A recent study shows that a 2003 reform of the length of resident on-duty hours could be connected to an increase in the rate of perioperative complications for patients treated for hip fractures. Among other things, this reform limited the resident workweek to 80 hours. This timeline corresponds to an increasing rate of worse outcomes seen in teaching hospitals, according to a study published in the September 2009 issue of The Journal of Bone and Joint Surgery (JBJS).
“The data suggests a statistically significant increase in selected complications after implementation of the duty-hour reforms in teaching hospitals. This may go against common assumptions regarding outcomes as they relate to the length of resident hours," said study lead author James M. Browne, MD, an orthopedic surgeon currently completing a fellowship in Rochester, MN. The study was performed at Duke University Medical Center.
On July 1, 2003, The Accreditation Council for Graduate Medical Education implemented a resident duty-hour reform for all medical and surgical residents in the U.S. Dr. Browne and his co-authors at Duke reviewed data from teaching and non-teaching hospitals for 48,430 patients treated for hip fractures in a nationwide inpatient sample database, reviewing groups from 2001 and 2002 before resident duty-hour reform, and from 2004 and 2005 after the reform.
This study sought to measure changes in the rate of patient death or resulting in-hospital complications since this reform. No increase in death rates was found, but increases in pneumonia, hematoma, transfusion, renal complications and non-routine discharge did occur.
In addition to an increase in the rate of medical complications, the study also notes an increase in length and cost of stay in teaching hospitals. Most would tend to agree with Dr. Browne’s assumptions. “I think it would be premature for a patient to make any medical decisions based on the results of this study. Remember, this is limited to hip fracture outcomes tracked during a limited time period and does not take into account any improvements in delivery of care since 2005.
“Surgeons and policy-makers need more data to understand the full impact of these duty hour changes on our patients. As we consider any kind of reform, we must continue to keep the safe delivery of care that results in successful patient outcomes as our number one priority," said Dr. Browne.
It appears to be a thin line for teaching hospitals to walk. Although the benefits, both short and long-term, could be significant for repealing these reforms and getting as much as possible out of residents, the goal is to preserve these entry level surgeons, not burn them out. However, with an aging population and collection of baby-boomers hitting a period of their lives where they will need greater healthcare, are hospitals stretching resources too far by not asking for more hours out of residents?
Orthopedic procedures, one would assume, will continue to be in great demand as a surging population encounters more back and joint issues that may require a surgical fix not too far in the future. The ability to not only attend to this growing patient group, but ensure their procedures are done as well as possible, not only impacts the vitally basic elements of patient health and well-being, but the underlying principle of containing hospital costs and healthcare provider time in dealing with related negative outcomes.
American Academy of Orthopedic Surgeons - www.aaos.org