BACKGROUND/RATIONALE:
Medical errors are believed to result in the deaths of tens of thousands of patients in American hospitals each year. Much of the direct care provided to patients in VA teaching hospitals is the responsibility of residents. In recent years, there has been an emerging consensus that the acute and chronic sleep deprivation of residency training likely contribute significantly to medical errors among residents. In response, the ACGME released rules effective July 1, 2003 that limited duty hours for all ACGME-accredited residency programs. The hope was that these changes would make residents more rested, decreasing patient mortality. Experts also worried that there would be negative effects from a drop in continuity of care.
OBJECTIVE(S):
The objectives of this study were to: a) examine the change in mortality; b) examine the change in mortality for patients who experienced complications (failure-to-rescue); c) examine the rate of change of AHRQ patient safety indicators (PSIs) and d) examine how length of stay, the probability of a prolonged length of stay (PLOS), and conditional length of stay (CLOS) changed, all following implementation of the ACGME duty hour rules
METHODS:
We used a multiple time series research design to examine whether the change in duty hour rules changed the underlying trend in patient outcomes in teaching hospitals, an approach which allows for greater detection of biases from unmeasured variables. This "difference-in-differences" design compares each hospital to itself, before and after reform, contrasting the changes in hospitals with more residents to the changes in hospitals with fewer or no residents, making adjustments for observed differences in patient risk factors.
FINDINGS/RESULTS:
Overall, we found that the new regulations did not have a strong impact on the rates of mortality or the probability of experiencing a prolonged stay. The PSI analyses showed that there was no systematic impact on potential safety-related events from duty hour reforms. The magnitude of any absolute increase was too small to be clinically meaningful and was inconsistent over time. Duty hour reform was not associated with changes in mortality or FTR rates for high risk medical or surgical patients. These results indicate that hospitals were able to cope with the reduction in resident work hours. Hospitals found ways to cope with any worsening of continuity of care associated with duty hour reform and succeeded in avoiding the adverse consequences predicted.
IMPACT:
The effects of the duty hour limitations are important to understand because they affect the care of the majority of inpatients treated in VA hospitals each year. Our analyses show that though the duty hour reform has not necessarily improved patient outcomes yet, it has not negatively affected them either. Many people worried about increased handoffs disrupting patient care and increasing the occurrence of negative outcomes. More studies need to be done to see how else the reform affected patient care in the VA health system. This will inform further efforts to reduce errors in VA teaching hospitals and clarify which mechanisms helped hospitals cope with the reduction in the residents' work hours.
PUBLICATIONS:
Journal Articles
- Silber JH, Romano PS, Rosen AK, Wang Y, Even-Shoshan O, Volpp KG. Failure-to-rescue: comparing definitions to measure quality of care. Medical Care. 2007; 45(10): 918-25.
- Myers JS, Bellini LM, Morris JB, Graham D, Katz J, Potts JR, Weiner C, Volpp KG. Internal medicine and general surgery residents' attitudes about the ACGME duty hours regulations: a multicenter study. Academic Medicine. 2006; 81(12): 1052-8.
