Physicians-in-training Does work-hours reform help?
Researchers, including an investigator from UC Davis Health System, have found that new national regulations greatly limiting work hours for physicians-in-training did not lead to increased patient deaths. That is one of the conclusions contained in two articles in this week's issue of the Journal of the American Medical Association (JAMA ).
Although residents are working fewer hours and getting more sleep, there are fewer residents on call at any one time and more patient handoffs due to shorter resident schedules. Many were concerned that this may harm patient care.
Analyzing more than eight million patient hospitalizations in the Medicare system and over 300,000 hospitalizations in the United States Veterans Affairs (VA) System, investigators found that duty-hour regulations for medical residents in the VA System significantly improved patient mortality. However, these regulations were not associated with either significant worsening or improvement in mortality for Medicare patients.
“We were surprised to find that work hour regulations appear to have had a beneficial effect on patients with major medical conditions in the VA hospital system, but not on elderly patients with the same conditions in non-federal hospitals,” said Patrick Romano, professor of medicine and pediatrics at UC Davis in Sacramento and one of the co-authors of the two JAMA studies. “We think that this difference may be due to VA hospitals' heavier reliance on physicians-in-training to fill their staffing needs, to better compliance with work hours regulations in VA hospitals or to other differences in hospital organization and management.”
Changes in work hours
In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour regulations for all accredited residency programs in response to growing concerns that the high number of deaths in hospitals from medical errors could be associated with residents working long hours and amidst mounting scientific evidence linking fatigue and impaired cognitive performance. These restrictions included working no more than 80 hours per week with one day per week free of all duties and no more than 24 continuous hours of work with an additional six hours for education and transfer of care.
—Mark Henderson, professor of internal medicine and residency program director
“What we wanted to determine was whether these new residency regulations were effective in lowering mortality for patients,” said Kevin Volpp, assistant professor of medicine and health care systems at the University of Pennsylvania and lead author of the two studies. “Reducing the long work hours of physicians in training is likely to be beneficial, but a necessary byproduct of this reform has been the increased number of patient handoffs between residents, which could adversely affect continuity of care. We wanted to see if these new regulations, on balance, improved patient outcomes.”
The VA study followed all patients admitted to acute-care VA hospitals from July 1, 2000 to June 30, 2005. The Medicare study followed all patients admitted to acute-care non-federal hospitals during this time period as well.
Both studies focused on medical patients admitted with principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, or stroke; or general, orthopedic, or vascular surgery patients. The main outcome measure for both studies was mortality within 30 days of hospital admission.
Reducing hospital errors
The duty-hours rules were one of the largest efforts ever enacted to reduce errors in teaching hospitals. UC Davis has physicians-in-training at several area hospitals, including UC Davis Medical Center and Sacramento's VA hospital on the grounds of the former Mather Air Force Base. It embraced the new rules by adding more hospital-based doctors to handle the volume of patients that couldn't be seen by residents once the changes in work hours went into effect.
“It's reassuring that researchers found significant improvements within one system and at least no major changes for the worse in the other,” said Mark Henderson, professor of internal medicine and a residency program director at UC Davis who was not involved with the studies. “We constantly are looking at ways to enhance the training process for doctors so that our ultimate goal of improving the quality of patient care while enhancing resident education can be achieved. The balancing act in all this is to make sure physicians spend enough time with patients and encounter enough diversity in their clinical experiences to achieve clinical competency.”
Both studies in this week's JAMA recommend further assessment of duty-hour regulations to better understand its impacts.
“There are a number of next steps we should take in this research,” said Romano. “Patient outcomes, such as complications rather than mortality, are important to understand. Different ways work hour regulations have been implemented could also be important.”
Romano added that one of the keys to understanding quality of care is not just looking at how many hours residents work, but how they work. How much time do residents spend on administrative tasks such as paperwork, for example? Are they seeing enough patients during their work hours to obtain the necessary medical experience that a physician needs?
“Our results from the VA suggest that, at least in certain settings for certain types of patients, hospitals can improve quality of life for physicians-in-training and reduce patient mortality at the same time. It's important to better understand those outcomes and build upon them,” said Romano.