Restricting residents’ work hours as required by the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reform does not reduce morbidity or mortality of patients across diverse surgical specialties, a new longitudinal study concludes. The results add to reports showing lack of benefit for general surgery patients.
“These findings suggest that recent changes to the structure of graduate medical education have not translated into improved surgical patient care,” the researchers write in their article published July 7 in the Journal of the American College of Surgeons.
“Potentially positive benefits resulting from a more rested resident workforce may, in part, be mitigated by reductions in continuity of care and errors in communication from increased handoffs. Several stakeholder organizations within surgery have also expressed concern that these reforms impede the ability to adequately train residents to enter independent practice due to reductions in clinical and operative experience,” they note. “As the ACGME’s duty hour policies continue to evolve, stakeholders should consider not only the importance of resident wellbeing, but also the empirical evidence suggesting the absence of an association between duty hour reform and improved outcomes in surgical patients.”
The researchers were led by Ravi Rajaram, MD, from the Division of Research and Optimal Patient Care, American College of Surgeons, and the Surgical Outcomes and Quality Improvement Center, Department of Surgery and Center for Healthcare Studies in the Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, both in Chicago, Illinois.
They analyzed data from patients from five surgical specialties (neurosurgery, obstetrics/gynecology, orthopedic surgery, urology, and vascular surgery) captured in the National Surgical Quality Improvement Program database of the American College of Surgeons.
They compared patient outcomes in the 1 year before vs 2 years after the 2011 ACGME reform was implemented for both teaching hospitals, defined as those where a resident was present intraoperatively in at least 75% of surgical cases, and nonteaching hospitals, defined as those where a resident was present intraoperatively in, at most, 5% of cases.
Analyses were based on data from between 37 and 114 hospitals and 22,158 to 61,640 patients, depending on the surgical specialty.
Results showed that both types of hospitals had a reduction in the unadjusted rate of 30-day death or serious morbidity during the study period for all surgical specialties. The greatest absolute reduction was seen for vascular surgery, with the rate declining from 19.0% to 14.9% in teaching hospitals and from 14.5% to 12.0% in nonteaching hospitals.
However, in multivariate difference-in-differences models, there was no significant reduction in this composite outcome comparing the periods before and after duty hour reform for any of the surgical specialties: neurosurgery (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.75 – 1.08; P = .26), obstetrics/gynecology (OR, 0.96; 95% CI, 0.71 – 1.30; P = .80), orthopedic surgery (OR, 0.95; 95% CI, 0.74 – 1.22; P = .70), urology (OR, 1.16; 95% CI; 0.89 – 1.51; P = .26), or vascular surgery (OR, 1.07; 95% CI, 0.93 – 1.22; P = .35).
“As non-teaching hospitals should not be affected by changes in resident duty hour policies, this group serves as a contemporaneous control to compare teaching hospitals to and more accurately approximate the effect of duty hour policies on patient care at teaching hospitals,” the authors note.
Results were the same for the first and the second postreform years, separately.
In addition, the findings remained essentially unchanged in sensitivity analyses that used alternate percentage thresholds to define a teaching hospital, and that instead stratified hospitals by teaching intensity, as determined from the resident-to-bed ratio.