Cost implications of ACGME's 2011 changes to resident duty hours and the training environment

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.

Figure 1

Total direct annual cost nationwide of ACGME’s 2011 Common Program Requirements as a function of the number of PGY1s transferring work to other providers, ranging from PGY1s in small programs (scenario X) to all PGY1s (scenario Y). (a) mixture of substitutes, (b) mid-level providers, © attending physicians, (c) expanded population of residents. Legend: —mean modeled estimate, ….95% confidence interval for mean modeled estimate.

Figure 2

Net cost to major teaching hospitals of ACGME’s 2011 Common Program Requirements as a function of the policy’s hypothetical effect on preventable adverse events (PAEs). (a) scenario X: most programs reorganize schedules to comply with 16-hour shift requirement; small programs transfer PGY1s’ excess work to other providers. (b) scenario Y: all programs transfer PGY1s’ excess work to other providers. (In this figure, the other providers are a mixture of substitutes). Legend: —mean modeled estimate, ….95% confidence interval for mean modeled estimate.

Figure 3

Net cost to society of ACGME’s 2011 Common Program Requirements as a function of the policy’s hypothetical effect on preventable adverse events (PAEs). (a) scenario X: most programs reorganize schedules to comply with 16-hour shift requirement; small programs transfer PGY1s’ excess work to other providers. (b) scenario Y: all programs transfer PGY1s’ excess work to other providers. (In this figure, the other providers are a mixture of substitutes). Legend: —mean modeled estimate, ….95% confidence interval for mean modeled estimate.

Figure 4

Cost-effectiveness to society of ACGME’s 2011 Common Program Requirements as a function of the policy’s hypothetical effect on preventable adverse events (PAEs). In this analysis, cost-effectiveness means incremental (i.e., additional) cost per PAE-related death averted. (a) scenario X: most programs reorganize schedules to comply with 16-hour shift requirement; small programs transfer PGY1s’ excess work to other providers. (b) scenario Y: all programs transfer PGY1s’ excess work to other providers. (In this figure, the other providers are a mixture of substitutes). Legend: —mean modeled estimate, ….95% confidence interval for mean modeled estimate.