Association of residency work hour reform with long term quality and costs of care of US physicians: observational studyBMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4134 (Published 10 July 2019) Cite this as: BMJ 2019;366:l4134
- Anupam B Jena, Ruth L Newhouse associate professor123,
- Monica Farid, graduate student4,
- Daniel Blumenthal, instructor5,
- Jay Bhattacharya, professor36
- 1Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115, USA
- 2Massachusetts General Hospital, Boston, MA, USA
- 3National Bureau of Economic Research, Cambridge, MA, USA
- 4Program in Health Policy, Faculty of Arts and Sciences, Harvard University, Cambridge, MA, USA
- 5Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
- 6Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA, USA
- Correspondence to: A B Jena @AnupamBJena on Twitter) (or
- Accepted 30 April 2019
Objective To determine whether 30 day mortality, 30 day readmissions, and inpatient spending vary according to whether physicians were exposed to work hour reforms during their residency.
Design Retrospective observational study.
Setting US Medicare.
Participants 20% random sample (n=485 685) of Medicare beneficiaries aged 65 years or more admitted to hospital and treated by a general internist during 2000-12.
Main outcome measures 30 day mortality, 30 day readmissions, and inpatient Medicare Part B spending among patients treated by first year internists who were fully exposed to the 2003 Accreditation Council for Graduate Medical Education (ACGME) work hour reforms during their residency (completed residency after 2006) compared with first year internists with partial or no exposure to reforms (completed residency before 2006). Senior internists not exposed to reforms during their residency served as a control group (10th year internists) for general trends in hospital care: a difference-in-difference analysis.
Results Exposure of physicians to work hour reforms during their residency was not associated with statistically significant differences in 30 day mortality, 30 day readmissions, or inpatient spending. Among 485 685 hospital admissions, 30 day mortality rates during 2000-06 and 2007-12 for patients of first year internists were 10.6% (12 567 deaths/118 014 hospital admissions) and 9.6% (13 521/140 529), respectively, and for 10th year internists were 11.2% (11 018/98 811) and 10.6% (13 602/128 331), for an adjusted difference-in-difference effect of −0.1 percentage points (95% confidence interval −0.8% to 0.6%, P=0.68). 30 day readmission rates for first year internists during 2000-06 and 2007-12 were 20.4% (24 074/118 014) and 20.4% (28 689/140 529), respectively, and for 10th year internists were 20.1% (19 840/98 811) and 20.5% (26 277/128 331), for an adjusted difference-in-difference effect of 0.1 percentage points (−0.9% to 1.1%, P=0.87). Medicare Part B inpatient spending for first year internists during 2000-06 and 2007-12 was $1161 (£911; €1024) and $1267 per hospital admission, respectively, and for 10th year internists was $1331 and $1599, for an adjusted difference-in-difference effect of −$46 (95% confidence interval −$94 to $2, P=0.06).
Conclusions Exposure of internists to work hour reforms during their residency was not associated with post-training differences in patient mortality, readmissions, or costs of care.
Contributors: All authors contributed to the design and conduct of the study, data collection and management, analysis interpretation of the data; and preparation, review, or approval of the manuscript. ABJ supervised the study and is the guarantor. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.
Funding: ABJ received funding from the Office of the Director, NIH (1DP5OD017897). The research conducted was independent of any involvement from the sponsor of the study. The study sponsor was not involved in study design, data interpretation, writing, or the decision to submit the article for publication. The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.
Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: external funding support from the Office of the Director, NIH (1DP5OD017897); no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work; ABJ reports receiving consulting fees unrelated to this work from Pfizer, Hill Rom Services, Bristol Myers Squibb, Novartis, Amgen, Eli Lilly, Vertex Pharmaceuticals, AstraZeneca, Celgene, Tesaro, Sanofi Aventis, Biogen, Precision Health Economics, and Analysis Group. DB reports receiving consulting fees unrelated to this work from Precision Health Economics. He is also employed at Devoted Health.
Ethical approval: This study was approved by the institutional review board at Harvard Medical School.
Data sharing: No additional data available.
Transparency: The lead author (ABJ) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies are disclosed.
This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.