What are the effects of making residents work fewer hours

When my dad was a resident, he regularly spent every other night in the hospital. I was usually on every fourth, sometimes every third. These days, residents are required to work many fewer hours in the interest of patient safety.

Some physicians argue that this is depriving them of necessary educational opportunities. They also argue that more handoffs from one doc to the next lead to worse outcomes. So what’s right? Two papers on point in this week’s JAMA. First, “Association of the 2011 ACGME Resident Duty Hour Reform With General Surgery Patient Outcomes and With Resident Examination Performance“:

IMPORTANCE In 2011, the Accreditation Council for Graduate Medical Education (ACGME) restricted resident duty hour requirements beyond those established in 2003, leading to concerns about the effects on patient care and resident training.

OBJECTIVE To determine if the 2011 ACGME duty hour reform was associated with a change in general surgery patient outcomes or in resident examination performance. DESIGN, SETTING, AND PARTICIPANTS Quasi-experimental study of general surgery patient outcomes 2 years before (academic years 2009-2010) and after (academic years 2012-2013) the 2011 duty hour reform. Teaching and nonteaching hospitals were compared using a difference-in-differences approach adjusted for procedural mix, patient comorbidities, and time trends. Teaching hospitals were defined based on the proportion of cases at which residents were present intraoperatively. Patients were those undergoing surgery at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). General surgery resident performance on the annual in-training, written board, and oral board examinations was assessed for this same period.

EXPOSURES National implementation of revised resident duty hour requirements on July 1, 2011, in all ACGME accredited residency programs.

MAIN OUTCOMES AND MEASURES Primary outcome was a composite of death or serious morbidity; secondary outcomes were other postoperative complications and resident examination performance.

RESULTS In the main analysis, 204 641 patients were identified from 23 teaching (n = 102 525) and 31 nonteaching (n = 102 116) hospitals. The unadjusted rate of death or serious morbidity improved during the study period in both teaching (11.6% [95% CI, 11.3%-12.0%] to 9.4% [95% CI, 9.1%-9.8%], P < .001) and nonteaching hospitals (8.7% [95% CI, 8.3%-9.0%] to 7.1% [95% CI, 6.8%-7.5%], P < .001). In adjusted analyses, the 2011 ACGME duty hour reform was not associated with a significant change in death or serious morbidity in either postreform year 1 (OR, 1.12; 95% CI, 0.98-1.28) or postreform year 2 (OR, 1.00; 95% CI, 0.86-1.17) or when both postreform years were combined (OR, 1.06; 95% CI, 0.93-1.20). There was no association between duty hour reform and any other postoperative adverse outcome. Mean (SD) in-training examination scores did not significantly change from 2010 to 2013 for first-year residents (499.7 [ 85.2] to 500.5 [84.2], P = .99), for residents from other postgraduate years, or for first-time examinees taking the written or oral board examinations during this period.

CONCLUSIONS AND RELEVANCE Implementation of the 2011 ACGME duty hour reform was not associated with a change in general surgery patient outcomes or differences in resident examination performance. The implications of these findings should be considered when evaluating the merit of the 2011 ACGME duty hour reform and revising related policies in the future.

So the changes did not lead to differences in patient outcomes. It also didn’t lead to residents’ performing worse on testing. Granted, neither of these are perfect measures, but they point to the changes not having obvious deleterious effects.

Next up, “Association of the 2011 ACGME Resident Duty Hour Reforms With Mortality and Readmissions Among Hospitalized Medicare Patients“:

IMPORTANCE Patient outcomes associated with the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms have not been evaluated at a national level.

OBJECTIVE To evaluate the association of the 2011 ACGME duty hour reforms with mortality and readmissions.

DESIGN, SETTING, AND PARTICIPANTS Observational study of Medicare patient admissions (6 384 273 admissions from 2 790 356 patients) to short-term, acute care, nonfederal hospitals (n = 3104) with principal medical diagnoses of acute myocardial infarction, stroke, gastrointestinal bleeding, or congestive heart failure or a Diagnosis Related Group classification of general, orthopedic, or vascular surgery. Of the hospitals, 96 (3.1%) were very major teaching, 138 (4.4%) major teaching, 442 (14.2%) minor teaching, 443 (14.3%) very minor teaching, and 1985 (64.0%) nonteaching.

EXPOSURE Resident-to-bed ratio as a continuous measure of hospital teaching intensity.

MAIN OUTCOMES AND MEASURES Change in 30-day all-location mortality and 30-day all-cause readmission, comparing patients in more intensive relative to less intensive teaching hospitals before (July 1, 2009–June 30, 2011) and after (July 1, 2011–June 30, 2012) duty hour reforms, adjusting for patient comorbidities, time trends, and hospital site.

RESULTS In the 2 years before duty hour reforms, there were 4 325 854 admissions with 288 422 deaths and 602 380 readmissions. In the first year after the reforms, accounting for teaching hospital intensity, there were 2 058 419 admissions with 133 547 deaths and 272 938 readmissions. There were no significant postreform differences in mortality accounting for teaching hospital intensity for combined medical conditions (odds ratio [OR], 1.00; 95% CI, 0.96-1.03), combined surgical categories (OR, 0.99; 95% CI, 0.94-1.04), or any of the individual medical conditions or surgical categories. There were no significant postreform differences in readmissions for combined medical conditions (OR, 1.00; 95 CI, 0.97-1.02) or combined surgical categories (OR, 1.00; 95% CI, 0.98-1.03). For the medical condition of stroke, there were higher odds of readmissions in the postreform period (OR, 1.06; 95% CI, 1.001-1.13). However, this finding was not supported by sensitivity analyses and there were no significant postreform differences for readmissions for any other individual medical condition or surgical category.

CONCLUSIONS AND RELEVANCE Among Medicare beneficiaries, there were no significant differences in the change in 30-day mortality rates or 30-day all-cause readmission rates for those hospitalized in more intensive relative to less intensive teaching hospitals in the year after implementation of the 2011 ACGME duty hour reforms compared with those hospitalized in the 2 years before implementation.

This study looked at whether duty hour changes were associated with 30-day mortality or readmission. And, once again, there were no significant differences between hospitals with more or less intensive schedules before and after reforms were put in place.

The accompanying editorial concludes:

First, with regard to potential short-term policy decisions on duty hour requirements, is it important to decide whether a null association with safety and education metrics is a positive or negative finding? In our roles as residency review committee chairs, we think this is the wrong question to ask because there was no justification for making the rules more complex or restrictive, as occurred in 2011.

Second, in the absence of improvement in patient outcomes in these 2 studies, how should the 2011 duty hour revisions be judged? … Many program directors have expressed great concern about the potential negative effects of this second set of changes, including effects on resident education, preparedness for senior roles, patient safety, and continuity of care. Thus, in the absence of clear data demonstrating benefit, the concerns of the educational community should be given credence and not be dismissed as mere perceptions.

Third, although high-quality observational studies such as these are very helpful, randomized data are lacking. Recognizing this gap in research, the educational community has proposed 2 randomized trials on duty hour requirements in medical and surgical residents that may provide more definitive information.



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