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Cost Implications of ACGME’s 2011 Changes to Resident Duty Hours and the Training Environment

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An Erratum to this article was published on 25 August 2011

Abstract

BACKGROUND

In July 2011, the Accreditation Council for Graduate Medical Education (ACGME) will implemented stricter duty-hour limits and related changes to the training environment. This may affect preventable adverse event (PAE) rates.

OBJECTIVES

To estimate direct costs under various implementation approaches, and examine net costs to teaching hospitals and cost-effectiveness to society across a range of hypothetical changes in PAEs.

DESIGN

A decision-analytical model represented direct costs and PAE rates, mortality, and costs.

DATA SOURCES

Published literature and publicly available data.

TARGET POPULATION

Patients admitted to hospitals with ACGME-accredited programs.

TIME HORIZON

One year.

PERSPECTIVES

All teaching hospitals, major teaching hospitals, society.

INTERVENTION

ACGME’s 2011 Common Program Requirements.

OUTCOME MEASURES

Direct annual costs (all accredited hospitals), net cost (major teaching hospitals), cost per death averted (society).

RESULTS OF BASE-ANALYSIS

Nationwide, duty-hour changes would cost $177 million annually if interns maintain current productivity, vs. up to $982 million if they transfer work to a mixture of substitutes; training-environment changes will cost $204 million. If PAEs decline by 7.2–25.8%, net costs to major teaching hospitals will be zero. If PAEs fall by 3%, the cost to society per death averted would be –$523,000 (95%-confidence interval: –$1.82 million to $685,000) to $2.44 million ($271,000 to $6.91 million). If PAEs rise, the policy will be cost-increasing for teaching hospitals and society.

RESULTS OF SENSITIVITY ANALYSIS

The total direct annual cost nationwide would be up to $1.34 billion using nurse practitioners/physician assistants, $1.64 billion using attending physicians, $820 million hiring additional residents, vs. 1.42 billion using mixed substitutes.

LIMITATIONS

The effect on PAEs is unknown. Data were limited for some model parameters.

CONCLUSION

Implementation decisions greatly affect the cost. Unless PAEs decline substantially, teaching hospitals will lose money. If PAEs decline modestly, the requirements might be cost-saving or cost-effective to society.

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References

  1. Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. 2008; http://www.iom.edu/Reports/2008/Resident-Duty-Hours-Enhancing-Sleep-Supervision-and-Safety.aspx. Accessed May 27, 2011.

  2. Nasca T. Letter to the Graduate Medical Education Community. 2009; http://www.acgme.org/acWebsite/home/nascalettercommunity2_2009.pdf Accessed May 27, 2011.

  3. Accreditation Council for Graduate Medical Education. Common Program Requirements. 2010; http://www.acgme.org/acwebsite/home/Common_Program_Requirements_07012011.pdf. Accessed May 27, 2011.

  4. Accreditation Council for Graduate Medical Education. Resident Duty Hours in the Learning and Working Environment: Comparison of 2003 and 2011 Standards. 2010; http://www.acgme.org/acwebsite/dutyhours/dh-ComparisonTable2003v2011.pdf. Accessed May 27, 2011.

  5. Nuckols TK, Bhattacharya J, Wolman DM, Ulmer C, Escarce JJ. Cost implications of reduced work hours and workloads for resident physicians. N Engl J Med. May 21 2009;360(21):2202–15.

    Article  PubMed  CAS  Google Scholar 

  6. Reed D, Fletcher K, Arora V. Systematic review: association of shift length, protected sleep time, and night float with patient care, residents' health, and education. Ann Intern Med. Dec 21, 2010 2010;153(12):829–42

    PubMed  Google Scholar 

  7. Nuckols T, Escarce J. ACGME Common Program Requirements: Potential Cost Implications of Changes to Resident Duty Hours and Related Changes to the Training Environment Announced on September 28, 2010. 2010; http://www.acgme.org/acwebsite/dutyhours/dh-FinalReportCostAnalysis2011CPRs.pdf.

  8. Fletcher K, Reed D, Arora V. Systematic Review of the Literature: Resident Duty Hours and Related Topics. 2009; http://acgme-2010standards.org/pdf/Resident_Duty_Hours_and_Related_Topics.pdf. Accessed May 27, 2011.

  9. Caruso J, Veloski J, Grasberger M, et al. Systematic Review of the Literature on the Impact of Variation in Residents' Duty Hour Schedules on Patient Safety: 2009. 2009; http://acgme-2010standards.org/research-testimony.html. Accessed May 27, 2011.

  10. Peterson LE, Johnson H, Pugno PA, Bazemore A, Phillips Jr RL. Training on the clock: family medicine residency directors' responses to resident duty hours reform. Acad Med. 2006;81(12):1032–7.

    Article  PubMed  Google Scholar 

  11. Antiel RM, Thompson SM, Reed DA, et al. ACGME duty-hour recommendations - a national survey of residency program directors. N Engl J Med. Aug 19 2010;363(8):e12.

    Article  PubMed  CAS  Google Scholar 

  12. Holt KD, Miller RS, Philibert I, Heard JK, Nasca TJ. Residents' perspectives on the learning environment: data from the Accreditation Council for Graduate Medical Education resident survey. Acad Med. Mar 2010;85(3):512–8.

    Article  PubMed  Google Scholar 

  13. Zebrack JR, Fletcher KE, Beasley BW, Whittle J. Ambulatory training since duty hour regulations: a survey of program directors. Am J Med. Jan 2010;123(1):89–94.

    Article  PubMed  Google Scholar 

  14. Landrigan CP, Barger LK, Cade BE, Ayas NT, Czeisler CA. Interns' compliance with accreditation council for graduate medical education work-hour limits. JAMA. 2006;296(9):1063–70.

    Article  PubMed  CAS  Google Scholar 

  15. Jagsi R, Shapiro J, Weissman JS, Dorer DJ, Weinstein DF. The educational impact of ACGME limits on resident and fellow duty hours: a pre-post survey study. Acad Med. 2006;81(12):1059–68.

    Article  PubMed  Google Scholar 

  16. Nasca T, Nylen J. Personal communication with Dr. Nuckols: Accreditation Council for Graduate Medical Education; 2010.

  17. Mendoza KA, Britt LD. Resident operative experience during the transition to work-hour reform. Arch Surg. Feb 2005;140(2):137–45.

    Article  PubMed  Google Scholar 

  18. Peabody T. The effect of work hour restrictions on the education of orthopaedic surgery residents. Clin Orthop Relat Res. Aug 2006;449:128–33.

    PubMed  Google Scholar 

  19. Cull WL, Mulvey HJ, Jewett EA, Zalneraitis EL, Allen CE, Pan RJ. Pediatric residency duty hours before and after limitations. Pediatrics. 2006;118(6):e1805-1811.

    Article  PubMed  Google Scholar 

  20. Horwitz LI, Krumholz HM, Huot SJ, Green ML. Internal medicine residents' clinical and didactic experiences after work hour regulation: a survey of chief residents. J Gen Intern Med. 2006;21(9):961–5.

    Article  PubMed  Google Scholar 

  21. Kusuma SK, Mehta S, Sirkin M, et al. Measuring the attitudes and impact of the eighty-hour workweek rules on orthopaedic surgery residents. J Bone Joint Surg Am. 2007;89(3):679–85.

    Article  PubMed  Google Scholar 

  22. Nuthalapaty FS, Carver AR, Nuthalapaty ES, Ramsey PS. The scope of duty hour-associated residency structure modifications. Am J Obstet Gynecol. 2006;194(1):282–8.

    Article  PubMed  Google Scholar 

  23. Wallach SL, Alam K, Diaz N, Shine D. How do internal medicine residency programs evaluate their resident float experiences? South Med J. Sep 2006;99(9):919–23.

    Article  PubMed  Google Scholar 

  24. Pezzi C, Leibrandt T, Suryadevara S, Heller JK, Hurley-Martonik D, Kukora JS. The present and future use of physician extenders in general surgery training programs: one response to the 80-hour work week. J Am Coll Surg. Apr 2009;208(4):587–91.

    Article  PubMed  Google Scholar 

  25. Block AE, Norton DM. Nurse labor effects of residency work hour limits. Nurs Econ. Nov-Dec 2008;26(6):368–73.

    PubMed  Google Scholar 

  26. National Organization for Research at the University of Chicago (NORC). GRADUATE MEDICAL EDUCATION: What Are We Paying For? Report to the Assistant Secretary for Planning and Evaluation. 2006; http://aspe.hhs.gov/health/reports/06/GradMedicalEdu/index.html. Accessed May 27, 2011.

  27. Horwitz LI, Krumholz HM, Green ML, Huot SJ. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166(11):1173–7.

    Article  PubMed  Google Scholar 

  28. Bureau of Labor Statistics. National compensation survey: occupational earnings in the United States. 2008; http://www.bls.gov/ncs/ncswage2006.htm. Accessed May 27, 2011.

  29. Bureau of Labor Statistics - Department of Labor. Employer cost for employee compensation: annual data for 2008. http://www.bls.gov/news.release/archives/ecec_03122009.pdf. Accessed May 27, 2011.

  30. American Association of Medical Colleges. AAMC Data Book: Medical Schools and Teaching Hospitals by the Numbers. Washington DC: AAMC Section for Medical School and Faculty Studies; 2010.

    Google Scholar 

  31. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. Jun 2008;17(3):216–23.

    Article  PubMed  Google Scholar 

  32. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38(3):261–71.

    Article  PubMed  CAS  Google Scholar 

  33. Thomas EJ, Orav EJ, Brennan TA. Hospital ownership and preventable adverse events. J Gen Intern Med. 2000;15(4):211–9.

    Article  PubMed  CAS  Google Scholar 

  34. Thornlow DK, Stukenborg GJ. The association between hospital characteristics and rates of preventable complications and adverse events. Med Care. 2006;44(3):265–9.

    Article  PubMed  Google Scholar 

  35. Hayward RA, Heisler M, Adams J, Dudley RA, Hofer TP. Overestimating outcome rates: statistical estimation when reliability is suboptimal. Health Serv Res. 2007;42(4):1718–38.

    Article  PubMed  Google Scholar 

  36. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA. 2001;286(4):415–20.

    Article  PubMed  CAS  Google Scholar 

  37. Mello MM, Studdert DM, Thomas EJ, Yoon CS, Brennan TA. Who Pays for Medical Errors? An Analysis of Adverse Event Costs, the Medical Liability System, and Incentives for Patient Safety Improvement. J Empir Legal Stud. 2007;4(4):835–60.

    Article  Google Scholar 

  38. Zhan C, Friedman B, Mosso A, Pronovost P. Medicare payment for selected adverse events: building the business case for investing in patient safety. Health Aff (Millwood). 2006;25(5):1386–93.

    Article  Google Scholar 

  39. U.S. Department of Labor - Occupational Safety and Health Administration. Statement by US Department of Labor's OSHA Assistant Secretary Dr. David Michaels on long work hours, fatigue and worker safety. 2010; http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=NEWS_RELEASES&p_id=18285. Accessed May 27, 2011.

  40. Public Citizen. Petition to Reduce Medical Resident Work Hours. 2010; http://www.citizen.org/hrg1917. Accessed May 27, 2011.

  41. Supreme Court of the United States. Mayo Foundation for Medical Education and Research et al versus United States2010.

  42. Council on Graduate Medical Education (COGME). Physician workforce policy guidelines for the United States, 2000–2020: sixteenth report. 2005; http://stanford.biocareers.com/articles/physician-workforce-policy-guidelines-united-states-2000-2020. Accessed June 3, 2011.

  43. Medicare Payment Advisory Commission. Report to the Congress: Aligning Incentives in Medicare. 2010; http://www.ncrponline.org/PDFs/2010/MEDPAC_Congress_June2010.pdf. Accessed May 27, 2011.

  44. Philibert I. Sleep loss and performance in residents and nonphysicians: a meta-analytic examination. Sleep. 2005;28(11):1392–402.

    PubMed  Google Scholar 

  45. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351(18):1838–48.

    Article  PubMed  CAS  Google Scholar 

  46. Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121:866–72.

    PubMed  CAS  Google Scholar 

  47. Petersen LA, Orav EJ, Teich JM, O’Neil AC, Brennan TA. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv. 1998;24:77–87.

    PubMed  CAS  Google Scholar 

  48. Viscusi WK, Aldy JE. The Value of a Statistical Life: A Critical Review of Market Estimates Throughout the World. J Risk Uncertain. 2003;27(1):5-76(72).

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Acknowledgements

An earlier version of this analysis was commissioned by the Accreditation Council for Graduate Medical Education (ACGME). ACGME representatives provided information related to selected model parameters, as specified in the paper. The authors were wholly responsible for conducting the analysis and preparing the manuscript; ACGME played no other roles in these activities. The authors performed a similar analysis for the Institute of Medicine in 2008. The authors have no other conflicts of interest. Teryl Nuckols, MD, MSHS is currently supported by a Mentored Clinical Scientist Career Development Award (K08) from the Agency for Healthcare Research and Quality (grant number HS17954).

The authors thank Jan Wilson, who provided research support, and Jodi Friedman, MD, who provided helpful feedback on the analysis.

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Correspondence to Teryl K. Nuckols MD, MSHS.

Additional information

An erratum to this article can be found at http://dx.doi.org/10.1007/s11606-011-1827-1.

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Nuckols, T.K., Escarce, J.J. Cost Implications of ACGME’s 2011 Changes to Resident Duty Hours and the Training Environment. J GEN INTERN MED 27, 241–249 (2012). https://doi.org/10.1007/s11606-011-1775-9

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