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Mortality Among Hospitalized Medicare Beneficiaries in the First 2 Years Following ACGME Resident Duty Hour Reform
Kevin G. Volpp, MD, PhD;
Amy K. Rosen, PhD;
Paul R. Rosenbaum, PhD;
Patrick S. Romano, MD, MPH;
Orit Even-Shoshan, MS;
Yanli Wang, MS;
Lisa Bellini, MD;
Tiffany Behringer, MS;
Jeffrey H. Silber, MD, PhD
JAMA. 2007;298(9):975-983.
Context The Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour regulations for physicians-in-training throughout the United States on July 1, 2003. The association of duty hour reform with mortality among patients in teaching hospitals nationally has not been well established.
Objective To determine whether the change in duty hour regulations was associated with relative changes in mortality among Medicare patients in hospitals of different teaching intensity.
Design, Setting, and Patients An observational study of all unique Medicare patients (N = 8 529 595) admitted to short-term, acute-care, general US nonfederal hospitals (N = 3321) using interrupted time series analysis with data from July 1, 2000, to June 30, 2005. All Medicare patients had principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, or stroke or a diagnosis related group classification of general, orthopedic, or vascular surgery. Logistic regression was used to examine the change in mortality for patients in more vs less teaching-intensive hospitals before (academic years 2000-2003) and after (academic years 2003-2005) duty hour reform, adjusting for patient comorbidities, common time trends, and hospital site.
Main Outcome Measure All-location mortality within 30 days of hospital admission.
Results In medical and surgical patients, no significant relative increases or decreases in the odds of mortality for more vs less teaching-intensive hospitals were observed in either postreform year 1 (combined medical conditions group: odds ratio [OR], 1.03; 95% confidence interval [CI], 0.98-1.07; and combined surgical categories group: OR, 1.05; 95% CI, 0.98-1.12) or postreform year 2 (combined medical conditions group: OR, 1.03; 95% CI, 0.99-1.08; and combined surgical categories group: OR, 1.01; 95% CI, 0.95-1.08) compared with the prereform years. The only condition for which there was a relative increase in mortality in more teaching-intensive hospitals postreform was stroke, but this association preceded the onset of duty hour reform. Compared with nonteaching hospitals, the most teaching-intensive hospitals had an absolute change in mortality from prereform year 1 to postreform year 2 of 0.42 percentage points (4.4% relative increase) for patients in the combined medical conditions group and 0.05 percentage points (2.3% relative increase) for patients in the combined surgical categories group, neither of which were statistically significant.
Conclusion The ACGME duty hour reform was not associated with either significant worsening or improvement in mortality for Medicare patients in the first 2 years after implementation.
Author Affiliations: Center for Health Equity Research and Promotion, Veterans Administration Hospital, Philadelphia, Pennsylvania (Dr Volpp); Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (Dr Silber and Mss Even-Shoshan and Wang);Departments of Medicine (Drs Volpp and Bellini, and Ms Behringer) and Pediatrics and Anesthesiology and Critical Care (Dr Silber), University of Pennsylvania School of Medicine, Philadelphia; Departments of Health Care Systems (Drs Volpp and Silber) and Statistics (Dr Rosenbaum), The Wharton School, University of Pennsylvania, Philadelphia; The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Drs Volpp and Silber, and Ms Even-Shoshan); Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts, and Center for Health Quality, Outcomes and Economic Research, Veterans Administration Hospital, Bedford, Massachusetts (Dr Rosen); and Division of General Medicine and Center for Healthcare Policy and Research, University of California Davis School of Medicine, Sacramento (Dr Romano).
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