ABSTRACT
BACKGROUND
The Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour regulations for residents in 2003 and again in 2011. While previous studies showed no systematic impacts in the first 2 years post-reform, the impact on mortality in subsequent years has not been examined.
OBJECTIVE
To determine whether duty hour regulations were associated with changes in mortality among Medicare patients in hospitals of different teaching intensity after the first 2 years post-reform.
DESIGN
Observational study using interrupted time series analysis with data from July 1, 2000 to June 30, 2008. Logistic regression was used to examine the change in mortality for patients in more versus less teaching-intensive hospitals before (2000–2003) and after (2003–2008) duty hour reform, adjusting for patient comorbidities, time trends, and hospital site.
PATIENTS
Medicare patients (n = 13,678,956) admitted to short-term acute care non-federal hospitals with principal diagnoses of acute myocardial infarction (AMI), gastrointestinal bleeding, or congestive heart failure (CHF); or a diagnosis-related group (DRG) classification of general, orthopedic, or vascular surgery.
MAIN MEASURE
All-location mortality within 30 days of hospital admission.
KEY RESULTS
In medical and surgical patients, there were no consistent changes in the odds of mortality at more vs. less teaching intensive hospitals in post-reform years 1–3. However, there were significant relative improvements in mortality for medical patients in the fourth and fifth years post-reform: Post4 (OR 0.88, 95 % CI [0.93–0.94]); Post5 (OR 0.87, [0.82–0.92]) and for surgical patients in the fifth year post-reform: Post5 (OR 0.91, [0.85–0.96]).
CONCLUSIONS
Duty hour reform was associated with no significant change in mortality in the early years after implementation, and with a trend toward improved mortality among medical patients in the fourth and fifth years. It is unclear whether improvements in outcomes long after implementation can be attributed to the reform, but concerns about worsening outcomes seem unfounded.
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Acknowledgements
This work was funded by grant R01 HL094593-01 from the NHLBI.
Conflict of Interest
The sponsors/funders have had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. There are no known financial conflicts of interest among any of the authors, including but not limited to employment/affiliation, grants or funding, honoraria, paid consultancies, expert testimony, stock ownership or options, and patents filed, received or pending. Both Dr. Volpp and Dr. Bellini served as unpaid members of the Committee on Innovations for the ACGME from 2005 to 2009.
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APPENDIX
APPENDIX
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Volpp, K.G., Small, D.S., Romano, P.S. et al. Teaching Hospital Five-Year Mortality Trends in the Wake of Duty Hour Reforms. J GEN INTERN MED 28, 1048–1055 (2013). https://doi.org/10.1007/s11606-013-2401-9
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DOI: https://doi.org/10.1007/s11606-013-2401-9