Changes in Outcomes for Internal Medicine Inpatients after Work-Hour Regulations

17 July 2007 | Volume 147 Issue 2

Background: Limits on resident work hours are intended to reduce fatigue-related errors, but may raise risk by increasing transfers of responsibility for patients.

Objective: To examine changes in outcomes for internal medicine patients after the implementation of work-hour regulations.

Design: Retrospective cohort study.

Setting: Urban, academic medical center.

Patients: 14 260 consecutive patients discharged from the teaching (housestaff) service and 6664 consecutive patients discharged from the nonteaching (hospitalist) service between 1 July 2002 and 30 June 2004.

Measurements: Outcomes included intensive care unit utilization, length of stay, discharge disposition, 30-day readmission rate to the study institution, pharmacist interventions to prevent error, drug–drug interactions and in-hospital death.

Results: The teaching service had net improvements in 3 outcomes. Relative to changes experienced by the nonteaching service, the rate of intensive care unit utilization decreased by 2.1% (95% CI, –3.3% to –0.7%; P = 0.002), the rate of discharge to home or rehabilitation facility versus elsewhere improved by 5.3% (CI, 2.6% to 7.6%; P < 0.001), and pharmacist interventions to prevent error were reduced by 1.92 interventions per 100 patient-days (CI, –2.74 to –1.03 interventions per 100 patient-days; P < 0.001). Teaching and nonteaching services had similar changes over time in length of stay, 30-day readmission rate, and adverse drug–drug interactions. In-hospital death was uncommon in both groups, and change over time was similar in the 2 groups.

Limitations: The study was a retrospective, nonrandomized design that assessed a limited number of outcomes. Teaching and nonteaching cohorts may not have been affected similarly by secular trends in patient care.

Conclusions: After the implementation of work-hour regulations, 3 of 7 outcomes improved for patients in the teaching service relative to those in the nonteaching service. The authors found no evidence of adverse unintended consequences after the institution of work-hour regulations.

Editors' Notes Context Studies of resident work-hour restrictions and patient outcomes have had design limitations and inconsistent findings. Contribution This study compared changes in the rates of 7 clinical measures over a 2-year period for patients discharged from a teaching service that followed the ACGME work-hour rules to changes for patients discharged from a nonteaching hospitalist service. Favorable changes in rates of intensive care unit utilization, discharge to home or a rehabilitation facility, and pharmacist interventions to prevent drug error were more marked in the teaching service than in the hospitalist service. Caution Without a direct comparison of teaching services with and without restricted hours, this study has similar design limitations as those of previous studies. —The Editors

 

Author and Article Information

From the Center for Outcomes Research and Evaluation, Yale–New Haven Hospital; and Yale University School of Medicine, New Haven, Connecticut, and Mid America Heart Institute and University of Missouri, Kansas City, Missouri.

Acknowledgments: The authors thank Francis W. Chan, MD; Cyrus Kapadia, MD; Victor Morris, MD; Dan Negoianu, MD; Amy M. Nuernberg, MD, MPH; and Jeanette M. Tetrault, MD, for providing detailed information about changes in the teaching and nonteaching services at Yale University. They also thank Lorraine Lee, BSPharm, and Jeffrey E. Topal, MD, for access to the pharmacy databases; Kim Brazo for generously sharing Press Ganey’s patient satisfaction data; and several anonymous reviewers for their constructive feedback.

Grant Support: Dr. Horwitz was supported by the U.S. Department of Veterans Affairs, and both Drs. Horwitz and Kosiborod were supported by the Robert Wood Johnson Clinical Scholars Program.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Leora Horwitz, MD, MHS, Section of General Internal Medicine, Yale University School of Medicine, IE-61 SHM, 333 Cedar Street, PO Box 208088, New Haven, CT 06520-8088; e-mail, leora.horwitz{at}yale.edu.

Current Author Addresses: Dr. Horwitz: Section of General Internal Medicine, Yale University School of Medicine, IE-61 SHM, 333 Cedar Street, PO Box 208088, New Haven, CT 06520-8088.

Dr. Kosiborod: Mid America Heart Institute, 4401 Wornall Road, 5th Floor, Kansas City, MO 64111.

Dr. Lin: Yale University School of Medicine, 300 George Street, New Haven, CT 06511-6624.

Dr. Krumholz: Yale University School of Medicine, IE-61 SHM, 333 Cedar Street, PO Box 208088, New Haven, CT 06520-8088.

Author Contributions: Conception and design: L.I. Horwitz, M. Kosiborod, H.M. Krumholz.

Analysis and interpretation of the data: L.I. Horwitz, M. Kosiborod, Z. Lin, H.M. Krumholz.

Drafting of the article: L.I. Horwitz.

Critical revision of the article for important intellectual content: M. Kosiborod, H.M. Krumholz.

Final approval of the article: L.I. Horwitz, M. Kosiborod, Z. Lin, H.M. Krumholz.

Statistical expertise: Z. Lin.

Obtaining of funding: L.I. Horwitz.

Administrative, technical, or logistic support: H.M. Krumholz.

Collection and assembly of data: L.I. Horwitz, Z. Lin.

Read all Rapid Responses

Response to: Horwitz et al. Ann Intern Med 2007; 147: 97-103

Dena E. Rifkin

Annals Online, 18 Jul 2007 [Full text]

Attending Faculty Members are Doing More with Restricted Resident Work Hours

Basil E. Akpunonu, et al.

Annals Online, 20 Jul 2007 [Full text]

In response to Dr. Rifkin:

Leora I. Horwitz, et al.

Annals Online, 24 Oct 2007 [Full text]

The junior doctors should get adequate time off

Dr Robert James

Annals Online, 25 Oct 2007 [Full text]