Introduction

The Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour restrictions for resident physicians on July 1, 2003, and the policy changes put into place addressed several facets of resident work requirements (box).^1–3 The primary aims of the new standards were to improve patient and resident safety. The decision was predicated on studies demonstrating that the reduction of fatigue and sleep deprivation among residents has beneficial effects, including increased quality of life, cognitive functioning, clinical performance, and the reduced risk of motor vehicle accidents.^4–13 There is still debate as to whether the reform was entirely beneficial, as some studies found improvements in mortality rates following the duty hour policy changes and others demonstrated trends of stagnancy or increased mortality.

Our study examined the association of duty hour restrictions on mortality in patients with primary discharge diagnoses of disorders or diseases of the nervous system. Furthermore, our study was designed to provide a novel approach to assess the effects of the changes in the ACGME standards. The existing literature examining the effect that the resident duty hour reform has had on patients dealing with neuropathology is rather limited. Furthermore, the studies that have attempted to assess this topic have predominantly focused on single site analyses of patients with specific diagnoses or procedures. Due to the current gaps in the literature, our study has examined the larger, more generalized cohort of patients by expanding the study sample to include all patients with neuropathology. The goal of this study was to determine if there was an association between the outcomes for this particular patient group and the ACGME standards modifications.

Methods

Results

Mortality Analysis

The respective mortality rates for teaching and non-teaching hospitals by year, along with P values, odds ratios, and 95% confidence intervals are displayed in the table. The pre-reform period (2000–2002) and peri-reform period (2003) revealed no difference between teaching and nonteaching hospital mortality in MDC01 admissions. The post-reform period saw teaching hospital mortality increase rapidly, rebound, and then decline at a slower rate compared to the steady decline observed in nonteaching hospitals (figure). Years 2005, 2008, and 2009 did not meet our study's standards for significance. The remaining post-reform years demonstrated significantly greater mortality rates in teaching hospitals compared to nonteaching hospitals.

table Mortality Comparisons of MDC01 Between Teaching and Nonteaching Hospitals by Year

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Discussion

This study demonstrates a potential association between the 2003 duty hour changes and increased mortality in teaching hospitals versus nonteaching hospitals in primary discharge diagnoses involving nervous system pathology. In contrast, from 2000 to 2003, differences in mortality rates for these diagnoses were not observed. Over this decade, mortality declined for both types of hospitals.

The current literature details possible explanations for how the duty hour reform may have negatively affected patient care. Hutter and colleagues¹⁶ noted concerns regarding the professional development of future surgeons, as well as challenges transitioning from a patient-oriented mentality to one of a shift-worker. However, these concerns of diminished resident professionalism due to development of a “shift work” mentality remain debated in the literature as possibly being overstated.¹⁷ Other concerns include diminished continuity of care, more frequent resident handoffs, and a general reduction in a training physician's clinical experience.^18–22 These potential challenges brought on by the duty hour restrictions may provide some explanation for the mortality trends observed in our study.

Although limited in quantity, there are several studies that have examined the duty hour reform's effects on specific nervous system pathology patient populations. Many of these studies have demonstrated worse patient outcomes following the duty hour reform, including neurological surgery trauma, craniotomy for meningiomas, spinal surgeries, brain tumors, and cerebrovascular neurological procedures.^23–26 These authors stipulated that the training and performance of neurological surgery residents is particularly vulnerable to the limitations that the duty hour reform placed on them. Furthermore, Grady and colleagues¹⁸ suggested that the reform may have exchanged the risks of resident fatigue for those of an inexperienced neurological surgery workforce. In contrast, 1 study found no difference in acute ischemic stroke mortality after the implementation of the duty hour reform.²⁷ While these studies individually examine very specific patient populations, cumulatively they may suggest that some patients are more susceptible than others to the obstacles the reform has placed on physicians.

This study has several limitations. The design allows merely the identification of an association between duty hour limits and mortality in patients with neuropathology diagnoses, and cannot attribute causality. Potential confounders include the tendency of teaching hospitals to have higher case complexity, to have patients with more comorbidities, and to have different demographic compositions. Additionally, not all teaching hospitals have accredited neurological surgery and/or neurology residency programs, and the NIS data limited our ability to identify these institutions.

Furthermore, variables such as severity of injury, chronicity, acuity, and comorbidities are not captured in this national database, thus confounding our ability to normalize for these variables. We attempted to add a novel perspective by using the broad patient cohort of MDC01; however, the generalization that subsequently occurs with this approach must be noted as a limitation due to the many unknowns regarding specific DRGs that may be driving the observed mortality fluctuations. Mortality may not necessarily be the best indicator for quality of care for every DRG, as benign diseases may never result in death regardless of the patient care. Future studies should attempt to account for these unknowns.

Conclusion

Prior to the implementation of the ACGME duty hour reform, the mortality rates of patients with nervous system pathology were comparable regardless of hospital teaching status in a national database that did not control for other differences between these hospitals. Following the reform, mortality rates for this patient population diverged between teaching and nonteaching institutions, with higher mortality rates observed in teaching hospitals for 4 of the next 7 years.