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Mortality among patients following work hours reform
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CHICAGO—In a national study of more than 8 million hospitalized Medicare patients, there was no increase in mortality in the first two years following duty hour reform that limited work hours for resident physicians, according to an article in the September 5 issue of JAMA, a theme issue on medical education.

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“Widespread concern about the number of deaths in U.S. hospitals from medical errors prompted the Accreditation Council for Graduate Medical Education (ACGME) to implement duty hour regulations effective July 1, 2003, for all ACGME-accredited residency programs. Work limitations for residents included no more than 80 hours per week, with 1 day in 7 free of all duties, averaged over 4 weeks; no more than 24 continuous hours with an additional 6 hours for education and transfer of care; in-house call no more frequently than every third night; and at least 10 hours of rest between duty periods,” the authors write. They add that although there is evidence linking fatigue and impaired cognitive performance, the association of duty hour reform with the rate of death among patients in teaching hospitals nationally has not been well established.

Kevin G. Volpp, M.D., Ph.D., and colleagues at the Philadelphia Veterans Affairs Medical Center, University of Pennsylvania School of Medicine, and Center for Outcomes Research of the Children's Hospital of Philadelphia, studied the association between changes in the ACGME duty hour rules and death rates among 8,529,595 Medicare patients in 3,321 hospitals of different teaching intensity, analyzing data from July 2000 to June 30, 2005. The patients had diagnoses of heart attack, congestive heart failure, gastrointestinal bleeding, or stroke or a diagnosis related group classification of general, orthopedic, or vascular surgery.

The researchers found that in medical and surgical patients, no significant relative increases or decreases in the odds of death for more vs. less teaching-intensive hospitals were observed in either post-reform year 1 or 2, compared with the pre-reform years. Compared with nonteaching hospitals, the most teaching-intensive hospitals had an absolute change in death rate from pre-reform year 1 to post-reform year 2 of 0.42 percentage points (4.4 percent relative increase) for patients in the combined medical conditions group and 0.05 percentage points (2.3 percent relative increase) for patients in the combined surgical categories group, neither of which were statistically significant.

“These results do not address whether the current design of duty hour rules is optimal, as other work has found significantly lower rates of errors with 16-hour vs. 24-hour to 36-hour shifts. Given the lack of evidence of improvements in outcomes in this study, research should focus on examining different approaches to duty hour design as well as measuring resident work intensity and clinically relevant patient outcomes in addition to mortality,” the authors conclude.
(JAMA. 2007;298(9):975-983.

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

RESIDENT DUTY HOUR REFORM ASSOCIATED WITH DECREASED RISK OF DEATH FOR PATIENTS AT VETERANS AFFAIRS HOSPITALS WITH CERTAIN CONDITIONS

In another study, Dr. Volpp and colleagues examined whether the change in duty hour regulations was associated with relative changes in the rate of death in hospitals of different teaching intensity within the U.S. Veterans Affairs (VA) system. The study included all patients (318,636) admitted to acute-care VA hospitals (n = 131), with data from July 2000 to June 30, 2005. All patients had diagnoses of heart attack, congestive heart failure, gastrointestinal bleeding, or stroke or a diagnosis related group classification of general, orthopedic, or vascular surgery.

In post-reform year 2, the odds of death decreased significantly in more teaching-intensive hospitals for medical patients, but not surgical patients. Compared with hospitals in the 25th percentile of teaching intensity, there was an absolute improvement in mortality from pre-reform year 1 to post-reform year 2 of 0.70 percentage points (11.1 percent relative decrease) and 0.88 percentage points (13.9 percent relative decrease) in hospitals in the 75th and 90th percentile of teaching intensity, respectively, for the combined medical conditions.

“Further assessment of how the reforms affected other clinical and educational outcomes in both VA and non-VA settings would be important before modification of the current duty hour standards,” the researchers write.

As for possible reasons for the differences in findings between these two studies by Volpp and colleagues, “they include the markedly greater mean resident-to-bed ratios at VA teaching hospitals compared with non-VA teaching hospitals, potentially greater autonomy for residents at VA hospitals, differences in staffing models and clinical volume, differing balances between the effects of decreased fatigue and worsened continuity, and potentially different degrees of unmeasured confounders,” the authors write.
(JAMA. 2007;298(9):984-992.

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

EDITORIAL: EVALUATING RESIDENT DUTY HOUR REFORMS — MORE WORK TO DO

In an accompanying editorial, David O. Meltzer, M.D., Ph.D., and Vineet M. Arora, M.D., M.A., of the University of Chicago, comment on the studies in this week’s JAMA on duty hour reforms.

“These results, together with another recent large study that found some evidence of mortality reductions in medical patients in teaching hospitals following duty hour reforms using data from a large fraction of U.S. hospitals, may be reassuring to those who feared that duty hour reforms would adversely affect patient outcomes. These studies may also provide some encouraging news for others who had hoped that duty hour reforms would improve outcomes.”
(JAMA. 2007;298(9):1055-1057.

Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc.

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