Comment; I trained before the restrictions were enacted. It was tough, but realistic to what I saw at times in my practice career. Am surprised that there was no significant impact on patient outcomes.
- Anupam B Jena, Ruth L Newhouse associate professor123,
- Monica Farid, graduate student4,
- Daniel Blumenthal, instructor5,
- Jay Bhattacharya, professor36
- Correspondence to: A B Jena jena@hcp.med.harvard.edu (or @AnupamBJena on Twitter)
- Accepted 30 April 2019
Abstract
Objective To determine whether 30 day mortality, 30 day readmissions, and inpatient spending vary according to whether physicians were exposed to work hour reforms during their residency.
Design Retrospective observational study.
Setting US Medicare.
Participants 20% random sample (n=485 685) of Medicare beneficiaries aged 65 years or more admitted to hospital and treated by a general internist during 2000-12.
Main outcome measures 30 day mortality, 30 day readmissions, and inpatient Medicare Part B spending among patients treated by first year internists who were fully exposed to the 2003 Accreditation Council for Graduate Medical Education (ACGME) work hour reforms during their residency (completed residency after 2006) compared with first year internists with partial or no exposure to reforms (completed residency before 2006). Senior internists not exposed to reforms during their residency served as a control group (10th year internists) for general trends in hospital care: a difference-in-difference analysis.
Results Exposure of physicians to work hour reforms during their residency was not associated with statistically significant differences in 30 day mortality, 30 day readmissions, or inpatient spending. Among 485 685 hospital admissions, 30 day mortality rates during 2000-06 and 2007-12 for patients of first year internists were 10.6% (12 567 deaths/118 014 hospital admissions) and 9.6% (13 521/140 529), respectively, and for 10th year internists were 11.2% (11 018/98 811) and 10.6% (13 602/128 331), for an adjusted difference-in-difference effect of −0.1 percentage points (95% confidence interval −0.8% to 0.6%, P=0.68). 30 day readmission rates for first year internists during 2000-06 and 2007-12 were 20.4% (24 074/118 014) and 20.4% (28 689/140 529), respectively, and for 10th year internists were 20.1% (19 840/98 811) and 20.5% (26 277/128 331), for an adjusted difference-in-difference effect of 0.1 percentage points (−0.9% to 1.1%, P=0.87). Medicare Part B inpatient spending for first year internists during 2000-06 and 2007-12 was $1161 (£911; €1024) and $1267 per hospital admission, respectively, and for 10th year internists was $1331 and $1599, for an adjusted difference-in-difference effect of −$46 (95% confidence interval −$94 to $2, P=0.06).
Conclusions Exposure of internists to work hour reforms during their residency was not associated with post-training differences in patient mortality, readmissions, or costs of care.
Introduction
A core purpose of graduate medical education in all countries is to prepare physicians for unsupervised practice. In the US, a frequently debated subject is whether this objective continues to be met since the implementation of several major residency work hour reforms by the Accreditation Council for Graduate Medical Education (ACGME). The first reform, in 2003, established a maximum 80 hour work week and prohibited shift lengths from exceeding 30 consecutive hours (see box).1 The second reform, in 2011, further capped shift lengths at 16 consecutive hours for interns and 28 hours for other trainees.2 The third reform, in 2017, allowed for longer shift lengths for interns, among other changes.3 Reductions in residency work hours and increased shift work in US academic medical centers have led to speculation that physicians completing residency today have less robust clinical experience before entering unsupervised practice compared with pre-reform residency cohorts.45678910 In contrast with this view, the marginal reduction in clinical skill resulting from fewer work hours might be small, particularly given already long work hours, and it might also be possible that residents who are less fatigued consolidate knowledge better and have equivalent or greater clinical competency both during and after residency.1112 Despite these alternative hypotheses, it is unknown whether the work hour reforms have had long term effects on post-training outcomes of physicians who completed residency during the period of these reforms.
Graduate medical education in the United States
- Medical training in the US comprises four years in medical school completed after an undergraduate degree (typically four years), followed by three years of residency training for those who seek to practice internal medicine. The first year of residency training is called the intern year
- Before 2003, physicians in training in US internal medicine residency programs routinely worked more than 80 hours a week, with shifts often lasting 30 hours or more
- Concerns about high work hours for resident physicians first arose in New York state in 1984 after a widely publicized death in a teaching hospital. The state imposed a reduction in work hours in July 1989
- In response to mounting concerns over medical errors as a result of fatigued resident physicians, and legislative action by the US House of Representatives proposing federal work hour limits, the Accreditation Council for Graduate Medical Education (ACGME) announced reforms to work hours in 2002, which took effect in July 2003
- The 2003 ACGME reforms restricted resident physicians to a maximum of 80 hours work a week, limited shifts to 24 hours (not including time for handoffs of patient care), limited in-hospital call to every third night, and mandated four days off every 28 days (on average one day a week). Subsequent reforms were enacted in 2011 and 2017
- Although several studies have evaluated the association of work hour reforms on outcomes of patients treated in teaching hospitals, with the purpose of understanding how resident work hours and shift structures influence patient outcomes, no national studies have been done of the association of these reforms with performance of physicians after residency training
To tackle similar concerns in Europe, the Council of Europe in Brussels developed the European Working Time Directive in 1998—a mandate that specified requirements for working hours, nighttime work, and rest periods for all public employees.10 The directive, which included physicians in training, limits employees to 48 hours work a week. The restriction in work hours has raised considerable debate as to its impact on graduate medical education and the performance of physicians entering independent practice.1013
Previous studies of residency work hour reforms in the US have focused on the immediate impacts of these reforms on the quality of care provided by resident physicians, as measured by patient outcomes in teaching intensive hospitals,14151617181920 rather than the later post-training quality of care provided by physicians who were exposed to reduced work hours during their residency. Similarly, in the United Kingdom, a meta-analysis of 13 studies evaluating the association between reduced work hours and the quality of resident education found no association in six studies, a negative association in six studies, and improvement in resident education in one study.21 One multicenter study of patient outcomes found no relation between reduced work hours and patient mortality, whereas another study found a small reduction in adverse events and errors. 21 No studies have evaluated the impact of reduced work hours from the European Working Time Directive on the performance of physicians after completion of training.
We conducted a national analysis of quality and costs of hospital care provided by internists who completed their residency in the US during 2000-12 and were variably exposed to the 2003 ACGME work hour restrictions during that period. Data on hospital admissions of Medicare patients were linked to detailed information on residency training of the physician for each hospital admission. We analyzed how quality and costs of inpatient care provided by physicians in their first year after completion of their internal medicine residency (ie, newly independent internists) varied across cohorts completing residency during 2000-12. Our goal was to examine whether physicians who were exposed to the 2003 ACGME work reforms during their residency had worse patient outcomes or higher costs of care in their first year of independent practice compared with physicians who completed residency before the reform.
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