Teaching hospital financial status and patient outcomes following ACGME duty hour reform

Abstract

Objective: To examine whether hospital financial health was associated with differential changes in outcomes after implementation of 2003 ACGME duty hour regulations.

Data sources/study setting: Observational study of 3,614,174 Medicare patients admitted to 869 teaching hospitals from July 1, 2000 to June 30, 2005.

Study design: Interrupted time series analysis using logistic regression to adjust for patient comorbidities, secular trends, and hospital site. Outcomes included 30-day mortality, AHRQ Patient Safety Indicators (PSIs), failure-to-rescue (FTR) rates, and prolonged length of stay (PLOS).

Principal findings: All eight analyses measuring the impact of duty hour reform on mortality by hospital financial health quartile, in postreform year 1 ("Post 1") or year 2 ("Post 2") versus the prereform period, were insignificant: Post 1 OR range 1.00-1.02 and Post 2 OR range 0.99-1.02. For PSIs, all six tests showed clinically insignificant effect sizes. The FTR rate analysis demonstrated nonsignificance in both postreform years (OR 1.00 for both). The PLOS outcomes varied significantly only for the combined surgical sample in Post 2, but this effect was very small, OR 1.03 (95% CI 1.02, 1.04).

Conclusions: The impact of 2003 ACGME duty hour reform on patient outcomes did not differ by hospital financial health. This finding is somewhat reassuring, given additional financial pressure on teaching hospitals from 2011 duty hour regulations.

Figure 1

Unadjusted Trends in Mortality for Medical Admissions by Hospital Financial Health Quartile Note. The Accreditation Council for Graduate Medical Education duty hour regulations were implemented on July 1, 2003. Prereform year 3 (Pre-3) included academic year 2000–2001 (July 1, 2000, to June 30, 2001); prereform year 2 (Pre-2), academic year 2001–2002; prereform year 1 (Pre-1), academic year 2002–2003; postreform year 1 (Post-1), academic year 2003–2004; and postreform year 2 (Post-2), academic year 2004–2005. No significant divergence was found in the degree to which mortality changed from prereform year 1 to either postreform year any group. Significance levels assess whether trend from prereform year 1 to postreform years 1 and 2, respectively, differed for less versus more financially healthy hospitals.

Figure 2

Unadjusted Trends in Mortality for Surgical Admissions by Hospital Financial Health Quartile Note. The Accreditation Council for Graduate Medical Education duty hour regulations were implemented on July 1, 2003. Prereform year 3 (Pre-3) included academic year 2000–2001 (July 1, 2000, to June 30, 2001); prereform year 2 (Pre-2), academic year 2001–2002; prereform year 1 (Pre-1), academic year 2002–2003; postreform year 1 (Post-1), academic year 2003–2004; and postreform year 2 (Post-2), academic year 2004–2005. No significant divergence was found in the degree to which mortality changed from prereform year 1 to either postreform year any group. Significance levels assess whether trend from prereform year 1 to postreform years 1 and 2, respectively, differed for less versus more financially healthy hospitals