On first glance, it seems self-evident: sleep-deprived physicians-intraining (residents) are more likely to make mistakes that could harm patients. Like pilots and truck drivers, these new physicians might need restrictions on how much they work. Such restrictions were created in 2003, but the impact of these new rules is unclear. Are patients any safer? Is hospital care more fragmented? Who’s doing the work that residents performed prior to duty hour reform? This Issue Brief summarizes several studies that offer evidence about the impact of these regulations on patient mortality, as well as on residents’ perceptions of the effects on quality of care, medical education, and residents’ quality of life

Silber, Jeffrey H

Volpp, Kevin G

English

ScholarlyCommons@Penn

University of PennsylvaniaScholarlyCommonsIssue Briefs Leonard Davis Institute of Health Economics10-2007A Wake-Up Call: Quality of Care After ResidentDuty Hour ReformKevin G. VolppUniversity of Pennsylvania, volpp70@wharton.upenn.eduJeffrey H. SilberUniversity of Pennsylvania, silber@email.chop.eduFollow this and additional works at: http://repository.upenn.edu/ldi_issuebriefsThis paper is posted at ScholarlyCommons. http://repository.upenn.edu/ldi_issuebriefs/69For more information, please contact repository@pobox.upenn.edu.Volpp, Kevin G. and Silber, Jeffrey H.. A Wake-Up Call: Quality of Care After Resident Duty Hour Reform. LDI Issue Briefs. 2007; 13(1). http://ldi.upenn.edu/brief/wake-call-quality-care-after-resident-duty-hour-reformA Wake-Up Call: Quality of Care After Resident Duty Hour ReformAbstractOn first glance, it seems self-evident: sleep-deprived physicians-intraining (residents) are more likely to makemistakes that could harm patients. Like pilots and truck drivers, these new physicians might need restrictionson how much they work. Such restrictions were created in 2003, but the impact of these new rules is unclear.Are patients any safer? Is hospital care more fragmented? Who’s doing the work that residents performed priorto duty hour reform? This Issue Brief summarizes several studies that offer evidence about the impact of theseregulations on patient mortality, as well as on residents’ perceptions of the effects on quality of care, medicaleducation, and residents’ quality of life.LicenseThis work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License.This brief is available at ScholarlyCommons: http://repository.upenn.edu/ldi_issuebriefs/69Issue BriefLDILeonard Davis Institute of Health Economics Volume 13, Number 1 • Sept/Oct 2007A Wake-Up Call: Quality of Care AfterResident Duty Hour ReformEditor’s note: On first glance, it seems self-evident: sleep-deprived physicians-in-training (residents) are more likely to make mistakes that could harm patients.Like pilots and truck drivers, these new physicians might need restrictions onhow much they work. Such restrictions were created in 2003, but the impact ofthese new rules is unclear. Are patients any safer?  Is hospital care more frag-mented? Who’s doing the work that residents performed prior to duty hourreform?  This Issue Brief summarizes several studies that offer evidence about theimpact of these regulations on patient mortality, as well as on residents’ percep-tions of the effects on quality of care, medical education, and residents’ qualityof life.In response to concerns about the numbers of hospitalized patients dying frommedical errors, the Accreditation Council for Graduate Medical Education(ACGME) instituted restrictions on the hours physicians-in-training can work,effective July 2003. These regulations represent arguably the largest nationaleffort ever undertaken to reduce medical errors in teaching hospitals.• The ACGME rules require that, when averaged over four weeks, residentsmust work no more than 80 hours per week and must have one day in sevenfree.  Residents may not work more than 24 continuous hours, though theyare allowed an additional six hours for education and transfer of care.  Theymust have in-house call no more frequently than every third night and have atleast 10 hours off between duty periods.• Controversy remains over whether the duty hour rules benefit patient care,adversely affect patient care and physician training, or do not go far enough inlimiting work hours.  A necessary byproduct of the reform has been anincrease in the number of handoffs between residents, which has led toconcerns about discontinuity of patient care.  If reduced work shifts do reducesleep deprivation and improve the quality of care, it is not clear whetherfurther reductions in work hours would further improve quality, as there is nofirm scientific basis for the duty hour standards as currently designed.Kevin G. Volpp, MD, PhDLDI Senior Fellow,Assistant Professor of Medicine andHealth Care SystemsThe University of PennsylvaniaJeffrey H. Silber, MD, PhDLDI Senior Fellow,Professor of Pediatrics, Anesthesiology andCritical Care, and Health Care SystemsThe University of PennsylvaniaDirector, Center for Outcomes ResearchThe Children’s Hospital of PhiladelphiaSince 2003, physicians-in-training may work nomore than 80 hours perweekTo shed light on the impact of the ACGME duty hour reforms, Volpp, Silber,and colleagues conducted complementary studies in two patient populations:Medicare beneficiaries in acute care, non-federal hospitals, and patients inVeterans Affairs (VA) hospitals. The VA system is the single largest provider ofresidency education in the U.S.• In both studies, investigators used data from July 2000 to July 2005 to com-pare risk-adjusted mortality rates pre- and post-duty hour reform.  Theymeasured mortality within 30 days of hospital admission in patients with aprincipal diagnosis of heart attack, heart failure, gastrointestinal bleeding,stroke, or a diagnosis related to general, orthopedic, or vascular surgery.• They compared changes over time between more intensive teaching hospitalsand less intensive teaching or non-teaching hospitals. They assessed whethermortality improved differentially following implementation of the duty hourreform, which primarily affected more intensive teaching hospitals.• The comparison with less intensive teaching hospitals allowed the investigatorsto control for technological improvements in care, changes in market condi-tions, and Medicare-specific initiatives such as pay-for-performance.Volpp, Silber, and colleagues analyzed data from more than 8.5 million Medicarepatients admitted to 3321 hospitals across the country. They adjusted for differ-ences in patients’ age, gender, comorbidities, and hospital site.• About 69% of the hospitals were non-teaching (treating 51% of patients) andabout 9% were major teaching hospitals (treating 14% of patients).• Compared to the two years before duty hour reform was implemented,patients in more intensive teaching hospitals post-reform were no more or lesslikely to die within 30 days than patients in less intensive or non-teachinghospitals.• The only condition for which there was a relative increase in mortality post-reform in teaching hospitals was stroke, but this trend began before the onsetof duty hour reform.The results were somewhat different when the investigators analyzed the effectsof duty hour reform in VA hospitals.  That study included more than 300,000patients from 131 VA hospitals.• VA hospitals were teaching-intensive, with about 85% being teaching hospi-tals and more than 50% being major teaching hospitals.• After adjusting for baseline differences, the investigators found significantdifferences for medical patients in more vs. less intensive teaching hospitals bypost-reform year 2 (2004-2005).  For example, the odds of surviving for apatient admitted with heart attack or the other medical conditions in post-reform year 2 improved 17% more in major teaching hospitals than in non-teaching hospitals. No comparable change in mortality was observed forsurgical patients.New studies investigatethe effect of duty hourreform on patientmortalityResident duty hour reformwas not associated withchanges in mortality forMedicare patients in thefirst two years ofimplementationIn the VA, resident dutyhour reform wasassociated with improvedmortality in medicalpatients, but not surgicalpatients• The investigators considered several explanations for the differences in theMedicare and VA studies. VA teaching hospitals are more teaching-intensivethan non-VA teaching hospitals, thereby amplifying the effects of residentwork hour reform. Differences in autonomy for residents or in staffing modelsor clinical volume might also account for the differing results, as could un-measured changes that occurred in teaching VA hospitals only.Another way to assess the impact of work regulations is to ask the residentsthemselves, especially those who experienced residency both before and afterduty hour reform.  In 2005, a team led by Myers and Volpp surveyed 200residents at six residency programs (three internal medicine, three generalsurgery) at five academic medical centers. The survey asked about residents’perceptions about the impact on quality of patient care, residency education, andthe residents’ quality of life. The response rate was 80% (159 residents).• The average number of sleep hours in the previous week was 45.9, just slightlygreater than the American Academy of Sleep Medicine’s cutoff for chronicsleep deprivation, which is 42 hours.  It is notable that 27% of residents in thestudy reported sleeping less than 42 hours, and thus, by definition, were stillsleep-deprived even after duty hour reform.• Residents reported that fatigue-related errors decreased slightly, but errorsrelated to reduced continuity of care significantly increased.• It is possible that the quality of the medical educational experience declined.Residents reported somewhat decreased opportunities for formal learning,bedside education, and procedures.• Residents, particularly surgical trainees, reported improvements in theirquality of life and reduced burnout because of the restrictions on work hours.These studies indicate that the net effects of resident duty hour reform remainunclear. It is clear that the restrictions did not increase patient mortality, and itappears that only within VA hospitals was there a possible benefit in terms ofdecreased mortality.• Given the lack of evidence on adverse patient outcomes, it is likely that theduty hour restrictions for residents are here to stay, given concerns about therelationship between sleep deprivation and cognitive performance and residentquality of life. The days of 100-hour work weeks for physicians-in-training arelikely over.  The United States has lagged behind reforms in Europe, whereresidents are allowed to work no more than 56 hours per week, and by 2009,no more than 48 hours per week.• As the resident survey indicates, the work rules may have had an effect onoutcomes other than mortality. Quantifying the degree to which the regula-tions affected discontinuity of care, other patient safety measures, residentwork intensity and education, and hospital costs should be a focus of futureresearch.Residents report thatreduced fatigue-relatederrors have been offset byerrors related todiscontinuity of carePOLICY IMPLICATIONSContinued on back.• These studies did not address whether the current design of work rules isoptimal, as other studies have found lower rates of errors with 16-hour vs. 24-36 hours shifts. Further research should examine different approaches to dutyhour design, as well as different hospital efforts to realign care in response toduty hour reform.This Issue Brief is based on the following articles:  K.G. Volpp, A.K. Rosen, P.R. Rosenbaum, P.S. Romano, O. Even-Shoshan, A. Canamucio, L.Bellini, T. Behringer, J.H. Silber. Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform.  JAMA,September 5, 2007, vol. 298, pp. 984-992;  K.G. Volpp, A.K. Rosen, P.R. Rosenbaum, P.S. Romano, O. Even-Shoshan, Y. Wang, L. Bellini, T.Behringer, J.H. Silber.  Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform.  JAMA,September 5, 2007, vol. 298, pp. 975-983; J.S. Myers, L.M. Bellini, J.B. Morris, D. Graham, J. Katz, J.R. Potts, C. Weiner, K.G. Volpp.  Internalmedicine and general surgery residents‚ attitudes about the ACGME duty hours regulations: a multicenter study.  Academic Medicine, December2006, vol. 81, pp. 1052-1058.Published by the Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA 19104-6218.Janet Weiner, MPH, Associate Director for Health Policy, Editor (215-573-9374)David A. Asch, MD, MBA, Executive DirectorIssue Briefs synthesize the results of research by LDI’s Senior Fellows, a consortium ofPenn scholars studying medical, economic, and social and ethical issues that influencehow health care is organized, financed, managed, and delivered in the United Statesand internationally. The LDI is a cooperative venture among Penn schools includingDental Medicine, Medicine, Nursing and Wharton, and the Children’s Hospital ofPhiladelphia. For additional information on this or other Issue Briefs, contact JanetWeiner (e-mail: weinerja@mail.med.upenn.edu; 215-573-9374).POLICY IMPLICATIONSContinuedWelcome to the new look of the Issue Brief.  Samegreat content.  Also this year, we will introducean occasional supplement to our series, called"Clinical Briefs,"  which will have specialrevelance to basic science, clinical, and biotech-nology audiences.Visit us on the web at www.upenn.edu/ldi© 2007 Leonard Davis InstituteNonprofit OrganizationU.S. PostageP  A  I  DPermit No. 2563Philadelphia, PA 19104Issue BriefPublished by theLeonard Davis Instituteof Health EconomicsUniversity of Pennsylvania3641 Locust WalkPhiladelphia, PA 19104-6218215.898.5611fax 215.898.0229ADDRESS CORRECTION REQUESTED

A Wake-Up Call: Quality of Care After Resident Duty Hour Reform

Kosmopolis

https://repository.upenn.edu/cgi/viewcontent.cgi?article=1045&amp;context=ldi_issuebriefs

A Wake-Up Call: Quality of Care After Resident Duty Hour Reform

Abstract

Similar works

Full text

Available Versions

ScholarlyCommons@Penn

Kosmopolis