Mortality Among Patients in VA Hospitals in the First 2 Years Following ACGME Resident Duty Hour Reform

Abstract

Conclusion: New duty hour regulations implemented by the Accreditation Council for Graduate Medical Education (ACGME) were associated with relative improvement in mortality in four common medical conditions in teaching-intensive Veterans Administration (VA) hospitals. No mortality changes were identified for surgical patients. Summary: On July 1, 2003, the ACGME instituted limitations in duty hours for United States resident physicians. The study sought to determine whether there was an associated change in mortality among hospitalized patients with duty hour reform. The authors determined whether there were associated relative changes in mortality in hospitals of different teaching intensity within the Department of Veterans Affairs health care system. This was an observational study of 318,636 acute care patients admitted to 131 VA hospitals from July 1, 2000, to June 30, 2005. Medical conditions studied were acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, and stroke. Patient admissions that were determined by Diagnosis-Related Groups to be related to general, orthopedic, or vascular surgery were also studied. A logistic regression analysis examined changes in mortality in more- or less-intensive teaching hospitals before and after duty hour reform. Adjustments were made for time trends, hospital sites, and patient comorbidities. The main outcome measure was death ≤30 days of hospital admission. Changes in mortality rates were not significant in the first year after reform in either medical or surgical patients. In year 2 after reform, mortality decreased significantly in more teaching-intensive hospitals for medical patients only. When hospitals with a resident-to-bed ratio of 1 were compared with hospitals with a resident-to-bed ratio of 0, mortality odds were reduced for patients with acute myocardial infarctions (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.33-0.71). For the medical conditions studied taken together, mortality in the hospitals with resident-to-bed ratio of 1 compared with those with resident-to-bed ratio of 0 was also less (OR, 0.74; 95% CI, 0.61-0.89). Similarly, mortality was improved in the three other medical conditions excluding acute myocardial infarction (OR, 0.79; 95% CI, 0.63-0.98). Compared with hospitals in the 25th percentile of teaching intensity, hospitals in the 75th percentile of teaching intensity had an 11.1% relative mortality decrease, and those in the 90th percentile of teaching intensity had a 15.9% relative decrease in mortality for all the combined medical conditions. Comment: This study raises a number of interesting questions about the impact of duty hour reform on in-hospital mortality. There are many possible explanations for the findings, including more attending involvement and more use of mid-level providers in response to the resident work hour restrictions. In addition, the failure of mortality rates to decrease in the surgical patients does not necessarily imply poor care of the surgical patients. Perhaps these patients were already getting excellent care, and this care was not affected by a decrease in work hours by the surgical residents. Nevertheless, surgical program directors must ask themselves whether they are doing well or whether they could be doing better, or perhaps both.