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Weaver MD, Sullivan JP, Landrigan CP, Barger LK. Systematic Review of the Impact of Physician Work Schedules on Patient Safety with Meta-Analyses of Mortality Risk. Jt Comm J Qual Patient Saf 2023; 49:634-647. [PMID: 37543449 DOI: 10.1016/j.jcjq.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 08/07/2023]
Abstract
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.
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Hulsegge G, Coenen P, Gascon GM, Pahwa M, Greiner B, Bohane C, Wong IS, Liira J, Riera R, Pachito DV. Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers. Cochrane Database Syst Rev 2023; 9:CD010639. [PMID: 37694838 PMCID: PMC10494487 DOI: 10.1002/14651858.cd010639.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
BACKGROUND Shift work is associated with insufficient sleep, which can compromise worker alertness with ultimate effects on occupational health and safety. Adapting shift work schedules may reduce adverse occupational outcomes. OBJECTIVES To assess the effects of shift schedule adaptation on sleep quality, sleep duration, and sleepiness among shift workers. SEARCH METHODS We searched CENTRAL, PubMed, Embase, and eight other databases on 13 December 2020, and again on 20 April 2022, applying no language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-RCTs, including controlled before-after (CBA) trials, interrupted time series, and cross-over trials. Eligible trials evaluated any of the following shift schedule components. • Permanency of shifts • Regularity of shift changes • Direction of shift rotation • Speed of rotation • Shift duration • Timing of start of shifts • Distribution of shift schedule • Time off between shifts • Split shifts • Protected sleep • Worker participation We included studies that assessed sleep quality off-shift, sleep duration off-shift, or sleepiness during shifts. DATA COLLECTION AND ANALYSIS Two review authors independently screened the titles and abstracts of the records recovered by the search, read through the full-text articles of potentially eligible studies, and extracted data. We assessed the risk of bias of included studies using the Cochrane risk of bias tool, with specific additional domains for non-randomised and cluster-randomised studies. For all stages, we resolved any disagreements by consulting a third review author. We presented the results by study design and combined clinically homogeneous studies in meta-analyses using random-effects models. We assessed the certainty of the evidence with GRADE. MAIN RESULTS We included 11 studies with a total of 2125 participants. One study was conducted in a laboratory setting and was not considered for drawing conclusions on intervention effects. The included studies investigated different and often multiple changes to shift schedule, and were heterogeneous with respect to outcome measurement. Forward versus backward rotation Three CBA trials (561 participants) investigated the effects of forward rotation versus backward rotation. Only one CBA trial provided sufficient data for the quantitative analysis; it provided very low-certainty evidence that forward rotation compared with backward rotation did not affect sleep quality measured with the Basic Nordic Sleep Questionnaire (BNSQ; mean difference (MD) -0.20 points, 95% confidence interval (CI) -2.28 to 1.89; 62 participants) or sleep duration off-shift (MD -0.21 hours, 95% CI -3.29 to 2.88; 62 participants). However, there was also very low-certainty evidence that forward rotation reduced sleepiness during shifts measured with the BNSQ (MD -1.24 points, 95% CI -2.24 to -0.24; 62 participants). Faster versus slower rotation Two CBA trials and one non-randomised cross-over trial (341 participants) evaluated faster versus slower shift rotation. We were able to meta-analyse data from two studies. There was low-certainty evidence of no difference in sleep quality off-shift (standardised mean difference (SMD) -0.01, 95% CI -0.26 to 0.23) and very low-certainty evidence that faster shift rotation reduced sleep duration off-shift (SMD -0.26, 95% CI -0.51 to -0.01; 2 studies, 282 participants). The SMD for sleep duration translated to an MD of 0.38 hours' less sleep per day (95% CI -0.74 to -0.01). One study provided very low-certainty evidence that faster rotations decreased sleepiness during shifts measured with the BNSQ (MD -1.24 points, 95% CI -2.24 to -0.24; 62 participants). Limited shift duration (16 hours) versus unlimited shift duration Two RCTs (760 participants) evaluated 80-hour workweeks with maximum daily shift duration of 16 hours versus workweeks without any daily shift duration limits. There was low-certainty evidence that the 16-hour limit increased sleep duration off-shift (SMD 0.50, 95% CI 0.21 to 0.78; which translated to an MD of 0.73 hours' more sleep per day, 95% CI 0.30 to 1.13; 2 RCTs, 760 participants) and moderate-certainty evidence that the 16-hour limit reduced sleepiness during shifts, measured with the Karolinska Sleepiness Scale (SMD -0.29, 95% CI -0.44 to -0.14; which translated to an MD of 0.37 fewer points, 95% CI -0.55 to -0.17; 2 RCTs, 716 participants). Shorter versus longer shifts One RCT, one CBA trial, and one non-randomised cross-over trial (692 participants) evaluated shorter shift duration (eight to 10 hours) versus longer shift duration (two to three hours longer). There was very low-certainty evidence of no difference in sleep quality (SMD -0.23, 95% CI -0.61 to 0.15; which translated to an MD of 0.13 points lower on a scale of 1 to 5; 2 studies, 111 participants) or sleep duration off-shift (SMD 0.18, 95% CI -0.17 to 0.54; which translated to an MD of 0.26 hours' less sleep per day; 2 studies, 121 participants). The RCT and the non-randomised cross-over study found that shorter shifts reduced sleepiness during shifts, while the CBA study found no effect on sleepiness. More compressed versus more spread out shift schedules One RCT and one CBA trial (346 participants) evaluated more compressed versus more spread out shift schedules. The CBA trial provided very low-certainty evidence of no difference between the groups in sleep quality off-shift (MD 0.31 points, 95% CI -0.53 to 1.15) and sleep duration off-shift (MD 0.52 hours, 95% CI -0.52 to 1.56). AUTHORS' CONCLUSIONS Forward and faster rotation may reduce sleepiness during shifts, and may make no difference to sleep quality, but the evidence is very uncertain. Very low-certainty evidence indicated that sleep duration off-shift decreases with faster rotation. Low-certainty evidence indicated that on-duty workweeks with shift duration limited to 16 hours increases sleep duration, with moderate-certainty evidence for minimal reductions in sleepiness. Changes in shift duration and compression of workweeks had no effect on sleep or sleepiness, but the evidence was of very low-certainty. No evidence is available for other shift schedule changes. There is a need for more high-quality studies (preferably RCTs) for all shift schedule interventions to draw conclusions on the effects of shift schedule adaptations on sleep and sleepiness in shift workers.
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Affiliation(s)
- Gerben Hulsegge
- The Netherlands Organization for Applied Scientific Research, TNO, Leiden, Netherlands
| | - Pieter Coenen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Gregg M Gascon
- OhioHealth, Columbus, Ohio, USA
- Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Manisha Pahwa
- Occupational Cancer Research Centre, Ontario Health, Toronto, Canada
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Birgit Greiner
- School of Public Health, University College Cork, Cork, Ireland
| | | | - Imelda S Wong
- Division of Science Integration, National Institute for Occupational Safety and Health, Cincinnati, OH, USA
| | - Juha Liira
- Department of Occupational Health, University of Turku, Turku, Finland
| | - Rachel Riera
- Cochrane Brazil Rio de Janeiro, Cochrane, Petrópolis, Brazil
- Center of Health Technology Assessment, Hospital Sírio-Libanês, São Paulo, Brazil
- Núcleo de Ensino e Pesquisa em Saúde Baseada em Evidência, Avaliação Tecnológica e Ensino em Saúde (NEP-Sbeats), Universidade Federal de São Paulo, São Paulo, Brazil
| | - Daniela V Pachito
- Prossono Centro de Diagnóstico e Medicina do Sono, Ribeirão Preto, São Paulo, Brazil
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Moen J. An Ergogenic Medical Education: Building Curricula to Optimize Performance and Decrease Burnout. Cureus 2021; 13:e17855. [PMID: 34660060 PMCID: PMC8502734 DOI: 10.7759/cureus.17855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2021] [Indexed: 11/05/2022] Open
Abstract
One of the most pervasive myths in our culture today is the belief that training increases performance. When, in fact, training decreases performance. The current structure of training programs and educational curriculums provide the evidence regarding the acceptance of this belief. Intense focus is placed on the quantity of training time with little regard for additional factors. In pursuit of excellence, maximizing training opportunity and learning exposure insists upon the sacrifice of recovery time. However, recovery is the necessary training period to increase performance. In athletics, training without recovery leads to overtraining syndrome. Burnout is the non-athletic equivalency seen in under-recovered learners and workers. As demonstrated by the climbing burnout rates, the current structure of educational programs, epitomized by medical residency, perpetuates the myth that more training equals better performance. The purpose of the article does not revolve around the presentation of novel research discoveries, but it insists upon the implementation of previously established performance data in curricula development beyond athletics. The inflection and deflection points along the growth and adaptation curves can be explicitly utilized to meet the educational and professional standards set forth by educational institutions. When tracking performance as the metric, initial training stimuli creates a descending slope, e.g., "training decreases performance." The concept that training creates a negative deflection is a neglected concept in academics. By incorporating this feature into learning environments, training can transition from surviving training redundancy to thriving with an optimal work:recovery ratio.
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Affiliation(s)
- Joshua Moen
- College of Health Education, Touro University California, Vallejo, USA
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Cordoza M, Basner M, Asch DA, Shea JA, Bellini LM, Carlin M, Ecker AJ, Malone SK, Desai SV, Katz JT, Bates DW, Small DS, Volpp KG, Mott CG, Coats S, Mollicone DJ, Dinges DF. Sleep and Alertness Among Interns in Intensive Care Compared to General Medicine Rotations: A Secondary Analysis of the iCOMPARE Trial. J Grad Med Educ 2021; 13:717-721. [PMID: 34721802 PMCID: PMC8527933 DOI: 10.4300/jgme-d-21-00045.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 07/08/2021] [Accepted: 07/22/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Medical interns are at risk for sleep deprivation from long and often rotating work schedules. However, the effects of specific rotations on sleep are less clear. OBJECTIVE To examine differences in sleep duration and alertness among internal medicine interns during inpatient intensive care unit (ICU) compared to general medicine (GM) rotations. METHODS This secondary analysis compared interns during a GM or ICU rotation from a randomized trial (2015-2016) of 12 internal medicine residency programs assigned to different work hour limit policies (standard 16-hour shifts or no shift-length limits). The primary outcome was sleep duration/24-hour using continuous wrist actigraphy over a 13-day period. Secondary outcomes assessed each morning during the concomitant actigraphy period were sleepiness (Karolinska Sleepiness Scale [KSS]), alertness (number of Brief Psychomotor Vigilance Test [PVT-B] lapses), and self-report of excessive sleepiness over past 24 hours. Linear mixed-effect models with random program intercept determined associations between each outcome by rotation, controlling for age, sex, and work hour policy followed. RESULTS Of 398 interns, 386 were included (n = 261 GM, n = 125 ICU). Average sleep duration was 7.00±0.08h and 6.84±0.10h, and number of PVT lapses were 5.5±0.5 and 5.7±0.7 for GM and ICU, respectively (all P > .05). KSS was 4.8±0.1 for both rotations. Compared to GM, ICU interns reported more days of excessive sleepiness from 12am-6am (2.6 vs 1.7, P < .001) and 6am-12pm (2.6 vs 1.9, P = .013) and had higher percent of days with sleep duration < 6 hours (27.6% vs 23.4%, P < .001). GM interns reported more days with no excessive sleepiness (5.3 vs 3.7, P < .001). CONCLUSIONS Despite ICU interns reporting more excessive sleepiness in morning hours and more days of insufficient sleep (<6 hours), overall sleep duration and alertness did not significantly differ between rotations.
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Affiliation(s)
- Makayla Cordoza
- Makayla Cordoza, PhD, RN, CCRN-K*, is a Lecturer, University of Pennsylvania
| | - Mathias Basner
- Mathias Basner, MD, PhD, MSc*, is a Professor, University of Pennsylvania
| | - David A. Asch
- David A. Asch, MD, MBA, is a Professor, University of Pennsylvania, and Practicing Physician, Corporal Michael J. Crescenz Veterans Affairs Medical Center
| | - Judy A. Shea
- Judy A. Shea, PhD, is a Professor, University of Pennsylvania
| | - Lisa M. Bellini
- Lisa M. Bellini, MD, is a Professor, University of Pennsylvania
| | - Michele Carlin
- Michele Carlin is a Project Manager, University of Pennsylvania
| | - Adrian J. Ecker
- Adrian J. Ecker is a Senior IT Project Leader, University of Pennsylvania
| | - Susan K. Malone
- Susan K. Malone, PhD, RN, is an Assistant Professor, New York University
| | - Sanjay V. Desai
- Sanjay V. Desai, MD, is a Professor, Johns Hopkins University
| | - Joel T. Katz
- Joel T. Katz, MD, is Vice Chair for Education, Brigham and Women's Hospital
| | - David W. Bates
- David W. Bates, MD, MSc, is Division of General Internal Medicine Chief, Brigham and Women's Hospital
| | - Dylan S. Small
- Dylan S. Small, PhD, is a Professor, University of Pennsylvania
| | - Kevin G. Volpp
- Kevin G. Volpp, MD, PhD, is a Professor, University of Pennsylvania, and Practicing Physician, Corporal Michael J. Crescenz Veterans Affairs Medical Center
| | | | - Sara Coats
- Sara Coats, BS, is Lead Project Coordinator, Pulsar Informatics
| | | | - David F. Dinges
- David F. Dinges, PhD, is a Professor, University of Pennsylvania; and iCOMPARE Research Group
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5
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Chaiyachati KH, Shea JA, Asch DA, Liu M, Bellini LM, Dine CJ, Sternberg AL, Gitelman Y, Yeager AM, Asch JM, Desai SV. Assessment of Inpatient Time Allocation Among First-Year Internal Medicine Residents Using Time-Motion Observations. JAMA Intern Med 2019; 179:760-767. [PMID: 30985861 PMCID: PMC8462976 DOI: 10.1001/jamainternmed.2019.0095] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
IMPORTANCE The United States spends more than $12 billion annually on graduate medical education. Understanding how residents balance patient care and educational activities may provide insights into how the modern physician workforce is being trained. OBJECTIVE To describe how first-year internal medicine residents (interns) allocate time while working on general medicine inpatient services. DESIGN, SETTING, AND PARTICIPANTS Direct observational secondary analysis, including 6 US university-affiliated and community-based internal medicine programs in the mid-Atlantic region, of the Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial, a cluster-randomized trial comparing different duty-hour policies. A total of 194 weekday shifts were observed and time motion data were collected, sampled by daytime, nighttime, and call shifts in proportion to the distribution of shifts within each program from March 10 through May 31, 2016. Data were analyzed from June 1, 2016, through January 5, 2019. MAIN OUTCOMES AND MEASURES Mean time spent in direct and indirect patient care, education, rounds, handoffs, and miscellaneous activities within a 24-hour period and in each of four 6-hour periods (morning, afternoon, evening, and night). Time spent multitasking, simultaneously engaged in combinations of direct patient care, indirect patient care, or education, and in subcategories of indirect patient care were tracked. RESULTS A total of 80 interns (55% men; mean [SD] age, 28.7 [2.3] years) were observed across 194 shifts, totaling 2173 hours. A mean (SD) of 15.9 (0.7) hours of a 24-hour period (66%) was spent in indirect patient care, mostly interactions with the patient's medical record or documentation (mean [SD], 10.3 [0.7] hours; 43%). A mean (SD) of 3.0 (0.1) hours was spent in direct patient care (13%) and 1.8 (0.3) hours in education (7%). This pattern was consistent across the 4 periods of the day. Direct patient care and education frequently occurred when interns were performing indirect patient care. Multitasking with 2 or more indirect patient care activities occurred for a mean (SD) of 3.8 (0.4) hours (16%) of the day. CONCLUSIONS AND RELEVANCE This study's findings suggest that within these US teaching programs, interns spend more time participating in indirect patient care than interacting with patients or in dedicated educational activities. These findings provide an essential baseline measure for future efforts designed to improve the workday structure and experience of internal medicine trainees, without making a judgment on the current allocation of time. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02274818.
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Affiliation(s)
- Krisda H Chaiyachati
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Judy A Shea
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - David A Asch
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Manqing Liu
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Lisa M Bellini
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - C Jessica Dine
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Alice L Sternberg
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Yevgeniy Gitelman
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Alyssa M Yeager
- Department of Medicine, Yale-New Haven Hospital, New Haven, Connecticut
| | - Jeremy M Asch
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia
| | - Sanjay V Desai
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
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6
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Basner M, Asch DA, Shea JA, Bellini LM, Carlin M, Ecker AJ, Malone SK, Desai SV, Sternberg AL, Tonascia J, Shade DM, Katz JT, Bates DW, Even-Shoshan O, Silber JH, Small DS, Volpp KG, Mott CG, Coats S, Mollicone DJ, Dinges DF. Sleep and Alertness in a Duty-Hour Flexibility Trial in Internal Medicine. N Engl J Med 2019; 380:915-923. [PMID: 30855741 PMCID: PMC6457111 DOI: 10.1056/nejmoa1810641] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A purpose of duty-hour regulations is to reduce sleep deprivation in medical trainees, but their effects on sleep, sleepiness, and alertness are largely unknown. METHODS We randomly assigned 63 internal-medicine residency programs in the United States to follow either standard 2011 duty-hour policies or flexible policies that maintained an 80-hour workweek without limits on shift length or mandatory time off between shifts. Sleep duration and morning sleepiness and alertness were compared between the two groups by means of a noninferiority design, with outcome measures including sleep duration measured with actigraphy, the Karolinska Sleepiness Scale (with scores ranging from 1 [extremely alert] to 9 [extremely sleepy, fighting sleep]), and a brief computerized Psychomotor Vigilance Test (PVT-B), with long response times (lapses) indicating reduced alertness. RESULTS Data were obtained over a period of 14 days for 205 interns at six flexible programs and 193 interns at six standard programs. The average sleep time per 24 hours was 6.85 hours (95% confidence interval [CI], 6.61 to 7.10) among those in flexible programs and 7.03 hours (95% CI, 6.78 to 7.27) among those in standard programs. Sleep duration in flexible programs was noninferior to that in standard programs (between-group difference, -0.17 hours per 24 hours; one-sided lower limit of the 95% confidence interval, -0.45 hours; noninferiority margin, -0.5 hours; P = 0.02 for noninferiority), as was the score on the Karolinska Sleepiness Scale (between-group difference, 0.12 points; one-sided upper limit of the 95% confidence interval, 0.31 points; noninferiority margin, 1 point; P<0.001). Noninferiority was not established for alertness according to the PVT-B (between-group difference, -0.3 lapses; one-sided upper limit of the 95% confidence interval, 1.6 lapses; noninferiority margin, 1 lapse; P = 0.10). CONCLUSIONS This noninferiority trial showed no more chronic sleep loss or sleepiness across trial days among interns in flexible programs than among those in standard programs. Noninferiority of the flexible group for alertness was not established. (Funded by the National Heart, Lung, and Blood Institute and American Council for Graduate Medical Education; ClinicalTrials.gov number, NCT02274818.).
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Affiliation(s)
- Mathias Basner
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - David A Asch
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Judy A Shea
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Lisa M Bellini
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Michele Carlin
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Adrian J Ecker
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Susan K Malone
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Sanjay V Desai
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Alice L Sternberg
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - James Tonascia
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - David M Shade
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Joel T Katz
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - David W Bates
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Orit Even-Shoshan
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Jeffrey H Silber
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Dylan S Small
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Kevin G Volpp
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Christopher G Mott
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Sara Coats
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Daniel J Mollicone
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - David F Dinges
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
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Silber JH, Bellini LM, Shea JA, Desai SV, Dinges DF, Basner M, Even-Shoshan O, Hill AS, Hochman LL, Katz JT, Ross RN, Shade DM, Small DS, Sternberg AL, Tonascia J, Volpp KG, Asch DA. Patient Safety Outcomes under Flexible and Standard Resident Duty-Hour Rules. N Engl J Med 2019; 380:905-914. [PMID: 30855740 PMCID: PMC6476299 DOI: 10.1056/nejmoa1810642] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
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.).
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Affiliation(s)
- Jeffrey H Silber
- From the Center for Outcomes Research, Children's Hospital of Philadelphia (J.H.S., O.E.-S., A.S.H., L.L.H., R.N.R.), the Departments of Pediatrics (J.H.S.), Anesthesiology and Critical Care (J.H.S.), and Medicine (L.M.B., J.A.S., K.G.V., D.A.A.), University of Pennsylvania School of Medicine, the Departments of Health Care Management (J.H.S., K.G.V., D.A.A.) and Statistics (D.S.S.), the Wharton School, the Leonard Davis Institute of Health Economics (J.H.S., J.A.S., D.S.S., K.G.V., D.A.A.), and the Department of Psychiatry (D.F.D., M.B.), University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (K.G.V., D.A.A.) - all in Philadelphia; the Departments of Medicine (S.V.D.), Epidemiology (D.M.S., A.L.S., J.T.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; and the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K.)
| | - Lisa M Bellini
- From the Center for Outcomes Research, Children's Hospital of Philadelphia (J.H.S., O.E.-S., A.S.H., L.L.H., R.N.R.), the Departments of Pediatrics (J.H.S.), Anesthesiology and Critical Care (J.H.S.), and Medicine (L.M.B., J.A.S., K.G.V., D.A.A.), University of Pennsylvania School of Medicine, the Departments of Health Care Management (J.H.S., K.G.V., D.A.A.) and Statistics (D.S.S.), the Wharton School, the Leonard Davis Institute of Health Economics (J.H.S., J.A.S., D.S.S., K.G.V., D.A.A.), and the Department of Psychiatry (D.F.D., M.B.), University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (K.G.V., D.A.A.) - all in Philadelphia; the Departments of Medicine (S.V.D.), Epidemiology (D.M.S., A.L.S., J.T.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; and the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K.)
| | - Judy A Shea
- From the Center for Outcomes Research, Children's Hospital of Philadelphia (J.H.S., O.E.-S., A.S.H., L.L.H., R.N.R.), the Departments of Pediatrics (J.H.S.), Anesthesiology and Critical Care (J.H.S.), and Medicine (L.M.B., J.A.S., K.G.V., D.A.A.), University of Pennsylvania School of Medicine, the Departments of Health Care Management (J.H.S., K.G.V., D.A.A.) and Statistics (D.S.S.), the Wharton School, the Leonard Davis Institute of Health Economics (J.H.S., J.A.S., D.S.S., K.G.V., D.A.A.), and the Department of Psychiatry (D.F.D., M.B.), University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (K.G.V., D.A.A.) - all in Philadelphia; the Departments of Medicine (S.V.D.), Epidemiology (D.M.S., A.L.S., J.T.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; and the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K.)
| | - Sanjay V Desai
- From the Center for Outcomes Research, Children's Hospital of Philadelphia (J.H.S., O.E.-S., A.S.H., L.L.H., R.N.R.), the Departments of Pediatrics (J.H.S.), Anesthesiology and Critical Care (J.H.S.), and Medicine (L.M.B., J.A.S., K.G.V., D.A.A.), University of Pennsylvania School of Medicine, the Departments of Health Care Management (J.H.S., K.G.V., D.A.A.) and Statistics (D.S.S.), the Wharton School, the Leonard Davis Institute of Health Economics (J.H.S., J.A.S., D.S.S., K.G.V., D.A.A.), and the Department of Psychiatry (D.F.D., M.B.), University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (K.G.V., D.A.A.) - all in Philadelphia; the Departments of Medicine (S.V.D.), Epidemiology (D.M.S., A.L.S., J.T.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; and the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K.)
| | - David F Dinges
- From the Center for Outcomes Research, Children's Hospital of Philadelphia (J.H.S., O.E.-S., A.S.H., L.L.H., R.N.R.), the Departments of Pediatrics (J.H.S.), Anesthesiology and Critical Care (J.H.S.), and Medicine (L.M.B., J.A.S., K.G.V., D.A.A.), University of Pennsylvania School of Medicine, the Departments of Health Care Management (J.H.S., K.G.V., D.A.A.) and Statistics (D.S.S.), the Wharton School, the Leonard Davis Institute of Health Economics (J.H.S., J.A.S., D.S.S., K.G.V., D.A.A.), and the Department of Psychiatry (D.F.D., M.B.), University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (K.G.V., D.A.A.) - all in Philadelphia; the Departments of Medicine (S.V.D.), Epidemiology (D.M.S., A.L.S., J.T.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; and the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K.)
| | - Mathias Basner
- From the Center for Outcomes Research, Children's Hospital of Philadelphia (J.H.S., O.E.-S., A.S.H., L.L.H., R.N.R.), the Departments of Pediatrics (J.H.S.), Anesthesiology and Critical Care (J.H.S.), and Medicine (L.M.B., J.A.S., K.G.V., D.A.A.), University of Pennsylvania School of Medicine, the Departments of Health Care Management (J.H.S., K.G.V., D.A.A.) and Statistics (D.S.S.), the Wharton School, the Leonard Davis Institute of Health Economics (J.H.S., J.A.S., D.S.S., K.G.V., D.A.A.), and the Department of Psychiatry (D.F.D., M.B.), University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (K.G.V., D.A.A.) - all in Philadelphia; the Departments of Medicine (S.V.D.), Epidemiology (D.M.S., A.L.S., J.T.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; and the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K.)
| | - Orit Even-Shoshan
- From the Center for Outcomes Research, Children's Hospital of Philadelphia (J.H.S., O.E.-S., A.S.H., L.L.H., R.N.R.), the Departments of Pediatrics (J.H.S.), Anesthesiology and Critical Care (J.H.S.), and Medicine (L.M.B., J.A.S., K.G.V., D.A.A.), University of Pennsylvania School of Medicine, the Departments of Health Care Management (J.H.S., K.G.V., D.A.A.) and Statistics (D.S.S.), the Wharton School, the Leonard Davis Institute of Health Economics (J.H.S., J.A.S., D.S.S., K.G.V., D.A.A.), and the Department of Psychiatry (D.F.D., M.B.), University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (K.G.V., D.A.A.) - all in Philadelphia; the Departments of Medicine (S.V.D.), Epidemiology (D.M.S., A.L.S., J.T.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; and the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K.)
| | - Alexander S Hill
- From the Center for Outcomes Research, Children's Hospital of Philadelphia (J.H.S., O.E.-S., A.S.H., L.L.H., R.N.R.), the Departments of Pediatrics (J.H.S.), Anesthesiology and Critical Care (J.H.S.), and Medicine (L.M.B., J.A.S., K.G.V., D.A.A.), University of Pennsylvania School of Medicine, the Departments of Health Care Management (J.H.S., K.G.V., D.A.A.) and Statistics (D.S.S.), the Wharton School, the Leonard Davis Institute of Health Economics (J.H.S., J.A.S., D.S.S., K.G.V., D.A.A.), and the Department of Psychiatry (D.F.D., M.B.), University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (K.G.V., D.A.A.) - all in Philadelphia; the Departments of Medicine (S.V.D.), Epidemiology (D.M.S., A.L.S., J.T.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; and the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K.)
| | - Lauren L Hochman
- From the Center for Outcomes Research, Children's Hospital of Philadelphia (J.H.S., O.E.-S., A.S.H., L.L.H., R.N.R.), the Departments of Pediatrics (J.H.S.), Anesthesiology and Critical Care (J.H.S.), and Medicine (L.M.B., J.A.S., K.G.V., D.A.A.), University of Pennsylvania School of Medicine, the Departments of Health Care Management (J.H.S., K.G.V., D.A.A.) and Statistics (D.S.S.), the Wharton School, the Leonard Davis Institute of Health Economics (J.H.S., J.A.S., D.S.S., K.G.V., D.A.A.), and the Department of Psychiatry (D.F.D., M.B.), University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (K.G.V., D.A.A.) - all in Philadelphia; the Departments of Medicine (S.V.D.), Epidemiology (D.M.S., A.L.S., J.T.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; and the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K.)
| | - Joel T Katz
- From the Center for Outcomes Research, Children's Hospital of Philadelphia (J.H.S., O.E.-S., A.S.H., L.L.H., R.N.R.), the Departments of Pediatrics (J.H.S.), Anesthesiology and Critical Care (J.H.S.), and Medicine (L.M.B., J.A.S., K.G.V., D.A.A.), University of Pennsylvania School of Medicine, the Departments of Health Care Management (J.H.S., K.G.V., D.A.A.) and Statistics (D.S.S.), the Wharton School, the Leonard Davis Institute of Health Economics (J.H.S., J.A.S., D.S.S., K.G.V., D.A.A.), and the Department of Psychiatry (D.F.D., M.B.), University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (K.G.V., D.A.A.) - all in Philadelphia; the Departments of Medicine (S.V.D.), Epidemiology (D.M.S., A.L.S., J.T.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; and the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K.)
| | - Richard N Ross
- From the Center for Outcomes Research, Children's Hospital of Philadelphia (J.H.S., O.E.-S., A.S.H., L.L.H., R.N.R.), the Departments of Pediatrics (J.H.S.), Anesthesiology and Critical Care (J.H.S.), and Medicine (L.M.B., J.A.S., K.G.V., D.A.A.), University of Pennsylvania School of Medicine, the Departments of Health Care Management (J.H.S., K.G.V., D.A.A.) and Statistics (D.S.S.), the Wharton School, the Leonard Davis Institute of Health Economics (J.H.S., J.A.S., D.S.S., K.G.V., D.A.A.), and the Department of Psychiatry (D.F.D., M.B.), University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (K.G.V., D.A.A.) - all in Philadelphia; the Departments of Medicine (S.V.D.), Epidemiology (D.M.S., A.L.S., J.T.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; and the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K.)
| | - David M Shade
- From the Center for Outcomes Research, Children's Hospital of Philadelphia (J.H.S., O.E.-S., A.S.H., L.L.H., R.N.R.), the Departments of Pediatrics (J.H.S.), Anesthesiology and Critical Care (J.H.S.), and Medicine (L.M.B., J.A.S., K.G.V., D.A.A.), University of Pennsylvania School of Medicine, the Departments of Health Care Management (J.H.S., K.G.V., D.A.A.) and Statistics (D.S.S.), the Wharton School, the Leonard Davis Institute of Health Economics (J.H.S., J.A.S., D.S.S., K.G.V., D.A.A.), and the Department of Psychiatry (D.F.D., M.B.), University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (K.G.V., D.A.A.) - all in Philadelphia; the Departments of Medicine (S.V.D.), Epidemiology (D.M.S., A.L.S., J.T.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; and the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K.)
| | - Dylan S Small
- From the Center for Outcomes Research, Children's Hospital of Philadelphia (J.H.S., O.E.-S., A.S.H., L.L.H., R.N.R.), the Departments of Pediatrics (J.H.S.), Anesthesiology and Critical Care (J.H.S.), and Medicine (L.M.B., J.A.S., K.G.V., D.A.A.), University of Pennsylvania School of Medicine, the Departments of Health Care Management (J.H.S., K.G.V., D.A.A.) and Statistics (D.S.S.), the Wharton School, the Leonard Davis Institute of Health Economics (J.H.S., J.A.S., D.S.S., K.G.V., D.A.A.), and the Department of Psychiatry (D.F.D., M.B.), University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (K.G.V., D.A.A.) - all in Philadelphia; the Departments of Medicine (S.V.D.), Epidemiology (D.M.S., A.L.S., J.T.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; and the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K.)
| | - Alice L Sternberg
- From the Center for Outcomes Research, Children's Hospital of Philadelphia (J.H.S., O.E.-S., A.S.H., L.L.H., R.N.R.), the Departments of Pediatrics (J.H.S.), Anesthesiology and Critical Care (J.H.S.), and Medicine (L.M.B., J.A.S., K.G.V., D.A.A.), University of Pennsylvania School of Medicine, the Departments of Health Care Management (J.H.S., K.G.V., D.A.A.) and Statistics (D.S.S.), the Wharton School, the Leonard Davis Institute of Health Economics (J.H.S., J.A.S., D.S.S., K.G.V., D.A.A.), and the Department of Psychiatry (D.F.D., M.B.), University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (K.G.V., D.A.A.) - all in Philadelphia; the Departments of Medicine (S.V.D.), Epidemiology (D.M.S., A.L.S., J.T.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; and the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K.)
| | - James Tonascia
- From the Center for Outcomes Research, Children's Hospital of Philadelphia (J.H.S., O.E.-S., A.S.H., L.L.H., R.N.R.), the Departments of Pediatrics (J.H.S.), Anesthesiology and Critical Care (J.H.S.), and Medicine (L.M.B., J.A.S., K.G.V., D.A.A.), University of Pennsylvania School of Medicine, the Departments of Health Care Management (J.H.S., K.G.V., D.A.A.) and Statistics (D.S.S.), the Wharton School, the Leonard Davis Institute of Health Economics (J.H.S., J.A.S., D.S.S., K.G.V., D.A.A.), and the Department of Psychiatry (D.F.D., M.B.), University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (K.G.V., D.A.A.) - all in Philadelphia; the Departments of Medicine (S.V.D.), Epidemiology (D.M.S., A.L.S., J.T.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; and the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K.)
| | - Kevin G Volpp
- From the Center for Outcomes Research, Children's Hospital of Philadelphia (J.H.S., O.E.-S., A.S.H., L.L.H., R.N.R.), the Departments of Pediatrics (J.H.S.), Anesthesiology and Critical Care (J.H.S.), and Medicine (L.M.B., J.A.S., K.G.V., D.A.A.), University of Pennsylvania School of Medicine, the Departments of Health Care Management (J.H.S., K.G.V., D.A.A.) and Statistics (D.S.S.), the Wharton School, the Leonard Davis Institute of Health Economics (J.H.S., J.A.S., D.S.S., K.G.V., D.A.A.), and the Department of Psychiatry (D.F.D., M.B.), University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (K.G.V., D.A.A.) - all in Philadelphia; the Departments of Medicine (S.V.D.), Epidemiology (D.M.S., A.L.S., J.T.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; and the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K.)
| | - David A Asch
- From the Center for Outcomes Research, Children's Hospital of Philadelphia (J.H.S., O.E.-S., A.S.H., L.L.H., R.N.R.), the Departments of Pediatrics (J.H.S.), Anesthesiology and Critical Care (J.H.S.), and Medicine (L.M.B., J.A.S., K.G.V., D.A.A.), University of Pennsylvania School of Medicine, the Departments of Health Care Management (J.H.S., K.G.V., D.A.A.) and Statistics (D.S.S.), the Wharton School, the Leonard Davis Institute of Health Economics (J.H.S., J.A.S., D.S.S., K.G.V., D.A.A.), and the Department of Psychiatry (D.F.D., M.B.), University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (K.G.V., D.A.A.) - all in Philadelphia; the Departments of Medicine (S.V.D.), Epidemiology (D.M.S., A.L.S., J.T.), and Biostatistics (J.T.), Johns Hopkins University, Baltimore; and the Department of Medicine, Brigham and Women's Hospital, Boston (J.T.K.)
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Bennett CL, McDonald DA, Dorner SC, Nadel ES, McDonald FS, McPherson JA. Association of the 2003 and 2011 ACGME Resident Duty Hour Reforms With Internal Medicine Initial Certification Examination Performance. J Grad Med Educ 2017; 9:789-790. [PMID: 29270281 PMCID: PMC5734346 DOI: 10.4300/jgme-d-17-00547.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
| | | | - Stephen C Dorner
- Resident Physician, Harvard Medical School and Massachusetts General Hospital
| | - Eric S Nadel
- Associate Professor and Emergency Medicine Program Director, Harvard Medical School and Massachusetts General Hospital
| | - Furman S McDonald
- Senior Vice President for Academic and Medical Affairs, American Board of Internal Medicine
| | - John A McPherson
- Vice Chair for Education and Internal Medicine Residency Program Director, Vanderbilt University Medical Center
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Krug MF, Golob AL, Wander PL, Wipf JE. Changes in Resident Well-Being at One Institution Across a Decade of Progressive Work Hours Limitations. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017; 92:1480-1484. [PMID: 28353505 PMCID: PMC5617767 DOI: 10.1097/acm.0000000000001675] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
PURPOSE To measure changes in markers of resident well-being over time as progressive work hours limitations (WHLs) were enforced, and to investigate resident perceptions of the 2011 WHLs. METHOD A survey study of internal medicine residents was conducted at the University of Washington's multihospital residency program in 2012. The survey included validated well-being questions: the Maslach Burnout Inventory, the two-question PRIME-MD depression screen, and career satisfaction questions. Chi-square tests were used to compare 2012 well-being questionnaire responses against nearly identical surveys conducted in 2001 and 2004 at the same institution. In addition, residents were asked to rate the impact of WHLs on resident well-being and education as well as patient care, and to state preferences for future WHLs. RESULTS Significantly different proportions of residents met burnout criteria across time, with fewer meeting criteria in 2012 than in 2001 (2001: 76% [87/115]; 2004: 64% [75/118]; 2012: 61% [68/112]; P = .039). Depression screening results also differed across time, with fewer screening positive in 2012 than in 2004 (2001: 45% [52/115]; 2004: 55% [65/118]; 2012 [35/112]: 31%; P = .001). Residents, especially seniors, reported perceived negative impacts of WHLs on their well-being, education, and patient care. Most senior residents favored reverting to the pre-July 2011 system of WHLs. Interns were more divided. CONCLUSIONS Validated measures of resident well-being changed across the three time points measured. Residents had the lowest rates of burnout and depression in 2012. Resident perceptions of the 2011 WHLs, however, were generally negative.
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Affiliation(s)
- Michael F Krug
- M.F. Krug is clinical assistant professor, Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington. A.L. Golob is acting assistant professor, Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, and attending physician, VA Puget Sound Healthcare System, Seattle, Washington. P.L. Wander is acting instructor, Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, and attending physician, VA Puget Sound Healthcare System, Seattle, Washington. J.E. Wipf is professor, Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, and section head of General Internal Medicine, VA Puget Sound Healthcare System, Seattle, Washington
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Choi Y, Kim D, Chong H, Mallow C, Bill J, Fojo AT, Blanchard M. Use of a 90-Minute Admission Window and Front-Fill System to Reduce Work Compression on a General Medicine Inpatient Teaching Service. J Grad Med Educ 2017; 9:245-249. [PMID: 28439362 PMCID: PMC5398156 DOI: 10.4300/jgme-d-16-00211.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 10/20/2016] [Accepted: 12/05/2016] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Duty hour limits have shortened intern shifts without concurrent reductions in workload, creating work compression. Multiple admissions during shortened shifts can result in poor training experience and patient care. OBJECTIVE To relieve work compression, improve resident satisfaction, and improve duty hour compliance in an academic internal medicine program. METHODS In 2014, interns on general ward services were allotted 90 minutes per admission from 3 pm to 7 pm, when the rate of admissions was high. Additional admissions arriving during the protected period were directed to hospitalists. Resident teams received 2 patients admitted by the night float team to start the call day (front-fill). RESULTS Of the 51 residents surveyed before and after the implementation of the intervention, 39 (77%) completed both surveys. Respondents reporting an unmanageable workload fell from 14 to 1 (P < .001), and the number of residents reporting that they felt unable to admit patients in a timely manner decreased from 14 to 2 (P < .001). Reports of adequate time with patients increased from 16 to 36 (P < .001), and residents indicating that they had time to learn from patients increased from 19 to 35 (P < .001). Reports of leaving on time after call days rose from 12 to 33 (P < .01), and overall satisfaction increased from 26 to 35 (P = .002). Results were similar when residents were resurveyed 6 months after the intervention. CONCLUSIONS Call day modifications improved resident perceptions of their workload and time for resident learning and patient care.
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Affiliation(s)
- Matthew D Alvin
- Resident Physician, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Hospital
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12
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Implementation of 2011 Duty Hours Regulations through a Workload Reduction Strategy and Impact on Residency Training. J Gen Intern Med 2016; 31:1475-1481. [PMID: 27514539 PMCID: PMC5130957 DOI: 10.1007/s11606-016-3840-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 05/19/2016] [Accepted: 07/27/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Training programs have implemented the 2011 ACGME duty hour regulations (DHR) using "workload compression" (WLC) strategies, attempting to fit similar clinical responsibilities into fewer working hours, or workload reduction (WLR) approaches, reducing the number of patient encounters per trainee. Many have expressed concern that these strategies could negatively impact patient care and learner outcomes. OBJECTIVE This study evaluates the medical knowledge and clinical impact of a WLR intervention in a single institution. DESIGN & PARTICIPANTS Nonrandomized intervention study with comparison to a historical control study among 58 PGY-1 internal medicine trainees in the 2 years after duty hour implementation [exposure cohort (EC), 7/1/2011-6/30/2013], compared to 2 years before implementation [comparison cohort (CC), 7/1/2009-6/30/2011]. MAIN MEASURES Process outcomes were average inpatient encounters, average new inpatient admissions, and average scheduled outpatient encounters per PGY-1 year. Performance outcomes included trainee inpatient and outpatient days on service, In-Training Examination (ITE) scores as an objective surrogate of medical knowledge, Case-Mix Index (CMI), and quality of care measures (30-day readmission rate, 30-day mortality rate, and average length of stay). KEY RESULTS Baseline characteristics and average numbers of inpatient encounters per PGY-1 class were similar between the EC and CC. However, the EC experienced fewer new inpatient admissions (157.47 ± 40.47 vs. 181.72 ± 25.45; p < 0.01), more outpatient encounters (64.80 ± 10.85 vs. 56.98 ± 6.59; p < 0.01), and had similar ITE percentiles (p = 0.58). Patients of similar complexity cared for by the EC also had a greater reduction in readmissions (21.21 % to 19.08 %; p < 0.01) than the hospital baseline (12.07 to 11.14 %; p < 0.01). CONCLUSIONS Our WLR resulted in a small decrease in the average number of new inpatient admissions and an increase in outpatient encounters. ITE and care quality outcomes were maintained or improved. While there is theoretical concern that reducing PGY-1 inpatient admissions volumes may negatively impact education and clinical care measures, this study found no evidence of such a trade-off.
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Scally CP, Sandhu G, Magas C, Gauger PG, Minter RM. Investigating the Impact of the 2011 ACGME Resident Duty Hour Regulations on Surgical Residency Programs: The Program Director Perspective. J Am Coll Surg 2015; 221:883-9.e1. [PMID: 26272015 PMCID: PMC4569491 DOI: 10.1016/j.jamcollsurg.2015.07.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 07/01/2015] [Accepted: 07/08/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND The 2011 ACGME regulations required substantial changes to the structure of general surgery residency programs, due primarily to the 16-hour in-house rule for PGY1 residents. However, the scope of changes that programs have undertaken to meet these requirements, and the educational impact of those changes, are poorly understood. STUDY DESIGN We performed in-depth qualitative interviews with general surgery program directors. Twenty program directors participated in the study; interviews were conducted until adequate thematic saturation was achieved. Participants were recruited from a stratified random sampling of residency programs in the United States to ensure a representative cohort. Interviews focused on changes in call schedule, interns' educational requirements, development, and satisfaction. RESULTS Most programs used a month-long night float (NF) rotation (14 of 20 [75%]). A minority of programs (5 of 20 [25%]) used a weekly rotating schedule, in which interns worked 5 to 6 nights in a month. Multiple programs (65%) had an NF in place before 2011; these programs made changes to and expanded their existing schedule to accommodate the new regulations. Commonly cited challenges to instituting NF included weekend coverage (60%) and providing adequate days off during day-to-night transition. Interns spent as much as 3 months of the year on NF. Only 5 programs made explicit changes to teaching schedules or developed a curriculum for residents on NF. Seventy-five percent of programs excused interns, explicitly or implicitly, from didactic teaching when on NF. Common themes noted by program directors included delayed maturation of trainees, interns being isolated from the team culture, and a conflict between the professional behaviors of "following the rules" and "doing what is right."
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Affiliation(s)
- Christopher P Scally
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI.
| | - Gurjit Sandhu
- Department of Surgery, University of Michigan, Ann Arbor, MI; Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI
| | | | - Paul G Gauger
- Department of Surgery, University of Michigan, Ann Arbor, MI; Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI
| | - Rebecca M Minter
- Department of Surgery, University of Michigan, Ann Arbor, MI; Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI
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