Despite concerns that duty hour reform might adversely affect the performance of new surgeons, this national study found no impact on patient outcomes, including 30-day mortality rates, failure-to-rescue, length of stay, and use of intensive care units. These findings should allay fears that reduced work hours during residency would produce surgeons less prepared for practice than their more experienced colleagues

Bilimoria, Karl Y.

Hill, Alexander S.

Hochman, Lauren L.

Itani, Kamal

Kelz, Rachel R.

Niknam, Bijan A.

Romano, Patrick S.

Rosenbaum, Paul R.

Sellers, Morgan M.

Sharpe, James E.

Silber, Jeffrey H.

Zhou, Hong

English

ObjectiveThe aim of the study was to address the controversy surrounding the effects of duty hour reform on new surgeon performance, we analyzed patients treated by new surgeons following the transition to independent practice.Summary background dataIn 2003, duty hour reform affected all US surgical training programs. Its impact on the performance of new surgeons remains unstudied.MethodsWe studied 30-day mortality among 1,483,074 Medicare beneficiaries undergoing general and orthopedic operations between 1999 and 2003 ("traditional" era) and 2009 and 2013 ("modern" era). The operations were performed by 2762 new surgeons trained before the reform, 2119 new surgeons trained following reform and 15,041 experienced surgeons. We used a difference-in-differences analysis comparing outcomes in matched patients treated by new versus experienced surgeons within each era, controlling for the hospital, operation, and patient risk factors.ResultsTraditional era odds of 30-day mortality among matched patients treated by new versus experienced surgeons were significantly elevated [odds ratio (OR) 1.13; 95% confidence interval (CI) (1.05, 1.22), P &lt; 0.001). The modern era elevated odds of mortality were not significant [OR 1.06; 95% CI (0.97-1.16), P = 0.239]. Relative performance of new and experienced surgeons with respect to 30-day mortality did not appear to change from the traditional era to the modern era [OR 0.93; 95% CI (0.83-1.05), P = 0.233]. There were statistically significant adverse changes over time in relative performance to experienced surgeons in prolonged length of stay [OR 1.08; 95% CI (1.02-1.15), P = 0.015], anesthesia time [9 min; 95% CI (8-10), P &lt; 0.001], and costs [255USD; 95% CI (2-508), P = 0.049].ConclusionsDuty hour reform showed no significant effect on 30-day mortality achieved by new surgeons compared to their more experienced colleagues. Patients of new surgeons, however, trained after duty hour reform displayed some increases in the resources needed for their care

Kelz, Rachel R

Niknam, Bijan A

Sellers, Morgan M

Sharpe, James E

Rosenbaum, Paul R

Hill, Alexander S

Hochman, Lauren L

Bilimoria, Karl Y

Romano, Patrick S

Silber, Jeffrey H

eScholarship - University of California

Duty Hour Reform and the Outcomes of Patients Treated by New Surgeons.

ScholarlyCommons@Penn

University of Pennsylvania ScholarlyCommons Research Briefs Leonard Davis Institute of Health Economics 12-10-2020 Duty Hour Reform and the Outcomes of Patients Treated by New Surgeons Rachel R. Kelz University of Pennsylvania Bijan A. Niknam Morgan M. Sellers University of Pennsylvania James E. Sharpe Paul R. Rosenbaum University of Pennsylvania See next page for additional authors Follow this and additional works at: https://repository.upenn.edu/ldi_researchbriefs  Part of the Interprofessional Education Commons, and the Surgery Commons Recommended Citation (OVERRIDE) This paper is posted at ScholarlyCommons. https://repository.upenn.edu/ldi_researchbriefs/68 For more information, please contact repository@pobox.upenn.edu. Duty Hour Reform and the Outcomes of Patients Treated by New Surgeons Abstract Despite concerns that duty hour reform might adversely affect the performance of new surgeons, this national study found no impact on patient outcomes, including 30-day mortality rates, failure-to-rescue, length of stay, and use of intensive care units. These findings should allay fears that reduced work hours during residency would produce surgeons less prepared for practice than their more experienced colleagues. Keywords duty hour, surgeon, surgical residency, surgery, medical education Disciplines Interprofessional Education | Medical Education | Surgery Comments License This work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License. Author(s) Rachel R. Kelz, Bijan A. Niknam, Morgan M. Sellers, James E. Sharpe, Paul R. Rosenbaum, Alexander S. Hill, Hong Zhou, Lauren L. Hochman, Karl Y. Bilimoria, Kamal Itani, Patrick S. Romano, and Jeffrey H. Silber This brief is available at ScholarlyCommons: https://repository.upenn.edu/ldi_researchbriefs/68 THE QUESTIONIn 2003, the Accreditation Council for Graduate Medical Education transformed surgical training—and stirred controversy—by implementing reforms to resident duty hours. Among other changes, the restructured residency experience produced a net loss of 6-12 months of clinical training (as a result of reduced work hours). Some program directors, experienced surgeons, and trainees themselves questioned whether these changes would affect the development of surgical skills, judgment, and autonomy. To date, studies of duty hour reform have largely focused on its impact on residents during training and on patients in academic medical centers. This study assesses the impact of duty hour reform on the performance of new surgeons after their transition to independent practice.The authors use a novel approach to account for potential changes over time in surgical performance that might be unrelated to duty hour reform. The study looks at whether the relative performance of new surgeons (compared to their more experienced colleagues) changed over two periods: 1999-2003 (pre-reform) and 2009-2013 (post-reform). Patients of new surgeons (defined as practicing less than three years) were matched by hospital and operation with patients of experienced surgeons (practicing greater than 10 years) in both periods; only the new surgeons in the later period had been trained after duty hour reform. More than 2,500 new/experienced surgeons were paired in the traditional era, and compared to nearly 1,900 new/experienced surgeons in the modern era.The question under study was whether the known gap in outcomes between new and experienced surgeons changed after duty hour reform. To find out, the authors compared 30-day mortality, readmissions, failure-to-rescue (death after developing a complication), and other outcomes in Medicare patients of general and orthopedic surgeons practicing in more than 1,400 hospitals nationwide.DATA  D R I V E N . P O L I C Y  F O C U S E DBRIEFResearchLDIResearch to Improve the Nation’s Health System   2020 . No. 3COLONIAL PENN CENTER   |   3641 LOCUST WALK   |   PHILADELPHIA, PA 19104-6218   |   LDI.UPENN.EDU   |   P: 215-898-5611   |   F: 215-898-0229   |    @PENNLDIDUTY HOUR REFORM AND THE OUTCOMES OF PATIENTS TREATED BY NEW SURGEONS Evaluating a New Paradigm in Surgical TrainingRachel R. Kelz, Bijan A. Niknam, Morgan M. Sellers, James E. Sharpe, Paul R. Rosenbaum, Alexander S. Hill, Hong Zhou,  Lauren L. Hochman, Karl Y. Bilimoria, Kamal Itani, Patrick S. Romano, and Jeffrey H. Silber.Annals of Surgery — April 2020KEYFINDINGS Despite concerns that duty hour reform might adversely affect the performance of new surgeons, this national study found no impact on patient outcomes, including 30-day mortality rates, failure-to-rescue, length of stay, and use of intensive care units. These findings should allay fears that reduced work hours during residency would produce surgeons less prepared for practice than their more experienced colleagues. BRIEFResearchLDILEAD AUTHORDR. RACHEL KELZRachel R. Kelz, MD, MSCE, MBA, FACS is a Professor of Surgery at the Perelman School of Medicine at the University of Pennsylvania. She is an Endocrine Surgeon and cares for patients at the Hospital of the University of Pennsylvania. Dr. Kelz serves as the Vice Chair of Clinical Research within the Department of Surgery. Dr. Kelz is recognized as a leader in surgical education and was awarded the Lindback Foundation award for distinguished teaching by the Provost of the University of Pennsylvania. She serves as the Surgeon Champion for the National Surgical Quality Improvement Program at Penn. Her work in outcomes and education has recently merged, and she is focusing on innovative approaches to combine administrative data with chart abstraction to identify opportunities to improve surgical education and performance.THE FINDINGSThe 30-day mortality rates of new surgeons were slightly higher than experienced surgeons in both training eras, but significantly higher only in the traditional era (7.0% vs. 6.3%). Importantly, the paired differences over the two periods did not change significantly in terms of 30-day mortality, 30-day failure-to-rescue, 30-day readmissions and death, ICU use, or length of stay. However, the paired differences indicated that patients of new surgeons trained in the modern era required increased anesthesia time (+9 minutes), experienced higher odds of prolonged stay (+8%), and higher 30-day resource costs (+$255, in 2013 dollars). The authors note that an emphasis on reducing readmissions in the modern era may encourage physicians to prolong length of stay. The results were similar for general and orthopedic surgeons, with a notable exception. Patients of new general surgeons trained in the modern era had relatively lower 30-day readmissions or death (-14%). However, this reflects a slight increase in 30-day readmissions among experienced surgeons across training eras, rather than a change in the rate of readmissions among new surgeons in the modern era. THE IMPLICATIONSThis is the first national study to address concerns about the impact of duty hour reform on the performance of new surgeons. By using contemporaneous experienced surgeons as controls, the authors address controversy surrounding the new educational model’s impact on patient outcomes. The study’s findings provide reassurance that patient outcomes did not suffer when surgical training was restructured. To our knowledge, this is the first study to use the patient outcomes of practicing surgeons to measure changes in surgical training. These methods can be a template for evaluating the impact of other educational reforms across medical specialties.  THE STUDYThe authors identified nearly 1.5 million fee-for-service Medicare beneficiaries aged 65.5 or older who underwent general or orthopedic surgery (requiring an incision) in two time frames: 1999-2003 and  2009-2013. They identified the operating physician for each patient using the Medicare Part B file. For patients with multiple qualifying surgeries, an operation was chosen randomly, so that each patient was included only once.They divided surgeons into four groups based on training era (before or after reform) and experience level (new or experienced). Surgeons trained before reform completed their entire residency prior to reform and began independent practice between 1999 and 2003. Surgeons trained after reform entered independent practice between 2009 and 2013. “New” physicians had less than three years of independent practice, and “experienced” ones had ten or more years of independent practice. In each training era, new and experienced surgeons operating in the same hospital were paired for this “difference in differences” analysis. This resulted in 2,578 pairs in the pre-reform era and 1,820 pairs in the post-reform era. Within each surgeon pair, the authors selected 10 patients of experienced surgeons and 10 patients of new surgeons for analysis. The patients were matched by procedure, demographics, and risk factors (such as comorbidities) that could contribute to differences in outcomes. The primary outcome was 30-day mortality; other outcomes included 30-day readmissions, anesthesia time, length-of-stay, ICU usage, and 30-day resource-based costs. Kelz RR, Niknam BA, Sellers MM, Sharpe JE, Rosenbaum PR, et al. Duty Hour Reform and the Outcomes of Patients of New Surgeons. Annals of Surgery. 2020 Apr;271(4):599-605. 0%1%2%3%4%5%6%7%8%No significant difference in relative performance of new and experienced surgeons from traditional to modern era30-DAY MORTALITY RATEFigure 1. Matched 30-day mortality rates, new and experienced surgeons, traditional and modern era.TRADITIONAL ERA MODERN ERANew Surgeons Experienced Surgeons

Duty Hour Reform and the Outcomes of Patients Treated by New Surgeons

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Duty Hour Reform and the Outcomes of Patients Treated by New Surgeons

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