Did Duty Hour Reform Lead to Better Outcomes Among the Highest Risk Patients?

Volpp, Kevin G.; Rosen, Amy K.; Rosenbaum, Paul R.; Romano, Patrick S.; Itani, Kamal M.F.; Bellini, Lisa M.; Even‐Shoshan, Orit; Cen, Liyi; Wang, Yanli; Halenar, Michael J; Silber, Jeffrey H.

doi:10.1007/s11606-009-1011-z

Cited by 67 publications

(71 citation statements)

References 35 publications

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“…Our fi ndings are consistent with studies showing that in-hospital outcomes for patients in the ICU improved over this time period independent of work-hour reforms. [43][44][45][46][47][48][49][50][51][52][53][54] Taken together, these results support the view that an ICU's readmission rate refl ects operational policies or practice variation not in the causal pathway to mortality. Th is conclusion is supported by complementary data indicating that the readmission rate of an ICU is uncorrelated with performance on other measures of ICU quality.…”

Section: Discussionsupporting

confidence: 64%

Assessing the Utility of ICU Readmissions as a Quality Metric

Brown

Ratcliffe

Halpern

2015

Chest

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BACKGROUND: ICU readmissions are associated with increased mortality and costs; however, it is unclear whether these outcomes are caused by readmissions or by residual confounding by illness severity. An assessment of temporal changes in ICU readmission in response to a specific policy change could help disentangle these possibilities. We sought to determine whether ICU readmission rates changed aft er 2003 Accreditation Council for Graduate Medical Education Resident Duty Hours reform ("reform") and whether there were temporally corresponding changes in other ICU outcomes.

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Section: Discussionsupporting

confidence: 64%

Assessing the Utility of ICU Readmissions as a Quality Metric

Brown

Ratcliffe

Halpern

2015

Chest

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“…Rosen et al demonstrated that in Medicare and VA patients, most patient safety indicators (PSIs), which are adverse events that are identifiable in administrative data, 77 were equally common in both time periods, although certain PSIs occurred more often in the post-duty hour time period in the VA patients (OR 1.63). 78 Silber et al found no increased risk of prolonged hospitalization in Medicare or VA patients. 79 …”

Section: Complicationsmentioning

confidence: 97%

Patient Safety, Resident Education and Resident Well-Being Following Implementation of the 2003 ACGME Duty Hour Rules

2011

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), bibliographies, pertinent reviews, and meeting abstracts. STUDY SELECTION: We included studies examining the relationship between the pre-and post-2003 time periods and patient outcomes (mortality, complications, errors), resident education (standardized test scores, clinical experience), and well-being (as measured by the Maslach Burnout Inventory). We excluded non-US studies. DATA EXTRACTION: One rater used structured data collection forms to abstract data on study design, quality, and outcomes. We synthesized the literature qualitatively and included a meta-analysis of patient mortality. RESULTS: Of 5,345 studies identified, 60 met eligibility criteria. Twenty-eight studies included an objective outcome related to patients; 10 assessed standardized resident examination scores; 26 assessed resident operative experience. Eight assessed resident burnout. Metaanalysis of the mortality studies revealed a significant improvement in mortality in the post-2003 time period with a pooled odds ratio (OR) of 0.9 (95% CI: 0.84, 0.95). These results were significant for medical (OR 0.91; 95% CI: 0.85, 0.98) and surgical patients (OR 0.86; 95% CI: 0.75, 0.97). However, significant heterogeneity was present (I 2 83%). Patient complications were more nuanced. Some increased in frequency; others decreased. Outcomes for resident operative experience and standardized knowledge tests varied substantially across studies. Resident well-being improved in most studies. LIMITATIONS: Most studies were observational. Not all studies of mortality provided enough information to be included in the meta-analysis. We used unadjusted odds ratios in the meta-analysis; statistical heterogeneity was substantial. Publication bias is possible. CONCLUSIONS:Since 2003, patient mortality appears to have improved, although this could be due to secular trends. Resident well-being appears improved. Change in resident educational experience is less clear.

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“…1 The new guidelines reiterated the 2003 recommendations (maximum of 80 h of work per week and direct patient care shifts no longer than 24 + 4 h) and restricted post-graduate year 1 (PGY-1) trainees to a maximum shift length of 16 h, with a minimum of 8 h off between shifts. 2,3 Studies of 2011 models, similar to outcomes following 2003 changes, [4][5][6][7][8] have yet to show any improvements in quality of care, 9-12 trainee education, 11 or resident well-being. 13 Also, program director and resident surveys have conveyed strong concerns about sacrificing continuity of care and educational activities for DHR compliance.…”

Section: Introductionmentioning

confidence: 99%