Authors of a research study designed to examine the long-term effects of the 2003 resident duty hour regulations on patient mortality found that the regulations, which were implemented by the Accreditation Council for Graduate Medical Education, did not worsen patient mortality.
"Implementation of the 2003 duty hour rules was arguably one of the largest efforts undertaken to reduce errors in teaching hospitals," wrote the study's authors. "The results of this study confirm that there were no systematic effects on mortality in the first three years post-reform, but suggest a relative improvement in mortality at high teaching intensity hospitals by the fifth year post-reform among both medical and surgical patients."
"Concerns about worsening outcomes seem unfounded," concluded researchers in an article in the August 2013 Journal of General Internal Medicine.
For purposes of the study, titled "Teaching Hospital Five-Year Mortality Trends in the Wake of Duty Hour Reforms(link.springer.com)," researchers looked at the effect of the 2003 resident duty hour regulations on mortality among medical and surgical patients enrolled in Medicare and treated at nonfederal hospitals between 2003 and 2008.
- Researchers conducted an observational study to determine whether duty hour regulations implemented in 2003 were associated with changes in mortality among Medicare patients in hospitals of different teaching intensity.
- Study authors found no consistent changes in mortality rates at "more versus less" teaching-intensive hospitals in post-reform years one to three.
- They found significant relative improvements in mortality for medical patients in the fourth and fifth years after reform and for surgical patients in the fifth year after reform.
They analyzed data from 13,678,956 Medicare patients admitted to 3,059 short-term, acute-care hospitals from July 1, 2000, to June 30, 2008. Patients included in the study had primary diagnoses of acute myocardial infarction (AMI), gastrointestinal bleeding or congestive heart failure, or they had a diagnosis-related group classification of general, orthopedic or vascular surgery.
Specifically, study authors measured mortality within 30 days of hospital admission for patients in "more versus less" teaching-intensive hospitals before duty hour reform (2000-2003) and for five years after (2003-2008). The primary measure of teaching intensity was the resident-to-bed ratio.
Researchers found no consistent changes in mortality rates one to three years after duty hour reforms were implemented. However, authors reported "significant relative improvements in mortality" for medical patients in the fourth and fifth years after reform and for surgical patients in the fifth year after reform.
For example, in pre-reform years 2000-2001, 255,233 patients diagnosed with AMI demonstrated an unadjusted mortality rate of 16.7 percent. In post-reform years 2003-2004, the mortality rate for 243,598 patients with the same diagnosis was 15.6 percent, and in post-reform years 2007-2008, the mortality rate for 190,069 patients diagnosed with AMI was 13.9 percent.
In the general surgical category in pre-reform years 2000-2001, 5.3 percent of 432,402 patients died. In post-reform years 2003-2004, 5.3 percent of 438,720 patients died, and in post reform years 2007-2008, 4.9 percent of 390,619 patients died.
Researchers acknowledged it was unclear whether improvements in patient outcomes several years after the implementation of duty hour reforms could, in fact, be attributed to the reforms, "since it cannot be determined whether the improvements would have been smaller or greater had no reform been implemented," they said.
Authors pointed out other major policy changes that occurred concurrently with implementation of duty hour reforms that could have positively affected mortality rates in teaching and nonteaching hospitals. Those changes included
- implementation of the Medicare Prescription Drug, Improvement and Modernization Act of 2003, which gave CMS the authority to financially penalize hospitals that did not report designated quality measures;
- passage of the Deficit Reduction Act of 2005, which increased the amount of the penalty, leading to a rapid increase in hospital participation;
- 225 new hospital participants in the Premier Hospital Quality Incentive Demonstration, which rewarded hospitals demonstrating high-quality care in certain clinical areas;
- rollout of the National Surgical Quality Improvement Program from the Department of Veterans Affairs to the private sector; and
- implementation of The Joint Commission's Surgical Care Improvement Project.
Researchers said their results did not address whether the design of duty hour rules was optimal. They called for more research to "examine whether similar patterns are observed in conjunction with the duty hour reform of 2011."
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