Patients Don't Get Short Shrift From Shorter Shifts for Residents

NEW HAVEN, Conn., June 12 -- Fewer hours in residency training do not appear to have led to substandard care, as some had predicted, according to a pair of studies.

Indeed, in-hospital deaths declined when the schedules of residents in teaching hospitals were reduced in the face of public outcry, found the studies.

When Yale-New Haven Hospital here pared its internal medicine residents' hours back to about 80 per week to comply with new regulations, the mortality rate for patients on the teaching service declined slightly but significantly, reported Leora Horwitz, M.D., M.H.S., of Yale, and colleagues.

At the same time, they reported online in the Annals of Internal Medicine, there was no change in the mortality rate for patients in the non-teaching service.

And despite concerns that more handing-off of patients from one resident to the next might result in more errors and delays, there were net improvements in three of seven clinical outcomes.

"We found that a major reorganization of patient care to reduce resident work hours was implemented without evidence of harm to patients, despite concern about possible adverse effects of discontinuity," the Yale team wrote. "These findings demonstrate the importance of rigorously evaluating policy changes implemented without previously proven benefit or harm."

In a separate study in the same issue of the Annals, Kanaka D. Shetty, M.D., M.S., of Stanford, and Jayanta Bhattacharya, M.D., Ph.D., and the National Bureau of Economic Research in Cambridge, Mass., looked at data on more than 1.2 million patients admitted to hospitals for medical care or surgery.

They found that there was a decrease in short-term mortality among high-risk medical patients, but not among surgical patients, when teaching hospital residents worked shorter shifts.

But for two editorialists, the jury on shorter hours is still out.

"Even if Hippocrates is satisfied, and work-hour rules probably do not ultimately harm patients, is the case closed? Not so fast," wrote Lee Goldman, M.D., M.P.H., dean of the faculties of Health Sciences and Medicine at Columbia University in New York, and Nicholas H. Fiebach, M.D, program director of house-staff training there.

"Little is known about how work-hour limits for residents affect the overall experience of patients and their families, nor how they affect nurses and other members of health care teams. Most important, the implications of the new rules for the adequacy of education and training remain uncertain," they wrote.

In the Yale-New Haven study, Dr. Horwitz and colleagues looked at changes in outcomes for internal medicine patients after the implementation in July 2003 of work-hour regulations by the Accreditation Council for Graduate Medical Education.

In the retrospective cohort study, they examined outcomes for 14,260 consecutive patients discharged from the teaching service and 6,664 consecutive patients discharged from the non-teaching (hospitalist) service of their hospital from July 2002 through June 2004.

They looked at intensive care unit utilization, length of stay, discharge disposition, 30-day readmission rates, pharmacist interventions to prevent error, drug-drug interactions, and in-hospital deaths.

They found that compared with the non-teaching side, the teaching side of the operation had net improvements in three of seven outcomes:

• The rate of intensive care unit utilization decreased by 2.1% (95% confidence interval, -3.3% to -0.7%; P=0.002)
• The rate of discharge to home or to a rehabilitation facility versus elsewhere improved by 5.3% (95% CI, 2.6% to 7.6%; P

They found that among the 1,268,738 medical patients examined, the cap on hours was associated with a 0.25% decrease in absolute risk for death (P=0.043), which corresponded to a 3.75% decrease in relative risk for death in medical patients per hospitalization.

"In subgroup analyses, particularly large improvements in mortality were observed among patients admitted for infectious diseases (change, -0.66%; P=0.007) and in medical patients older than 80 years of age (change, -0.71%; P=0.005)," they wrote.

Among the 243,207 surgical patients, however, the change in regulations were not associated with statistically significant changes in mortality (change, 0.13%; P=0.54).

They acknowledged that their study was limited by the fact that teaching status was assigned according to hospital characteristics because direct information on each patient's provider was not available, and that the results reflect changes associated with the sum of regulations, and not specifically with caps on work hours.

In their editorial, Dr. Goldman and Dr. Fiebacg noted that resident work-hour changes need to be accompanied by improved supervision.

"Transfers of care, also known as 'sign-outs' (already a weak link in most training programs), need increased attention on reorganized teaching services," they wrote. "Often overlooked in the commotion over work-hour limits were parallel appeals for increased supervision of house staff, especially at night; even well-rested house staff should have better access to and oversight by more senior clinicians."