Residency work-hours reform. A cost analysis including preventable adverse events

The evolving role of advanced practice providers in transplantation: a literature review

PURPOSE OF REVIEW

Solid organ transplantation is a life-saving procedure, often performed in critically ill patients, and advanced practice providers (APPs) have increasingly been incorporated into the multidisciplinary transplant team. A literature review was performed and reinforces the value of transplant APPs, details their evolving roles and responsibilities, and highlights innovative solutions created to address complex problems.

RECENT FINDINGS

The literature review revealed a deficit of quality quantitative data supporting the utilization of APPs in transplantation. Thus, data regarding the value of APPs in critical care was also analyzed.

SUMMARY

The limited data despite decades long integration of transplant APPs into the multidisciplinary team, suggests there are likely positive outcomes and innovations that go undocumented. Thus, there are missed opportunities for learning and improvement. Transplant programs investing time and mentorship to support APP research will identify strengths and weaknesses within our existing care models, discover cost saving innovations, and continue to optimize the role of APPs in delivering high quality care that is efficient and evidence based.

The Emerging Role of Nurse Practitioners and Physician Assistants in Liver Transplantation

The evolving role of nurse practitioners (NPs) and physician assistants (PAs) in the United States continues to progress. NP and PA responsibilities have expanded from primary care practices to medical and surgical specialties. They provide acute care in hospitals and intensive care units, and they serve as educators, lobbyists, and researchers. Questions have arisen from NP/PA leaders, physician leaders, and administrators on how to best implement a successful NP/PA model within their practice. This article reviews some common themes in the literature by looking at the current state of NP/PA practice, outlines some practice models established therein, and provides recommendations for implementing a successful NP/PA model in a liver transplant practice.

Relative productivity of nurse practitioner and resident physician care models in the pediatric emergency department

OBJECTIVES

Duty hour restrictions limit the use of resident physicians in pediatric emergency departments (PEDs). We sought to determine the relative clinical productivity of PED attending physicians working with residents compared with PED attending physicians working with nurse practitioners (NPs).

METHODS

In a tertiary care PED with multiple care models (PED attending physicians with residents and/or fellows, PED attending physicians with NPs, PED attending physicians alone), we identified periods when care was provided concurrently and exclusively by a PED attending physician with 1 to 2 residents (resident pod) and a PED attending physician with 1 NP (NP pod). Billing records were reviewed to determine relative value units (RVUs) generated and patients seen by each PED attending physician. Emergency Severity Index (ESI) triage scores were used to compare patient acuities.

RESULTS

The NP pods generated 5.35 RVUs per hour and the resident pods generated 4.35 RVUs per hour, with a significant difference of 1.00 RVUs per hour (95% confidence interval, 0.19-1.82). The NP pods saw 2.18 patients per hour, whereas the resident pods saw 1.90 patients per hour. This difference of 0.28 was not statistically significant (95% confidence interval, -0.07 to 0.62). Patient acuity was similar. Thirteen percent of the NP pod patients had the highest triage severity levels of ESI-1 and ESI-2, whereas 19% of the resident pod patients were ESI-1 and ESI-2 (P = 0.06).

CONCLUSIONS

Pediatric emergency department attending physicians in an NP care model had greater clinical productivity, measured by RVUs, than PED attending physicians in a resident care model while treating similar patient populations.

Organizational interventions in response to duty hour reforms

BACKGROUND

Changes in resident duty hours in Europe and North America have had a major impact on the internal organizational dynamics of health care organizations. This paper examines, and assesses the impact of, organizational interventions that were a direct response to these duty hour reforms.

METHODS

The academic literature was searched through the SCOPUS database using the search terms "resident duty hours" and "European Working Time Directive," together with terms related to organizational factors. The search was limited to English-language literature published between January 2003 and January 2012. Studies were included if they reported an organizational intervention and measured an organizational outcome.

RESULTS

Twenty-five articles were included from the United States (n=18), the United Kingdom (n=5), Hong Kong (n=1), and Australia (n=1). They all described single-site projects; the majority used post-intervention surveys (n=15) and audit techniques (n=4). The studies assessed organizational measures, including relationships among staff, work satisfaction, continuity of care, workflow, compliance, workload, and cost. Interventions included using new technologies to improve handovers and communications, changing staff mixes, and introducing new shift structures, all of which had varying effects on the organizational measures listed previously.

CONCLUSIONS

Little research has assessed the organizational impact of duty hour reforms; however, the literature reviewed demonstrates that many organizations are using new technologies, new personnel, and revised and innovative shift structures to compensate for reduced resident coverage and to decrease the risk of limited continuity of care. Future research in this area should focus on both micro (e.g., use of technology, shift changes, staff mix) and macro (e.g., culture, leadership support) organizational aspects to aid in our understanding of how best to respond to these duty hour reforms.

Inpatient safety outcomes following the 2011 residency work-hour reform

BACKGROUND

The impact of the 2011 residency work-hour reforms on patient safety is not known.

OBJECTIVE

To evaluate the association between implementation of the 2011 reforms and patient safety outcomes at a large academic medical center.

DESIGN

Observational study using difference-in-differences estimation strategy to evaluate whether safety outcomes improved among patients discharged from resident and hospitalist (nonresident) services before (2008-2011) and after (2011-2012) residency work-hour changes.

PATIENTS

All adult patients discharged from general medicine services from July 2008 through June 2012.

MEASUREMENTS

Outcomes evaluated included length of stay, 30-day readmission, intensive care unit (ICU) admission, inpatient mortality, and presence of Maryland Hospital Acquired Conditions. Independent variables included time period (pre- vs postreform), resident versus hospitalist service, patient age at admission, race, gender, and case mix index.

RESULTS

Patients discharged from the resident services in the postreform period had higher likelihood of an ICU stay (5.7% vs 4.5%, difference 1.4%; 95% confidence interval [CI]: 0.5% to 2.2%), and lower likelihood of 30-day readmission (17.2% vs 20.1%, difference 2.8%; 95 % CI: 1.3 to 4.3%) than patients discharged from the resident services in the prereform period. Comparing pre- and postreform periods on the resident and hospitalist services, there were no significant differences in patient safety outcomes.

CONCLUSIONS

In the first year after implementation of the 2011 work-hour reforms relative to prior years, we found no change in patient safety outcomes in patients treated by residents compared with patients treated by hospitalists. Further study of the long-term impact of residency work-hour reforms is indicated to ensure improvement in patient safety.

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

OBJECTIVE

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

DATA SOURCES/STUDY SETTING

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

STUDY DESIGN

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

PRINCIPAL FINDINGS

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

CONCLUSIONS

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

Effects of fatigue on surgeon performance and surgical outcomes: a systematic review

BACKGROUND

Sleep deprivation and disturbances in circadian rhythms generally lead to poor performance, but is there a link in surgery? This review aimed to determine whether fatigue has an impact on surgeon performance or surgical outcomes.

METHODS

Studies were identified by searching EMBASE, CINAHL, PubMed, The Cochrane Library, Current Contents and clinical trials databases. Inclusion of relevant studies was by application of a predetermined protocol and independent assessment by two reviewers. Each included study was critically appraised for its study quality according to the methods used for Cochrane Reviews. Data from included studies were extracted by one researcher using standardized data extraction tables developed a priori and checked by a second researcher.

RESULTS

From 823 potentially relevant studies, a total of 16 studies were included in this review: two randomized controlled trials, five non-randomized comparative studies and nine case series. Of five studies that directly measure clinical performance, three studies reported no significant difference as a result of sleep deprivation, while two studies found increases in complications or errors. Eleven studies assessed psychomotor skill performance using a variety of simulation-based methods when a participant was rested and/or fatigued. Two randomized controlled trials reported no significant differences, while the nine remaining studies reported mixed results. Surgical residents with less surgical training/experience appeared to be more affected than more senior residents.

CONCLUSION

There is little evidence, as yet, to inform the issue of the effect of fatigue on surgical performance.

Graduate medical education funding: a Massachusetts General Hospital case study and review

During the past century, graduate medical education funding has evolved in response to the increasing specialization of modern medicine as well as the need for federal funding to effectively sustain specialty training. This article reviews historical and current funding methods for graduate medical education and examines current funding using Massachusetts General Hospital (MGH) as a case example. Notably, it also explores whether graduate medical education funding at a large academic center such as MGH is commensurate with expenditures.

The gastroenterologist and industry: changing winds

The medical device and pharmaceutical industry is facing mounting pressure to produce cost-effectiveness and clinical-effectiveness data in order for their products to be acceptable for approval by the Federal Drug Administration and then for payer reimbursement. The implications of these increasing burdens on our field will become apparent in everyday practice. This article outlines these challenges and discusses possible ways to improve the situation.

Orthopaedic resident and program director opinions of resident duty hours: a national survey

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) established national guidelines for resident duty hours in July 2003. Following an Institute of Medicine report in December 2008, the ACGME recommended further restrictions on resident duty hours that went into effect in July 2011. We conducted a national survey to assess the opinions of orthopaedic residents and of directors of residency and fellowship programs in the U.S. regarding the 2003 and 2011 ACGME resident duty-hour regulations and the effects of these regulations on resident education and patient care.

METHODS

A fifteen-item questionnaire was electronically distributed by the Candidate, Resident, and Fellow Committee of the American Academy of Orthopaedic Surgeons (AAOS) to all U.S. orthopaedic residents (n = 3860) and directors of residency programs (n = 184) and fellowship programs (n = 496) between January and April 2011. Thirty-four percent (1314) of the residents and 27% (185) of the program directors completed the questionnaire. Statistical analyses were performed to detect differences between the responses of residents and program directors and between the responses of junior and senior residents.

RESULTS

The responses of orthopaedic residents and program directors differed significantly (p < 0.001) for fourteen of the fifteen survey items. The responses of residents and program directors were divergent for questions regarding the 2003 rules. Overall, 71% of residents thought that the eighty-hour work week was appropriate, whereas only 38% of program directors agreed (p < 0.001). Most program directors (70%) did not think that the 2003 duty-hour rules had improved patient care, whereas only 24% of residents responded in the same way (p < 0.001). The responses of residents and program directors to questions regarding the 2011 duty-hour rules were generally compatible, but the degree to which they perceived the issues was different. Only 18% of residents and 19% of program directors thought that the suggested strategic five-hour evening rest period implemented in July 2011 for on-call residents was appropriate (p > 0.05), and both groups (84% of residents and 74% of program directors) also disagreed with the limitation of intern shifts to sixteen hours (p < 0.001). Seventy percent of residents and 79% of program directors thought that the new duty-hour regulations would result in an increased number of handoffs that would be detrimental to patient care (p < 0.001). The mean responses of junior residents and senior residents differed for eight of the fifteen survey items (p < 0.001), with the responses of senior residents more closely resembling those of program directors on six of these eight questions. The mean responses and percentiles for the survey items did not differ significantly between residency directors and fellowship directors (p > 0.05).

CONCLUSIONS

This national survey indicated significant differences between the opinions of orthopaedic residents and program (residency and fellowship) directors regarding the 2003 ACGME resident duty-hour regulations and the effects of these regulations on resident education and patient care. However, both residents and program directors agreed that the further reductions in duty hours in the 2011 rules may be detrimental to resident education and patient care.

Cost implications of reduced work hours and workloads for resident physicians

BACKGROUND

Although the Accreditation Council for Graduate Medical Education (ACGME) limits the work hours of residents, concerns about fatigue persist. A new Institute of Medicine (IOM) report recommends, among other changes, improved adherence to the 2003 ACGME limits, naps during extended shifts, a 16-hour limit for shifts without naps, and reduced workloads.

METHODS

We used published data to estimate labor costs associated with transferring excess work from residents to substitute providers, and we examined the effects of our assumptions in sensitivity analyses. Next, using a probability model to represent labor costs as well as mortality and costs associated with preventable adverse events, we determined the net costs to major teaching hospitals and cost-effectiveness across a range of hypothetical changes in the rate of preventable adverse events.

RESULTS

Annual labor costs from implementing the IOM recommendations were estimated to be $1.6 billion (in 2006 U.S. dollars) across all ACGME-accredited programs ($1.1 billion to $2.5 billion in sensitivity analyses). From a 10% decrease to a 10% increase in preventable adverse events, net costs per admission ranged from $99 to $183 for major teaching hospitals and from $17 to $266 for society. With 2.5% to 11.3% decreases in preventable adverse events, costs to society per averted death ranged from $3.4 million to $0.

CONCLUSIONS

Implementing the four IOM recommendations would be costly, and their effectiveness is unknown. If highly effective, they could prevent patient harm at reduced or no cost from the societal perspective. However, net costs to teaching hospitals would remain high.

Factors associated with intern fatigue

BACKGROUND

Prior data suggest that fatigue adversely affects patient safety and resident well-being. ACGME duty hour limitations were intended, in part, to reduce resident fatigue, but the factors that affect intern fatigue are unknown.

OBJECTIVE

To identify factors associated with intern fatigue following implementation of duty hour limitations.

DESIGN

Cross-sectional confidential survey of validated questions related to fatigue, sleep, and stress, as well as author-developed teamwork questions.

SUBJECTS

Interns in cognitive specialties at the University of California, San Francisco.

MEASUREMENTS

Univariate statistics characterized the distribution of responses. Pearson correlations elucidated bivariate relationships between fatigue and other variables. Multivariate linear regression models identified factors independently associated with fatigue, sleep, and stress.

RESULTS

Of 111 eligible interns, 66 responded (59%). In a regression analysis including gender, hours worked in the previous week, sleep quality, perceived stress, and teamwork, only poorer quality of sleep and greater perceived stress were significantly associated with fatigue (p < 0.001 and p = 0.02, respectively). To identify factors that may affect sleep, specifically duty hours and stress, a secondary model was constructed. Only greater perceived stress was significantly associated with diminished sleep quality (p = 0.04), and only poorer teamwork was significantly associated with perceived stress (p < 0.001). Working >80 h was not significantly associated with perceived stress, quality of sleep, or fatigue.

CONCLUSIONS

Simply decreasing the number of duty hours may be insufficient to reduce intern fatigue. Residency programs may need to incorporate programmatic changes to reduce stress, improve sleep quality, and foster teamwork in order to decrease intern fatigue and its deleterious consequences.

Resident perceptions of the impact of work hour limitations

BACKGROUND

Mandatory work hour limitations for residents began in July 2003. There has been little evaluation of the impact of the new limitations on Internal Medicine residency training.

OBJECTIVE

To assess Internal Medicine residents' perceptions of the impact of work hour limitations on clinical experiences, patient care, resident education, and well-being, and their compliance with the limitations.

DESIGN AND PARTICIPANTS

Cross-sectional survey administered to Internal Medicine residents at 1 large U.S. teaching hospital.

MEASUREMENTS

Resident perceptions using 5-point Likert scales, and self-reported compliance. Exploratory factor analysis was used to identify underlying domains and develop scales.

RESULTS

The survey response rate was 85%. Five domains were identified by factor analysis: 1) clinical experience, 2) patient care and safety, 3) communication, 4) satisfaction with training, and 5) work-rest balance. Residents perceived work hour limitations to have a negative impact on clinical experience (mean scale score 1.84, 1 = negative, 5 = positive), patient care and safety (2.64), and communication domains (1.98). Effects on satisfaction (3.12) and work-rest balance domains (2.95) were more positive. Senior residents perceived more negative effects of work hour limitations than interns. Compliance was difficult; 94% interns and 70% residents reported violating work hour limits. Patient care and teaching duties were the main reasons for work hour violations.

CONCLUSIONS

This study suggests that the current work hour limitations may be having unintended negative consequences on residency training. Ongoing monitoring to evaluate the impact of program changes as a result of work hour regulation is crucial to improving residency training.

Resident perceptions of the impact of work hour limitations

BACKGROUND

Mandatory work hour limitations for residents began in July 2003. There has been little evaluation of the impact of the new limitations on Internal Medicine residency training.

OBJECTIVE

To assess Internal Medicine residents' perceptions of the impact of work hour limitations on clinical experiences, patient care, resident education, and well-being, and their compliance with the limitations.

DESIGN AND PARTICIPANTS

Cross-sectional survey administered to Internal Medicine residents at 1 large U.S. teaching hospital.

MEASUREMENTS

Resident perceptions using 5-point Likert scales, and self-reported compliance. Exploratory factor analysis was used to identify underlying domains and develop scales.

RESULTS

The survey response rate was 85%. Five domains were identified by factor analysis: 1) clinical experience, 2) patient care and safety, 3) communication, 4) satisfaction with training, and 5) work-rest balance. Residents perceived work hour limitations to have a negative impact on clinical experience (mean scale score 1.84, 1 = negative, 5 = positive), patient care and safety (2.64), and communication domains (1.98). Effects on satisfaction (3.12) and work-rest balance domains (2.95) were more positive. Senior residents perceived more negative effects of work hour limitations than interns. Compliance was difficult; 94% interns and 70% residents reported violating work hour limits. Patient care and teaching duties were the main reasons for work hour violations.

CONCLUSIONS

This study suggests that the current work hour limitations may be having unintended negative consequences on residency training. Ongoing monitoring to evaluate the impact of program changes as a result of work hour regulation is crucial to improving residency training.

The impact of duty hours on resident self reports of errors

BACKGROUND

Resident duty hour limitations aim, in part, to reduce medical errors. Residents' perceptions of the impact of duty hours on errors are unknown.

OBJECTIVE

To determine residents' self-reported contributing factors, frequency, and impact of hours worked on suboptimal care practices and medical errors.

DESIGN

Cross-sectional survey.

SUBJECTS

164 Internal Medicine Residents at the University of California, San Francisco.

MEASUREMENTS AND RESULTS

Residents were asked to report the frequency and contributing factors of suboptimal care practices and medical errors, and how duty hours impacted these practices and aspects of resident work-life. One hundred twenty-five residents (76%) responded. The most common suboptimal care practices were working while impaired by fatigue and forgetting to transmit information during sign-out. In multivariable models, residents who felt overwhelmed with work (p = 0.02) and who reported spending >50% of their time in nonphysician tasks (p = 0.002) were more likely to report suboptimal care practices. Residents reported work-stress (a composite of fatigue, excessive workload, distractions, stress, and inadequate time) as the most frequent contributing factor to medical errors. In multivariable models, only engaging in suboptimal practices was associated with self-report of higher risk for medical errors (p < 0.001); working more than 80 hours per week was not associated with suboptimal care or errors.

CONCLUSION

Our findings suggest that administrative load and work stressors are more closely associated with resident reports of medical errors than the number of hours work. Efforts to reduce resident duty hours may also need to address the nature of residents' work to reduce errors.

Internal medicine residents' clinical and didactic experiences after work hour regulation: a survey of chief residents

BACKGROUND

Work hour regulations for house staff were intended in part to improve resident clinical and educational performance.

OBJECTIVE

To characterize the effect of work hour regulation on internal medicine resident inpatient clinical experience and didactic education.

DESIGN

Cross-sectional mail survey.

PARTICIPANTS

Chief residents at all accredited U.S. internal medicine residency programs outside New York.

MEASUREMENTS AND MAIN RESULTS

The response rate was 62% (202/324). Most programs (72%) reported no change in average patient load per intern after work hour regulation. Many programs (48%) redistributed house staff admissions through the call cycle. The number of admissions per intern on long call (the day interns have the most admitting responsibility) decreased in 31% of programs, and the number of admissions on other days increased in 21% of programs. Residents on outpatient rotations were given new ward responsibilities in 36% of programs. Third-year resident ward and float time increased in 34% of programs, while third-year elective time decreased in 22% of programs. The mean weekly hours allotted to educational activities did not change significantly (12.7 vs 12.4, P = .12), but 56% of programs reported a decrease in intern attendance at educational activities.

CONCLUSIONS

In response to work hour regulation, many internal medicine programs redistributed rather than reduced residents' inpatient clinical experience. Hours allotted to educational activities did not change; however, most programs saw a decrease in intern attendance at conferences, and many reduced third-year elective time.

Myths and Realities of the 80-Hour Work Week

BACKGROUND

Myths are so ingrained into cultural traditions that emotion frequently overshadows a rational evaluation of the facts. The reduction in resident work hours has resulted in the formation of several myths. The purpose of this review is to examine the published data on resident work hours to separate out myth from reality.

METHODS

An electronic database was searched for publications related to resident training, work-hours, continuity of care, sleep deprivation, quality of life, patient safety, clinical/operative experience, faculty work hours, and surgical education.

RESULTS

Sleep deprivation has been shown to be harmful, and residents played a role in advocating for work-hour limits. Surgical residents have seen a less dramatic improvement in quality of life compared with other disciplines. Work-hour reductions have decreased participation in clinic but have not resulted in a significant decline in clinical or operative exposure. Limiting resident work hours will unlikely result in a decrease health-care cost. Reduction in resident work hours has not resulted in an improvement or deterioration in patient outcome. Reduction of work hours has not increased faculty work hours nor made surgery a more attractive career choice.

CONCLUSIONS

Despite strongly held opinions, resident work-hour reduction has resulted in little significant change in lifestyle, clinical exposure, patient well-being, faculty work hours, or medical student recruitment.