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

  • Hospital Medicine
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

Background

Earlier work demonstrated that ACGME duty hour reform did not adversely affect mortality, with slight improvement noted among specific subgroups.

Objective

To determine whether resident duty hour reform differentially affected the mortality risk of high severity patients or patients who experienced post-operative complications (failure-to-rescue).

Design

Observational study using interrupted time series analysis with data from July 1, 2000 - June 30, 2005. Fixed effects logistic regression was used to examine the change in the odds of mortality or failure-to-rescue (FTR) in more versus less teaching-intensive hospitals before and after duty hour reform.

Participants

All unique Medicare patients (n = 8,529,595) admitted to short-term acute care non-federal hospitals and all unique VA patients (n = 318,636 patients) with principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, stroke or a DRG classification of general, orthopedic or vascular surgery.

Measurements and Main Results

We measured mortality within 30 days of hospital admission and FTR, measured by death among patients who experienced a surgical complication. The odds of mortality and FTR generally changed at similar rates for higher and lower risk patients in more vs. less teaching intensive hospitals. For example, comparing the mortality risk for the 10% of Medicare patients with highest risk to the other 90% of patients in post-reform year 1 for combined medical an OR of 1.01 [95% CI 0.90, 1.13], for combined surgical an OR of 0.91 [95% CI 0.80, 1.04], and for FTR an OR of 0.94 [95% CI 0.80, 1.09]. Findings were similar in year 2 for both Medicare and VA. The two exceptions were a relative increase in mortality for the highest risk medical (OR 1.63 [95% CI 1.08, 2.46]) and a relative decrease in the high risk surgical patients within VA in post-reform year 1 (OR 0.52 [95% CI 0.29, 0.96]).

Conclusions

ACGME duty hour reform was not associated with any consistent improvements or worsening in mortality or failure-to-rescue rates for high risk medical or surgical patients.

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Acknowledgements

This work was supported primarily by grant VA HSR&D IIR 04.202.1 and NHLBI R01 HL082637, with additional support from National Science Foundation grant SES-0646002. The sponsors/funders have had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. Dr. Volpp had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. We also thank Yun Teng for her assistance with the analyses. Everyone who contributed significantly to this work has been acknowledged.

Conflict of Interest

None disclosed.

Author information

Authors and Affiliations

  1. Center for Health Equity Research and Promotion, Veteran’s Administration Hospital, 1232 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104–6021, USA

    Kevin G. Volpp MD, PhD & Michael J. Halenar BA

  2. Department of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, PA, USA

    Kevin G. Volpp MD, PhD, Lisa Bellini MD, Liyi Cen MS & Michael J. Halenar BA

  3. Department of Health Care Management, The Wharton School, The University of Pennsylvania, Philadelphia, PA, USA

    Kevin G. Volpp MD, PhD & Jeffrey H. Silber MD, PhD

  4. Center for Health Incentives, The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA

    Kevin G. Volpp MD, PhD

  5. Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA

    Amy K. Rosen PhD

  6. Center for Health Quality, Outcomes and Economic Research, Veteran’s Administration Hospital, Bedford, MA, USA

    Amy K. Rosen PhD

  7. Department of Statistics, The Wharton School, The University of Pennsylvania, Philadelphia, PA, USA

    Paul R. Rosenbaum PhD

  8. Division of General Medicine and Center for Healthcare Policy and Research, University of California Davis School of Medicine, Davis, CA, USA

    Patrick S. Romano MD, MPH

  9. Department of Surgery, VA Boston Health Care System and Boston University, Boston, MA, USA

    Kamal M.F. Itani MD

  10. Center for Outcomes Research, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA

    Orit Even-Shoshan MS, Yanli Wang MS & Jeffrey H. Silber MD, PhD

  11. The Department of Pediatrics, The University of Pennsylvania School of Medicine, Philadelphia, PA, USA

    Jeffrey H. Silber MD, PhD

  12. The Department Anesthesiology and Critical Care, The University of Pennsylvania School of Medicine, Philadelphia, PA, USA

    Jeffrey H. Silber MD, PhD

  13. The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA, USA

    Orit Even-Shoshan MS & Jeffrey H. Silber MD, PhD

Authors
  1. Kevin G. Volpp MD, PhD
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  2. Amy K. Rosen PhD
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  3. Paul R. Rosenbaum PhD
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  4. Patrick S. Romano MD, MPH
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  5. Kamal M.F. Itani MD
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  6. Lisa Bellini MD
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  7. Orit Even-Shoshan MS
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  8. Liyi Cen MS
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  9. Yanli Wang MS
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  10. Michael J. Halenar BA
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  11. Jeffrey H. Silber MD, PhD
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Corresponding author

Correspondence to Kevin G. Volpp MD, PhD.

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Volpp, K.G., Rosen, A.K., Rosenbaum, P.R. et al. Did Duty Hour Reform Lead to Better Outcomes Among the Highest Risk Patients?. J GEN INTERN MED 24, 1149–1155 (2009). https://doi.org/10.1007/s11606-009-1011-z

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  • DOI: https://doi.org/10.1007/s11606-009-1011-z

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