Did Duty Hour Reform Lead to Better Outcomes Among the Highest Risk Patients?

  • Kevin G. VolppEmail author
  • Amy K. Rosen
  • Paul R. Rosenbaum
  • Patrick S. Romano
  • Kamal M.F. Itani
  • Lisa Bellini
  • Orit Even-Shoshan
  • Liyi Cen
  • Yanli Wang
  • Michael J. Halenar
  • Jeffrey H. Silber
Hospital Medicine



Earlier work demonstrated that ACGME duty hour reform did not adversely affect mortality, with slight improvement noted among specific subgroups.


To determine whether resident duty hour reform differentially affected the mortality risk of high severity patients or patients who experienced post-operative complications (failure-to-rescue).


Observational study using interrupted time series analysis with data from July 1, 2000 - June 30, 2005. Fixed effects logistic regression was used to examine the change in the odds of mortality or failure-to-rescue (FTR) in more versus less teaching-intensive hospitals before and after duty hour reform.


All unique Medicare patients (n = 8,529,595) admitted to short-term acute care non-federal hospitals and all unique VA patients (n = 318,636 patients) with principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, stroke or a DRG classification of general, orthopedic or vascular surgery.

Measurements and Main Results

We measured mortality within 30 days of hospital admission and FTR, measured by death among patients who experienced a surgical complication. The odds of mortality and FTR generally changed at similar rates for higher and lower risk patients in more vs. less teaching intensive hospitals. For example, comparing the mortality risk for the 10% of Medicare patients with highest risk to the other 90% of patients in post-reform year 1 for combined medical an OR of 1.01 [95% CI 0.90, 1.13], for combined surgical an OR of 0.91 [95% CI 0.80, 1.04], and for FTR an OR of 0.94 [95% CI 0.80, 1.09]. Findings were similar in year 2 for both Medicare and VA. The two exceptions were a relative increase in mortality for the highest risk medical (OR 1.63 [95% CI 1.08, 2.46]) and a relative decrease in the high risk surgical patients within VA in post-reform year 1 (OR 0.52 [95% CI 0.29, 0.96]).


ACGME duty hour reform was not associated with any consistent improvements or worsening in mortality or failure-to-rescue rates for high risk medical or surgical patients.


medical errors internship and residency education, medical, graduate personnel staffing and scheduling continuity of patient care 



This work was supported primarily by grant VA HSR&D IIR 04.202.1 and NHLBI R01 HL082637, with additional support from National Science Foundation grant SES-0646002. 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. Dr. Volpp had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. We also thank Yun Teng for her assistance with the analyses. Everyone who contributed significantly to this work has been acknowledged.

Conflict of Interest

None disclosed.


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Copyright information

© Society of General Internal Medicine 2009

Authors and Affiliations

  • Kevin G. Volpp
    • 1
    • 2
    • 3
    • 4
    Email author
  • Amy K. Rosen
    • 5
    • 6
  • Paul R. Rosenbaum
    • 7
  • Patrick S. Romano
    • 8
  • Kamal M.F. Itani
    • 9
  • Lisa Bellini
    • 2
  • Orit Even-Shoshan
    • 10
    • 13
  • Liyi Cen
    • 2
  • Yanli Wang
    • 10
  • Michael J. Halenar
    • 1
    • 2
  • Jeffrey H. Silber
    • 3
    • 10
    • 11
    • 12
    • 13
  1. 1.Center for Health Equity Research and PromotionVeteran’s Administration HospitalPhiladelphiaUSA
  2. 2.Department of MedicineThe University of Pennsylvania School of MedicinePhiladelphiaUSA
  3. 3.Department of Health Care Management, The Wharton SchoolThe University of PennsylvaniaPhiladelphiaUSA
  4. 4.Center for Health Incentives, The Leonard Davis Institute of Health EconomicsThe University of PennsylvaniaPhiladelphiaUSA
  5. 5.Department of Health Policy and ManagementBoston University School of Public HealthBostonUSA
  6. 6.Center for Health Quality, Outcomes and Economic ResearchVeteran’s Administration HospitalBedfordUSA
  7. 7.Department of Statistics, The Wharton SchoolThe University of PennsylvaniaPhiladelphiaUSA
  8. 8.Division of General Medicine and Center for Healthcare Policy and ResearchUniversity of California Davis School of MedicineDavisUSA
  9. 9.Department of SurgeryVA Boston Health Care System and Boston UniversityBostonUSA
  10. 10.Center for Outcomes ResearchThe Children’s Hospital of PhiladelphiaPhiladelphiaUSA
  11. 11.The Department of PediatricsThe University of Pennsylvania School of MedicinePhiladelphiaUSA
  12. 12.The Department Anesthesiology and Critical CareThe University of Pennsylvania School of MedicinePhiladelphiaUSA
  13. 13.The Leonard Davis Institute of Health EconomicsThe University of PennsylvaniaPhiladelphiaUSA

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