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Impact of ACGME Work-Hour Restrictions on the Outcomes of Coronary Artery Bypass Grafting in a Cohort of 600,000 Patients

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Background

Since the resident physician 80-h/wk restriction was implemented on July 1, 2003, little has been learned about the impact of this reform on patient outcomes after coronary artery bypass grafting (CABG).

Methods

Using the Nationwide Inpatient Sample database, we identified 614,177 patients who underwent isolated CABG from 1998 through 2007. Of the 374,947 patients who underwent CABG at a teaching hospital, 133,285 (36%) belonged to the post-reform group. Hierarchic logistic and multivariable regression models were used to assess the independent effect of the reform after adjusting for potential confounding factors. Outcomes assessed were operative morbidity and mortality, and length of stay. Outcomes of CABG patients at non-teaching hospitals were used to control for time bias.

Results

In teaching hospitals, after risk adjustment, the post-reform era was associated with lower mortality risk (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.56–0.63; P < 0.001) but greater operative morbidity (OR, 1.5; 95% CI, 1.43–1.58; P < 0.001). Although the implementation of work-hour reforms was correlated with shorter lengths of stay, there were fewer routine home discharges (OR, 0.73; 95% CI, 0.73–0.76; P < 0.001). Outcomes at non-teaching hospitals were similar, except that operative morbidity rates were lower during the post-reform era.

Conclusions

The implementation of the resident work-hour reform in teaching hospitals did not affect mortality rates in CABG patients but was associated with increased morbidity. Further studies are needed to identify the reasons for the post-reform increase in postoperative complications at teaching hospitals.

Introduction

The implementation of the Accreditation Council for Graduate Medical Education's (ACGME) resident work-hour restriction on July 1, 2003, caused the surgical community to react with significant concern about the potential implications of these regulations for both patient care and resident education. Surgical training is particularly challenging and had historically demanded long hours of supervised mentorship and dedicated time spent in patient care, as envisioned by Dr. William Halstead, who is considered the pioneer of modern surgical training in the United States [1]. The traditional surgical culture of education and care relied heavily on team effort and continuity of care, which helped the timely anticipation and management of changes in a patient's clinical condition.

The focus of most residency programs during the initial phase of implementation of the work-hour reform was to ensure compliance with the resident work-hour limit without compromising patient care. Studies have focused on residents' performance, training experience, teaching skills, in-service exam results, and ability to pass board examinations after these rules were implemented 2, 3, 4, 5. In addition, several studies have addressed patient outcomes 6, 7, 8, 9, 10, 11. The outcome studies did not reveal any adverse impact of duty-hour reform on morbidity or mortality rates in various medical and surgical specialties. Nevertheless, many surgeons feel skeptical about the restrictions and their impact on the quality of care, as recent survey results suggest 12, 13.

New technological advancements and better perioperative care have allowed several common operations to be downgraded to fast track or outpatient procedures, for which continuity of care becomes less important. However, complex procedures such as cardiac operations still require a tremendous amount of team effort and uninterrupted care, and are logically more likely to be affected by the implementation of restrictions that affect resident work hours and training.

In a recent pilot study, we reviewed the outcomes of patients who underwent cardiac surgery at our institution and reported improved mortality rates after the implementation of resident work-hour restrictions compared with before their implementation [14]. Because different institutions have adopted different mechanisms to compensate for the ACGME work-hour regulations, it is hard to generalize from the results of one particular program. Therefore, we performed a nationwide study of outcomes in patients who underwent isolated CABG operations before and after the implementation of the 80-h work reform. We examined results obtained in teaching hospitals and compared them with results from non-teaching hospitals.

Section snippets

Data Source

Data were obtained from the United States Nationwide Inpatient Sample (NIS); these data were collected from 1998 through 2007. The NIS is a database of hospital inpatient stays that is maintained by the Agency for Healthcare Research and Quality as part of the Healthcare Cost and Utilization Project (HCUP) [15]. A 10-y time span was chosen so that our study would encompass a good number of years on either side of the date when the ACGME work-hour reform was implemented (July 1, 2003), enabling

Patient Characteristics

Baseline characteristics were compared among patients who underwent CABG at teaching versus non-teaching hospitals and before versus after the implementation of the ACGME work-hour regulations (Table 2). Although patients who underwent CABG before and after the implementation of the regulations differed statistically in age, the small effect size (d = 0.028) suggested that the difference was negligible. The same appeared to be true for the baseline Deyo comorbidity scores (d = 0.088) and

Discussion

The implementation of the work-hour reforms for residents probably remains the most significant event in this decade for resident education. The Bell Commission in New York State laid the foundation for the subsequent implementation of the 80-h work-hour regulations by the ACGME, which stemmed from the circumstances surrounding the demise of Libby Zion [22]. Although the Bell Commission's recommendations were implemented in New York State in 1988, it took more than a decade for these principles

Acknowledgments

The authors acknowledge Stephen N. Palmer, Ph.D., E.L.S., for contributing to the editing of this manuscript.

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