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IIR 04-202 – HSR&D Study

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IIR 04-202
Impact of Resident Work Hours on Errors and Quality in VA Hospitals
Kevin G. Volpp MD PhD
Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
Philadelphia, PA
Funding Period: June 2005 - November 2007

BACKGROUND/RATIONALE:
Medical errors are believed to result in the deaths of tens of thousands of patients in American hospitals each year. Much of the direct care provided to patients in VA teaching hospitals is the responsibility of residents. In recent years, there has been an emerging consensus that the acute and chronic sleep deprivation of residency training likely contribute significantly to medical errors among residents. In response, the ACGME released rules effective July 1, 2003 that limited duty hours for all ACGME-accredited residency programs. The hope was that these changes would make residents more rested, decreasing patient mortality. Experts also worried that there would be negative effects from a drop in continuity of care.

OBJECTIVE(S):
The objectives of this study were to: a) examine the change in mortality; b) examine the change in mortality for patients who experienced complications (failure-to-rescue); c) examine the rate of change of AHRQ patient safety indicators (PSIs) and d) examine how length of stay, the probability of a prolonged length of stay (PLOS), and conditional length of stay (CLOS) changed, all following implementation of the ACGME duty hour rules

METHODS:
We used a multiple time series research design to examine whether the change in duty hour rules changed the underlying trend in patient outcomes in teaching hospitals, an approach which allows for greater detection of biases from unmeasured variables. This "difference-in-differences" design compares each hospital to itself, before and after reform, contrasting the changes in hospitals with more residents to the changes in hospitals with fewer or no residents, making adjustments for observed differences in patient risk factors.

FINDINGS/RESULTS:
Overall, we found that the new regulations did not have a strong impact on the rates of mortality or the probability of experiencing a prolonged stay. The PSI analyses showed that there was no systematic impact on potential safety-related events from duty hour reforms. The magnitude of any absolute increase was too small to be clinically meaningful and was inconsistent over time. Duty hour reform was not associated with changes in mortality or FTR rates for high risk medical or surgical patients. These results indicate that hospitals were able to cope with the reduction in resident work hours. Hospitals found ways to cope with any worsening of continuity of care associated with duty hour reform and succeeded in avoiding the adverse consequences predicted.

IMPACT:
The effects of the duty hour limitations are important to understand because they affect the care of the majority of inpatients treated in VA hospitals each year. Our analyses show that though the duty hour reform has not necessarily improved patient outcomes yet, it has not negatively affected them either. Many people worried about increased handoffs disrupting patient care and increasing the occurrence of negative outcomes. More studies need to be done to see how else the reform affected patient care in the VA health system. This will inform further efforts to reduce errors in VA teaching hospitals and clarify which mechanisms helped hospitals cope with the reduction in the residents' work hours.

PUBLICATIONS:

Journal Articles

  1. Silber JH, Rosenbaum PR, Rosen AK, Romano PS, Itani KM, Cen L, Mi L, Halenar MJ, Even-Shoshan O, Volpp KG. Prolonged hospital stay and the resident duty hour rules of 2003. Medical care. 2009 Dec 1; 47(12):1191-200.
  2. Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Itani KM, Bellini L, Even-Shoshan O, Cen L, Wang Y, Halenar MJ, Silber JH. Did duty hour reform lead to better outcomes among the highest risk patients? Journal of general internal medicine. 2009 Oct 1; 24(10):1149-55.
  3. Rosen AK, Loveland SA, Romano PS, Itani KM, Silber JH, Even-Shoshan OO, Halenar MJ, Teng Y, Zhu J, Volpp KG. Effects of resident duty hour reform on surgical and procedural patient safety indicators among hospitalized Veterans Health Administration and Medicare patients. Medical care. 2009 Jul 1; 47(7):723-31.
  4. Silber JH, Rosenbaum PR, Romano PS, Rosen AK, Wang Y, Teng Y, Halenar MJ, Even-Shoshan O, Volpp KG. Hospital teaching intensity, patient race, and surgical outcomes. Archives of surgery (Chicago, Ill. : 1960). 2009 Feb 1; 144(2):113-20; discussion 121.
  5. Volpp KG, Landrigan CP. Building physician work hour regulations from first principles and best evidence. JAMA : the journal of the American Medical Association. 2008 Sep 10; 300(10):1197-9.
  6. Volpp KG. A delicate balance: physician work hours, patient safety, and organizational efficiency. Circulation. 2008 May 20; 117(20):2580-2.
  7. Silber JH, Romano PS, Rosen AK, Wang Y, Even-Shoshan O, Volpp KG. Failure-to-rescue: comparing definitions to measure quality of care. Medical care. 2007 Oct 1; 45(10):918-25.
  8. Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Canamucio A, Bellini L, Behringer T, Silber JH. Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. JAMA : the journal of the American Medical Association. 2007 Sep 5; 298(9):984-92.
  9. Myers JS, Bellini LM, Morris JB, Graham D, Katz J, Potts JR, Weiner C, Volpp KG. Internal medicine and general surgery residents' attitudes about the ACGME duty hours regulations: a multicenter study. Academic Medicine. 2006 Dec 1; 81(12):1052-8.
Journal Other

  1. Volpp KG, Rosen AK, Rosenbaum P, Romano P, Bellini L, Silber J. Resident duty hour reform and mortality in hospitalized patients [letter to the editor]. [Letter to the Editor]. JAMA : the journal of the American Medical Association. 2007 Dec 26; 298(24):2866.
VA Cyberseminars

  1. Volpp KG. Physician duty hour reform: highlights of recent findings and future directions. [Cyberseminar]. 2008 Oct 1.
Conference Presentations

  1. Volpp KG. Duty hour regulation for residents: what we know and future directions. Paper presented at: American Academy of Sleep Medicine Annual Meeting; 2009 Jun 5; Seattle, WA.
  2. Volpp KG. ACGME duty hour reform: impacts on clinical outcomes and future directions. Paper presented at: Accreditation Council for Graduate Medical Education on Improving the Learning Environment Committee Annual Meeting; 2009 Mar 5; Grapevine, TX.
  3. Rosen A, Loveland S, Romano P, Rosenbaum P, Silber J, Volpp K. Rates of patient safety indicators (PSIs) among VA patients in the first two years following ACGME resident duty hour reform. Paper presented at: AcademyHealth Annual Research Meeting; 2008 Jun 8; Washington, DC.
  4. Loveland SA, Rosen AK, Romano PS, Silber JH, Rosenbaum PR, Even-Shoshan O, Halenar M, Volpp KG. The effect of ACGME resident duty hour reform on three patient safety indicator composite measures. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD.
  5. Volpp KG, Rosen AK, Rosenbaum PR, Romano P, Even-Shoshan O, Canamuico A, Loveland S, Silber JH. The impact of the ACGME duty hour tules on mortality rates in teaching hospitals. Paper presented at: AcademyHealth Annual Research Meeting; 2007 Jun 3; Orlando, FL.
  6. Volpp KG, Rosen AK, Rosenbaum PR, Romano P, Even-Shoshan O, Canamucio A, Loveland S, Silber JH. The impact of the ACGME duty hour rules on PSI rates in VA hospitals. Paper presented at: AcademyHealth Annual Research Meeting; 2007 Jun 1; Orlando, FL.
  7. Myers JS, Bellini LM, Morris J, Graham D, Katz J, Potts JR, Wiener C, Volpp KG. Internal medicine and general surgery residents' attitudes about the ACGME duty hour regulations: a multicenter study. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2006 Apr 1; Los Angeles, CA.
  8. Volpp KG. Reducing errors and improving the work environment for residents. Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA.
  9. Volpp KG. Research on the learning environment and errors in teaching hospitals. Paper presented at: Accreditation Council for Graduate Medical Education on Improving the Learning Environment Committee Annual Meeting; 2005 Apr 1; Chicago, IL.


DRA: Health Systems
DRE: none
Keywords: Education (provider), Quality assessment, Safety
MeSH Terms: none

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