Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform.
BACKGROUND
The Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour regulations for physicians-in-training throughout the United States on July 1, 2003. The association of duty hour reform with mortality among patients in teaching hospitals nationally has not been well established.


OBJECTIVE
To determine whether the change in duty hour regulations was associated with relative changes in mortality among Medicare patients in hospitals of different teaching intensity.


METHODS
An observational study of all unique Medicare patients (N = 8 529 595) admitted to short-term, acute-care, general US nonfederal hospitals (N = 3321) using interrupted time series analysis with data from July 1, 2000, to June 30, 2005. All Medicare patients had principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, or stroke or a diagnosis related group classification of general, orthopedic, or vascular surgery. Logistic regression was used to examine the change in mortality for patients in more vs less teaching-intensive hospitals before (academic years 2000-2003) and after (academic years 2003-2005) duty hour reform, adjusting for patient comorbidities, common time trends, and hospital site.


METHODS
All-location mortality within 30 days of hospital admission.


RESULTS
In medical and surgical patients, no significant relative increases or decreases in the odds of mortality for more vs less teaching-intensive hospitals were observed in either postreform year 1 (combined medical conditions group: odds ratio [OR], 1.03; 95% confidence interval [CI], 0.98-1.07; and combined surgical categories group: OR, 1.05; 95% CI, 0.98-1.12) or postreform year 2 (combined medical conditions group: OR, 1.03; 95% CI, 0.99-1.08; and combined surgical categories group: OR, 1.01; 95% CI, 0.95-1.08) compared with the prereform years. The only condition for which there was a relative increase in mortality in more teaching-intensive hospitals postreform was stroke, but this association preceded the onset of duty hour reform. Compared with nonteaching hospitals, the most teaching-intensive hospitals had an absolute change in mortality from prereform year 1 to postreform year 2 of 0.42 percentage points (4.4% relative increase) for patients in the combined medical conditions group and 0.05 percentage points (2.3% relative increase) for patients in the combined surgical categories group, neither of which were statistically significant.


CONCLUSIONS
The ACGME duty hour reform was not associated with either significant worsening or improvement in mortality for Medicare patients in the first 2 years after implementation.
Volpp
Kevin G
KG
Center for Health Equity Research and Promotion, Veterans Administration Hospital, Philadelphia, Pennsylvania 19104-6021, USA. volpp70@wharton.upenn.edu
Rosen
Amy K
AK
Rosenbaum
Paul R
PR
Romano
Patrick S
PS
Even-Shoshan
Orit
O
Wang
Yanli
Y
Bellini
Lisa
L
Behringer
Tiffany
T
Silber
Jeffrey H
JH
D000068:Accreditation / Q000592:standards; D019538:Health Care Surveys; D017052:Hospital Mortality / Q000639:trends*; D006784:Hospitals, Teaching / Q000592:standards* / Q000706:statistics & numerical data*; D006801:Humans; D007396:Internship and Residency / Q000592:standards*; D016015:Logistic Models; D006278:Medicare / Q000706:statistics & numerical data*; D010043:Outcome and Process Assessment, Health Care; D010561:Personnel Staffing and Scheduling / Q000592:standards*; D015397:Program Evaluation; D020379:Risk Adjustment; D014481:United States; D014940:Work Schedule Tolerance; D000078329:Workforce