Journal of General Internal Medicine

, Volume 27, Issue 2, pp 241–249 | Cite as

Cost Implications of ACGME’s 2011 Changes to Resident Duty Hours and the Training Environment

  • Teryl K. NuckolsEmail author
  • José J. Escarce
Original Research



In July 2011, the Accreditation Council for Graduate Medical Education (ACGME) will implemented stricter duty-hour limits and related changes to the training environment. This may affect preventable adverse event (PAE) rates.


To estimate direct costs under various implementation approaches, and examine net costs to teaching hospitals and cost-effectiveness to society across a range of hypothetical changes in PAEs.


A decision-analytical model represented direct costs and PAE rates, mortality, and costs.


Published literature and publicly available data.


Patients admitted to hospitals with ACGME-accredited programs.


One year.


All teaching hospitals, major teaching hospitals, society.


ACGME’s 2011 Common Program Requirements.


Direct annual costs (all accredited hospitals), net cost (major teaching hospitals), cost per death averted (society).


Nationwide, duty-hour changes would cost $177 million annually if interns maintain current productivity, vs. up to $982 million if they transfer work to a mixture of substitutes; training-environment changes will cost $204 million. If PAEs decline by 7.2–25.8%, net costs to major teaching hospitals will be zero. If PAEs fall by 3%, the cost to society per death averted would be –$523,000 (95%-confidence interval: –$1.82 million to $685,000) to $2.44 million ($271,000 to $6.91 million). If PAEs rise, the policy will be cost-increasing for teaching hospitals and society.


The total direct annual cost nationwide would be up to $1.34 billion using nurse practitioners/physician assistants, $1.64 billion using attending physicians, $820 million hiring additional residents, vs. 1.42 billion using mixed substitutes.


The effect on PAEs is unknown. Data were limited for some model parameters.


Implementation decisions greatly affect the cost. Unless PAEs decline substantially, teaching hospitals will lose money. If PAEs decline modestly, the requirements might be cost-saving or cost-effective to society.


ACGME residents duty hours costs training 



An earlier version of this analysis was commissioned by the Accreditation Council for Graduate Medical Education (ACGME). ACGME representatives provided information related to selected model parameters, as specified in the paper. The authors were wholly responsible for conducting the analysis and preparing the manuscript; ACGME played no other roles in these activities. The authors performed a similar analysis for the Institute of Medicine in 2008. The authors have no other conflicts of interest. Teryl Nuckols, MD, MSHS is currently supported by a Mentored Clinical Scientist Career Development Award (K08) from the Agency for Healthcare Research and Quality (grant number HS17954).

The authors thank Jan Wilson, who provided research support, and Jodi Friedman, MD, who provided helpful feedback on the analysis.

Supplementary material

11606_2011_1775_MOESM1_ESM.pdf (70 kb)
ESM 1 (PDF 69.9 kb)


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Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  1. 1.Division of General Internal Medicine and Health Services ResearchDavid Geffen School of Medicine at the University of CaliforniaLos AngelesUSA
  2. 2.The RAND CorporationSanta MonicaUSA

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