Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform

Duty hours, quality of care, and patient safety: general surgery resident perceptions

BACKGROUND

The balance between patient treatment risks and training residents to proficiency is confounded by duty-hour limits. Stricter limits have been recommended to enhance quality and safety, although supporting data are scarce.

STUDY DESIGN

A previously piloted survey was delivered with the 2010 American Board of Surgery In-Training Examination (ABSITE). First postgraduate year (PGY1) and PGY2 trainees took the Junior examination (IJE); PGY3 and above took the Senior examination (ISE). Residency type, size, and location were linked to examinees using program codes. Five survey items queried all residents about the impact of further hour limits on care quality; online test residents answered 7 more items probing medical error sources. Data were analyzed using factorial ANOVA for association with sex, PGY level, and program demographics.

RESULTS

There were 6,161 categorical surgery residents who took the ABSITE: 60% men, 60% ISE, and two-thirds in university programs. Paper (n = 5,079) and online (n = 1,082) examinees were similar. Item response rates ranged from 91% to 98%. Few (<25%) perceived that stricter hour limits would improve care quality to a large or maximal extent. IJE plus West and Northeast residents significantly more often favored fewer hours. Factors perceived as contributing to medical errors usually or always by ≥ 15% of residents were incomplete handoffs, inexperience or lack of knowledge, insufficient ancillary personnel, and excessive workload.

CONCLUSIONS

Most categorical surgery residents do not perceive that reduced duty hours will noticeably improve quality of care. Resident perceptions of causes of medical errors suggest that system changes are more likely to enhance patient safety than further hour limits.

The perspective of the vascular surgery trainee on new ACGME regulations, fatigue, resident training, and patient safety

OBJECTIVE

To assess the opinions of vascular surgery trainees on the new Accreditation Council for Graduate Medical Education (ACGME) guidelines.

METHODS

A questionnaire was developed and electronically distributed to trainee members of the Society for Vascular Surgery.

RESULTS

Of 238 eligible vascular trainees, 38 (16%) participated. Respondents were predominantly 30 to 35 years of age (47%), male (69%), in 2-year fellowship (73%), and at large academic centers (61%). Trainees report occasionally working while fatigued (63%). Fellows were more likely to report for duty while fatigued (P = .012) than integrated vascular residents. Respondents thought further work-hour restrictions would not improve patient care or training (P < .05) and may not lead to more sleep or improved quality of life. Respondents reported that duty hours should vary by specialty (81%) and allow flexibility in the last years of training (P < .05).

CONCLUSIONS

Vascular surgery trainees are concerned about further duty-hour restrictions on patient care, education, and training and fatigue mitigation has to be balanced against the need to adequately train vascular surgeons.

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.

The long-term effect of premier pay for performance on patient outcomes

BACKGROUND

Pay for performance has become a central strategy in the drive to improve health care. We assessed the long-term effect of the Medicare Premier Hospital Quality Incentive Demonstration (HQID) on patient outcomes.

METHODS

We used Medicare data to compare outcomes between the 252 hospitals participating in the Premier HQID and 3363 control hospitals participating in public reporting alone. We examined 30-day mortality among more than 6 million patients who had acute myocardial infarction, congestive heart failure, or pneumonia or who underwent coronary-artery bypass grafting (CABG) between 2003 and 2009.

RESULTS

At baseline, the composite 30-day mortality was similar for Premier and non-Premier hospitals (12.33% and 12.40%, respectively; difference, -0.07 percentage points; 95% confidence interval [CI], -0.40 to 0.26). The rates of decline in mortality per quarter at the two types of hospitals were also similar (0.04% and 0.04%, respectively; difference, -0.01 percentage points; 95% CI, -0.02 to 0.01), and mortality remained similar after 6 years under the pay-for-performance system (11.82% for Premier hospitals and 11.74% for non-Premier hospitals; difference, 0.08 percentage points; 95% CI, -0.30 to 0.46). We found that the effects of pay for performance on mortality did not differ significantly among conditions for which outcomes were explicitly linked to incentives (acute myocardial infarction and CABG) and among conditions not linked to incentives (congestive heart failure and pneumonia) (P=0.36 for interaction). Among hospitals that were poor performers at baseline, mortality was similar in the two groups of hospitals at the start of the study (15.12% and 14.73%; difference, 0.39 percentage points; 95% CI, -0.36 to 1.15), with similar rates of improvement per quarter (0.10% and 0.07%; difference, -0.03 percentage points; 95% CI, -0.08 to 0.02) and similar mortality rates at the end of the study (13.37% and 13.21%; difference, 0.15 percentage points; 95% CI, -0.70 to 1.01).

CONCLUSIONS

We found no evidence that the largest hospital-based pay-for-performance program led to a decrease in 30-day mortality. Expectations of improved outcomes for programs modeled after Premier HQID should therefore remain modest.

The effect of improving processes of care on patient outcomes: evidence from the United Kingdom's quality and outcomes framework

BACKGROUND

Despite the extensive use of process of care measures in pay-for-performance programs, little is known about the effect of improving process performance on patient outcomes.

METHODS

Retrospective longitudinal analysis of data extracted from 7228 family practices in the United Kingdom's Quality and Outcomes Framework pay-for-performance program. We estimated the proportion of the change in outcome performance over time which was attributable to change in process performance for 5 chronic conditions (diabetes, coronary heart disease, stroke, epilepsy, and hypertension). Our analytic strategy accounted for bias resulting from unmeasured processes of care and severity of illness.

RESULTS

The estimated improvement in composite outcomes that was attributable to improved process was 29.6% for diabetes, 25.6% for coronary heart disease, 34.7% for stroke, 29.1% for epilepsy, and 17.7% for hypertension. The relationship between processes and outcomes varied little across patient and practice characteristics.

CONCLUSIONS

Improvement in process performance in English family practices led to improvements in patient outcomes. Although the effect was modest at the practice-level, process improvements seem to have led to substantial improvements in population health.

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.

Results of a national neurosurgery resident survey on duty hour regulations

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) duty hour standards that began July 2011 will further limit resident duty hours.

OBJECTIVE

To survey neurosurgery residents in the United States on duty hour violations under the current system and the predicted effects on education and patient safety of the new regulations.

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

Three hundred seventy-seven neurosurgery residents mailed surveys back to the study center (34% response rate). More than one-third of respondents reported violating the 80-hour rule occasionally or frequently (36%). Thirty-one residents (8%) reported having been involved in a motor vehicle collision or life-threatening event and 20 (6%) reported having made a medical error resulting in patient harm after an extended shift. Eighty-three percent disagreed with the 16-hour proposed regulation for postgraduate year 1. The majority of respondents thought that the new standards will have a negative or strongly negative effect on their residency training (72%).

CONCLUSION

This national duty hour survey of neurosurgical residents reveals considerable concern over the new ACGME proposed standards. The majority of respondents believe that the new standards will have a negative effect on their residency training. Furthermore, this survey indicates an overwhelming negative attitude toward mandated duty hour regulations among neurosurgical residents. Duty hour violations reported in this survey may be a more honest depiction of true violations than previous surveys and are higher than expected.

Systematic review and meta-analysis of the effect of North American working hours restrictions on mortality and morbidity in surgical patients

Background

Short duty hours, imposed by the Accreditation Council of Graduate Medical Education (ACGME) regulations, have been claimed to be associated with loss of continuity of care among surgical patients, leading to a potentially increased risk of adverse surgical outcomes. This systematic review and meta-analysis assessed the strength of associations between duty hour restrictions and morbidity and mortality of various surgical procedures.

Methods

MEDLINE, Embase, BIOSIS Previews®, the Education Resources Information Center and the Cochrane Central Register of Controlled Trials (January 2000 to September 2009) were searched, and reports screened to identify comparative studies of mortality and morbidity before and after the introduction of ACGME regulation periods. Random-effects (RE) and quality-effects (QE) meta-analyses were performed to determine the risk of morbidity or death associated with long duty hours compared with shorter duty hours. Results are presented as odds ratio (OR) with 95 per cent confidence interval.

Results

A total of 19 data sets (10 articles), including 730 648 subjects in the mortality studies and 64 346 in the morbidity studies, were analysed. Long duty hours were associated with a non-significantly increased risk of death compared with shorter duty hours (OR 1·28, 0·94 to 1·73). There was no difference in morbidity between the two groups (OR 1·03, 0·67 to 1·57). Mortality associations were generally stronger for general surgery, more recent studies and higher-quality studies. Heterogeneity was evident among the studies included.

Conclusion

The reduction in working hours has not affected patient care negatively in terms of demonstrable differences in morbidity and mortality. However, it cannot be distinguished whether this effect is actually due to a non-detrimental effect of the reduction in working hours or whether any such detriment is offset by continually improving patient care and increased surgical supervision.

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.

Review article: closing the research gap at the interface of learning and clinical practice

PURPOSE

The dialogue at the interface of education and clinical practice highlights areas of critical importance to the development of new approaches for educating anesthesiologists. The purpose of this article is to examine the literature on education and acquisition of competence in three areas relevant to the interface of learning and clinical practice, with the aim to suggest a research agenda that adds to the evidence on preparing physicians for independent practice. The three areas are: 1) transitions across the continuum of education; 2) the effect of reductions in hours of clinical training on competence; and 3) efforts to incorporate the competencies and CanMEDS roles into teaching and evaluation.

PRINCIPAL FINDINGS

Fifty-six articles relevant to one or more of the themes were identified in the review, including 21 studies of transitions (in, during, and after residency education), 19 studies on the effects of duty hour limits on residents' acquisition of competence, and 16 articles that assessed competency-based teaching and assessment in anesthesiology. Overall, the findings suggested a relative paucity of scientific evidence and a need for research and the development of new scientific theory. Studies generally treated one of the themes in isolation, while in actuality they interact to produce optimal as well as suboptimal learning situations, while medical education research often is limited by small samples, brief follow-up, and threats to validity. This suggests a "research gap" where editorials and commentaries have moved ahead of an evidence base for education. Promising areas for research include preparation for care deemed important by society, work to apply knowledge about the development of expertise in other disciplines to medicine, and ways to embed the competencies in teaching and evaluation more effectively.

CONCLUSION

Closing the research gap in medical education will require clear direction for future work. The starting point, at an institution or nationally, is dialogue within the specialty to achieve consensus on some of the most pressing questions.

Effects of a night-team system on resident sleep and work hours

OBJECTIVE

In 2009, Children's Hospital Boston implemented a night-team system on general pediatric wards to reduce extended work shifts. Residents worked 5 consecutive nights for 1 week and worked day shifts for the remainder of the rotation. Of note, resident staffing at night decreased under this system. The objective of this study was to assess the effects of this system on resident sleep and work hours.

METHODS

We conducted a prospective cohort study in which residents on the night-team system logged their sleep and work hours on work days. These data were compared with similar data collected in 2004, when there was a traditional call system.

RESULTS

In 2004 and 2009, mean shift length was 15.22 ± 6.86 and 12.92 ± 5.70 hours, respectively (P = .161). Daily work hours were 10.49 ± 6.85 and 8.79 ± 6.42 hours, respectively (P = .08). Nightly sleep time decreased from 6.72 ± 2.60 to 4.77 ± 2.46 hours (P < .001). Total sleep time decreased from 7.50 ± 3.13 to 5.47 ± 2.34 hours (P < .001).

CONCLUSIONS

Implementation of a night-team system was unexpectedly associated with decreased sleep hours. As residency programs create work schedules that are compliant with the 2011 Accreditation Council for Graduate Medical Education duty-hour standards, resident sleep should be monitored carefully.

Patient safety, resident education and resident well-being following implementation of the 2003 ACGME duty hour rules

CONTEXT

The ACGME-released revisions to the 2003 duty hour standards.

OBJECTIVE

To review the impact of the 2003 duty hour reform as it pertains to resident and patient outcomes.

DATA SOURCES

Medline (1989-May 2010), Embase (1989-June 2010), bibliographies, pertinent reviews, and meeting abstracts.

STUDY SELECTION

We included studies examining the relationship between the pre- and post-2003 time periods and patient outcomes (mortality, complications, errors), resident education (standardized test scores, clinical experience), and well-being (as measured by the Maslach Burnout Inventory). We excluded non-US studies.

DATA EXTRACTION

One rater used structured data collection forms to abstract data on study design, quality, and outcomes. We synthesized the literature qualitatively and included a meta-analysis of patient mortality.

RESULTS

Of 5,345 studies identified, 60 met eligibility criteria. Twenty-eight studies included an objective outcome related to patients; 10 assessed standardized resident examination scores; 26 assessed resident operative experience. Eight assessed resident burnout. Meta-analysis of the mortality studies revealed a significant improvement in mortality in the post-2003 time period with a pooled odds ratio (OR) of 0.9 (95% CI: 0.84, 0.95). These results were significant for medical (OR 0.91; 95% CI: 0.85, 0.98) and surgical patients (OR 0.86; 95% CI: 0.75, 0.97). However, significant heterogeneity was present (I(2) 83%). Patient complications were more nuanced. Some increased in frequency; others decreased. Outcomes for resident operative experience and standardized knowledge tests varied substantially across studies. Resident well-being improved in most studies.

LIMITATIONS

Most studies were observational. Not all studies of mortality provided enough information to be included in the meta-analysis. We used unadjusted odds ratios in the meta-analysis; statistical heterogeneity was substantial. Publication bias is possible.

CONCLUSIONS

Since 2003, patient mortality appears to have improved, although this could be due to secular trends. Resident well-being appears improved. Change in resident educational experience is less clear.

Readmission rates for Hispanic Medicare beneficiaries with heart failure and acute myocardial infarction

BACKGROUND

Hispanics are the fastest growing segment of the US population and have a higher prevalence of cardiovascular risk factors than non-Hispanic whites. However, little is known about whether elderly Hispanics have higher readmission rates for heart failure (HF) and acute myocardial infarction (AMI) than whites and whether this is due to site of care.

METHODS

We examined hospitalizations for Medicare patients with a primary discharge diagnosis of HF and AMI in 2006 to 2008. We categorized hospitals in the top decile of proportion of Hispanic patients as "Hispanic serving" and used logistic regression to examine the relationship between patient ethnicity, hospital Hispanic-serving status, and readmissions.

RESULTS

Hispanic patients had higher risk-adjusted readmission rates than whites for both HF (27.9% vs 25.9%, odds ratio [OR] 1.11, 95% CI 1.07-1.14, P < .001) and AMI (23.0% vs 21.0%, OR 1.12, 95% CI 1.07-1.18, P < .001). Similarly, Hispanic-serving hospitals had higher readmission rates than non-Hispanic-serving hospitals for both HF (27.4% vs 25.8%, OR 1.09, 95% CI 1.06-1.12, P < .001) and AMI (23.0% vs 20.8%, OR 1.13, 95% CI 1.09-1.18, P < .001). In analyses considering ethnicity and site of care simultaneously, both Hispanics and whites had higher readmission rates at Hispanic-serving hospitals.

CONCLUSIONS

Elderly Hispanic patients are more likely to be readmitted for HF and AMI than whites, partly due to the hospitals where they receive care. Our findings suggest that targeting the site of care and these high-risk patients themselves will be necessary to reduce disparities in readmissions for this growing group of patients.

The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries

BACKGROUND

A key goal of resident duty hour reform by the Accreditation Council for Graduate Medical Education (ACGME) in 2003 was to improve patient outcomes.

OBJECTIVE

To assess whether the reform led to a change in readmission rates.

DESIGN

Observational study using multiple time series analysis with hospital discharge data from July 1, 2000 to June 30, 2005. Fixed effects logistic regression was used to examine the change in the odds of readmission in more versus less teaching-intensive hospitals before and after duty hour reform.

PARTICIPANTS

All unique Medicare patients (n = 8,282,802) admitted to acute-care nonfederal hospitals with principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, or stroke (combined medical group), or a DRG classification of general, orthopedic, or vascular surgery (combined surgical group).

MAIN MEASURES

Primary outcome was 30-day all-cause readmission. Secondary outcomes were (1) readmission or death within 30 days of discharge, and (2) readmission, death during the index admission, or death within 30 days of discharge.

KEY RESULTS

For the combined medical group, there was no evidence of a change in readmission rates in more versus less teaching-intensive hospitals [OR = 0.99 (95% CI 0.94, 1.03) in post-reform year 1 and OR = 0.99 (95% CI 0.95, 1.04) in post-reform year 2]. There was also no evidence of relative changes in readmission rates for the combined surgical group: OR = 1.03 (95% CI 0.98, 1.08) for post-reform year 1 and OR = 1.02 (95% CI 0.98, 1.07) for post-reform year 2. Findings for the secondary outcomes combining readmission and death were similar.

CONCLUSIONS

Among Medicare beneficiaries, there were no changes in hospital readmission rates associated with resident duty hour reform.

Duty hour recommendations and implications for meeting the ACGME core competencies: views of residency directors

OBJECTIVE

To describe the views of residency program directors regarding the effect of the 2010 duty hour recommendations on the 6 core competencies of graduate medical education.

METHODS

US residency program directors in internal medicine, pediatrics, and general surgery were e-mailed a survey from July 8 through July 20, 2010, after the 2010 Accreditation Council for Graduate Medical Education (ACGME) duty hour recommendations were published. Directors were asked to rate the implications of the new recommendations for the 6 ACGME core competencies as well as for continuity of inpatient care and resident fatigue.

RESULTS

Of 719 eligible program directors, 464 (65%) responded. Most program directors believe that the new ACGME recommendations will decrease residents' continuity with hospitalized patients (404/464 [87%]) and will not change (303/464 [65%]) or will increase (26/464 [6%]) resident fatigue. Additionally, most program directors (249-363/464 [53%-78%]) believe that the new duty hour restrictions will decrease residents' ability to develop competency in 5 of the 6 core areas. Surgery directors were more likely than internal medicine directors to believe that the ACGME recommendations will decrease residents' competency in patient care (odds ratio [OR], 3.9; 95% confidence interval [CI], 2.5-6.3), medical knowledge (OR, 1.9; 95% CI, 1.2-3.2), practice-based learning and improvement (OR, 2.7; 95% CI, 1.7-4.4), interpersonal and communication skills (OR, 1.9; 95% CI, 1.2-3.0), and professionalism (OR, 2.5; 95% CI, 1.5-4.0).

CONCLUSION

Residency program directors' reactions to ACGME duty hour recommendations demonstrate a marked degree of concern about educating a competent generation of future physicians in the face of increasing duty hour standards and regulation.

Thirty-day readmission rates for Medicare beneficiaries by race and site of care

CONTEXT

Understanding whether and why there are racial disparities in readmissions has implications for efforts to reduce readmissions.

OBJECTIVE

To determine whether black patients have higher odds of readmission than white patients and whether these disparities are related to where black patients receive care.

DESIGN

Using national Medicare data, we examined 30-day readmissions after hospitalization for acute myocardial infarction (MI), congestive heart failure (CHF), and pneumonia. We categorized hospitals in the top decile of proportion of black patients as minority-serving. We determined the odds of readmission for black patients compared with white patients at minority-serving vs non-minority-serving hospitals.

SETTING AND PARTICIPANTS

Medicare Provider Analysis Review files of more than 3.1 million Medicare fee-for-service recipients who were discharged from US hospitals in 2006-2008.

MAIN OUTCOME MEASURE

Risk-adjusted odds of 30-day readmission.

RESULTS

Overall, black patients had higher readmission rates than white patients (24.8% vs 22.6%, odds ratio [OR], 1.13; 95% confidence interval [CI], 1.11-1.14; P < .001); patients from minority-serving hospitals had higher readmission rates than those from non-minority-serving hospitals (25.5% vs 22.0%, OR, 1.23; 95% CI, 1.20-1.27; P < .001). Among patients with acute MI and using white patients from non-minority-serving hospitals as the reference group (readmission rate 20.9%), black patients from minority-serving hospitals had the highest readmission rate (26.4%; OR, 1.35; 95% CI, 1.28-1.42), while white patients from minority-serving hospitals had a 24.6% readmission rate (OR, 1.23; 95% CI, 1.18-1.29) and black patients from non-minority-serving hospitals had a 23.3% readmission rate (OR, 1.20; 95% CI, 1.16-1.23; P < .001 for each); patterns were similar for CHF and pneumonia. The results were unchanged after adjusting for hospital characteristics including markers of caring for poor patients.

CONCLUSION

Among elderly Medicare recipients, black patients were more likely to be readmitted after hospitalization for 3 common conditions, a gap that was related to both race and to the site where care was received.

Early effects of resident work-hour restrictions on patient safety: a systematic review and plea for improved studies

BACKGROUND

since the inception of the eighty-hour work week, work hour restrictions have incited considerable debate. Work hour policies were designed to prevent medical errors and to reduce patient morbidity and mortality. It is unclear whether work hour restrictions have been helpful in medicine in general and in orthopaedic surgery specifically. This systematic review of the literature was designed to determine the success of these restrictions in terms of patient mortality, medical errors, and complications.

METHODS

a systematic review of the literature was performed to determine if work hour rules have improved patient and systems-based outcomes and reduced physician errors as measured by mortality, medical errors, and complications. A random effects model was utilized to determine whether patient mortality rates were improved under the new rules.

RESULTS

the odds of patient death before implementation of the work hour rules were 1.12 (95% confidence interval, 1.07 to 1.17) times those after implementation. These differences were consistent across disciplines. The data concerning medical or surgical complications before and after the institution of the work hour rules were mixed. There was little information in these studies concerning direct medical errors. The odds of death in nonteaching cohorts were not significantly different from that in teaching cohorts.

CONCLUSIONS

there appears to be a decrease in mortality following the institution of work hour rules. The difference seen in teaching cohorts is not significantly different from that in nonteaching cohorts. It is unclear whether this difference would have been observed even without work hour restrictions. No study has shown a reduction in mortality for orthopaedic patients in teaching cohorts that was greater than that observed in nonteaching cohorts. Because of methodological concerns and the lack of current literature linking physician fatigue and physician underperformance with patient mortality, it is unclear whether the goals of the work hour reductions have been achieved. Furthermore, because of a lack of a so-called dose-response relationship between work hour reduction and patient mortality, it is uncertain whether further reductions would be beneficial.

LEVEL OF EVIDENCE

therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Evidence on the efficacy of inpatient spending on Medicare patients

CONTEXT

It is widely believed that a significant amount, perhaps as much as 20 to 30 percent, of health care spending in the United States is wasted, despite market forces such as managed care organizations and large, self-insured firms with a financial incentive to eliminate waste of this magnitude.

METHODS

This article uses Medicare claims data to study the association between inpatient spending and the thirty-day mortality of Medicare patients admitted to hospitals between 2001 and 2005 for surgery (general, orthopedic, vascular) and medical conditions (acute myocardial infarction [AMI], congestive heart failure [CHF], stroke, and gastrointestinal bleeding).

FINDINGS

Estimates from the analysis indicated that except for AMI patients, a 10 percent increase in inpatient spending was associated with a decrease of between 3.1 and 11.3 percent in thirty-day mortality, depending on the type of patient.

CONCLUSIONS

Although some spending may be inefficient, the results suggest that the amount of waste is less than conventionally believed, at least for inpatient care.

Returns to physician human capital: evidence from patients randomized to physician teams

Physicians play a major role in determining the cost and quality of healthcare, yet estimates of these effects can be confounded by patient sorting. This paper considers a natural experiment where nearly 30,000 patients were randomly assigned to clinical teams from one of two academic institutions. One institution is among the top medical schools in the U.S., while the other institution is ranked lower in the distribution. Patients treated by the two programs have similar observable characteristics and have access to a single set of facilities and ancillary staff. Those treated by physicians from the higher ranked institution have 10-25% less expensive stays than patients assigned to the lower ranked institution. Health outcomes are not related to the physician team assignment. Cost differences are most pronounced for serious conditions, and they largely stem from diagnostic-testing rates: the lower ranked program tends to order more tests and takes longer to order them.

Optimal Deployment of Trauma Personnel in the 80-Hour Work Week Era Based on Peak Times of Trauma Patient Arrival

In the 80-hour work week era, optimal distribution of the residency workforce is critical. Little data exist as to whether current hours of hospital staffing parallel trends in trauma activity. The purpose of this study was to determine peak periods of trauma volume, severity, need for operative intervention, and mortality and determine if there are differences in mortality based on time period of arrival. We performed a retrospective analysis of the 17,167 patients admitted to our academic Level I trauma center between 2000 and 2007. Each admission was plotted against time of arrival and trends noted. A significant increase in activity occurred between 1700 and 0100 hours. Compared with other shifts, this shift had a disproportionately higher number of patients with penetrating injuries, need for operative intervention, Injury Severity Score (ISS) greater than 15, and death ( P < 0.0001). After adjusting for ISS and penetrating trauma, arrival time was not predictive of mortality (OR 0.97, CI 0.87-1.08, P = 0.6). In conclusion, a peak in trauma activity occurs during an evening shift between 1700 and 0100 hours. In an era of optimizing resident training within the constraints of an 80-hour work week, strong consideration should be made for deploying personnel to match these findings.

Aggressive treatment style and surgical outcomes

OBJECTIVE

Aggressive treatment style, as defined by the Dartmouth Atlas of Health Care, has been implicated as an important factor contributing to excessively high medical expenditures. We aimed to determine the association between aggressive treatment style and surgical outcomes.

DATA SOURCES/STUDY SETTING

Medicare admissions to 3,065 hospitals for general, orthopedic, and vascular surgery between 2000 and 2005 (N = 4,558,215 unique patients).

STUDY DESIGN

A retrospective cohort analysis.

RESULTS

For elderly surgical patients, aggressive treatment style was not associated with significantly increased complications, but it was associated with significantly reduced odds of mortality and failure-to-rescue. The odds ratio for complications in hospitals at the 75th percentile of aggressive treatment style compared with those at the 25th percentile (a U.S.$10,000 difference) was 1.01 (1.00-1.02), p<.066; whereas the odds of mortality was 0.94 (0.93-0.95), p<.0001; and for failure-to-rescue it was 0.93 (0.92-0.94), p<.0001. Analyses that used alternative measures of aggressiveness--hospital days and ICU days--yielded similar results, as did analyses using only low-variation procedures.

CONCLUSIONS

Attempting to reduce aggressive care that is not cost effective is a laudable goal, but policy makers should be aware that there may be improved outcomes associated with patients undergoing surgery in hospitals with a more aggressive treatment style.

Impact of the 80-hour workweek on surgical case exposure within a general surgery residency program

OBJECTIVE

The objective of this statistical analysis was to test the hypothesis that implementation of the 80-hour workweek restrictions for General Surgery residents at Riverside Methodist Hospital after July 2003 decreased their operative experience relative to surgical residents trained at Riverside before these changes.

DESIGN, SETTING, PARTICIPANTS

Data were collected from the Accreditation Council for Graduate Medical Education national database and from Riverside Methodist Hospital's General Surgery Residency records for a sampling of academic years before and after the duty-hour changes in surgical education (July 1, 2003). Current procedural terminology (CPT) surgical procedure codes logged by postgraduate year (PGY) 5 General Surgery residents 15 years before and 5 years after implementation of the 80-hour workweek were compared. The outcome variables "total major cases" and "Chief cases" were compared between 2 study groups defined by the time intervals exclusively before July 2003 ("pre") and inclusively after July 2003 ("post"). Hospital general surgical case volume for the study intervals was also tallied. Statistical analyses included 1- and 2-sided t-tests, nonparametric tests, and t-tests on a 3-parameter logarithmic transformation of the data.

RESULTS

Despite an upward trend in total general surgery cases (slope = 25/year, p = 0.005), there was a statistically significant decrease in the operative experience for categorical surgical residents following the 80-hour workweek restrictions. The mean (SD) number of major cases performed by "pre"-restriction residents during their training significantly exceeded that of their "post" cohorts (1395 [326] vs 953 [134], p < 0.001). The training for PGY 5 residents was similarly influenced (345 [81] vs 237 [55], p < .0001).

CONCLUSIONS

Despite an increase in the total number of major operative cases available, the volume of cases performed by residents has decreased after implementation of the Accreditation Council for Graduate Medical Education (ACGME) work-hour restrictions. Our data suggest that the impact of the 80-hour workweek has had a detrimental effect on the conventional resident training experience.

To leave or to lie? Are concerns about a shift-work mentality and eroding professionalism as a result of duty-hour rules justified?

CONTEXT

Medical educators worry that the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty-hour rules (DHR) have encouraged a "shift work" mentality among residents and eroded their professionalism by forcing them either to abandon patients when they have worked for eighty hours or lie about the number of hours worked. In this qualitative study, we explore how medical and surgical residents perceive and respond to DHR by examining the "local" organizational culture in which their work is embedded.

METHODS

In 2008, we conducted three months of ethnographic observation of internal medicine and general surgery residents as they went about their everyday work in two hospitals affiliated with the same training program, as well as in-depth interviews with seventeen residents. Field notes and interview transcripts were analyzed for perceptions and behaviors in regard to beginning and leaving work, reporting duty hours, and expressing opinions about DHR.

FINDINGS

The respondents did not exhibit a "shift work" mentality in relation to their work. We found that residents: (1) occasionally stay in the hospital in order to complete patient care tasks even when, according to the clock, they are required to leave, because the organizational culture stresses performing work thoroughly, (2) do not blindly embrace noncompliance with DHR but are thoughtful about the tradeoffs inherent in the regulations, and (3) express nuanced and complex reasons for erroneously reporting duty hours, suggesting that reporting hours worked is not a simple issue of lying or truth telling.

CONCLUSIONS

Concerns about DHR and the erosion of resident professionalism resulting from the development of a "shift work" mentality likely have been overstated. Instead, the influence of DHR on professionalism is more complex than the conventional wisdom suggests and requires additional assessment.

Trends in the inpatient quality indicators: the Veterans Health Administration experience

BACKGROUND

The Agency for Healthcare Research and Quality Inpatient Quality Indicators (IQIs), which include in-hospital mortality and utilization rates, have received little attention in the Veterans Health Administration (VA), despite extensive private sector use for quality improvement.

OBJECTIVES

We examined the following: the feasibility of applying the IQIs to VA data; temporal trends in national VA IQI rates; temporal and regional IQI trends in geographic areas defined by Veterans Integrated Service Networks' (VISNs); and VA versus non-VA (Nationwide Inpatient Sample) temporal trends.

METHODS

We derived VA- and VISN-level IQI observed rates, risk-adjusted rates, and observed to expected ratios (O/Es), using VA inpatient data (2004-2007). We examined the trends in VA- and VISN-level rates using weighted linear regression, variation in VISN-level O/Es, and compared VA to non-VA trends.

RESULTS

VA in-hospital mortality rates from selected medical conditions (stroke, hip fracture, pneumonia) decreased significantly over time; procedure-related mortality rates were unchanged. Laparoscopic cholecystectomy rates increased significantly. A few VISNs were consistently high or low outliers for the medical-related mortality IQIs. Within any given year, utilization indicators, especially cardiac catheterization and cholecystectomy, showed the most inter-VISN variation. Compared with the non-VA, VA medical-related mortality rates for the above-mentioned conditions decreased more rapidly, whereas laparascopic cholecystectomy rates rose more steeply.

CONCLUSIONS

The IQIs are easily applied to VA administrative data. They can be useful to tracks rate trends over time, reveal variation between sites, and for trend comparisons with other healthcare systems. By identifying potential quality events related to mortality and utilization, they may complement existing VA quality improvement initiatives.

Impact of timing of birth and resident duty-hour restrictions on outcomes for small preterm infants

OBJECTIVE

The goal was to examine the impact of birth at night, on the weekend, and during July or August (the first months of the academic year) and the impact of resident duty-hour restrictions on mortality and morbidity rates for very low birth weight infants.

METHODS

Outcomes were analyzed for 11,137 infants with birth weights of 501 to 1250 g who were enrolled in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network registry in 2001-2005. Approximately one-half were born before the introduction of resident duty-hour restrictions in 2003. Follow-up assessments at 18 to 22 months were completed for 4508 infants. Mortality rate, short-term morbidities, and neurodevelopmental outcome were examined with respect to the timing of birth.

RESULTS

There was no effect of the timing of birth on mortality rate and no impact on the risks of short-term morbidities except that the risk of retinopathy of prematurity (stage > or =2) was higher after the introduction of duty-hour restrictions and the risk of retinopathy of prematurity requiring operative treatment was lower for infants born during the late night than during the day. There was no impact of the timing of birth on neurodevelopmental outcome except that the risk of hearing impairment or death was slightly lower among infants born in July or August.

CONCLUSION

In this network, the timing of birth had little effect on the risks of death and morbidity for very low birth weight infants, which suggests that staffing patterns were adequate to provide consistent care.

Longitudinal research databases in medical education: facilitating the study of educational outcomes over time and across institutions

Many education research questions cannot be answered using participants from one institution or short periods of follow-up. In response to societal demands for accountability and evidence of effectiveness, new models of research must be developed to study the outcomes of educational activities. Following the 2007 Millennium Conference on Medical Education Research, organizers assigned a task force to explore the use of longitudinal databases in education research. This article summarizes the task force's findings. Similar to the Framingham studies in clinical medicine, longitudinal databases assemble prospectively collected information to retrospectively answer questions of interest. Many studies using such databases have been published. The task force identified three general approaches to database-type research. First, institutions can obtain identified information from existing sources, link it with school-specific information and other identified information, deidentify it, and merge it with similar information from other collaborating schools. Second, researchers can obtain from existing sources deidentified information on large samples and explore associations within this dataset. Third, investigators can design and implement databases to prospectively collect trainee information over time and across multiple institutions for the purpose of education research. Although costly, such comprehensive, purpose-built databases would ensure the availability of information needed to answer a variety of medical education research questions. Millennium Conference participants believed that stakeholders should explore the funding and development of such prospective databases. In the meantime, education researchers should use existing sources of individualized learner data to better understand how to develop competent, compassionate clinicians.

Effectiveness of a course designed to teach handoffs to medical students

INTRODUCTION

Handoffs of patient care are increasingly common and are known to contribute to medical errors. A significant number, if not the large majority, of first-year Internal Medicine residents have not received formal education pertaining to handoffs during medical school.

AIM

To develop a program designed to teach handoffs to medical students entering their fourth year of training.

SETTING

University of Colorado Denver School of Medicine.

PROGRAM DESCRIPTION

Our Handoff Selective was first offered in April 2007 as part of a 2-week Integrated Clinician's Course conducted once yearly between the third and fourth years of medical school. The Selective consisted of a didactic session in which communication theory and elements were discussed and a practicum in which students used faculty-developed case scenarios to practice both giving and receiving handoffs.

PROGRAM EVALUATION

Sixty (the maximum number of spots available) out of 150 students participated in the course, although many more students chose the course than spots available. Prior to taking the Selective, medical students' confidence in performing handoffs was poor, but it improved after the course (P < 0.001); 92% of students felt the Handoff Selective was "useful" or "extremely useful." While both components of the course were thought to be useful to the large majority of students, the practicum portion was thought to be more useful (P < 0.001).

DISCUSSION

Formal education on handoffs is well received by medical students and improves their self-perceived understanding and performance of handoffs.

Relationships of the location and content of rounds to specialty, institution, patient-census, and team size

Objective

Existing observational data describing rounds in teaching hospitals are 15 years old, predate duty-hour regulations, are limited to one institution, and do not include pediatrics. We sought to evaluate the effect of medical specialty, institution, patient-census, and team participants upon time at the bedside and education occurring on rounds.

Methods and Participants

Between December of 2007 and October of 2008 we performed 51 observations at Lucile Packard Children's Hospital, Seattle Children's Hospital, Stanford University Hospital, and the University of Washington Medical Center of 35 attending physicians. We recorded minutes spent on rounds in three location and seven activity categories, members of the care team, and patient-census.

Results

Results presented are means. Pediatric rounds had more participants (8.2 vs. 4.1 physicians, p<.001; 11.9 vs. 2.4 non-physicians, p<.001) who spent more minutes in hallways (96.9 min vs. 35.2 min, p<.001), fewer minutes at the bedside (14.6 vs. 38.2 min, p = .01) than internal medicine rounds. Multivariate regression modeling revealed that minutes at the bedside per patient was negatively associated with pediatrics (−2.77 adjusted bedside minutes; 95% CI −4.61 to −0.93; p<.001) but positively associated with the number of non-physician participants (0.12 adjusted bedside minutes per non physician participant; 95% CI 0.07 to 0.17; p = <.001). Education minutes on rounds was positively associated with the presence of an attending physician (2.70 adjusted education minutes; 95% CI 1.27 to 4.12; p<.001) and with one institution (1.39 adjusted education minutes; 95% CI 0.26 to 2.53; p = .02).

Conclusions

Pediatricians spent less time at the bedside on rounds than internal medicine physicians due to reasons other than patient-census or the number of participants in rounds. Compared to historical data, internal medicine rounds were spent more at the bedside engaged in patient care and communication, and less upon educational activities.

Evaluation of a redesign initiative in an internal-medicine residency

BACKGROUND

Several organizations have advocated for comprehensive redesign of graduate medical training, but the effect that residency redesign will have on measures of patient satisfaction, resident and intern (trainee) satisfaction, and patient care is unknown.

METHODS

We designed an experimental inpatient-medicine service with reduced resident workload comprising two teams, with each team consisting of two attending physicians, two residents, and three interns. Attending physicians, selected for their teaching prowess, supervised the teams throughout the workday and during bedside team-teaching rounds. This experimental model was compared with a control model comprising two teams, with each consisting of one resident and two interns, plus multiple supervising attending physicians who volunteered to participate. Patients were alternately assigned to the experimental teams and the control teams, subject to limits on the number of patients interns are allowed to admit.

RESULTS

Over a 12-month period, 1892 patients were assigned to the experimental teams and 2096 to the control teams; the average census per intern was 3.5 and 6.6 patients, respectively. Overall satisfaction was significantly higher among trainees on the experimental teams than among those on the control teams (78% and 55%, respectively; P=0.002). As compared with the control teams, the experimental teams were not associated with a higher average length of patient stay or readmission rate; adherence to standards for quality of inpatient care was similar in both groups of teams. Interns on the experimental teams spent more time in learning and teaching activities than did interns on the control teams (learning: 20% of total time vs. 10%, P=0.01; teaching: 8% of total time vs. 2%, P=0.006).

CONCLUSIONS

As compared with a traditional inpatient care model, an experimental model characterized by reduced trainee workload and increased participation of attending physicians was associated with higher trainee satisfaction and increased time for educational activities.

The availability of clinical protocols in US teaching intensive care units

PURPOSE

Clinical protocols to standardize care may improve patient outcomes but worsen trainee education. Our objective was to determine the availability of clinical protocols in teaching medical intensive care units (ICUs).

MATERIALS AND METHODS

We administered an electronic questionnaire regarding protocol availability in 5 specific clinical areas. All directors of adult medical ICUs in US teaching hospitals were eligible to participate.

RESULTS

The response rate was 70%. Eighty-six percent of ICU directors reported availability of protocols for ventilation liberation, 73% for sedation, 62% for sepsis resuscitation, 60% for lung-protective ventilation, and 48% for life support withdrawal. Ventilation liberation protocols are most often started and driven by respiratory therapists (40% and 90%); sedation started by residents (41%) and driven by nurses (95%); sepsis resuscitation started and driven by residents (49% and 46%); lung-protective ventilation started by attending physicians (39%) and driven by respiratory therapists (67%); and life support withdrawal started by attending physicians (93%) and driven by nurses (47%).

CONCLUSIONS

There is wide variation in clinical protocol availability among teaching hospitals. Further study of the effect of protocols on education is needed.

Sleep deprivation, physician performance, and patient safety

Long work hours, overnight call duty, and rotating shifts are implicit features of hospital medical practice. Rigorous schedules have been deemed necessary to fulfill the professional obligation of patient beneficence, to optimize trainee learning, and to respond to economic realities. However, the resultant disruption and restriction of physicians' sleep produce demonstrable neurobehavioral impairments that may threaten other fundamental professional mandates, such as that of primum non nocere ("first, do no harm"). This article provides a basic overview of sleep/wake regulatory processes, examines the impact of physician schedules on sleep/wake homeostasis, summarizes the laboratory-demonstrated effects of sleep loss on humans, highlights recent literature on the personal and professional effects of sleep loss on physicians, and, finally, discusses the specific countermeasure of work-hour limits applicable to resident physicians but not attending physicians.

Resident fatigue: is there a patient safety issue?

BACKGROUND

In 2003, the 80-hour resident workweek was implemented in response to concerns that fatigued residents led to substandard patient care. Existing evidence links fatigue with impaired human performance; however, this has not consistently translated into similar impairment in the clinical arena. There is now discussion of additional work hour restrictions. Sentinel events are major medical mistakes tracked by the Joint Commission (JC). Root cause analysis of these events can determine if resident fatigue plays a role in medical errors.

METHODS

A retrospective review of sentinel events in our health system from January 2004 to July 2008 was performed. A root cause analysis for each event was performed. The JC national databank of sentinel events from 1995 to 2007 was also reviewed. In addition, a literature search was performed.

RESULTS

At our institution, 110 sentinel events were identified. Root cause analysis showed no evidence of resident fatigue involvement. The JC's national databank includes 4,817 sentinel events. No documented evidence of resident fatigue was found.

CONCLUSIONS

Our data did not provide any evidence to support the contention that resident fatigue leads to increased medical errors. Clinical data supporting a direct relationship between resident fatigue and compromised patient safety must be demonstrated before further work hour restrictions are made. More research must be done. The JC should consider monitoring sentinel events for resident fatigue.

Prolonged hospital stay and the resident duty hour rules of 2003

BACKGROUND

Resident duty hour reforms of 2003 had the potential to create a major impact on the delivery of inpatient care.

OBJECTIVE

We examine whether the reforms influenced the probability of a patient experiencing a prolonged hospital length of stay (PLOS), a measure reflecting either inefficiency of care or the development of complications that may slow the rate of discharge.

RESEARCH DESIGN

Conditional logistic models to compare PLOS in more versus less teaching-intensive hospitals before and after the reform, adjusting for patient comorbidities, common time trends, and hospital site.

SUBJECTS

Medicare (N = 6,059,015) and Veterans Affairs (VA) (N = 210,276) patients admitted for medical conditions (acute myocardial infarction, heart failure, stroke, or gastrointestinal bleeding) or surgical procedures (general, orthopedic, and vascular) from July 2000 to June 2005.

MEASURES

Prolonged length of stay.

RESULTS

Modeling all medical conditions together, the odds of prolonged stay in the first year post reform at more versus less teaching intensive hospitals was 1.01 (95% CI: 0.97-1.05) for Medicare and 1.07 (0.94-1.20) for the VA. Results were similarly negative in the second year post reform. For "combined surgery" the post year 1 odds ratios were 1.04 (0.98-1.09) and 0.94 (0.78-1.14) for Medicare and the VA respectively, and similarly unchanged in post year 2. Isolated increases in the probability of prolonged stay did occur for some vascular surgery procedures.

CONCLUSIONS

Hospitals generally found ways to cope with duty hour reform without increasing the prevalence of prolonged hospital stays, a marker of either inefficient care or complications.

Impact of proposed institute of medicine duty hours: family medicine residency directors' perspective

PURPOSE

To examine the opinions of family medicine residency program directors concerning the potential impact of the Institute of Medicine (IOM) resident duty hour recommendations on patient care and resident education.

METHODS

A survey was mailed to 455 family medicine residency program directors. Data were summarized and analyzed using Epi Info statistical software. Significance was set at the P < .01 level.

RESULTS

A total of 265 surveys were completed (60.9% response rate). A majority of family medicine residency program directors disagreed or strongly disagreed that the recent IOM duty hour recommendations will, in general, result in improved patient safety and resident education. Further, a majority of respondents disagreed or strongly disagreed that the proposed IOM rules would result in residents becoming more compassionate, more effective family physicians.

CONCLUSION

A majority of family medicine residency program directors believe that the proposed IOM duty hour recommendations would have a primarily detrimental effect on both patient care and resident education.

Testing the association between patient safety indicators and hospital structural characteristics in VA and nonfederal hospitals

This study tested the association between hospital structural characteristics-teaching status, bedsize, and nurse staffing-and potentially preventable adverse events. The authors calculated 14 Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) and a PSI composite, using discharge databases from VA and nonfederal hospitals. This study compared the likelihood of PSI events in hospitals, controlling for structural and other characteristics, including patients' case-mix. Additional controls were employed to account for differences in VA versus nonfederal patients and data. The study found some associations, most notably a positive (unfavorable) association between status as a major teaching hospital and six PSIs. However, for most PSIs, the authors found no association between the structural characteristics tested and likelihood of PSI events. The study's findings extend previous research showing a lack of consistent relationship between structural characteristics and patient safety. However, the results also suggest continued need for examination of the relationship between teaching status and potentially preventable adverse events.