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Limiting Residents' Hours Has Little Impact on Patient Mortality

There had been concerns that lack of continuity could lead to problems

TUESDAY, Sept. 4 (HealthDay News) -- Limiting the hours that medical residents can work has made no difference in death rates among Medicare patients in the first two years since the new rules were instituted, a new study found.

The reform was associated with improvements in mortality for patients with common medical conditions at VA hospitals, however.

"We can say conclusively that the duty-hour regulations did not worsen patient mortality. There was a lot of concern about that, and we can conclusively say that's not the case," said Dr. Kevin G. Volpp, staff physician and core faculty member at the Center for Health Equity, Research and Promotion at the Philadelphia Veterans Affairs Medical Center. "We can also say that there's some evidence of benefit in terms of mortality outcomes."

The researchers still don't know if there are benefits in other measures besides mortality, and what impact the changes are having on educational results.

"The big question is how regulating work hours will affect the quality of training of the next generation of physicians who will be taking care of all of us for the next several decades," said Volpp, an assistant professor of medicine and health care systems at the University of Pennsylvania School of Medicine and Wharton School of Business. "That's the question no one really knows the answer to."

Both studies are published in the Sept. 5 issue of the Journal of the American Medical Association, a theme issue on medical education. Volpp was lead author of both papers.

Starting July 1, 2003, the Accreditation Council for Graduate Medical Education, which evaluates and accredits U.S. medical school residency programs, limited the maximum working hours for residents to 80 a week.

"Before, residents commonly worked 90 to 120 hours a week and sometimes 60 or 72 hours in a row," Volpp said.

The action was taken in response to concerns that lengthy hours left residents tired and prone to making dangerous medical errors.

But others have expressed concern that decreased continuity of care would have negative effects on patient outcomes.

For the first study, Volpp and his colleagues looked at more than 8.5 million Medicare patients admitted to 3,321 teaching hospitals from July 1, 2000, to June 30, 2005. The patients had been diagnosed with heart attack, congestive heart failure, gastrointestinal bleeding or stroke, or were undergoing different types of surgery.

Overall, the changes in work hours made no difference in the odds of dying.

But since the reforms were implemented, the most teaching-intensive hospitals (those with a large percentage of residents) had a 0.42 percent absolute increase in death rates for patients with one of the medical conditions and a 0.05 percent absolute increase in death rates for surgical patients, compared to non-teaching hospitals (no residents). Neither increase was considered statistically significant.

The second study looked at more than 300,000 patients admitted to 131 acute-care VA hospitals between July 1, 2000, and June 30, 2005, with the same constellation of diagnoses as in the first study.

By the end of the second year of the new work rules, the risk of dying decreased significantly in more teaching-intensive hospitals for the medical patients but not for the surgical patients.

"I think there are a couple of key reasons why we may have observed these significant improvements in VA but not non-VA settings," Volpp said. "The VA [hospitals] are more teaching-intensive, so you might expect that if there are beneficial effects, that those effects might be bigger in VA hospitals."

"A second reason is that work intensity is generally believed to be lower in VA hospitals than non-VA hospitals. In other words, residents are probably less overtaxed than in non-VA hospitals, so it's possible that this type of reform might be more effective in a setting in which residents are not running around like crazy," he continued. "A third reason is that there's much better information systems within the VA, so things like the problems with continuity of care may have been less problematic."

Diane Pinakiewicz, president of the National Patient Safety Foundation, said, "We all understand from all the work that's been done in aviation and other fields that [fatigue] is a work force issue that plays a role in error and we have to do something about it. The question is what is the best thing to do. We have to figure out a way to optimize work force hours better than we have."

A third study in the journal found that Canadian physicians who fared poorly on the patient-physician communication segment of the national licensing exam were the subject of more complaints on issues such as communication or quality-of-care. The authors suggested that licensing exams could be modified to pinpoint these attributes more efficiently and earlier in the process.

Finally, another study found that about 75 percent of medical residents said they didn't understand the statistics they read in medical journals, statistics that are necessary to provide the best and most current care for patients.

More information

The National Patient Safety Foundation has more on patient safety.

SOURCES: Kevin G. Volpp, M.D., Ph.D., staff physician and core faculty member, Center for Health Equity, Research and Promotion, Philadelphia Veterans Affairs Medical Center, and assistant professor of medicine and health care systems, University of Pennsylvania School of Medicine and Wharton School of Business, Philadelphia; Diane Pinakiewicz, president, National Patient Safety Foundation, North Adams, Mass.; Sept. 5, 2007, Journal of the American Medical Association

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