Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance

JAMA. 2014 Dec 10;312(22):2374-84. doi: 10.1001/jama.2014.15277.


Importance: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) restricted resident duty hour requirements beyond those established in 2003, leading to concerns about the effects on patient care and resident training.

Objective: To determine if the 2011 ACGME duty hour reform was associated with a change in general surgery patient outcomes or in resident examination performance.

Design, setting, and participants: Quasi-experimental study of general surgery patient outcomes 2 years before (academic years 2009-2010) and after (academic years 2012-2013) the 2011 duty hour reform. Teaching and nonteaching hospitals were compared using a difference-in-differences approach adjusted for procedural mix, patient comorbidities, and time trends. Teaching hospitals were defined based on the proportion of cases at which residents were present intraoperatively. Patients were those undergoing surgery at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). General surgery resident performance on the annual in-training, written board, and oral board examinations was assessed for this same period.

Exposures: National implementation of revised resident duty hour requirements on July 1, 2011, in all ACGME accredited residency programs.

Main outcomes and measures: Primary outcome was a composite of death or serious morbidity; secondary outcomes were other postoperative complications and resident examination performance.

Results: In the main analysis, 204,641 patients were identified from 23 teaching (n = 102,525) and 31 nonteaching (n = 102,116) hospitals. The unadjusted rate of death or serious morbidity improved during the study period in both teaching (11.6% [95% CI, 11.3%-12.0%] to 9.4% [95% CI, 9.1%-9.8%], P < .001) and nonteaching hospitals (8.7% [95% CI, 8.3%-9.0%] to 7.1% [95% CI, 6.8%-7.5%], P < .001). In adjusted analyses, the 2011 ACGME duty hour reform was not associated with a significant change in death or serious morbidity in either postreform year 1 (OR, 1.12; 95% CI, 0.98-1.28) or postreform year 2 (OR, 1.00; 95% CI, 0.86-1.17) or when both postreform years were combined (OR, 1.06; 95% CI, 0.93-1.20). There was no association between duty hour reform and any other postoperative adverse outcome. Mean (SD) in-training examination scores did not significantly change from 2010 to 2013 for first-year residents (499.7 [ 85.2] to 500.5 [84.2], P = .99), for residents from other postgraduate years, or for first-time examinees taking the written or oral board examinations during this period.

Conclusions and relevance: Implementation of the 2011 ACGME duty hour reform was not associated with a change in general surgery patient outcomes or differences in resident examination performance. The implications of these findings should be considered when evaluating the merit of the 2011 ACGME duty hour reform and revising related policies in the future.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Accreditation / standards
  • Adult
  • Aged
  • Education, Medical, Graduate / standards*
  • Female
  • General Surgery / education*
  • General Surgery / standards
  • Hospitals, Teaching / standards
  • Humans
  • Internship and Residency / standards*
  • Male
  • Middle Aged
  • Morbidity
  • Odds Ratio
  • Outcome Assessment, Health Care
  • Personnel Staffing and Scheduling*
  • Postoperative Complications
  • Retrospective Studies
  • Surgical Procedures, Operative / mortality*
  • Surgical Procedures, Operative / standards
  • United States
  • Work Schedule Tolerance