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

Socioeconomic, Patient, and Hospital Determinants for the Utilization of Peripheral Nerve Blocks in Total Joint Arthroplasty

BACKGROUND

While peripheral nerve blocks (PNBs) are associated with various improved outcomes in patients undergoing total hip or knee arthroplasty (THA/TKA), disparities in PNB utilization have been reported. This study assessed the importance of socioeconomic, demographic, clinical, and hospital determinants in explaining PNB utilization using the population-attributable risk (PAR) framework. Subsequently, we examined the association between PNB use and 3 secondary outcomes: Centers for Medicare and Medicaid Services (CMS)-defined complications, 90-day all-cause readmissions, and length of stay >3 days.

METHODS

This retrospective cohort study included 52,926 THA and 94,795 TKA cases from the 5% 2012 to 2021 Medicare dataset. Mixed-effects logistic regression models measured the association between study variables and PNB utilization. Variables of interest were demographic (age, sex), clinical (outpatient setting, diagnosis, prior hospitalizations in the year before surgery, Deyo-Charlson index, obesity, (non)-opioid abuse, smoking), socioeconomic (neighborhood Social Deprivation Index, race and ethnicity) and hospital variables (beds, ownership, region, rurality, resident-to-bed ratio). The model was used for the calculation of variable-specific and variable category-specific PARs (presented in percentages), reflecting the proportion of variation in PNB use explained after eliminating variables (or groups of variables) of interest with all other factors held constant. Subsequently, regression models measured the association between PNB use and secondary outcomes. Associations are presented with odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

Socioeconomic and demographic variables accounted for only a small proportion of variation in PNB use (up to 3% and 7%, respectively). Clinical (THA: 46%; TKA: 34%) and hospital variables (THA: 31%; TKA: 22%) were the primary drivers of variation. In THA, variation by clinical variables was driven by increased PNB use in the inpatient setting (OR, 1.28 [95% CI, 1.07-1.53]) and decreased use in patients with ≥2 prior hospitalizations (OR, 0.72 [95% CI, 0.57-0.90]). Moreover, nonosteoarthritis diagnoses associated with reduced PNB utilization in THA (OR, 0.64 [95% CI, 0.58-0.72]) and TKA (OR, 0.35 [95% CI, 0.34-0.37]).In TKA, PNB use was subsequently associated with fewer complications (OR, 0.82 [95% CI, 0.75-0.90]) and less prolonged length of stay (OR, 0.90 [95% CI, 0.86-0.95]); no association was found for readmissions (OR, 0.98 [95% CI, 0.93-1.03]). In THA, associations did not reach statistical significance.

CONCLUSIONS

Among THA and TKA patients on Medicare, large variations exist in the utilization of PNBs by clinical and hospital variables, while demographic and socioeconomic variables played a limited role. Given the consistent benefits of PNBs, particularly in TKA patients, more standardized provision may be warranted to mitigate the observed variation.

Mortality Among Older Medical Patients at Flagship Hospitals and Their Affiliates

BACKGROUND

We define a "flagship hospital" as the largest academic hospital within a hospital referral region and a "flagship system" as a system that contains a flagship hospital and its affiliates. It is not known if patients admitted to an affiliate hospital, and not to its main flagship hospital, have better outcomes than those admitted to a hospital outside the flagship system but within the same hospital referral region.

OBJECTIVE

To compare mortality at flagship hospitals and their affiliates to matched control patients not in the flagship system but within the same hospital referral region.

DESIGN

A matched cohort study PARTICIPANTS: The study used hospitalizations for common medical conditions between 2018-2019 among older patients age ≥ 66 years. We analyzed 118,321 matched pairs of Medicare patients admitted with pneumonia (N=57,775), heart failure (N=42,531), or acute myocardial infarction (N=18,015) in 35 flagship hospitals, 124 affiliates, and 793 control hospitals.

MAIN MEASURES

30-day (primary) and 90-day (secondary) all-cause mortality.

KEY RESULTS

30-day mortality was lower among patients in flagship systems versus control hospitals that are not part of the flagship system but within the same hospital referral region (difference= -0.62%, 95% CI [-0.88%, -0.37%], P<0.001). This difference was smaller in affiliates versus controls (-0.43%, [-0.75%, -0.11%], P=0.008) than in flagship hospitals versus controls (-1.02%, [-1.46%, -0.58%], P<0.001; difference-in-difference -0.59%, [-1.13%, -0.05%], P=0.033). Similar results were found for 90-day mortality.

LIMITATIONS

The study used claims-based data.

CONCLUSIONS

In aggregate, within a hospital referral region, patients treated at the flagship hospital, at affiliates of the flagship hospital, and in the flagship system as a whole, all had lower mortality rates than matched controls outside the flagship system. However, the mortality advantage was larger for flagship hospitals than for their affiliates.

Public opinion of resident physician work hours in 2022

OBJECTIVE

The purpose of this study was to characterize public awareness and opinion regarding resident physician work hours in the United States.

METHODS

We conducted a nationally representative cross-sectional survey among adults in the United States. Demographic quota-based sampling was conducted by Qualtrics to match 2020 United States Census estimates of age, sex, race, and ethnicity. Descriptive statistics are presented. Hypothesis testing was conducted to identify characteristics associated with agreement with current resident physician work-hour policies.

RESULTS

4763 adults in the United States participated in the study. 97.1% of the public believes that resident physicians should not work 24-hour shifts and 95.6% believe the current 80 hours resident work week is too long. 66.4% of the participants reported that the maximum shift duration should be 12 consecutive hours or fewer, including 22.9% who recommended a maximum shift length of 8 hours. Similarly, 66.4% reported that maximum weekly work hours should be 59 or fewer, including 24.9% who recommended a maximum of 40 weekly work hours.

CONCLUSIONS

Nearly all US adults disagree with current work-hour policies for resident physicians. Public opinion supports limiting shifts to no more than 12 consecutive hours and weekly work to no more than 60 hours, which is in sharp contrast to current regulations that permit of 28 hours shifts and 80 hours of work per week.

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.

The Association of Experienced Long Working Hours and Depression, Anxiety, and Suicidal Ideation Among Chinese Medical Residents During the COVID-19 Pandemic: A Multi-Center Cross-Sectional Study

Background

Long working hours are common among medical residents and may increase the risk of mental disorders. We aimed to investigate the association between experienced long working hours and depression, anxiety, and suicidal ideation among Chinese medical residents during the COVID-19 pandemic.

Methods

This study was conducted in September 2022; 1343 residents from three center in Northeastern China were included in the final analysis (effective response rate: 87.61%). The data were collected from participants via online self-administered questionnaires. Depression and anxiety were measured by the Patient Health Questionnaire (PHQ-9) and the General Anxiety Disorder (GAD-7) scale, respectively. Adjusted odds ratios and 95% confidence intervals were determined after adjusting for potential confounders by binary unconditional logistic regression.

Results

The effective response rate was 87.61%. Among the 1343 participants, 12.88% (173), 9.90% (133), and 9.68% (130) had experienced major depression, major anxiety, and suicidal ideation, respectively. We found that longer weekly worktime increased the risk of major depression, particularly in those who worked for more than 60 hours per week (≥ 61 hours vs ≤ 40 hours, OR=1.87, P for trend = 0.003). However, this trend was not observed for either major anxiety or suicidal ideation (P for trend > 0.05 for both).

Conclusion

This study revealed that there was a considerable incidence of poor mental health among medical residents; furthermore, the longer weekly worktime was associated with a higher risk of major depression, especially for those who worked more than 60 hours per week, but this association was not observed in either major anxiety or suicidal ideation. This may help policymakers to develop targeted interventions.

Pulling Back from the Brink: A Multi-Pronged Approach to Address General Surgery Resident Clinical Work Hour Adherence

PURPOSE

The conflict between prioritizing education for surgical trainees, promoting trainee wellness, and maintaining optimal patient care has remained challenging since the introduction of the Accreditation Council for Graduate Medical Education (ACGME) work hour restrictions in 2003. There is still a dearth of research examining which interventions successfully enable duty hour adherence. This study assessed the impact of a combination of strategic interventions on improving clinical work hour adherence.

METHODS

Monthly clinical work hour submission rates were assessed for all general surgery residents at a single university-based residency program over a 3-year period (2018-2021). Interventions targeted 3 domains and were implemented between academic years 2018 to 2019 (control) and 2020 to 2021 (intervention): 1) improving the accuracy and transparency of work hour reporting, 2) facilitating more timely interventions, and 3) structural scheduling changes. All 80-hour work week and continuous work hour violations were assessed. Findings were also compared to the corresponding ACGME Resident Survey results.

RESULTS

There was no significant difference in the rate of monthly work hour submissions pre- and postintervention (78% vs 75%, p = 0.057). However, the number of total reported monthly violations decreased significantly (mean 13.8 vs 2.4, p < 0.01), including decreases in both 80-hour work week and continuous work hour violations (mean 4.7 vs 1.6, p < 0.001 and 9.1 vs 0.8, p < 0.001, respectively). Reported compliance also increased on the annual ACGME resident surveys, where 61% vs 95% of residents felt they were compliant with the 80-hour work week and 71% vs 95% felt they were compliant with the continuous work hours (2018-19 vs 2020-21).

CONCLUSION

Innovative strategies addressing schedule changes, the culture of work hour reporting, and early intervention significantly decreased the number of duty hour violations at our institution. Reported resident compliance also improved based on ACGME Resident Survey data. These data may inform similar multifaceted approaches at other institutions to improve overall work hour adherence.

Mandating Limits on Workload, Duty, and Speed in Radiology

Research has not yet quantified the effects of workload or duty hours on the accuracy of radiologists. With the exception of a brief reduction in imaging studies during the 2020 peak of the COVID-19 pandemic, the workload of radiologists in the United States has seen relentless growth in recent years. One concern is that this increased demand could lead to reduced accuracy. Behavioral studies in species ranging from insects to humans have shown that decision speed is inversely correlated to decision accuracy. A potential solution is to institute workload and duty limits to optimize radiologist performance and patient safety. The concern, however, is that any prescribed mandated limits would be arbitrary and thus no more advantageous than allowing radiologists to self-regulate. Specific studies have been proposed to determine whether limits reduce error, and if so, to provide a principled basis for such limits. This could determine the precise susceptibility of individual radiologists to medical error as a function of speed during image viewing, the maximum number of studies that could be read during a work shift, and the appropriate shift duration as a function of time of day. Before principled recommendations for restrictions are made, however, it is important to understand how radiologists function both optimally and at the margins of adequate performance. This study examines the relationship between interpretation speed and error rates in radiology, the potential influence of artificial intelligence on reading speed and error rates, and the possible outcomes of imposed limits on both caseload and duty hours. This review concludes that the scientific evidence needed to make meaningful rules is lacking and notes that regulating workloads without scientific principles can be more harmful than not regulating at all.

The impact of trainees' working hour regulations on outcome in CABG and valve surgery in the State of New York

BACKGROUND AND AIM

In 2011, the Accreditation Council for Graduate Medical Education (ACGME) restricted the first-year residents' duty-hour to less than 16-hour shifts, decreased the maximum shift duration for senior residents, and increased minimum time off after on-call duties. Whether these changes may have impacted the outcomes in cardiac surgery remains unclear.

METHODS

We performed a difference-in-difference analysis of the New York State Cardiac Surgery Reporting System data in 2004-2006 (before the duty-hour policies change) and 2014-2016 (after the change). We evaluated differences in 30-day risk-adjusted mortality rates (RAMR) in coronary artery bypass grafting (CABG) and valve surgeries, stratifying data by hospital type: teaching hospitals (TH) versus nonteaching hospitals (NTH). NTH served as the control not affected by the duty-hour policies.

RESULTS

(1) The overall surgical volume for CABG surgery has decreased over time (37,645-24,991), while the volume for valve surgery remained similar (20,969-21,532); (2) TH had better short-term outcomes for CABG procedures during 2014-2016 (median RAMR: 1.01% vs. 1.55% in TH vs. NTH, respectively; p = .025) as well as for valve procedures during both 2004-2006 (5.16% vs. 7.49%, p = .020) and 2014-2016 (2.59% vs. 4.09%, p = .033); (3) at difference-in-difference analysis, trainees' duty-hour regulations were not associated with worsening short-term outcomes in both CABG (p = .296) and valve (p = .651) procedures performed in TH.

CONCLUSION

The introduction of the 2011 trainees' duty-hour regulations was not associated with worse short-term outcomes for CABG and valve surgery performed in the State of NY by TH.

Quality Improvement and Patient Safety Education in Internal Medicine Residency Training Program: An Exploratory Qualitative Study

BACKGROUND

Quality improvement and patient safety (QIPS) are a global health priority. Accordingly, QIPS education in medical education became mandatory. Despite that, information about QIPS education in postgraduate training in Saudi Arabia is limited. This study aimed to explore the educational aspects of QIPS in the internal medicine residency training program at King Abdulaziz Hospital in Al Ahsa, Saudi Arabia.

METHODS

This was a qualitative study employing the constructivist grounded theory approach. The sample size was determined using the theoretical saturation point, and we utilized a purposeful sampling technique. A semi-structured interview was used for data collection and was conducted between September 6 and October 20, 2020.

RESULTS

Twenty-two internal medicine trainee residents were required to serve the study purpose. The emerged themes were organized under awareness, education, barriers and opportunities and improvement priorities. Awareness of participants about the QIPS concept, importance, and value of education was found. The participants did not recognize specific dedicated QIPS education components under the structured training program. However, they recognized participation in patient safety-oriented activities but not in quality improvement activities. Consultants' observations and written exams were perceived as the assessment tools. Barriers including time limitation and opportunities including participation in quality improvement projects were identified. Participants suggested making QIPS education mandatory under the training program as an improvement priority.

CONCLUSION

This study highlighted the awareness of internal medicine residents of the QIPS concept, importance, and value of QIPS education. However, we found crucial gaps related to education including lack of a dedicated QIPS component under the training program. There is a need for multicenter studies to measure the magnitude of our findings for improvement of QIPS education in residency training in Saudi Arabia. This is the first study about QIPS education in residency training in Saudi Arabia up to our best knowledge.

Trends in Coded Indications for Percutaneous Coronary Interventions in Medicare and the Veterans Affairs After Implementation of Hospital-Level Reporting of Appropriate Use Criteria

BACKGROUND

In 2009, the American College of Cardiology and American Heart Association published Appropriate Use Criteria for Coronary Revascularization (AUC) to aid patient selection for percutaneous coronary intervention (PCI). The subsequent decline in inappropriate PCIs was interpreted as a success of AUC. However, there are concerns clinicians reclassify nonacute PCIs to acute indications to fulfill AUC.

METHODS

A longitudinal, observational difference-in-differences analysis was performed using administrative claims from US Department of Veterans Affairs (VA) beneficiaries coenrolled in Medicare and from a national random sample of Medicare beneficiaries, undergoing PCI from September 30, 2009, to December 31, 2013. Non-VA hospitals participating in the American College of Cardiology CathPCI registry began receiving AUC reports in 2011, while VA hospitals did not receive reports, serving as quasiexperimental and control cohorts, respectively. We measured the proportion of PCIs coded for acute myocardial infarction, unstable angina, and nonacute coronary syndrome indications by quarter.

RESULTS

There were 87 464 and 30 251 PCIs performed in the Medicare and VA cohorts, respectively. In Medicare, proportion of PCIs coded for acute myocardial infarction and unstable angina changed from 31.9% and 12.6% in quarter 4 2009 to 41.0% and 10.5% in quarter 4 2013, an associated 2.00% (95% CI, 1.56%-2.44%; P<0.001) increase per year in PCIs coded for acute coronary syndrome indications. In the VA, proportion of PCIs coded for acute myocardial infarction and unstable angina changed from 26.5% and 15.7% in quarter 4 2009 to 34.3% and 12.3% in quarter 4 2013, an associated 1.20% (95% CI, 0.56%-1.88%; P=0.001) increase per year in PCIs coded for acute coronary syndrome indications. Difference-in-differences modeling found no statistically significant change in PCI coded for acute indications between Medicare and VA, pre- and post-AUC reporting.

CONCLUSIONS

After introduction of AUC assessments and reporting, we observed comparable increases in coding for acute myocardial infarction and corresponding decreases in coding for unstable angina and nonacute coronary syndrome indications among national cohorts of Medicare and VA enrollees. The provision of appropriate use reporting did not appear to have a substantial impact on the proportion of PCIs coded for acute indications during this study period.

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.

Does Increased Schedule Flexibility Lead to Change? A National Survey of Program Directors on 2017 Work Hours Requirements

BACKGROUND

The learning and working environment for resident physicians shifted dramatically over the past two decades, with increased focus on work hours, resident wellness, and patient safety. Following two multi-center randomized trials comparing 16-h work limits for PGY-1 trainees to more flexible rules, the ACGME implemented new flexible work hours standards in 2017.

OBJECTIVE

We sought to determine program directors' (PDs) support for the work hour changes and programmatic response.

DESIGN

In 2017, US Internal Medicine PDs were surveyed about their degree of support for extension of PGY-1 work hour limits, whether they adopted the new maximum continuous work hours permitted, and reasons for their decisions.

KEY RESULTS

The response rate was 70% (266/379). Fifty-seven percent of PDs (n = 151) somewhat/strongly support the new work hour rules for PGY-1 residents, while only 25% of programs (N = 66) introduced work periods greater than 16-h on any rotation. Higher rates of adopting change were seen in PDs who strongly/somewhat supported the change (56/151 [37%], P < 0.001), had tenure of 6+ years (33/93 [35%], P = 0.005), were of non-general internal medicine subspecialty (30/80 [38%], P = 0.003), at university-based programs (35/101 [35%], P = 0.009), and with increasing number of approved positions (< 38, 10/63 [16%]; 38-58, 13/69 [19%]; 59-100, 15/64 [23%]; > 100, 28/68 [41%], P = 0.005). Areas with the greatest influence for PDs not extending work hours were the 16-h rule working well (56%) and risk to PGY1 well-being (47%).

CONCLUSIONS

Although the majority of PDs support the ACGME 2017 work hours rules, only 25% of programs made immediate changes to extend hours. These data reveal that complex, often competing, forces influence PDs' decisions to change trainee schedules.

Case for hospital nurse-to-patient ratio legislation in Queensland, Australia, hospitals: an observational study

OBJECTIVES

To determine whether there was variation in nurse staffing across hospitals in Queensland prior to implementation of nurse-to-patient ratio legislation targeting medical-surgical wards, and if so, the extent to which nurse staffing variation was associated with poor outcomes for patients and nurses.

DESIGN

Analysis of cross-sectional data derived from nurse surveys linked with admitted patient outcomes data.

SETTING

Public hospitals in Queensland.

PARTICIPANTS

4372 medical-surgical nurses and 146 456 patients in 68 public hospitals.

MAIN OUTCOME MEASURES

30-day mortality, quality and safety indicators, nurse outcomes including emotional exhaustion and job dissatisfaction.

RESULTS

Medical-surgical nurse-to-patient ratios before implementation of ratio legislation varied significantly across hospitals (mean 5.52 patients per nurse; SD=2.03). After accounting for patient characteristics and hospital size, each additional patient per nurse was associated with 12% higher odds of 30-day mortality (OR=1.12; 95% CI 1.01 to 1.26). Each additional patient per nurse was associated with poorer outcomes for nurses including 15% higher odds of emotional exhaustion (OR=1.15; 95% CI 1.07 to 1.23) and 14% higher odds of job dissatisfaction (OR=1.14; 95% CI 1.02 to 1.28), as well as higher odds of concerns about quality of care (OR=1.12; 95% CI 1.01 to 1.25) and patient safety (OR=1.32; 95% CI 1.11 to 1.57).

CONCLUSIONS

Before ratios were implemented, nurse staffing varied considerably across Queensland hospital medical-surgical wards and higher nurse workloads were associated with patient mortality, low quality of care, nurse emotional exhaustion and job dissatisfaction. The considerable variation across hospitals and the link with outcomes suggests that taking action to improve staffing levels was prudent.

Duty Hour Reform and the Outcomes of Patients Treated by New Surgeons

OBJECTIVE

The aim of the study was to address the controversy surrounding the effects of duty hour reform on new surgeon performance, we analyzed patients treated by new surgeons following the transition to independent practice.

SUMMARY BACKGROUND DATA

In 2003, duty hour reform affected all US surgical training programs. Its impact on the performance of new surgeons remains unstudied.

METHODS

We studied 30-day mortality among 1,483,074 Medicare beneficiaries undergoing general and orthopedic operations between 1999 and 2003 ("traditional" era) and 2009 and 2013 ("modern" era). The operations were performed by 2762 new surgeons trained before the reform, 2119 new surgeons trained following reform and 15,041 experienced surgeons. We used a difference-in-differences analysis comparing outcomes in matched patients treated by new versus experienced surgeons within each era, controlling for the hospital, operation, and patient risk factors.

RESULTS

Traditional era odds of 30-day mortality among matched patients treated by new versus experienced surgeons were significantly elevated [odds ratio (OR) 1.13; 95% confidence interval (CI) (1.05, 1.22), P < 0.001). The modern era elevated odds of mortality were not significant [OR 1.06; 95% CI (0.97-1.16), P = 0.239]. Relative performance of new and experienced surgeons with respect to 30-day mortality did not appear to change from the traditional era to the modern era [OR 0.93; 95% CI (0.83-1.05), P = 0.233]. There were statistically significant adverse changes over time in relative performance to experienced surgeons in prolonged length of stay [OR 1.08; 95% CI (1.02-1.15), P = 0.015], anesthesia time [9 min; 95% CI (8-10), P < 0.001], and costs [255USD; 95% CI (2-508), P = 0.049].

CONCLUSIONS

Duty hour reform showed no significant effect on 30-day mortality achieved by new surgeons compared to their more experienced colleagues. Patients of new surgeons, however, trained after duty hour reform displayed some increases in the resources needed for their care.

Comparing Outcomes and Costs of Surgical Patients Treated at Major Teaching and Nonteaching Hospitals: A National Matched Analysis

OBJECTIVE

To compare outcomes and costs between major teaching and nonteaching hospitals on a national scale by closely matching on patient procedures and characteristics.

BACKGROUND

Teaching hospitals have been shown to often have better quality than nonteaching hospitals, but cost and value associated with teaching hospitals remains unclear.

METHODS

A study of Medicare patients at 340 teaching hospitals (resident-to-bed ratios ≥ 0.25) and matched patient controls from 2444 nonteaching hospitals (resident-to-bed ratios < 0.05).We studied 86,751 pairs admitted for general surgery (GS), 214,302 pairs of patients admitted for orthopedic surgery, and 52,025 pairs of patients admitted for vascular surgery.

RESULTS

In GS, mortality was 4.62% in teaching hospitals versus 5.57%, (a difference of -0.95%, <0.0001), and overall paired cost difference = $915 (P < 0.0001). For the GS quintile of pairs with highest risk on admission, mortality differences were larger (15.94% versus 18.18%, difference = -2.24%, P < 0.0001), and paired cost difference = $3773 (P < 0.0001), yielding $1682 per 1% mortality improvement at 30 days. Patterns for vascular surgery outcomes resembled general surgery; however, orthopedics outcomes did not show significant differences in mortality across teaching and nonteaching environments, though costs were higher at teaching hospitals.

CONCLUSIONS

Among Medicare patients, as admission risk of mortality increased, the absolute mortality benefit of treatment at teaching hospitals also increased, though accompanied by marginally higher cost. Major teaching hospitals appear to return good value for the extra resources used in general surgery, and to some extent vascular surgery, but this was not apparent in orthopedic surgery.

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.

The Measurement of Orthopaedic Surgeon Burnout Using a Validated Wearable Device

Purpose

The purpose of this study was (1) to determine the prevalence of burnout in orthopaedic surgeons and (2) to determine whether there is an association or correlation between subject-specific variables (age, attending physician, resident, postgraduate year level, gender, number of calls, total hours worked, and total hours of sleep) and burnout.

Methods

Surgeons were prospectively enrolled and provided with a validated wearable device. Subject-specific variables were recorded. Participants completed the Maslach Burnout Inventory and Patient-Reported Outcomes Measurement Information System (PROMIS-29) weekly. Burnout and burnout risk were defined. Multivariate analysis and bivariate correlations were used to determine the association and correlation between subject-specific variables and burnout. Residents were compared to attending surgeons.

Results

Of the 26 enrolled subjects, 21 (15 males, 6 females; mean age 37.2 ± 10.9) completed the 4-week study. Residents worked significantly more hours per week than attending surgeons (68.5 ± 15.2 versus 49.9 ± 7.5, P = 0.009). Of the orthopaedic surgeons, 6 (28.6%) experienced burnout, and 7 (33.3%) orthopaedic surgeons were at risk for burnout. There was no significant difference in burnout rates between residents and attending surgeons (P > 0.05). The number of overnight calls was significantly correlated with increased burnout (r = 0.435, P = 0.049). Female gender was significantly associated (P = 0.041) and correlated (r = 0.558, P = 0.009) with burnout. There was no significant association with burnout between the number of hours worked and hours of sleep.

Conclusions

The rate of burnout was less than 50% among orthopaedic surgeons. The number of overnight calls and female gender are significantly correlated with increased burnout. There was no significant correlation between hours worked and hours of sleep in surgeon burnout.

Clinical Relevance

Burnout is an increasingly common problem among orthopaedic surgeons, and it can have significant negative effects on surgeons' health and patients' outcomes. Identifying the predictors of burnout would allow surgeons to address these risk factors and reduce burnout.

Sleep and Work in ICU Physicians During a Randomized Trial of Nighttime Intensivist Staffing

OBJECTIVES

To compare sleep, work hours, and behavioral alertness in faculty and fellows during a randomized trial of nighttime in-hospital intensivist staffing compared with a standard daytime intensivist model.

DESIGN

Prospective observational study.

SETTING

Medical ICU of a tertiary care academic medical center during a randomized controlled trial of in-hospital nighttime intensivist staffing.

PATIENTS

Twenty faculty and 13 fellows assigned to rotations in the medical ICU during 2012.

INTERVENTIONS

As part of the parent study, there was weekly randomization of staffing model, stratified by 2-week faculty rotation. During the standard staffing model, there were in-hospital residents, with a fellow and faculty member available at nighttime by phone. In the intervention, there were in-hospital residents with an in-hospital nighttime intensivist. Fellows and faculty completed diaries detailing their sleep, work, and well-being; wore actigraphs; and performed psychomotor vigilance testing daily.

MEASUREMENTS AND MAIN RESULTS

Daily sleep time (mean hours [SD]) was increased for fellows and faculty in the intervention versus control (6.7 [0.3] vs 6.0 [0.2]; p < 0.001 and 6.7 [0.1] vs 6.4 [0.2]; p < 0.001, respectively). In-hospital work duration did not differ between the models for fellows or faculty. Total hours of work done at home was different for both fellows and faculty (0.1 [< 0.1] intervention vs 1.0 [0.1] control; p < 0.001 and 0.2 [< 0.1] intervention vs 0.6 [0.1] control; p < 0.001, respectively). Psychomotor vigilance testing did not demonstrate any differences. Measures of well-being including physical exhaustion and alertness were improved in faculty and fellows in the intervention staffing model.

CONCLUSIONS

Although no differences were measured in patient outcomes between the two staffing models, in-hospital nighttime intensivist staffing was associated with small increases in total sleep duration for faculty and fellows, reductions in total work hours for fellows only, and improvements in subjective well-being for both groups. Staffing models should consider how work duration, sleep, and well-being may impact burnout and sustainability.

Comparing Outcomes and Costs of Medical Patients Treated at Major Teaching and Non-teaching Hospitals: A National Matched Analysis

BACKGROUND

Teaching hospitals typically pioneer investment in new technology and cultivate workforce characteristics generally associated with better quality, but the value of this extra investment is unclear.

OBJECTIVE

Compare outcomes and costs between major teaching and non-teaching hospitals by closely matching on patient characteristics.

DESIGN

Medicare patients at 339 major teaching hospitals (resident-to-bed (RTB) ratios ≥ 0.25); matched patient controls from 2439 non-teaching hospitals (RTB ratios < 0.05).

PARTICIPANTS

Forty-three thousand nine hundred ninety pairs of patients (one from a major teaching hospital and one from a non-teaching hospital) admitted for acute myocardial infarction (AMI), 84,985 pairs admitted for heart failure (HF), and 74,947 pairs admitted for pneumonia (PNA).

EXPOSURE

Treatment at major teaching hospitals versus non-teaching hospitals.

MAIN MEASURES

Thirty-day all-cause mortality, readmissions, ICU utilization, costs, payments, and value expressed as extra cost for a 1% improvement in survival.

KEY RESULTS

Thirty-day mortality was lower in teaching than non-teaching hospitals (10.7% versus 12.0%, difference = - 1.3%, P < 0.0001). The paired cost difference (teaching - non-teaching) was $273 (P < 0.0001), yielding $211 per 1% mortality improvement. For the quintile of pairs with highest risk on admission, mortality differences were larger (24.6% versus 27.6%, difference = - 3.0%, P < 0.0001), and paired cost difference = $1289 (P < 0.0001), yielding $427 per 1% mortality improvement at 30 days. Readmissions and ICU utilization were lower in teaching hospitals (both P < 0.0001), but length of stay was longer (5.5 versus 5.1 days, P < 0.0001). Finally, individual results for AMI, HF, and PNA showed similar findings as in the combined results.

CONCLUSIONS AND RELEVANCE

Among Medicare patients admitted for common medical conditions, as admission risk of mortality increased, the absolute mortality benefit of treatment at teaching hospitals also increased, though accompanied by marginally higher cost. Major teaching hospitals appear to return good value for the extra resources used.

Cardiac Autonomic Modulation during on-Call Duty under Working Hours Restriction

Background: Medical residency is a time of high stress and long working hours, which increase the risk of cardiovascular disease. This study aimed to investigate the autonomic modulation of resident physicians throughout the on-call duty cycle. Methods: Spectral analysis of heart rate variability (HRV) was used to compute cardiac parasympathetic modulation (high-frequency power, HF) and cardiac sympathetic modulation (normalized low-frequency power, LF%, and the ratio of LF and HF, LF/HF) of 18 residents for a consecutive 4-day cycle. Results: Male residents show reduced cardiac sympathetic modulation (i.e., higher LF/HF and LF%) than the female interns. Medical residents’ cardiac parasympathetic modulation (i.e., HF) significantly increased on the first and the second post-call day compared with the pre-call day. In contrast, LF% was significantly decreased on the first and the second post-call day compared with the pre-call day. Similarly, LF/HF was significantly decreased on the second post-call day compared with the pre-call day. LF/HF significantly decreased on the first post-call day and on the second post-call day from on-call duty. Conclusion: The guideline that limits workweeks to 80 h and shifts to 28 h resulted in reduced sympathetic modulation and increased parasympathetic modulation during the two days following on-call duty.

Diagnostic Testing During Pediatric Hospitalizations: The Role of Attending In-House Coverage and Daytime Exposure

OBJECTIVE

Overuse of diagnostic tests is of particular concern for pediatric academic medical centers. Our objective was to measure variation in testing based on proportion of hospitalization during the day versus night and the association between attending in-house coverage on the teaching service and test utilization for hospitalized pediatric patients.

METHODS

Electronic health record data from 11,567 hospitalizations to a large, Northeastern, academic pediatric hospital were collected between January 2007 and December 2010. The patient-level dataset included orders for laboratory and imaging tests, information about who placed the order, and the timing of the order. Using a cross-sectional effect modification analysis, we estimated the difference in test utilization attributable to attending in-house coverage.

RESULTS

We found that admission to the teaching service was independently associated with higher utilization of laboratory and imaging tests. However, the number of orders was 0.76 lower (95% confidence interval:-1.31 to -0.21, P = .006) per 10% increase in the proportion in the share of the hospitalization that occurred during daytime hours on the teaching services, which is attributable to direct attending supervision.

CONCLUSIONS

Direct attending care of hospitalized pediatric patients at night was associated with slightly lower diagnostic test utilization.

Association of Hospital Participation in a Regional Trauma Quality Improvement Collaborative With Patient Outcomes

Importance

The American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) provides feedback to hospitals on risk-adjusted outcomes. The Michigan Trauma Quality Improvement Program (MTQIP) goes beyond the provision of feedback alone, focusing on collaborative quality improvement. It is unknown whether the addition of a collaborative approach to benchmark reporting improves outcomes.

Objective

To evaluate the association of hospital participation in the ACS TQIP (benchmark reporting) or the MTQIP (benchmark reporting and collaborative quality improvement) with outcomes compared with control hospitals that did not participate in either program.

Design, Setting, and Participants

In this cohort study, data from the National Trauma Data Bank from 2009 to 2015 were used. A total of 2 373 130 trauma patients 16 years or older with an Injury Severity Score of 5 or more were identified from 98 ACS TQIP hospitals, 23 MTQIP hospitals, and 429 nonparticipating hospitals, based on program participation status in 2011. A difference-in-differences analytic approach was used to evaluate whether hospital participation in the ACS TQIP or the MTQIP was associated with improved outcomes compared with nonparticipation in a quality improvement program.

Exposures

Hospital participation in MTQIP, a quality improvement collaborative, compared with ACS TQIP participation and nonparticipating hospitals.

Main Outcomes and Measures

In-hospital mortality, mortality or hospice, major complications, and venous thromboembolism events were assessed.

Results

Of the 2 373 130 included trauma patients, 64.2% were men and 73.0% were white, and the mean (SD) age was 50.7 (21.9) years. After accounting for patient factors and preexisting time trends toward improved outcomes, there was a statistically significant improvement in major complications after (vs before) hospital enrollment in the MTQIP collaborative compared with nonparticipating hospitals (odds ratio [OR], 0.89; 95% CI, 0.83-0.95) or ACS TQIP hospitals (OR, 0.88; 95% CI, 0.82-0.94). A similar result was observed for venous thromboembolism (MTQIP vs nonparticipating: OR, 0.78; 95% CI, 0.69-0.88; MTQIP vs ACS TQIP: OR, 0.84; 95% CI, 0.74-0.95), for which MTQIP targeted specific performance improvement efforts. Hospital participation in both ACS TQIP and MTQIP was associated with improvement in mortality or hospice (ACS TQIP vs nonparticipating: OR, 0.90; 95% CI, 0.87-0.93; MTQIP vs nonparticipating: OR, 0.88; 95% CI, 0.81-0.96). Hospitals participating in MTQIP achieved the lowest overall risk-adjusted mortality in the postenrollment period (4.2%; 95% CI, 4.1-4.3).

Conclusions and Relevance

This study demonstrates that hospital participation in a regional collaborative quality improvement program is associated with improved patient outcomes beyond benchmark reporting alone while promoting compliance with processes of care.

Evaluating Missouri's Handgun Purchaser Law: A Bracketing Method for Addressing Concerns About History Interacting with Group

In the comparative interrupted time series design (also called the method of difference-in-differences), the change in outcome in a group exposed to treatment in the periods before and after the exposure is compared with the change in outcome in a control group not exposed to treatment in either period. The standard difference-in-difference estimator for a comparative interrupted time series design will be biased for estimating the causal effect of the treatment if there is an interaction between history in the after period and the groups; for example, there is a historical event besides the start of the treatment in the after period that benefits the treated group more than the control group. We present a bracketing method for bounding the effect of an interaction between history and the groups that arises from a time-invariant unmeasured confounder having a different effect in the after period than the before period. The method is applied to a study of the effect of the repeal of Missouri's permit-to-purchase handgun law on its firearm homicide rate. We estimate that the effect of the permit-to-purchase repeal on Missouri's firearm homicide rate is bracketed between 0.9 and 1.3 homicides per 100,000 people, corresponding to a percentage increase of 17% to 27% (95% confidence interval: 0.6, 1.7 or 11%, 35%). A placebo study provides additional support for the hypothesis that the repeal has a causal effect of increasing the rate of state-wide firearm homicides.

Survey results of job status of residents in a standardized residency training program

BACKGROUND

The history of standardized residency training programs (SRTP) in China is not long. As one of the top medical colleges in China, Peking Union Medical College Hospital (PUMCH) has the history and experience of the oldest SRTP in the country. Understanding the job status of PUMCH residents would be conducive to a better development of the national resident training in the future.

METHODS

This study analyzed the demographic information, job burnout scale, working time, and job status of postgraduate year 1-3 residents that took part in the SRTP of the Department of Internal Medicine of PUMCH in August 2017.

RESULTS

The survey data of 159 residents (including PUMCH residents, local-resident-trainees, and clinical postgraduates) were collected. The average working time was 11.38 ± 1.55 h per day and 83.28 ± 8.80 h per week. The average night shift frequency was 4.74 ± 0.59 days. There were 100 residents (62.2%) with symptoms of job burnout, which had a certain correlation with working time (p < 0.05). The self-evaluation of the clinical postgraduates about their working quality of life was lower than that of other residents (p < 0.05). There were various reasons for long working-time, great work pressure, and job burnout. Job burnout was independently associated with the average working time per day (OR = 2.35, 95% CI: 1.47-3.75, P < 0.001) and average length of duty period (OR = 1.52, 95% CI: 1.26-1.84, P < 0.001).

CONCLUSION

The job burnout of residents that took part in SRTP at the PUMCH could not be ignored, which had a certain correlation with work time and early training background.

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.

Associations Between In-Hospital Mortality, Health Care Utilization, and Inpatient Costs With the 2011 Resident Duty Hour Revision

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) has mandated revisions to residents' work hours to improve patient safety and enhance resident education and wellness. The impact on clinical outcomes on a national level is poorly understood.

OBJECTIVE

We examined data from before and after the ACGME 2011 duty hour revision and looked for differences between teaching and nonteaching US hospitals.

METHODS

A retrospective observational study of patients admitted to hospitals in the 2-year periods before and after the 2011 duty hour revision was conducted, utilizing a nationally representative data set. We compared patient and hospital characteristics using standardized differences. With nonteaching hospitals serving as the control group, we used multiple group interrupted time series segmented regression analysis to test for postrevision level and trend changes in mortality, length of stay (LOS), and costs.

RESULTS

We examined more than 117 million hospitalizations. At teaching and nonteaching hospitals, trends in mortality and LOS in prerevision and postrevision periods were not significantly different (all P > .05). A significant monthly reduction in cost per hospitalization was noted postrevision at teaching hospitals (P = .019) but not at nonteaching hospitals (P = .62). In the 2 years following the 2011 revision, there was a monthly reduction in cost per hospitalization (-$52.28; 95% confidence interval -$116.90 to -$12.32; P = .026) at teaching relative to nonteaching hospitals.

CONCLUSIONS

There were no differences in mortality or LOS between teaching and nonteaching hospitals. However, there was a small decrease in cost per hospitalization at teaching hospitals following the 2011 revision.

Geographic variation in the delivery of high-value inpatient care

OBJECTIVES

To measure value in the delivery of inpatient care and to quantify its variation across U.S. regions.

DATA SOURCES / STUDY SETTING

A random (20%) sample of 33,713 elderly fee-for-service Medicare beneficiaries treated in 2,232 hospitals for a heart attack in 2013.

STUDY DESIGN

We estimate a production function for inpatient care, defining output as stays with favorable patient outcomes in terms of survival and readmission. The regression model includes hospital inputs measured by treatment costs, as well as patient characteristics. Region-level effects in the production function are used to estimate the productivity and value of the care delivered by hospitals within regions.

DATA COLLECTION / EXTRACTION METHODS

Medicare claims and enrollment files, linked to the Dartmouth Atlas of Health Care and Inpatient Prospective Payment System Impact Files.

PRINCIPAL FINDINGS

Hospitals in the hospital referral region at the 90th percentile of the value distribution delivered 54% more high-quality stays than hospitals at the 10th percentile could have delivered, after adjusting for treatment costs and patient severity.

CONCLUSIONS

Variation in the delivery of high-value inpatient care points to opportunities for better quality and lower costs.

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.).

An enhanced recovery program in colorectal surgery is associated with decreased organ level rates of complications: a difference-in-differences analysis

BACKGROUND

Perioperative care has lacked coordination and standardization. Enhanced recovery programs (ERPs) have been shown to decrease aggregate complications across surgical specialties. We hypothesize that the sustained implementation of an ERP will be associated with a decrease in a broad range of complications at the organ system level.

STUDY DESIGN

Adult patients undergoing elective colorectal procedures between 1/2011 and 10/2016 were included. Patients were stratified based on exposure to a sustained ERP (7/2014-10/2016) after an 18-month wash-in period in a pre-post analysis. The primary outcome was 30-day complication rate by organ category as collected by National Surgical Quality Improvement Program (NSQIP) abstractors. Demographic and other patient level data were collected. Complication rates were compared using multivariable regression employing a differences-in-differences (DiD) approach using the national NSQIP PUF file to account for secular trends.

RESULTS

A total of 1182 patients were included in this study, with 47% treated in an ERP. The two groups were similar in age, gender, race, BMI, comorbidity index, and procedure type. In a multivariable DiD analysis, significant reductions were seen in surgical site infection (OR 0.30; 95% CI 0.20-0.43), postoperative pulmonary complications (OR 0.46; 95% CI 0.24-0.90), transfusion (OR 0.27; 95% CI 0.15-0.51), urinary tract infections (OR 0.34; 95% CI 0.18-0.66), sepsis (OR 0.35; 95% CI 0.20-0.61), and cardiac complications (OR 0.10; 95% CI 0.01-0.84). A reduction in return to the operating room and 30-day readmission was also observed. Median length of stay (LOS) decreased from 5.2 to 3.5 days (p < 0.001). No significant changes occurred for acute kidney injury and hematologic complications.

CONCLUSION

An ERP was associated with reduced complication rates across a wide range of organ categories and > 1.5-day reduction in LOS in a colorectal surgery population.

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.

Lower Postsurgical Mortality for Individuals with Dementia with Better-Educated Hospital Workforce

OBJECTIVES

To investigate whether care in a hospital with more nurses holding at least a Bachelor of Science in Nursing (BSN) degree is associated with lower mortality for individuals with Alzheimer's disease and related dementias (ADRD) undergoing surgery ADRD.

DESIGN

Cross-sectional data from 2006-07 Medicare claims were linked with the Multi-State Nursing Care and Patient Safety Survey of nurses in 4 states.

SETTING

Adult, nonfederal, acute care hospitals in California, Florida, New Jersey, and Pennsylvania (N=531).

PARTICIPANTS

Medicare beneficiaries aged 65 and older with and without ADRD undergoing general, orthopedic, or vascular surgery (N=353,333; ADRD, n=46,163; no ADRD, n=307,170).

MEASUREMENTS

Thirty-day mortality and failure to rescue (death after a complication).

RESULTS

Controlling for hospital, procedure, and individual characteristics, each 10% increase in the proportion of BSN nurses was associated with 4% lower odds of death (odds ratio (OR)=0.96, 95% confidence interval (CI)=0.93-0.98) for individuals without ADRD, but 10% lower odds of death (OR=0.90, 95% CI=0.87-0.94) for those with ADRD. Each 10% increase in the proportion of nurses holding a BSN degree or higher was associated with 5% lower odds of failure to rescue (OR=0.95, 95% CI=0.92-0.98) for individuals without ADRD but 10% lower odds of failure to rescue (OR=0.90, 95% CI=0.87-0.94) for those with ADRD.

CONCLUSION

Individuals undergoing surgery who have coexisting ADRD are more likely to die within 30 days of admission and die after a complication than those without ADRD. Having more BSN nurses in the hospital improves the odds of good outcomes for all individuals and has a much greater effect in individuals with ADRD.

Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine

BACKGROUND

Concern persists that inflexible duty-hour rules in medical residency programs may adversely affect the training of physicians.

METHODS

We randomly assigned 63 internal medicine residency programs in the United States to be governed by standard duty-hour policies of the 2011 Accreditation Council for Graduate Medical Education (ACGME) or by more flexible policies that did not specify limits on shift length or mandatory time off between shifts. Measures of educational experience included observations of the activities of interns (first-year residents), surveys of trainees (both interns and residents) and faculty, and intern examination scores.

RESULTS

There were no significant between-group differences in the mean percentages of time that interns spent in direct patient care and education nor in trainees' perceptions of an appropriate balance between clinical demands and education (primary outcome for trainee satisfaction with education; response rate, 91%) or in the assessments by program directors and faculty of whether trainees' workload exceeded their capacity (primary outcome for faculty satisfaction with education; response rate, 90%). Another survey of interns (response rate, 49%) revealed that those in flexible programs were more likely to report dissatisfaction with multiple aspects of training, including educational quality (odds ratio, 1.67; 95% confidence interval [CI], 1.02 to 2.73) and overall well-being (odds ratio, 2.47; 95% CI, 1.67 to 3.65). In contrast, directors of flexible programs were less likely to report dissatisfaction with multiple educational processes, including time for bedside teaching (response rate, 98%; odds ratio, 0.13; 95% CI, 0.03 to 0.49). Average scores (percent correct answers) on in-training examinations were 68.9% in flexible programs and 69.4% in standard programs; the difference did not meet the noninferiority margin of 2 percentage points (difference, -0.43; 95% CI, -2.38 to 1.52; P=0.06 for noninferiority). od Institute and the ACGME; iCOMPARE ClinicalTrials.gov number, NCT02274818 .).

CONCLUSIONS

There was no significant difference in the proportion of time that medical interns spent on direct patient care and education between programs with standard duty-hour policies and programs with more flexible policies. Interns in flexible programs were less satisfied with their educational experience than were their peers in standard programs, but program directors were more satisfied. (Funded by the National Heart, Lung, and Blo

Hospital Characteristics and the Agency for Healthcare Research and Quality Inpatient Quality Indicators: A Systematic Review

BACKGROUND

The Agency for Healthcare Research and Quality Inpatient Quality Indicators (IQIs) include inpatient mortality for selected procedures and medical conditions. They have assumed an increasingly prominent role in hospital comparisons. Healthcare delivery and policy-related decisions need to be driven by reliable research that shows associations between hospital characteristics and quality of inpatient care delivered.

OBJECTIVES

To systematically review the literature on associations between hospital characteristics and IQIs.

METHODS

We systematically searched PubMed and gray literature (2000-2012) for studies relevant to 14 hospital characteristics and 17 IQIs. We extracted data for study characteristics, IQIs analyzed, and hospital characteristics (e.g., teaching status, bed size, patient volume, rural vs. urban location, and nurse staffing).

RESULTS

We included 16 studies, which showed few significant associations. Four hospital characteristics (higher hospital volume, higher nurse staffing, urban vs. rural status, and higher hospital financial resources) had statistically significant associations with lower mortality and selected IQIs in approximately half of the studies. For example, there were no associations between nurse staffing and four IQIs; however, approximately 50% of studies showed a statistically significant relationship between nurse staffing and lower mortality for six IQIs. For two hospital characteristics-higher bed size and disproportionate share percentage-all statistically significant associations had higher mortality. Five hospital characteristics (teaching status, system affiliation, ownership, minority-serving hospitals, and electronic health record status) had some studies with significantly positive and some with significantly negative associations, and many studies with no association.

CONCLUSIONS

We found few associations between hospital characteristics and mortality IQIs. Differences in study methodology, coding across hospitals, and hospital case-mix adjustment may partly explain these results. Ongoing research will evaluate potential mechanisms for the identified associations.

Acute Myocardial Infarction Mortality During Dates of National Interventional Cardiology Meetings

Background

Previous research has found that patients with acute cardiovascular conditions treated in teaching hospitals have lower 30‐day mortality during dates of national cardiology meetings.

Methods and Results

We analyzed 30‐day mortality among Medicare beneficiaries hospitalized with acute myocardial infarction (overall, ST‐segment–elevation myocardial infarction, and non–ST‐segment–elevation myocardial infarction) from January 1, 2007, to November 31, 2012, in major teaching hospitals during dates of a major annual interventional cardiology meeting (Transcatheter Cardiovascular Therapeutics) compared with identical nonmeeting days in the ±5 weeks. Treatment differences were assessed. We used a database of US physicians to compare interventional cardiologists who practiced and did not practice during meeting dates (“stayers” and “attendees,” respectively) in terms of demographic characteristics and clinical and research productivity. Unadjusted and adjusted 30‐day mortality rates were lower among patients admitted during meeting versus nonmeeting dates (unadjusted, 15.3% [482/3153] versus 16.7% [5208/31 556] [P=0.04]; adjusted, 15.4% versus 16.7%; difference −1.3% [95% confidence interval, −2.7% to −0.1%] [P=0.05]). Rates of interventional cardiologist involvement were similar between dates (59.5% versus 59.8% of hospitalizations; P=0.88), as were percutaneous coronary intervention rates (30.2% versus 29.1%; P=0.20). Mortality reductions were largest among patients with non–ST‐segment–elevation myocardial infarction not receiving percutaneous coronary intervention (16.9% versus 19.5% adjusted 30‐day mortality; P=0.008). Compared with stayers, attendees were of similar age and sex, but had greater publications (18.9 versus 6.3; P<0.001), probability of National Institutes of Health funding (5.3% versus 0.4%; P<0.001), and clinical trial leadership (10.3% versus 3.9%; P<0.001), and they performed more percutaneous coronary interventions annually (85.6 versus 63.3; P<0.001).

Conclusions

Hospitalization with acute myocardial infarction during Transcatheter Cardiovascular Therapeutics meeting dates was associated with lower 30‐day mortality, predominantly among patients with non–ST‐segment–elevation myocardial infarction who were medically managed.

Surgical resident involvement in foot and ankle surgery

BACKGROUND

Surgical resident participation in the operating room is necessary for education and progression toward safe and independent practice. However, the impact of resident involvement on patient outcomes in foot and ankle surgery is unknown.

METHODS

The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2012) was used to identify common foot and ankle procedures (by Current Procedural Taxonomy (CPT) code) performed by orthopedic surgeons. Resident participation was determined using the NSQIP-collected variable 'pgy'; cases missing the pgy variable were excluded. Multivariate regression models were constructed to determine an association between resident involvement and 30-day morbidity (total, medical, and surgical complications) and 30-day mortality, when controlling for patient demographics, comorbidities, American Society for Anesthesiologist (ASA) status, body mass index (BMI), and smoking status.

RESULTS

A total of 13,685 cases were analyzed for 24 common foot and ankle operations. Overall mortality rate was 3.60%. Overall complication rate was 16.9%; 10.9% had medical and 8.3% had surgical complications. Residents were involved in 55.6% of cases. In unadjusted analyses, resident cases were less likely to be emergent, but were performed on more complicated patients (i.e. higher comorbidity burden, higher ASA scores). Resident cases had increased total morbidity (18.8% vs. 14.6%, p<0.001), medical complications (12.5% vs. 9.0%, p<0.001), and surgical complications (8.7% vs. 7.7%, p=0.03), but similar mortality frequency (3.8% vs. 3.3%, p=0.2). In multivariable analyses, resident cases did not correlate with 30-day mortality, 30-day total morbidity, or 30-day surgical complications; resident cases were, however, associated with increased medical complications [Odds Ratio (OR) 1.18 (95% Confidence Interval (CI) 1.02-1.37, p=0.03)] and longer length of stay [Coeff 2.38 (1.68-3.09), p<0.001]. Subgroup analyses of orthopedic-only cases demonstrated no statistical association between resident involvement and mortality, total morbidity, or medical complications; a decrease in surgical complications was observed for open reduction internal fixation cases [OR 0.23 (0.06-0.82), p=0.02].

CONCLUSIONS

Resident involvement in foot and ankle surgery is not associated with changes in 30-day mortality, 30-day total morbidity, or 30-day surgical complication rates. Residents operate on more medically complex patients who experience higher medical complication rates and longer postoperative length of stay; however, the cause and directionality of this relationship remains to be determined. Efforts to improve the quality of foot and ankle surgery with resident involvement should target reductions in post-operative medical complications.

LEVEL OF EVIDENCE

Prognostic study, Level II.

The July Effect on Maternal Peripartum Complications before and after Resident Duty Hour Reform: A Population-Based Retrospective Cohort Study

Objective To compare maternal birth complications early versus late in the academic year and to evaluate the impact of resident work hour limitation on the "July effect." Study Design We conducted a retrospective, population-based cohort study of 628,414 singleton births in Washington State from 1987 to 2012 measuring the adjusted risk of maternal peripartum complications early (July/August) versus late (April/May) in the academic year. To control for seasonal outcome variation unrelated to trainees' involvement in care as well as long-term trends in maternal complications unrelated to variation in trainees' effect on outcomes across the academic year, we employed difference-in-differences methods contrasting outcomes at teaching to nonteaching hospitals for deliveries before and after restriction of resident work hours in July 2003. Results Prior to resident work hour limitation in July 2003, women delivering early in the academic year at teaching hospitals suffered more complications (relative risk [RR] 1.05; 95% confidence interval [CI]: 1.00-1.09; p = 0.03). After July 2003, complication risk did not vary significantly across the academic year except at teaching-intensive hospitals, where July/August deliveries experienced fewer complications (RR: 0.95; 95% CI: 0.92-0.98; p = 0.001). Conclusion Women delivering at teaching hospitals early in the academic year suffered a modest but significant increase in complications before but not after resident work hour reform.

Patient Mortality During Unannounced Accreditation Surveys at US Hospitals

IMPORTANCE

In the United States, hospitals receive accreditation through unannounced on-site inspections (ie, surveys) by The Joint Commission (TJC), which are high-pressure periods to demonstrate compliance with best practices. No research has addressed whether the potential changes in behavior and heightened vigilance during a TJC survey are associated with changes in patient outcomes.

OBJECTIVE

To assess whether heightened vigilance during survey weeks is associated with improved patient outcomes compared with nonsurvey weeks, particularly in major teaching hospitals.

DESIGN, SETTING, AND PARTICIPANTS

Quasi-randomized analysis of Medicare admissions at 1984 surveyed hospitals from calendar year 2008 through 2012 in the period from 3 weeks before to 3 weeks after surveys. Outcomes between surveys and surrounding weeks were compared, adjusting for beneficiaries' sociodemographic and clinical characteristics, with subanalyses for major teaching hospitals. Data analysis was conducted from January 1 to September 1, 2016.

EXPOSURES

Hospitalization during a TJC survey week vs nonsurvey weeks.

MAIN OUTCOMES AND MEASURES

The primary outcome was 30-day mortality. Secondary outcomes were rates of Clostridium difficile infections, in-hospital cardiac arrest mortality, and Patient Safety Indicators (PSI) 90 and PSI 4 measure events.

RESULTS

The study sample included 244 787 and 1 462 339 admissions during survey and nonsurvey weeks with similar patient characteristics, reason for admission, and in-hospital procedures across both groups. There were 811 598 (55.5%) women in the nonsurvey weeks (mean [SD] age, 72.84 [14.5] years) and 135 857 (55.5%) in the survey weeks (age, 72.76 [14.5] years). Overall, there was a significant reversible decrease in 30-day mortality for admissions during survey (7.03%) vs nonsurvey weeks (7.21%) (adjusted difference, -0.12%; 95% CI, -0.22% to -0.01%). This observed decrease was larger than 99.5% of mortality changes among 1000 random permutations of hospital survey date combinations, suggesting that observed mortality changes were not attributable to chance alone. Observed mortality reductions were largest in major teaching hospitals, where mortality fell from 6.41% to 5.93% during survey weeks (adjusted difference, -0.38%; 95% CI, -0.74% to -0.03%), a 5.9% relative decrease. We observed no significant differences in admission volume, length of stay, or secondary outcomes.

CONCLUSIONS AND RELEVANCE

Patients admitted to hospitals during TJC survey weeks have significantly lower mortality than during nonsurvey weeks, particularly in major teaching hospitals. These results suggest that changes in practice occurring during periods of surveyor observation may meaningfully affect patient mortality.

Impact of the 2003 ACGME Resident Duty Hour Reform on Hospital-Acquired Conditions: A National Retrospective Analysis

BACKGROUND

The Accreditation Council for Graduate Medical Education reforms in 2003 instituted an 80-hour weekly limit for resident physicians. Critics argue that these restrictions have increased handoffs among residents and the potential for a decline in patient safety. "Never events" hospital-acquired conditions (HACs) are a set of preventable events used as a quality metric in hospital safety analyses.

OBJECTIVE

This analysis evaluated post-work hour reform effects on HAC incidence for US hospital inpatients, using the National Inpatient Sample.

METHODS

Data were collected from 2000-2002 (pre-2003) and 2004-2006 (post-2003) time periods. HAC incidence in academic and non-academic centers was evaluated in multivariate analysis assessing for likelihood of HAC occurrence, prolonged length of stay (pLOS), and increased total charges.

RESULTS

The data encompassed approximately 111 million pre-2003 and 117 million post-2003 admissions. Patients were 10% more likely to incur a HAC in the post-2003 versus pre-2003 era (odds ratio [OR] = 1.10; 95% confidence interval [CI] 1.06-1.14; P < .01). Teaching hospitals exhibited an 18% (OR = 1.18; 95% CI 1.11-1.27; P < .01) increase in HAC likelihood, with no change in nonteaching settings (OR = 1.03; 95% CI 1.00-1.06; P > .05). Patients with ≥ 1 HAC were associated with a 60% likelihood of elevated charges (OR = 1.60; 95% CI 1.50-1.72; P < .01) and 65% likelihood of pLOS (OR = 1.65; 95% CI 1.60-1.70; P < .01).

CONCLUSIONS

Post-2003 era patients were associated with 10% increased likelihood of HAC, with effects noted primarily at teaching hospitals.