Two recent reports on the impact of hospital resident work-hour limits did little to settle the debate on their worth.
In two reports published in the Sept. 5 edition of the Journal of the American Medical Association, researchers didn't have much positive to point to while studying the effects of limiting medical residents to an 80-hour workweek. But they also found that previous fears that patients would suffer from sloppy handoffs and poor continuity of care have not materialized either. The results also appear to offer another piece of evidence showing the value in the VistA electronic medical record used by the Veterans Affairs health system.
Few argue that limiting their duty hours doesn't help improve residents' concentration; however, concerns still persist about whether it is worth the cost and if it contributes to declining professionalism and educational opportunities.
"Whether you're talking to a glass half-full or half-empty crowd, you can get either side with this one," said Nancy Foster, vice president of quality and patient-safety policy at the American Hospital Association.
The two reports, both written by Kevin Volpp and colleagues at the Philadelphia Veterans Affairs Medical Center and the University of Pennsylvania School of Medicine, looked at 30-day mortality rates for some 8.5 million Medicare beneficiaries and about 318,600 patients at VA acute-care hospitals who were admitted for heart attack, congestive heart failure, gastrointestinal bleeding or stroke, or for general, orthopedic or vascular surgery. Statistics for the academic years 2000-03 were compared with the academic years 2003-05 in an effort to gauge the impact of the Accreditation Council for Graduate Medical Educations requirement to limit residents to 80-hour workweeks starting in 2003.
Mortality decreases in the VA hospitals were in the 11.1% to 13.9% range for nonsurgical patients, with more improvement shown in hospitals with higher teaching "intensity" (as measured by a resident-to-bed ratio). No such improvement was shown for the surgical patients. (The various changes in mortality measures for the Medicare patients were deemed statistically insignificant.)
"Mortality is a crude indicator, but it's an important one," said Kenneth Kizer, the physician who led the VA health system from October 1994 to September 1999, and is now chairman and chief executive officer of Medsphere Systems Corp. "This doesn't affirm those crying that this would cause all sorts of problems with discontinuity of care. I don't think those concerns are borne out by these data. ... The fact that you dont see negative effects may be the more important finding in the long term."
Volpp, an assistant professor of medicine and healthcare systems at the University of Pennsylvania, said he received feedback from colleagues who were concerned that the study would unearth negative findings, so the fact that there weren't any came as a relief to many. "That was important finding No. 1, I would agree," he said.
Arguments that there is no evidence showing that patient safety is improved by limiting resident work hours are often countered with the statement that parachutes have never been tested in a double-blind, randomized control study either.
"Well, it's kind of close to that," Kizer said. "For people who have been through residencies where you're a walking zombie, there is a certain inherent logic that has face validity."
He said the same logic applies to the explanation that the VA system showed lower mortality because its EMR helped provide safer handoffs and better continuity of care.
"That falls into the parachute category as well," Kizer said. "If you practice in the VA with the system it has in place, it rapidly becomes apparent how helpful and useful it is to have all the patients information at your fingertips. This study is almost a 'so what?' At best, it's just going to add more data to why we should move to an electronic medical record."
Foster said that if any improvements resulted from decreasing resident work hours, there was a need for more "sensitive indicators." Foster added, however, that if an indicator could be found for "patient harm," then maybe a link to resident work hours could be drawn more conclusively.
Some hospital executives question the value of the limits. In Denver, University of Colorado Hospital President and Chief Executive Officer Bruce Schroffel said the requirements have led to higher costs because of the wider employment of nurse practitioners, physician assistants and other "physician extenders"and he would be shocked if these changes contribute to an increase in quality.
Bruce Bagley, the American Academy of Family Physicians' medical director of quality improvement, disagreed somewhat, arguing that the scut work residents were required to do before work limits were imposed may have impaired their decisionmaking ability at times. Still, Bagley said that it's hard to isolate the impact of shorter resident work hours and then link that to positive mortality statistics at the VAwhich were probably more attributable to its systematic approach to care and access to EMR data.
Robert Dickler, senior vice president of healthcare affairs at the American Association of Medical Colleges, suggested that studies be done to see if there are links to resident work hours and changes in patient morbidity or a hospitals performance on other quality indicators. Dickler said one thing that needs to be measured is the impact the lighter workload has on resident education.
"Does this undercut their ability to do all the procedures and is it harder to get residents all the experience they need?" he asked.
Schroffel said he would like someone to study the psychological changes physicians undergo in the move from being less of a professional and more of an hourly worker.
"Clearly there's an upside, but there's also a downside," he said. "And there's some risk when you make these changes."
Volpp, however, noted that critics of the 80-hour work limit rarely mention how there is never this discussion in other industries that require a high degree of alertness.
"One of the things that is really interesting is thateven at 80 hoursmedicine is an outlier," he said, especially when compared with airline pilots, truck drivers, nuclear power plant engineers, air-traffic controllers and other jobs where a link has been recognized between safety and fatigue.
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