Teaching Hospital Five-Year Mortality Trends in the Wake of Duty Hour Reforms
Purchase on Springer.com
$39.95 / €34.95 / £29.95*
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.
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.
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.
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.
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.
All-location mortality within 30 days of hospital admission.
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]).
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.
- Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. Washington: National Academy Press; 2000.
- Accreditation Council for Graduate Medical Education. Resident duty hours language: Final requirements. 2003; http://www.acgme.org. Accessed February 18, 2013.
- Accreditation Council for Graduate Medical Education. Report of the work group on resident duty hours and the learning environment. June 11, 2002. In: The ACGME’s approach to limit resident duty hours 12 months after implementation: a summary of achievements, 2004. 2006; http://www.acgme.org/acgmeweb/Portals/0/PFAssets/PublicationsPapers/dh_dutyhoursummary2003–04.pdf. Accessed February 18, 2013.
- Volpp KG, Rosen AK, Rosenbaum PR, et al. Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298(9):975–83. CrossRef
- Volpp KG, Rosen AK, Rosenbaum PR, et al. Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298(9):984–92. CrossRef
- Shetty KD, Bhattacharya J. Changes in hospital mortality associated with residency work-hour regulations. Ann Intern Med. 2007;147(2):73–80. CrossRef
- Volpp KG, Rosen AK, Rosenbaum PR, et al. Did duty hour reform lead to better outcomes among the highest risk patients? J Gen Intern Med. 2009;24(10):1149–55. CrossRef
- Rosen AK, Loveland SA, Romano PS, et al. Effects of resident duty hour reform on surgical and procedural patient safety indicators among hospitalized Veterans Health Administration and Medicare patients. Med Care. 2009;47(7):723–31. CrossRef
- Press MJ, Silber JH, Rosen AK, et al. The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries. J Gen Intern Med. 2011;26(4):405–11. CrossRef
- Silber JH, Rosenbaum PR, Rosen AK, et al. Prolonged hospital stay and the resident duty hour rules of 2003. Med Care. 2009;47(12):1191–200. CrossRef
- Nasca TJ, Day SH, Amis ES, Jr. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010.
- Croasdale M. Johns Hopkins Penalized for Resident Hour Violations. 2003; http://www.ama-assn.org/amednews/2003/09/15/prsc0915.htm. Accessed February 18, 2013.
- Killelea BK, Chao L, Scarpinato V, Wallack MK. The 80-hour workweek. Surg Clin N Am. 2004;84(6):1557–72, x.
- Fletcher KE, Reed DA, Arora VM. Patient safety, resident education and resident well-being following implementation of the 2003 ACGME duty hour rules. J Gen Intern Med. 2011;26(8):907–19. CrossRef
- Moonesinghe SR, Lowery J, Shahi N, Millen A, Beard JD. Impact of reduction in working hours for doctors in training on postgraduate medical education and patients’ outcomes: systematic review. BMJ (Clin Res Ed). 2011;342:d1580. CrossRef
- Iezzoni LI. Risk Adjustment for Measuring Health-care Outcomes. 3rd ed. Chicago: Health Administration Press; 2003.
- Rockall TA, Logan RF, Devlin HB, Northfield TC. Variation in outcome after acute upper gastrointestinal haemorrhage. The National Audit of Acute Upper Gastrointestinal Haemorrhage. Lancet. 1995;346(8971):346–50. CrossRef
- Agency for Healthcare Research and Quality. Inpatient Quality Indicators Download. AHRQ Quality Indicators. 2007; http://www.qualityindicators.ahrq.gov/downloads/software/sas/v21r4/iqi_guide_rev4.pdf Accessed February 18, 2013.
- Second Report of the California Hospitals Outcomes Project. Acute Myocardial Infarction 1996; http://repositories.cdlib.org/chsrpc/coshpd/index.html#1996. Accessed February 18, 2013.
- Iezzoni LI, Burnside S, Sickles L, Moskowitz MA, Sawitz E. Coding of acute myocardial infarction: clinical policy and implications. Ann Intern Med. 1988;109:745–51. CrossRef
- Kiyota Y, Schneeweiss S, Glynn RJ, Cannuscio CC, Avorn J, Solomon DH. Accuracy of Medicare claims-based diagnosis of acute myocardial infarction: estimating positive predictive value on the basis of review of hospital records. Am Hear J. 2004;148(1):99–104. CrossRef
- Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8–27. CrossRef
- Lawthers AG, McCarthy EP, Davis RB, Petersen LE, Palmer RH, Iezzoni LI. Identification of in-hospital complications from claims data: is it valid? Med Care. 2000;38(8):785–95. CrossRef
- Keeler EB, Rubenstein LV, Kahn KL, et al. Hospital characteristics and quality of care. JAMA. 1992;268(13):1709–14. CrossRef
- Allison JJ, Kiefe CI, Weissman NW, et al. Relationship of hospital teaching status with quality of care and mortality for Medicare patients with acute MI. JAMA. 2000;284(10):1256–62. CrossRef
- Taylor DH, Whellan DJ, Sloan FA. Effects of admission to a teaching hospital on the cost and quality of care for Medicare beneficiaries. N Engl J Med. 1999;340(4):293–9. CrossRef
- Campbell DT, Stanley JC. Experimental and Quasi-Experimental Designs for Research. Dallas: Houghton Mifflin Company; 1963.
- Shadish WR, Cook TD, Campbell DT. Experimental and Quasi-Experimental Designs for Generalized Causal Inference. Boston: Houghton-Mifflin; 2002.
- Rosenbaum PR. Stability in the absence of treatment. J Am Stat Assoc. 2001;96:210–9. CrossRef
- Field C, Welsh A. Bootstrapping clustered data. J R Stat Soc Ser B Methodol. 2007;69:369–90. CrossRef
- CMS. Fiscal year 2009 quality measure reporting for 2010 payment update 2009; https://www.cms.gov/HospitalQualityInits/downloads/HospitalRHQDAPU200808.pdf. Accessed February 18, 2013.
- CMS. Premier Hospital Quality Incentive Demonstration. 2011; https://www.cms.gov/HospitalQualityInits/35_HospitalPremier.asp. Accessed February 18, 2013.
- RAC. Critical access hospital (CAH) frequently asked questions. Health and human services information for rural America 2011; http://www.raconline.org/topics/hospitals/cahfaq.php. Accessed February 18, 2013.
- Landrigan CP, Barger LK, Cade BE, Ayas NT, Czeisler CA. Interns’ compliance with accreditation council for graduate medical education work-hour limits. JAMA. 2006;296(9):1063–70. CrossRef
- Accreditation Council for Graduate Medical Education. The ACGME’s approach to limit resident duty hours 12 months after implementation: A summary of achievements, 2004. 2006; http://www.acgme.org/acgmeweb/Portals/0/PFAssets/PublicationsPapers/dh_dutyhoursummary2003-04.pdf. Accessed February 18, 2013.
- Pellegrini VD Jr, Peabody T, Dinges DF, Moody J, Fabri PJ. Symposium resident work-hour guidelines. A sentence or an opportunity for orthopaedic education? J Bone Joint Surg Am. 2005;87(11):2576–86. CrossRef
- Teaching Hospital Five-Year Mortality Trends in the Wake of Duty Hour Reforms
Journal of General Internal Medicine
Volume 28, Issue 8 , pp 1048-1055
- Cover Date
- Print ISSN
- Online ISSN
- Springer US
- Additional Links
- patient outcomes
- duty hour reform
- administrative data
- Industry Sectors
- Kevin G. Volpp MD, PhD (1) (2) (3) (4)
- Dylan S. Small PhD (5)
- Patrick S. Romano MD, MPH (6)
- Kamal M. F. Itani MD (7)
- Amy K. Rosen PhD (8) (9)
- Orit Even-Shoshan MS (10) (12)
- Yanli Wang MS (10)
- Lisa Bellini MD (2)
- Michael J. Halenar BA (1) (2)
- Sophia Korovaichuk BA (10)
- Jingsan Zhu MBA (2) (4)
- Jeffrey H. Silber MD, PhD (10) (11) (12) (3)
- Author Affiliations
- 1. Center for Health Equity Research and Promotion, Veteran’s Administration Hospital, 1120 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104-6021, USA
- 2. Department of Medicine, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
- 3. Department of Health Care Management, The Wharton School, The University of Pennsylvania, Philadelphia, PA, USA
- 4. The Leonard Davis Institute, Center for Health Incentives and Behavioral Economics, The University of Pennsylvania, Philadelphia, PA, USA
- 5. Department of Statistics, The Wharton School, The University of Pennsylvania, Philadelphia, PA, USA
- 6. Division of General Medicine and Center for Healthcare Policy and Research, University of California Davis School of Medicine, Sacramento, CA, USA
- 7. Department of Surgery, VA Boston Healthcare System and Boston University, Boston, MA, USA
- 8. Center for Organization, Leadership and Management Research, VA Boston Healthcare System, Boston, MA, USA
- 9. Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA
- 10. Center for Outcomes Research, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- 12. Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
- 11. The Departments of Pediatrics and Anesthesiology and Critical Care, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA