Impact of duty hours restrictions on quality of care and clinical outcomes.
BACKGROUND
In July 2003, the Accreditation Council for Graduate Medical Education instituted residency duty-hours requirements in response to growing concerns regarding clinician fatigue and the incidence of medical errors. These changes, which limited maximum continuous hours worked and total hours per week, often resulted in increased discontinuity of care. The objective of this study was to assess the impact of the duty-hours restrictions on quality of care and outcomes of patients with acute coronary syndrome.


METHODS
We performed a retrospective analysis of 1003 consecutive patients with acute coronary syndrome admitted to the University of Michigan Hospital between July 2002 and June 2004. Patients were stratified by hospital admission during academic year 2002-2003 (pre-duty-hours changes, n=572) and academic year 2003-2004 (post-duty-hours changes, n=431). Main outcome measures included differences in adherence to quality indicators, length of stay, and in-hospital and 6-month adverse events.


RESULTS
Post-duty-hours changes, there was an increase in the usage of beta-blockers (85.8% vs 93.8%, P <.001), angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (65.7% vs 71.8%, P=.046), and statins (76.2% vs 84.0%, P=.002) at time of discharge. Length of stay decreased from 3.1 days to 2.8 days, P=.002. There was no difference in in-hospital mortality (4.2% vs 2.8%, P=.23). Six-month mortality (8.0% vs 3.8%, P=.007) and risk-adjusted 6-month mortality (odds ratio 0.53, 95% confidence interval, 0.28-0.99, P=.05) decreased after the duty-hours changes.


CONCLUSIONS
Implementation of the Accreditation Council for Graduate Medical Education residency duty-hours restrictions on an academic inpatient cardiology service was associated with improved quality of care and efficiency in patients admitted with acute coronary syndrome. In addition, improved efficiency did not adversely impact patient outcomes, including mortality.
Bhavsar
Jignesh
J
Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA.
Montgomery
Daniel
D
Li
Jin
J
Kline-Rogers
Eva
E
Saab
Fadi
F
Motivala
Apurva
A
Froehlich
James B
JB
Parekh
Vikas
V
Del Valle
John
J
Eagle
Kim A
KA
D054058:Acute Coronary Syndrome / Q000188:drug therapy*; D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D057911:Angiotensin Receptor Antagonists; D001241:Aspirin / Q000627:therapeutic use; D005260:Female; D017408:Guidelines as Topic; D006784:Hospitals, Teaching; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D007396:Internship and Residency / Q000592:standards*; D007587:Job Description; D007902:Length of Stay; D008297:Male; D008824:Michigan; D008875:Middle Aged; D010561:Personnel Staffing and Scheduling; D010820:Physicians; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care; D012189:Retrospective Studies; D016896:Treatment Outcome; D014940:Work Schedule Tolerance; D016526:Workload
D000319:Adrenergic beta-Antagonists; D057911:Angiotensin Receptor Antagonists; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D001241:Aspirin