Duty Hour Reform in a Shifting Medical Landscape

The circumstances that led to the death of Libby Zion in 1984 prompted national discussions about the impact of resident fatigue on patient outcomes. Nearly 30 years later, national duty hour reforms largely motivated by patient safety concerns have demonstrated a negligible impact of duty hour reductions on patient mortality. We suggest that the lack of an impact of duty hour reforms on patient mortality is due to a different medical landscape today than existed in 1984. Improvements in quality of care made possible by computerized order entry, automated medication checks, inpatient pharmacists, and increased resident supervision have, among other systemic changes, diminished the adverse impact that resident fatigue is able to have on patient outcomes. Given this new medical landscape, advocacy towards current and future duty hour reforms may be best justified by evidence of the impact of duty hour reform on resident wellbeing, education, and burnout.     

The Impact of Resident Duty Hour Reform on Hospital Readmission Rates Among Medicare Beneficiaries

Background  

A key goal of resident duty hour reform by the Accreditation Council for Graduate Medical Education (ACGME) in 2003 was to improve patient outcomes.     

Teaching Hospital Five-Year Mortality Trends in the Wake of Duty Hour Reforms

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour regulations for residents in 2003 and again in 2011. While previous studies showed no systematic impacts in the first 2 years post-reform, the impact on mortality in subsequent years has not been examined.

OBJECTIVE

To determine whether duty hour regulations were associated with changes in mortality among Medicare patients in hospitals of different teaching intensity after the first 2 years post-reform.

DESIGN

Observational study using interrupted time series analysis with data from July 1, 2000 to June 30, 2008. Logistic regression was used to examine the change in mortality for patients in more versus less teaching-intensive hospitals before (2000–2003) and after (2003–2008) duty hour reform, adjusting for patient comorbidities, time trends, and hospital site.

PATIENTS

Medicare patients (n?=?13,678,956) admitted to short-term acute care non-federal hospitals with principal diagnoses of acute myocardial infarction (AMI), gastrointestinal bleeding, or congestive heart failure (CHF); or a diagnosis-related group (DRG) classification of general, orthopedic, or vascular surgery.

MAIN MEASURE

All-location mortality within 30 days of hospital admission.

KEY RESULTS

In medical and surgical patients, there were no consistent changes in the odds of mortality at more vs. less teaching intensive hospitals in post-reform years 1–3. However, there were significant relative improvements in mortality for medical patients in the fourth and fifth years post-reform: Post4 (OR 0.88, 95 % CI [0.93–0.94]); Post5 (OR 0.87, [0.82–0.92]) and for surgical patients in the fifth year post-reform: Post5 (OR 0.91, [0.85–0.96]).

CONCLUSIONS

Duty hour reform was associated with no significant change in mortality in the early years after implementation, and with a trend toward improved mortality among medical patients in the fourth and fifth years. It is unclear whether improvements in outcomes long after implementation can be attributed to the reform, but concerns about worsening outcomes seem unfounded.     

Patient Perceptions of Whom is Most Involved in Their Care with Successive Duty Hour Limits

BACKGROUND

Although direct patient care is necessary for experiential learning during residency, inpatient perceptions of the roles of resident and attending physicians in their care may have changed with residency duty hours.

OBJECTIVE

We aimed to assess if patients’ perceptions of who is most involved in their care changed with residency duty hours.

DESIGN

This was a prospective observational study over 12 years at a single institution.

PARTICIPANTS

Participants were 22,408 inpatients admitted to the general medicine teaching service from 2001 to 2013, who completed a 1-month follow-up phone interview.

MAIN MEASURES

Percentage of inpatients who reported an attending, resident, or intern as most involved in their care by duty hour period (pre-2003, post-2003–pre-2011, post-2011).

KEY RESULTS

With successive duty hour limits, the percentage of patients who reported the attending as most involved in their care increased (pre-2003 20 %, post-2003–pre-2011 29 %, post-2011 37 %, p < 0.001). Simultaneously, fewer patients reported a housestaff physician (resident or intern) as most involved in their care (pre-2003 20 %, post-2003–pre-2011 17 %, post-2011 12 %, p < 0.001). In multinomial regression models controlling for patient age, race, gender and hospitalist as teaching attending, the relative risk ratio of naming the resident versus the attending was higher in the pre-2003 period (1.44, 95 % CI 1.28-1.62, p < 0.001) than the post-2003–pre-2011 (reference group). In contrast, the relative risk ratio for naming the resident versus the attending was lower in the post-2011 period (0.79, 95 % CI 0.68-0.93, p = 0.004) compared to the reference group.

CONCLUSIONS

After successive residency duty hours limits, hospitalized patients were more likely to report the attending physician and less likely to report the resident or intern as most involved in their hospital care. Given the importance of experiential learning to the formation of clinical judgment for independent practice, further study on the implications of these trends for resident education and patient safety is warranted.KEY WORDS: resident duty hours, patient perceptions, hospital care     

Evaluating Electronic Referrals for Specialty Care at a Public Hospital

BACKGROUND  

Poor communication between referring clinicians and specialists may lead to inefficient use of specialist services. San Francisco General Hospital implemented an electronic referral system (eReferral) that facilitates iterative pre-visit communication between referring and specialty clinicians to improve the referral process.     

Rationale for Combination Therapy as Initial Treatment for Hypertension

Recent hypertension guidelines recommend initiating antihypertensive therapy with a combination of two or more agents in patients whose blood pressure exceeds their appropriate blood pressure goal by 20/10 mm Hg. This recommendation is based on the knowledge that the majority of patients with blood pressures of this magnitude will not achieve sufficient blood pressure reduction with monotherapy. Further, compared with high-dose monotherapy, combination therapy is often associated with fewer adverse effects and, for this reason, may improve patient adherence. Bringing patients to blood pressure goal quickly is likely to improve clinical outcomes. This article discusses the rationale for using combination antihypertensive therapy as initial therapy for high blood pressure in selected patients and reviews data from a study of 364 high-risk patients with Stage 2 hypertension in which a fixed-dose combination product (amlodipine besylate/benazepril HCl) proved more successful as initial therapy than high-dose monotherapy (amlodipine besylate) in reducing blood pressure.     

Back to the Hospital for Chronic Care: a Hybrid Generalist Model

Singapore, like many countries, is attempting to meet the growing healthcare needs of an ageing population with a high burden of chronic diseases. Despite efforts to integrate and increase healthcare capacity, longstanding challenges remain difficult to overcome. Recently, policymakers have considered a new approach to building chronic and eldercare capacity—the Integrated General Hospital (IGH). The development of the IGH model is motivated by a combination of factors: the limit to which the primary care system can manage patients with increasingly complex chronic diseases, a longstanding preference of patients for hospital-based specialty services and patients experiencing fragmented care delivery. The IGH model links hospital care teams and community-based care providers, to facilitate the management of patients throughout the care continuum in a single integrated site. It is hoped that this hospital-led model for chronic care can meet patients’ needs and preferences and reduce fragmentation of care.     

Diabetes Technologies and Hospital Care: The Effect of Diabetes on Hospital Readmissions

Hospital readmission is an important contributor to total medical expenditures and is an emerging indicator of quality of care. Diabetes, similar to other chronic medical conditions, is associated with increased risk of hospital readmission. Risk factors include previous hospitalization, extremes in age, and socioeconomic barriers. Preliminary studies suggest that acute and/or chronic glycemic control may be of importance when diabetes is the primary diagnosis or when it is a comorbidity. Very limited evidence from prospective randomized controlled trials aimed at improving glycemic control is available. However, whether one concludes that inpatient or outpatient glycemic control is partly responsible for reduced hospitalizations, attention to glycemic control in the hospital may facilitate sustained glycemic control post-discharge. Limited prospective and retrospective evidence suggest that the involvement of a diabetes specialist team may improve readmission rates, but attention to more generalized comprehensive approaches may also be worthwhile. Prospective interventional studies targeting interventions for improving glycemic control are needed to determine whether glycemic control impacts readmission rates.     

An Assessment of Hospital Care for the Alcoholic Patient

Current medical practice, vis-à-vis chemical dependency, was assessed in a university hospital setting. Findings indicate that the majority of physicians and nurses at this facility (1) did not take adequate alcohol and drug use histories, (2) did not identify chemical dependency as a medical problem even when they knew dependency was present, and (3) did not involve themselves in treatment or treatment recommendations even when the problem was identified.     

Fundamental Reform of Payment for Adult Primary Care: Comprehensive Payment for Comprehensive Care

Primary care is essential to the effective and efficient functioning of health care delivery systems, yet there is an impending crisis in the field due in part to a dysfunctional payment system. We present a fundamentally new model of payment for primary care, replacing encounter-based imbursement with comprehensive payment for comprehensive care. Unlike former iterations of primary care capitation (which simply bundled inadequate fee-for-service payments), our comprehensive payment model represents new investment in adult primary care, with substantial increases in payment over current levels. The comprehensive payment is directed to practices to include support for the modern systems and teams essential to the delivery of comprehensive, coordinated care. Income to primary physicians is increased commensurate with the high level of responsibility expected. To ensure optimal allocation of resources and the rewarding of desired outcomes, the comprehensive payment is needs/risk-adjusted and performance-based. Our model establishes a new social contract with the primary care community, substantially increasing payment in return for achieving important societal health system goals, including improved accessibility, quality, safety, and efficiency. Attainment of these goals should help offset and justify the costs of the investment. Field tests of this and other new models of payment for primary care are urgently needed.     

Bacterial Infections in Cirrhotic Patients in a Tertiary Care Hospital

Background and Aims: Patients with cirrhosis are immu-nocompromised and at higher risk of developing infections compared to the general population. The aim of t...