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Mortality Among Patients in VA Hospitals 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;
Anne Canamucio, MS;
Lisa Bellini, MD;
Tiffany Behringer, MS;
Jeffrey H. Silber, MD, PhD
JAMA. 2007;298:984-992.
Context Limitations in duty hours for physicians-in-training in the United States were established by the Accreditation Council for Graduate Medical Education (ACGME) and implemented on July 1, 2003. The association of these changes with mortality among hospitalized patients has not been well established.
Objective To determine whether the change in duty hour regulations was associated with relative changes in mortality in hospitals of different teaching intensity within the US Veterans Affairs (VA) system.
Design, Setting, and Patients An observational study of all unique patients (N = 318 636) admitted to acute-care VA hospitals (N = 131) using interrupted time series analysis with data from July 1, 2000, to June 30, 2005. All patients had principal diagnoses of acute myocardial infarction (AMI), 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 postreform year 1, no significant relative changes in mortality were observed for either medical or surgical patients. In postreform year 2, the odds of mortality decreased significantly in more teaching-intensive hospitals for medical patients only. Comparing a hospital having a resident-to-bed ratio of 1 with a hospital having a resident-to-bed ratio of 0, the odds of mortality were reduced for patients with AMI (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.33-0.71), for the 4 medical conditions together (OR, 0.74; 95% CI, 0.61-0.89), and for the 3 medical conditions excluding AMI (OR, 0.79; 95% CI, 0.63-0.98). Compared with hospitals in the 25th percentile of teaching intensity, there was an absolute improvement in mortality from prereform year 1 to postreform year 2 of 0.70 percentage points (11.1% relative decrease) and 0.88 percentage points (13.9% relative decrease) in hospitals in the 75th and 90th percentile of teaching intensity, respectively, for the combined medical conditions.
Conclusions The ACGME duty hour reform was associated with significant relative improvement in mortality for patients with 4 common medical conditions in more teaching-intensive VA hospitals in postreform year 2. No associations were identified for surgical patients.
Author Affiliations: Center for Health Equity Research and Promotion, Veterans Administration Hospital, Philadelphia, Pennsylvania (Dr Volpp and Ms Canamucio); Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadephia, Pennsylvania (Dr Silber and Ms Even-Shoshan); 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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