Loveland SA (Center for Health Quality, Outcomes and Economic Research, Bedford VA and Boston University School of Public Health), Rosen AK
(Center for Health Quality, Outcomes and Economic Research, Bedford VA and Boston University School of Public Health), Romano PS
(Division of General Medicine and Center for Healthcare Policy and Research, University of California Davis School of Medicine), Silber JH
(Center for Outcomes Research, The Children’s Hospital of Philadelphia; Univ of Penn: School of Medicine, Wharton, Leonard Davis Inst of Health Econ), Rosenbaum PR
(Department of Statistics, Wharton School, University of Pennsylvania), Even-Shoshan O
(Center for Outcomes Research, The Children’s Hospital of Philadelphia; The Leonard Davis Institute of Health Economics, University of Pennsylvania), Halenar M
(University of Pennsylvania School of Medicine), Volpp KG
(Center for Health Equity Research and Promotion, Philadelphia VA; Univ of Penn: School of Medicine, Wharton, Leonard Davis Inst of Health Econ)
The ACGME rules in 2003 limiting residents’ work hours were intended to reduce medical errors in hospitals, but there are concerns about possible adverse effects of duty hour reform on patient safety, especially due to decreased continuity of care. The objective of this study was to examine the impact of duty hour reform on changes in adverse event rates among more vs. less teaching-intensive VA hospitals.
We analyzed all unique patients admitted to acute-care VA hospitals (N=4,345,801 patients from 131 hospitals) from July 1, 2000 to June 30, 2005. Data were obtained from the VA Patient Treatment File and the VA Office of Academic Affiliations. Our primary outcomes were 3 composite measures using the AHRQ Patient Safety Indicators (PSIs). We grouped PSIs into Nurse-Sensitive (e.g., Postoperative Hip Fracture), Continuity-of-Care related (e.g., Postoperative Thromboembolism), and Technical (e.g., Iatrogenic Pneumothorax). We ran conditional logistic regressions to examine change in PSI rates for patients in more vs. less teaching-intensive hospitals before and after duty hour reform, adjusting for patient comorbidities, common time trends, and stratifying on hospital site.
For the Nurse-Sensitive composite, in the 2nd year post-reform, the risk of PSIs was higher in more vs. less teaching-intensive hospitals (OR=1.65, 95% CI[1.15-2.38] p=0.0067). For the Continuity-of-Care (OR=1.03, 95% CI [0.82-1.30] P=0.79) and Technical(OR=1.097, 95% CI [0.83-1.45] P=0.52) composites, there were no significant differences in risk between more and less teaching-intensive hospitals in either post-reform year.
Preliminary results suggest an increase in rates of the Nurse-Sensitive indicators at more vs less teaching-intensive hospitals, No other adverse impact of duty hour reform on indicators of patient safety, derived from administrative data, was seen, although low prevalence of these indicators means that confidence intervals are too wide to rule out clinically significant effects. Further work will check robustness of analyses to adjustment for DRGs and which specific PSIs contribute the most to these results.
Regulation of work hours for physicians in training has not resulted in improved hospital performance on PSIs. Further refinement of duty hour standards may be needed to improve performance on patient safety indicators.