Patient safety, resident education and resident well-being following implementation of the 2003 ACGME duty hour rules

Abstract

Context: The ACGME-released revisions to the 2003 duty hour standards.

Objective: To review the impact of the 2003 duty hour reform as it pertains to resident and patient outcomes.

Data sources: Medline (1989-May 2010), Embase (1989-June 2010), bibliographies, pertinent reviews, and meeting abstracts.

Study selection: We included studies examining the relationship between the pre- and post-2003 time periods and patient outcomes (mortality, complications, errors), resident education (standardized test scores, clinical experience), and well-being (as measured by the Maslach Burnout Inventory). We excluded non-US studies.

Data extraction: One rater used structured data collection forms to abstract data on study design, quality, and outcomes. We synthesized the literature qualitatively and included a meta-analysis of patient mortality.

Results: Of 5,345 studies identified, 60 met eligibility criteria. Twenty-eight studies included an objective outcome related to patients; 10 assessed standardized resident examination scores; 26 assessed resident operative experience. Eight assessed resident burnout. Meta-analysis of the mortality studies revealed a significant improvement in mortality in the post-2003 time period with a pooled odds ratio (OR) of 0.9 (95% CI: 0.84, 0.95). These results were significant for medical (OR 0.91; 95% CI: 0.85, 0.98) and surgical patients (OR 0.86; 95% CI: 0.75, 0.97). However, significant heterogeneity was present (I(2) 83%). Patient complications were more nuanced. Some increased in frequency; others decreased. Outcomes for resident operative experience and standardized knowledge tests varied substantially across studies. Resident well-being improved in most studies.

Limitations: Most studies were observational. Not all studies of mortality provided enough information to be included in the meta-analysis. We used unadjusted odds ratios in the meta-analysis; statistical heterogeneity was substantial. Publication bias is possible.

Conclusions: Since 2003, patient mortality appears to have improved, although this could be due to secular trends. Resident well-being appears improved. Change in resident educational experience is less clear.

Figure 1

Flow chart summarizing the number of abstracts/papers reviewed for this project and the reasons for excluding abstracts/papers from further review.

Figure 2

Forest plot illustrating the odds ratios for mortality in the post-2003 time period as compared to the pre-2003 time period. Odds ratios are illustrated for medical patients, surgical patients and overall. The two studies by Volpp included both medical and surgical patients. For those studies, the medical patient data were included in the top portion with the other medical studies, and the surgical patient data were included in the bottom portion with the surgical studies. The boxes around the mean represent the study weight, while the lines extending outward from the mean represent the 95% confidence interval around the odds ratio.