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 The new research casts additional doubt on the theory that shorter
shifts improve patient care through fewer medical errors by tired
doctors. It also alleviates some concerns that more shift changes
will lead to more mistakes, said one researcher.
“We actually found that neither of these are true,” said Dr. Mitesh
Patel, one study’s lead author from the Veterans Administration
Hospital and the Perelman School of Medicine at the University of
Pennsylvania in Philadelphia.
In response to concerns from the public and government officials
over preventable medical errors made by tired doctors, the
Accreditation Council for Graduate Medical Education (ACGME)
restricted the shifts of the most junior trainee doctors -
first-year residents, who are also known as interns - to 16 hours
and capped the shifts of the more senior residents at 28 hours in
July 2011.
The restrictions were built on existing regulations from 2003 that
limited resident work-weeks to 80 hours.
While research had mainly focused on the 2003 limits, new data from
the 2011 restrictions are allowing researchers to examine their
effects.
In one study, Patel and his colleagues used data from about 2.8
million patients on Medicare, the U.S. government health insurance
program for the elderly and disabled.
The patients were admitted to over 3,000 hospitals about 6.4 million
times, from July 2009 through June 2012, for conditions such as
heart attack, stroke and heart failure.
Comparing the two years before the restrictions were put in place
and the year after they went into effect, the researchers found no
significant differences in rates of death or readmission to the
hospital within 30 days.
Beforehand, there were about 4.3 million admissions, 288,422 deaths
and 602,380 readmissions. Afterward, there were about 2.1 million
admissions, 133,547 deaths and 272,938 readmissions.
Some people were hopeful that the regulations would improve
outcomes, but "that did not occur,” Patel said. Others were
concerned that outcomes would be worse, but "that wasn’t true either
- at least in the first year.”
In a second study published in the same journal, researchers found
no change in outcomes among people who had surgeries in the two
years before and after the 2011 restrictions.
Additionally, they found no change in test scores of the residents
from 2010 and 2013.
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“There was really no impact of the duty hour restrictions,” said Dr.
Karl Bilimoria, the study’s senior author from the Northwestern
University Feinberg School of Medicine in Chicago.
Dr. Sanjay Desai, director of the residency program at The Johns
Hopkins Hospital in Baltimore, told Reuters Health the lack of a
difference after the restrictions demonstrates the complex
relationship between duty hours and patient outcomes.
He said resident work-hours is only one part of what leads to how a
patient fares. There is also supervision from more experienced
doctors, electronic monitoring systems and other checks in place to
prevent medical errors.
“It’s one component of so many that play a role in that
relationship,” said Desai, who wasn’t involved in the new study. “To
me it seems that these observational trials have demonstrated the
intended effect of these changes hasn’t been realized.”
Bilimoria told Reuters Health that the lack of difference between
the two time periods is not necessarily good news.
“Just because we don’t demonstrate a worsening of outcomes doesn’t
mean it’s safe,” he said.
For example, doctors in training who get to know a patient best
during a stay in intensive care may need to hand the case off to a
new doctor if they reach their duty hour limit for the day. The
limits interrupt the continuity of care, Bilimoria said.
“We would argue that these duty hour limits aren’t improving care
and should be repealed,” he said of the 2011 restrictions.
“I think this study highlights a couple things that’s important for
patients,” he said. “It highlights most of the surgical
establishment – and medical establishment – think that these duty
hour requirements get in the way of taking care of patients. We
should certainly be interested in how we’re training future
doctors.”
SOURCE: http://bit.ly/1zL9z66, http://bit.ly/1zpOG20 and http://bit.ly/1sg6ff5
JAMA, online December 9, 2014.
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