No change in health or education outcomes following implementation of duty-hour restrictions
1. In these two retrospective studies, there was no difference in 30-day mortality, readmissions, or serious morbidity among medical or surgical patients after the implementation of the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty-hour reform.
2. There was no change in general surgery resident performance on written examinations after the implementation of the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty-hour reform.
Evidence Rating Level: 2 (Good) Â Â Â Â Â Â Â Â Â Â
Study Rundown: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) implemented new policies regarding the number of hours residents can work. This limited the number of consecutive hours trainees are permitted spend in the hospital. Patel et. al. compared 30-day mortality and 30-day readmission rates before and after the 2011 duty-hour reform. Medicare data was used to analyze 6,384,273 admissions for 2,790,356 individuals in 3,104 hospitals across the US between July 1, 2009 and June 30, 2012. Included individuals were admitted for acute myocardial infarction, stroke, gastrointestinal bleeding, congestive heart failure, or for a complaint relating to general, vascular, or orthopedic surgery. There were no overall differences between 30-day mortality or readmission rates in the study.
Rajaram et. al. conducted a study including 204,641 individuals who underwent any general surgery procedure between July 1, 2009 and June 30, 2013 in 54 hospitals with general surgery residency programs compared mortality and serious morbidity rates in the first 30 days after surgery and resident written examination performance before and after the 2011 duty-hour reform. In this study there was no difference in rates of death or serious morbidity in the first 30 days following surgery. There was also no difference in resident written examination performance.
Taken together, these two studies suggest that the 2011 ACGME duty-hour reform has resulted in no significant change in patient outcomes or resident acquisition of knowledge. While it is reassuring that there has not been a detrimental effect in either arena, it is discouraging to note that there has been no improvement either, particularly with regards to patient health outcomes. Nevertheless, a randomized controlled study should be performed to obtain a more complete understanding of any changes that may be associated with the 2011 duty-hour reform.
Click to read Patel et al, published today in JAMA
Click to read Rajaram et al, published today in JAMA
Click to read an accompanying editorial, published today in JAMA
Relevant Reading: Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships?
In-Depth [retrospective cohort]: Patel et. al. compared 30-day mortality and readmission and Rajaram et. al. compared mortality and serious morbidity in the 30 days following surgery before and after the 2011 ACGME duty-hour reform. Patel et. al. found no difference in 30-day mortality in medical (OR 1.00, 95% CI 0.96-1.03, p=0.75) or surgical categories (OR 0.99, 95% CI 0.94-1.04, p=0.64). There was also no difference in 30-day readmission in medical (OR 1.00, 95% CI 0.97-1.02, p=0.71) or surgical categories (OR 1.00, 95% CI 0.98-1.03, p=0.88). There were higher odds of readmission for stroke (OR 1.06, 95% CI 1.001-1.13, p=0.047), but no other individual medical or surgical condition. Rajaram et. al. found that there was no difference in 30-day mortality or serious morbidity following surgical procedures before and after the 2011 duty-hour reform (OR 1.06, 95% CI 0.93-1.20). They also found that examination performance for first year residents (post-graduate year-1 or interns) was no different between 2010 and 2013 (p=0.99) and that comparing 2011 to post-reform test performance for other years of training showed no difference in performance (p=0.41).
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