Morbidity, mortality, and health care costs for patients undergoing spine surgery following the ACGME resident duty-hour reform

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The Accreditation Council for Graduate Medical Education (ACGME) implemented resident duty-hour restrictions on July 1, 2003, in concern for patient and resident safety. Whereas studies have shown that duty-hour restrictions have increased resident quality of life, there have been mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay (LOS), and charges in patients who underwent spine surgery.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, LOS, and charges by comparing the prereform (2000–2002) and postreform (2005–2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>A total of 693,058 patients were included in the study. The overall complication rate was 8.6%, with patients in the postreform era having a significantly higher rate than those in the pre–duty-hour restriction era (8.7% vs 8.4%, p &lt; 0.0001). Examination of hospital teaching status revealed complication rates to decrease in nonteaching hospitals (8.2% vs 7.6%, p &lt; 0.0001) while increasing in teaching institutions (8.6% vs 9.6%, p &lt; 0.0001) in the duty-hour reform era. The DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching institutions to had a significantly greater increase in complications during the postreform era (p = 0.0002). The overall mortality rate was 0.37%, with no significant difference between the pre– and post–duty-hour eras (0.39% vs 0.36%, p = 0.12). However, the mortality rate significantly decreased in nonteaching hospitals in the postreform era (0.30% vs 0.23%, p = 0.0008), while remaining the same in teaching institutions (0.46% vs 0.46%, p = 0.75). The DID analysis to compare the changes in mortality between groups revealed that the difference between the effects approached significance (p = 0.069). The mean LOS for all patients was 4.2 days, with hospital stay decreasing in nonteaching hospitals (3.7 vs 3.5 days, p &lt; 0.0001) while significantly increasing in teaching institutions (4.7 vs 4.8 days, p &lt; 0.0001). The DID analysis did not demonstrate the magnitude of change for each group to differ significantly (p = 0.26). Total patient charges were seen to rise significantly in the post–duty-hour reform era, increasing from $40,000 in the prereform era to $69,000 in the postreform era. The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.55).</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The implementation of duty-hour restrictions was associated with an increased risk of postoperative complications for patients undergoing spine surgery. Therefore, contrary to its intended purpose, duty-hour reform may have resulted in worse patient outcomes. Additional studies are needed to evaluate strategies to mitigate these effects and assist in the development of future health care policy.</jats:p></jats:sec>

Association of Hospital Teaching Status with Neurosurgical Outcomes: An Instrumental Variable Analysis

“…Prior investigations have demonstrated inferior care provided by residents treating patients undergoing cranial and spinal operations after the implementation of the Accreditation of Graduate Medical Education duty-hour restrictions. 4,5,11 These researchers cite decreased resident experience in medical management, poorer operative skills, increased number of hand-outs, and fragmentation of care as the reasons behind their observations. The possibility of concurrent surgeries and limited supervision can also not be excluded.…”

Duty hour restrictions and surgical complications for head and neck key indicator procedures

“…2 Others reported contrary findings. 3 Furthermore, several teaching facilities believe the new standards created unnecessary barriers to providing quality training for residents. [11][12][13] Two recent large-scale studies were conducted on the impact of duty hour restrictions for general surgery residents: the FIRST trial 14 and a systematic review of 135 articles pertaining to surgical resident duty hours.…”

“…Some institutions have conducted studies showing worse patient outcomes following duty hour implementation, 2 with others to the contrary. 3 Studies in neurosurgery, orthopedic surgery, and cardiac surgery programs have looked at outcomes using the National Inpatient Sample (NIS) database, with equivocal results. [4][5][6][7][8] We aimed to characterize any differences in otolaryngology key indicator head and neck procedure-specific complications before and after duty hour reform.…”

Association of Resident Duty Hour Restrictions on Mortality of Nervous System Disease and Disorder

“…Many of these studies have demonstrated worse patient outcomes following the duty hour reform, including neurological surgery trauma, craniotomy for meningiomas, spinal surgeries, brain tumors, and cerebrovascular neurological procedures. [23][24][25][26] These authors stipulated that the training and performance of neurological surgery residents is particularly vulnerable to the limitations that the duty hour reform placed on them. Furthermore, Grady and colleagues 18 suggested that the reform may have exchanged the risks of resident fatigue for those of an inexperienced neurological surgery workforce.…”