Surgical Interns On Home Call Do Not Decrease Patient Safety

Emma Hitt, PhD

December 18, 2012

Having interns on call at home rather than at the hospital was not linked to postoperative morbidity or mortality among patients who underwent general, vascular, urologic, or cardiac surgery, according to a new report presented by Zachary J. Kastenberg, MD, from the Stanford University School of Medicine in California, and colleagues in an article published online December 17 in the Archives of Surgery.

According to the researchers, in July 2011, surgical interns were prohibited from being on call from home by the new Accreditation Council for Graduate Medical Education guidelines on work hours.

"The effects of this rule are being felt specifically within small training programs or affiliated hospitals, which typically have just a few residents to cover multiple inpatient services and/or hospitals," the authors note.

However, they point out, there exists "no objective evidence in the medical literature to support the hypothesis that intern home call leads to higher patient morbidity or mortality."

The current prospective study, conducted at a university-affiliated tertiary Veterans Affairs Medical Center, sought to evaluate this issue further.

Data from patients included in the Veterans Affairs National Surgical Quality Improvement Program database who underwent an operation performed by general, vascular, urologic, or cardiac surgery services between fiscal years (FYs) 1999 and 2010 were included in the analysis.

Thirty-day unadjusted morbidity and mortality rates were calculated during FYs 1999-2003 (during which the first call for all patients went to an in-hospital intern) and were compared with a subsequent period (FYs 2004-2010, during which the first call went to an intern on home call).

Unadjusted overall morbidity rates decreased from the first and second periods, from 12.14% to 10.19% (P = .003), suggesting that on-call from home was associated with a better outcome. This translated to an annual risk reduction of 6.03% (P < .001).

Death rates also decreased significantly between the 2 periods, going from 1.76% to 1.26% (P = .05), although there was no significant change in the risk-adjusted mortality observed-to-expected ratios during the study.

"We found no correlation between intern home call and increased rates of morbidity or mortality in postoperative patients," Dr. Kastenberg and colleagues conclude.

"This study highlights the importance of using objective evidence to develop regulatory policy," they add, and "illustrates the need to incorporate objective evidence into the design of future resident staffing policy."

In an invited critique, Karen Horvath, MD, from the Department of Surgery at the University of Washington in Seattle, notes that the findings indicate that when interns were sent to home call, "the emergencies were handled and the outcomes were stable (mortality) or even improved (morbidity). Interns were available to then participate in clinic and the operating room the following day, which would have been missed with in-hospital call (because of the 24 + 6 rule, which necessitated that they go home the next morning)," she added. "Yet, in 2010, at significant cost, this same program was mandated to get rid of intern home call — a move driven by fear, not data."

According to Dr. Horvath, "If the data shows that quality care is maintained, then hopefully we will make a data-driven decision to reverse the current ban on intern home call."

This study was supported in part by a grant from the Agency for Healthcare Research and Quality to Dr. Kastenberg. One coauthor's work was supported by a Harold Amos Medical Faculty Development Award from the Robert Wood Johnson Foundation. The other authors and Dr. Horvath have disclosed no relevant financial relationships.

Arch Surg. Published online December 17, 2012. Article abstract, Editorial extract