Kanaka D. Shetty, MD, MS; Jayanta Bhattacharya, MD, PhD
Disclaimer: The views expressed herein are those of the authors and do not necessarily reflect the views of the Department of Veterans Affairs, National Bureau of Economic Research, or the Center for Health Policy and Center for Primary Care and Outcomes Research.
Acknowledgments: The authors thank Drs. Alan Garber, Douglas Owens, Mark Hlatky, and Priya Pillutla for helpful comments on earlier versions of this manuscript.
Grant Support: Dr. Shetty was supported by a Department of Veterans Affairs Fellowship in Ambulatory Care Practice and Research. Dr. Bhattacharya was supported by the National Institute on Aging.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Kanaka D. Shetty, MD, MS, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304.
Current Author Addresses: Drs. Shetty and Bhattacharya: Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304.
Author Contributions: Conception and design: K. Shetty, J. Bhattacharya.
Analysis and interpretation of the data: K. Shetty, J. Bhattacharya.
Drafting of the article: K. Shetty.
Critical revision of the article for important intellectual content: K. Shetty, J. Bhattacharya.
Final approval of the article: K. Shetty, J. Bhattacharya.
Provision of study materials or patients: K. Shetty.
Statistical expertise: K. Shetty, J. Bhattacharya.
Obtaining of funding: J. Bhattacharya.
Collection and assembly of data: K. Shetty.
In 2002, the Accreditation Council on Graduate Medical Education enacted regulations, effective 1 July 2003, that limited work hours for all residency programs in the United States.
To determine whether work-hour regulations were associated with changes in mortality in hospitalized patients.
Comparison of mortality rates in high-risk teaching service patients hospitalized before and after July 2003, with nonteaching service patients used as a control group.
551 U.S. community hospitals included in the Healthcare Cost and Utilization Project's Nationwide Inpatient Survey between January 2001 and December 2004.
1 511 945 adult patients admitted for 20 medical and 15 surgical diagnoses.
In 1 268 738 medical patients examined, the regulations were associated with a 0.25% reduction in the absolute mortality rate (P = 0.043) and a 3.75% reduction in the relative risk for death. 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). By contrast, in 243 207 surgical patients, regulations were not associated with statistically significant changes (change, 0.13%; P = 0.54).
Teaching status was assigned according to hospital characteristics because direct information on each patient's provider was not available. Results reflect changes associated with the sum of regulations, not specifically with caps on work hours.
The work-hour regulations were associated with decreased short-term mortality among high-risk medical patients in teaching hospitals but were not associated with statistically significant changes among surgical patients in teaching hospitals.
The health effects of regulations restricting housestaff work hours to 75 hours per week are largely unknown.
The authors measured inpatient mortality of 1 268 738 patients admitted to 551 hospitals with medical diagnoses and 243 207 patients admitted for surgical diagnoses before and after 2003, when the work-hour regulation took effect. After 2003, the mortality rate for medical patients—but not surgical patients—decreased more in teaching hospitals than nonteaching hospitals.
The authors classified a hospital as “teaching” if it had a residency program; however, some teaching hospitals have nonteaching patients.
Limiting residents' work hours was associated with lower in-hospital mortality rates for medical patients in teaching hospitals.
Table 1. Included Diagnoses*
Table 2. Baseline Characteristics of Patients
Table 3. Hospital Characteristics
Table 4. Changes in Mortality in Medical Patients after Work-Hour Regulations
Changes in mortality among medical patients.
Top. Medical patients. Middle. Medical patient subgroups. Bottom. Medical patients, previous years. Error bars represent 95% CIs.
Table 5. Changes in Mortality in Surgical Patients after Work-Hour Regulations
Changes in mortality among surgical patients.
Error bars represent 95% CIs.
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Shetty KD, Bhattacharya J. Changes in Hospital Mortality Associated with Residency Work-Hour Regulations. Ann Intern Med. 2007;147:73-80. doi: 10.7326/0003-4819-147-2-200707170-00161
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Published: Ann Intern Med. 2007;147(2):73-80.
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