Association for Academic SurgeryEducationImpact of ACGME Work-Hour Restrictions on the Outcomes of Coronary Artery Bypass Grafting in a Cohort of 600,000 Patients
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.
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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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2019, Journal of Thoracic and Cardiovascular SurgeryEffect of Home-Call on Otolaryngology Resident Education: A Pilot Study
2017, Journal of Surgical EducationCitation Excerpt :In the United States and in Canada, resident duty hour restrictions (DHRs) were recently implemented with an intent of limiting long resident work hours to improve patient care and decrease adverse events, while having a simultaneous positive effect on resident well-being.8-12 However, since their implementation, studies that have examined the efficacy of DHRs to achieve these objectives have not uniformly demonstrated positive effects in either domain.13-28 Furthermore, the widespread implementation of DHRs has led to increasing concern over resident educational outcomes.17,20,29-31
Cirrhosis as a moderator of outcomes in coronary artery bypass grafting and off-pump coronary artery bypass operations: A 12-year population-based study
2013, Annals of Thoracic SurgeryCitation Excerpt :Using the methods described before, we excluded patients who underwent other cardiac procedures during the same admission [14]. In the published literature, the feasibility of querying the NIS database for cardiac surgical procedures and stratifying the comorbidity score has been established [15, 17]. Cirrhotic patients were identified using ICD-9-CM codes listed in Appendix 1.
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2013, Journal of Thoracic and Cardiovascular SurgeryCitation Excerpt :Generalized multivariate regression was used to assess the predictors of primary outcomes with adjustment for potential confounding factors, which included age, gender, race, insurance payer, hospital bed size, admission type, and individual components of the comorbidity index. Because we were handling a very large sample size, which is typical with NIS-based analysis; effect–size statistics were computed to assess the practical implications of statistically significant P values, similar to previous studies.10,11 Cohen's d was calculated for continuous data by using pooled standard deviations and was appropriately weighted for unequal sample size.13
Neurological surgery: The influence of physical and mental demands on humans performing complex operations
2013, Journal of Clinical NeuroscienceCitation Excerpt :One study that reported the experience of a single residency training program found that the rate of morbidity in all neurosurgical patients increased after implementation of reduced work hours.91 This finding has been replicated in studies using a nationwide database, showing increased mortality in patients admitted to teaching but not non-teaching hospitals after work-hour reform for coronary artery bypass graft surgery,92 hip fracture,93 and neurosurgical trauma.94 Additionally, the resident American Board of Neurological Surgery written exam scores have declined since the introduction of restricted work hours,95 suggesting the potential negative impact of reduced time spent in patient care on resident knowledge.
Academic time at a level 1 trauma center: No resident, no problem?
2012, Journal of Surgical EducationCitation Excerpt :To date, most of the literature has demonstrated that the limitation of work hours did not affect the outcome of patients negatively; even better outcomes were reported in a large retrospective study.2-7 By contrast, contradictory results have been demonstrated in the literatures of surgical subspecialty, including trauma.6-12 To complement the workload uncovered by residents under the work-hour restriction, a large number of surgical program currently hire the advanced practice providers (APPs), physician assistant (PA) and nurse practitioner (NP).13-16