Dataset Information

Understanding the effect of resident duty hour reform: a qualitative study.

ABSTRACT:

Background

Concern surrounding the effect of resident fatigue on patient care recently led the National Steering Committee on Resident Duty Hours to publish Canadian recommendations suggesting that duty periods of 24 or more consecutive hours without restorative sleep should be avoided. We sought to characterize how different training programs are preparing for the effect of such changes on education, patient care and provider well-being.

Methods

Using constructivist grounded theory methodology, we conducted 18 one-on-one semistructured interviews with program directors, division directors and department chiefs from 11 residency programs affiliated with one Canadian medical school. We gathered and analyzed data iteratively until we reached theoretical saturation.

Results

The key theme articulated by our participants was that changes in resident duty hours would potentially lead to gaps in the provision of clinical care. These changes affect acute care specialties based primarily in the inpatient setting (e.g., medicine, surgery) more than primarily ambulatory (e.g., family medicine) or shift-model based (e.g., emergency) specialties. Potential strategies to address gaps in clinical care include resident-based solutions, faculty-based solutions and solutions based on other providers (e.g., nonacademic physicians, physician extenders). Each solution has unique advantages and disadvantages in terms of education, continuity of care, preparedness for practice and provider well-being.

Interpretation

Our data-driven framework serves as a guide for programs to anticipate challenges of satisfying clinical care needs in the face of changes to resident duty hours, while balancing education, care continuity, preparedness for practice and provider well-being. Our findings challenge the "one-size-fits-all" approach to changes to resident duty hours and endorse flexibility in enacting duty hour regulations based on specialty-specific factors.

SUBMITTER: Wu PE

PROVIDER: S-EPMC4084747 | biostudies-literature | 2014 Apr

REPOSITORIES: biostudies-literature

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Publications

Understanding the effect of resident duty hour reform: a qualitative study.

Wu Peter E PE Stroud Lynfa L McDonald-Blumer Heather H Wong Brian M BM

CMAJ open 20140401 2

<h4>Background</h4>Concern surrounding the effect of resident fatigue on patient care recently led the National Steering Committee on Resident Duty Hours to publish Canadian recommendations suggesting that duty periods of 24 or more consecutive hours without restorative sleep should be avoided. We sought to characterize how different training programs are preparing for the effect of such changes on education, patient care and provider well-being.<h4>Methods</h4>Using constructivist grounded theo ...[more]

PMID: 25077127

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Project description:ObjectiveThe aim of the study was to address the controversy surrounding the effects of duty hour reform on new surgeon performance, we analyzed patients treated by new surgeons following the transition to independent practice.Summary background dataIn 2003, duty hour reform affected all US surgical training programs. Its impact on the performance of new surgeons remains unstudied.MethodsWe studied 30-day mortality among 1,483,074 Medicare beneficiaries undergoing general and orthopedic operations between 1999 and 2003 ("traditional" era) and 2009 and 2013 ("modern" era). The operations were performed by 2762 new surgeons trained before the reform, 2119 new surgeons trained following reform and 15,041 experienced surgeons. We used a difference-in-differences analysis comparing outcomes in matched patients treated by new versus experienced surgeons within each era, controlling for the hospital, operation, and patient risk factors.ResultsTraditional era odds of 30-day mortality among matched patients treated by new versus experienced surgeons were significantly elevated [odds ratio (OR) 1.13; 95% confidence interval (CI) (1.05, 1.22), P < 0.001). The modern era elevated odds of mortality were not significant [OR 1.06; 95% CI (0.97-1.16), P = 0.239]. Relative performance of new and experienced surgeons with respect to 30-day mortality did not appear to change from the traditional era to the modern era [OR 0.93; 95% CI (0.83-1.05), P = 0.233]. There were statistically significant adverse changes over time in relative performance to experienced surgeons in prolonged length of stay [OR 1.08; 95% CI (1.02-1.15), P = 0.015], anesthesia time [9 min; 95% CI (8-10), P < 0.001], and costs [255USD; 95% CI (2-508), P = 0.049].ConclusionsDuty hour reform showed no significant effect on 30-day mortality achieved by new surgeons compared to their more experienced colleagues. Patients of new surgeons, however, trained after duty hour reform displayed some increases in the resources needed for their care.

Project description:BackgroundConcern persists that extended shifts in medical residency programs may adversely affect patient safety.MethodsWe conducted a cluster-randomized noninferiority trial in 63 internal-medicine residency programs during the 2015-2016 academic year. Programs underwent randomization to a group with standard duty hours, as adopted by the Accreditation Council for Graduate Medical Education (ACGME) in July 2011, or to a group with more flexible duty-hour rules that did not specify limits on shift length or mandatory time off between shifts. The primary outcome for each program was the change in unadjusted 30-day mortality from the pretrial year to the trial year, as ascertained from Medicare claims. We hypothesized that the change in 30-day mortality in the flexible programs would not be worse than the change in the standard programs (difference-in-difference analysis) by more than 1 percentage point (noninferiority margin). Secondary outcomes were changes in five other patient safety measures and risk-adjusted outcomes for all measures.ResultsThe change in 30-day mortality (primary outcome) among the patients in the flexible programs (12.5% in the trial year vs. 12.6% in the pretrial year) was noninferior to that in the standard programs (12.2% in the trial year vs. 12.7% in the pretrial year). The test for noninferiority was significant (P = 0.03), with an estimate of the upper limit of the one-sided 95% confidence interval (0.93%) for a between-group difference in the change in mortality that was less than the prespecified noninferiority margin of 1 percentage point. Differences in changes between the flexible programs and the standard programs in the unadjusted rate of readmission at 7 days, patient safety indicators, and Medicare payments were also below 1 percentage point; the noninferiority criterion was not met for 30-day readmissions or prolonged length of hospital stay. Risk-adjusted measures generally showed similar findings.ConclusionsAllowing program directors flexibility in adjusting duty-hour schedules for trainees did not adversely affect 30-day mortality or several other measured outcomes of patient safety. (Funded by the National Heart, Lung, and Blood Institute and Accreditation Council for Graduate Medical Education; iCOMPARE ClinicalTrials.gov number, NCT02274818.).

Project description:Earlier work demonstrated that ACGME duty hour reform did not adversely affect mortality, with slight improvement noted among specific subgroups.To determine whether resident duty hour reform differentially affected the mortality risk of high severity patients or patients who experienced post-operative complications (failure-to-rescue).Observational study using interrupted time series analysis with data from July 1, 2000 - June 30, 2005. Fixed effects logistic regression was used to examine the change in the odds of mortality or failure-to-rescue (FTR) in more versus less teaching-intensive hospitals before and after duty hour reform.All unique Medicare patients (n = 8,529,595) admitted to short-term acute care non-federal hospitals and all unique VA patients (n = 318,636 patients) with principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, stroke or a DRG classification of general, orthopedic or vascular surgery.We measured mortality within 30 days of hospital admission and FTR, measured by death among patients who experienced a surgical complication. The odds of mortality and FTR generally changed at similar rates for higher and lower risk patients in more vs. less teaching intensive hospitals. For example, comparing the mortality risk for the 10% of Medicare patients with highest risk to the other 90% of patients in post-reform year 1 for combined medical an OR of 1.01 [95% CI 0.90, 1.13], for combined surgical an OR of 0.91 [95% CI 0.80, 1.04], and for FTR an OR of 0.94 [95% CI 0.80, 1.09]. Findings were similar in year 2 for both Medicare and VA. The two exceptions were a relative increase in mortality for the highest risk medical (OR 1.63 [95% CI 1.08, 2.46]) and a relative decrease in the high risk surgical patients within VA in post-reform year 1 (OR 0.52 [95% CI 0.29, 0.96]).ACGME duty hour reform was not associated with any consistent improvements or worsening in mortality or failure-to-rescue rates for high risk medical or surgical patients.

Dataset Information

Understanding the effect of resident duty hour reform: a qualitative study.

Background

Methods

Results

Interpretation

Publications

Understanding the effect of resident duty hour reform: a qualitative study.

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