of patients' admissions did not affect readmission rates, and together with other evidence may suggest that readmissions are not an unambiguous quality indicator for in-hospital care.

Academic time at a level 1 trauma center: no resident, no problem?

BACKGROUND

Globally, the compliance of resident work-hour restrictions has no impact on trauma outcome. However, the effect of protected education time (PET), during which residents are unavailable to respond to trauma patients, has not been studied. We hypothesized that PET has no impact on the outcome of trauma patients.

METHODS

We conducted a retrospective review of relevant patients at an academic level I trauma center. During PET, a trauma attending and advanced practice providers (APPs) responded to trauma activations. PGY1, 3, and 4 residents were also available at all other times. The outcome of new trauma patient activations during Thursday morning 3-hours resident PET was compared with same time period on other weekdays (non-PET) using a univariate and multivariate analysis.

RESULTS

From January 2005 to April 2010, a total of 5968 trauma patients were entered in the registry. Of these, 178 patients (2.98%) were included for study (37 PET and 141 non-PET). The mean injury severity score (ISS) was 16.2. Although no significant difference were identified in mortality, complications, or length of stay (LOS), we do see that length of emergency department stay (ED-LOS) tends to be longer during PET, although not significantly (314 vs 381 minutes, p = 0.74). On the multiple logistic regression model, PET was not a significant factor of complications, LOS, or ED-LOS.

CONCLUSIONS

Few trauma activations occur during PET. New trauma activations can be staffed safely by trauma activations and APPs. However, there could be some delays in transferring patients to appropriate disposition. Additional study is required to determine the effect of PET on existing trauma inpatients.

A global template for reforming residency without work-hours restrictions: decrease caseloads, increase education. Findings of the Japan Resident Workload Study Group

BACKGROUND

Japanese physician training programs are currently not subject to rigorous national standardization. Despite residency restructuring in 2004, little is known about the current work allocation of residents in Japan.

AIMS

We quantified the amount of time that Japanese junior residents spend in service versus education in the context of caseload, fatigue, and low-value administrative work.

METHODS

In this prospective, time-and-motion study, the activity of 1st- and 2nd-year residents at three Japanese community hospitals was observed at 5-min intervals over 1 week, and categorized as patient care, academic, non-patient care, and personal. Self-reported sleep data and caseload information were simultaneously collected. Data were subanalyzed by gender, training level, hospital, and shift.

RESULTS

A total of 64 participating residents spent substantially more time in patient care activities than education (59.5% vs. 6.8%), and little time on low-value, non-patient work (5.1%). Residents reported a median 5 h of sleep before shifts and excessive sleepiness (median Epworth score, 12). Large variations in caseload were reported (median 10 patients, range 0-60).

CONCLUSIONS

New physicians in Japan deliver a large volume of high-value patient care, while receiving little structured education and enduring substantial sleep deprivation. In programs without work-hour restrictions, caseload limits may improve safety and quality.