Sleep and Alertness in a Duty-Hour Flexibility Trial in Internal Medicine

Basner, Mathias; Asch, David A.; Shea, Judy A.; Bellini, Lisa M.; Carlin, Michele M.; Ecker, Adrian J.; Malone, Susan Kohl; Desai, Sanjay V.; Sternberg, Alice L.; Tonascia, James; Shade, David M.; Katz, Joel T.; Bates, David W.; Even‐Shoshan, Orit; Silber, Jeffrey H.; Small, Dylan S.; Volpp, Kevin G.; Mott, Christopher G.; Coats, Sara; Mollicone, Daniel J.; Dinges, David F.

doi:10.1056/nejmoa1810641

Cited by 49 publications

(73 citation statements)

References 40 publications

(40 reference statements)

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“…Sleep deprivation (SD) is becoming increasingly common in our hectic society. 1 Understanding the consequences of SD and neuroimaging mechanisms is of great importance. 2 , 3 Previous task and resting-state functional magnetic resonance imaging (rs-fMRI) studies have verified extensive voxel-level and network-level brain-function alterations after SD, 4 , 5 largely covering the frontal lobe, thalamus, default-mode network and frontoparietal network.…”

Section: Introductionmentioning

confidence: 99%

<p>Gradually Increased Interhemispheric Functional Connectivity During One Night of Sleep Deprivation</p>

Zhu¹,

Ren²,

Zhu³

et al. 2020

NSS

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Background: It is well known that circadian rhythms and sleep homeostasis contribute to a pronounced trough in sleepiness and behavioral performance at night. However, the underlying neuroimaging mechanisms remain unclear. How brain-function connectivity is modulated during sleep deprivation (SD) has been rarely examined. Methods: By increasing the number of scanning sessions during SD, the current study used voxel-mirrored homotopic connectivity (VMHC) to investigate dynamic changes in interhemispheric communication during one night of SD. Every 2 hours from 10 pm to 06 am (session 1, 10 pm; session 2, 12 am; session 3, 2 am; session 4, 4 am; session 5, 6 am), functional magnetic resonance-imaging data and Stanford Sleepiness Scale (SSS) scores were collected from 36 healthy participants with intermediate chronotype. Dynamic changes in SSS scores and VMHC were determined using one-way repeated-measure ANOVA with the false discovery-rate method to correct for multiple comparisons. Results: Significant time effects for VMHC were found mainly in the bilateral thalamus, bilateral superior temporal gyrus, and bilateral precentral gyrus. SSS scores and VMHC in these areas were both found to be monotonously increased during SD. Furthermore, significant positive associations were found between SSS valu and VMHC values in the left superior temporal and right superior gyri. Conclusion: These findings might represent the dynamic modulation of circadian rhythm merely or the interaction effects of both circadian rhythm and sleep homeostasis on interhemispheric connectivity within the thalamus, default-mode network, and sensorimotor network. Our study provides more comprehensive information on how SD regulates brain connectivity between hemispheres and adds new evidence of neuroimaging correlates of increased sleepiness after SD.

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Section: Introductionmentioning

confidence: 99%

<p>Gradually Increased Interhemispheric Functional Connectivity During One Night of Sleep Deprivation</p>

Zhu¹,

Ren²,

Zhu³

et al. 2020

NSS

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“…Recent changes have allowed for flexibility in the previously mandated standard duty hours that were implemented by the Accreditation Council for Graduate Medical Education (ACGME) in July 2011. The potential impact of relaxing duty hour restrictions was assessed in the Individualized Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial, which recently demonstrated that chronic sleep loss and sleepiness were similar among interns in flexible programs and standard programs 44 . Further, no detriment to patient safety outcomes was observed 45 .…”

Section: Discussionmentioning

confidence: 99%

Day-to-day variability in sleep parameters and depression risk: a prospective cohort study of training physicians

et al. 2021

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While 24-h total sleep time (TST) is established as a critical driver of major depression, the relationships between sleep timing and regularity and mental health remain poorly characterized because most studies have relied on either self-report assessments or traditional objective sleep measurements restricted to cross-sectional time frames and small cohorts. To address this gap, we assessed sleep with a wearable device, daily mood with a smartphone application and depression through the 9-item Patient Health Questionnaire (PHQ-9) over the demanding first year of physician training (internship). In 2115 interns, reduced TST (b = −0.11, p < 0.001), later bedtime (b = 0.068, p = 0.015), along with increased variability in TST (b = 0.4, p = 0.0012) and in wake time (b = 0.081, p = 0.005) were associated with more depressive symptoms. Overall, the aggregated impact of sleep variability parameters and of mean sleep parameters on PHQ-9 were similar in magnitude (both r2 = 0.01). Within individuals, increased TST (b = 0.06, p < 0.001), later wake time (b = 0.09, p < 0.001), earlier bedtime (b = − 0.07, p < 0.001), as well as lower day-to-day shifts in TST (b = −0.011, p < 0.001) and in wake time (b = −0.004, p < 0.001) were associated with improved next-day mood. Variability in sleep parameters substantially impacted mood and depression, similar in magnitude to the mean levels of sleep parameters. Interventions that target sleep consistency, along with sleep duration, hold promise to improve mental health.

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“…A companion article, which details the sleep and alertness of a subgroup of interns in this trial, shows that those who followed flexible schedules did not sleep for shorter periods than those in standard programs but did change their sleep patterns to compensate for longer shifts. 2 Either way, this trial suggests that well-meaning regulations that were designed to correct past problems in hospitals need to be judged against their current relevance.…”

Section: Discussionmentioning

confidence: 99%

“…In addition, the trial assessed sleep patterns and alertness among interns, with findings that showed noninferiority of the duration of sleep in the flexible programs to that in the standard programs (see the article by Basner et al in this issue of the Journal ). 2…”

mentioning

confidence: 99%

Patient Safety Outcomes under Flexible and Standard Resident Duty-Hour Rules

Silber

Bellini²,

Shea

et al. 2019

N Engl J Med

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BACKGROUND Concern persists that extended shifts in medical residency programs may adversely affect patient safety. METHODS We 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. RESULTS The 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. CONCLUSIONS Allowing 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.)

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Sleep and Alertness in a Duty-Hour Flexibility Trial in Internal Medicine

Cited by 49 publications

References 40 publications

<p>Gradually Increased Interhemispheric Functional Connectivity During One Night of Sleep Deprivation</p>

<p>Gradually Increased Interhemispheric Functional Connectivity During One Night of Sleep Deprivation</p>

Day-to-day variability in sleep parameters and depression risk: a prospective cohort study of training physicians

Patient Safety Outcomes under Flexible and Standard Resident Duty-Hour Rules

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