title: Association Between End-of-Rotation Resident Transition in Care and Mortality Among Hospitalized Patients.
abstract: OBJECTIVE
  Shift-to-shift transitions in care among house staff are associated with adverse events. However, the association between end-of-rotation transition (in which care of the patient is transferred) and adverse events is uncertain.
  
  
  OBJECTIVE
  To examine the association of end-of-rotation house staff transitions with mortality among hospitalized patients.
  
  
  METHODS
  Retrospective multicenter cohort study of patients admitted to internal medicine services (N = 230 701) at 10 university-affiliated US Veterans Health Administration hospitals (2008-2014).
  
  
  METHODS
  Transition patients (defined as those admitted prior to an end-of-rotation transition who died or were discharged within 7 days following transition) were stratified by type of transition (intern only, resident only, or intern + resident) and compared with all other discharges (control). An alternative analysis comparing admissions within 2 days before transition with admissions on the same 2 days 2 weeks later was also conducted.
  
  
  METHODS
  The primary outcome was in-hospital mortality. Secondary outcomes included 30-day and 90-day mortality and readmission rates. A difference-in-difference analysis assessed whether outcomes changed after the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations. Adjustments included age, sex, race/ethnicity, month, year, length of stay, comorbidities, and hospital.
  
  
  RESULTS
  Among 230 701 patient discharges (mean age, 65.6 years; men, 95.8%; median length of stay, 3.0 days), 25 938 intern-only, 26 456 resident-only, and 11 517 intern + resident end-of-rotation transitions occurred. Overall mortality was 2.18% in-hospital, 9.45% at 30 days, and 14.43% at 90 days. Adjusted hospital mortality was significantly greater in transition vs control patients for the intern-only group (3.5% vs 2.0%; odds ratio [OR], 1.12 [95% CI, 1.03-1.21]) and the intern + resident group (4.0% vs 2.1%; OR, 1.18 [95% CI, 1.06-1.33]), but not for the resident-only group (3.3% vs 2.0%; OR, 1.07 [95% CI, 0.99-1.16]). Adjusted 30-day and 90-day mortality rates were greater in all transition vs control comparisons (30-day mortality: intern-only group, 14.5% vs 8.8%, OR, 1.17 [95% CI, 1.13-1.22]; resident-only group, 13.8% vs 8.9%, OR, 1.11 [95% CI, 1.04-1.18]; intern + resident group, 15.5% vs 9.1%, OR, 1.21 [95% CI, 1.12-1.31]; 90-day mortality: intern-only group, 21.5% vs 13.5%, OR, 1.14 [95% CI, 1.10-1.19]; resident-only group, 20.9% vs 13.6%, OR, 1.10 [95% CI, 1.05-1.16]; intern + resident group, 22.8% vs 14.0%, OR, 1.17 [95% CI, 1.11-1.23]). Duty hour changes were associated with greater adjusted hospital mortality for transition patients in the intern-only group and intern + resident group than for controls (intern-only: OR, 1.11 [95% CI, 1.02-1.21]; intern + resident: OR, 1.17 [95% CI, 1.02-1.34]). The alternative analyses did not demonstrate any significant differences in mortality between transition and control groups.
  
  
  CONCLUSIONS
  Among patients admitted to internal medicine services in 10 Veterans Affairs hospitals, end-of-rotation transition in care was associated with significantly higher in-hospital mortality in an unrestricted analysis that included most patients, but not in an alternative restricted analysis. The association was stronger following institution of ACGME duty hour regulations.
authors.affiliation: Division of Pulmonary Sciences and Critical Care, University of Colorado School of Medicine, Denver2Department of Medicine, New York University School of Medicine, New York.
authors.forename: Joshua L
authors.initials: JL
authors.lastname: Denson
authors.affiliation: Cumming School of Medicine, University of Calgary, Alberta, Canada4Veterans Affairs New York Harbor Healthcare System, New York.
authors.forename: Ashley
authors.initials: A
authors.lastname: Jensen
authors.affiliation: Department of Medicine, New York University School of Medicine, New York.
authors.forename: Harry S
authors.initials: HS
authors.lastname: Saag
authors.affiliation: Department of Population Health, New York University School of Medicine, New York.
authors.forename: Binhuan
authors.initials: B
authors.lastname: Wang
authors.affiliation: Department of Mathematical Sciences, New Jersey Institute of Technology, Newark.
authors.forename: Yixin
authors.initials: Y
authors.lastname: Fang
authors.affiliation: Department of Medicine, New York University School of Medicine, New York5Department of Population Health, New York University School of Medicine, New York.
authors.forename: Leora I
authors.initials: LI
authors.lastname: Horwitz
authors.affiliation: Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York.
authors.forename: Laura
authors.initials: L
authors.lastname: Evans
authors.affiliation: Department of Medicine, New York University School of Medicine, New York4Veterans Affairs New York Harbor Healthcare System, New York5Department of Population Health, New York University School of Medicine, New York.
authors.forename: Scott E
authors.initials: SE
authors.lastname: Sherman
mesh_terms: D000368:Aged; D015331:Cohort Studies; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006787:Hospitals, Veterans / Q000706:statistics & numerical data; D006801:Humans; D007388:Internal Medicine / Q000592:standards; D007396:Internship and Residency / Q000592:standards*; D008297:Male; D010351:Patient Discharge; D012189:Retrospective Studies; D000069341:Transitional Care / Q000592:standards*; D014481:United States / Q000453:epidemiology