10:29pm Thursday 23 November 2017

U of M study finds a reduction in neurosurgical resident hours appears to have no significant positive effect on patient outcomes

The reduction in resident duty hours was mandated in 2003 by the Accreditation Council for Graduate Medical Education (ACGME) when it imposed a mandatory maximum 80-hour work-week restriction on medical residents. Prior to this mandate, residents often worked in excess of 100 hours per week.

Findings were published today in the Journal of Neurosurgery.

Researchers sought to determine if regulation of neurosurgery resident duty hours resulted in significant changes in readily available measures of clinical outcome such as in-hospital mortality, discharge disposition, in-hospital complications, or in-hospital procedures. Researchers analyzed hospital-based data from Nationwide Inpatient Sample, a large hospital database, three years before (2000-2002) and three years after (2004-2006) the ACGME restrictions.

“The results of our study are part of an increasing body of evidence that limitations on resident work hours in the way they have been implemented have not had a measurable effect on important patient outcomes,” said Stephen Haines, M.D., professor and department head, Department of Neurosurgery at the University of Minnesota, who led the study. “Further long term study will be needed to determine if resident education has been improved or harmed by the regulations. One hopes that, in the future, if major changes in physician education are proposed to improve patient outcomes, research clearly demonstrating important improvements in outcome will precede the imposition of the regulations.”

Researchers addressed the greatest potential bias of the study, the effect of passage of time on clinical outcomes irrespective of individual interventions, by making four comparisons of clinical outcomes before and after ACGME in training hospitals in New York State and elsewhere.

The comparisons and results are as follows:

Comparison 1: Differences in clinical outcomes between regulated training hospitals in New York State (NY) and unregulated training hospitals in other states before the ACGME regulations were implemented (NY 2000–2002 vs. non-NY in 2000–2002):

Despite statewide-imposed regulations in New York State, the researchers found no significant differences in clinical outcomes between regulated training hospitals in New York and unregulated training hospitals in other states before the ACGME regulations came into effect.

In this comparison, the researchers did find a significantly lower mean length of hospital stay and a significantly higher mean cost of hospitalization in the non-NY hospitals.

Comparison 2: Differences in clinical outcomes in non-NY training hospitals before and after the ACGME regulations were implemented (non-NY 2000–2002 vs non-NY 2004–2006):

The researchers found no significant changes in clinical outcomes in non-NY training hospitals after the ACGME regulations came into effect.

At first examination there seemed to be a significant difference in hospital discharge disposition, but this difference became insignificant when the analysis was adjusted for patient age and sex as well as risk factors.

The author identified significantly higher percentages of patients with sepsis or pulmonary embolism, and significantly lower percentages of patients receiving thrombolytic therapy in non-NY training hospitals after the ACGME regulations were put in place. In addition, both the mean length of hospital stay and mean hospital charges were significantly higher in non-NY hospitals after the ACGME regulations were in place.

Comparison 3: Differences in clinical outcomes in NY training hospitals before and after the ACGME regulations were implemented (NY 2000–2002 vs NY 2004–2006):

The researchers found no significant changes in clinical outcomes in NY training hospitals after the ACGME regulations came into effect.

Significantly more patients were identified as having sepsis or needing mechanical ventilation in NY training hospitals after the ACGME regulations were put in place. In addition, statistically significant differences were identified in a longer mean length of hospital stay and higher hospital charges after the regulations were put in place.

Comparison 4: Differences in clinical outcomes between non-NY and NY training hospitals after the ACGME regulations were implemented (non-NY 2004–2006 vs NY 2004–2006):

With ACGME regulations in place, the researchers found some significant differences in clinical outcomes between non-NY and NY training hospitals. 

A multivariate regression analysis taking into account adjustments for patient age and sex, as well as risk factors, found statistically significant differences in hospital discharge disposition: after the ACGME regulations were in effect, there were significantly fewer discharges to home and significantly more discharges to long-term facilities in the NY hospitals compared with the non-NY hospitals.

In addition, statistically significant differences were found between the two groups with respect to mean length of hospital stay, with longer stays shown in the NY hospitals.

Researchers also believe that further modifications of regulations governing duty hours could lead to less operative experience, longer residencies, and the need for a greater number of residents to cover patient care, and greater costs for implementation of new regulations.

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