No Effect of Resident Hour Limits on Neurosurgical Outcomes

Laird Harrison

October 22, 2013

SAN FRANCISCO — Restrictions on duty hours for neurosurgery residents has not resulted in significant changes in mortality for neurosurgery patients, a new study shows.

The study did show a slight drop in the proportion of US neurosurgery patients who went straight home from the hospital after 2003, when the Accreditation Council for Graduate Medical Education (ACGME) limited the hours residents could be required to work.

But overall, "there weren't any dramatic changes before or after the work hour changes," Kiersten Norby, MD, told Medscape Medical News.

Dr. Norby, a resident at Hennepin County Medical Center in Minneapolis, Minnesota, presented the study findings here at the Congress of Neurological Surgeons (CNS) 2013 Annual Meeting.

Sleep-Deprived Residents

Concerns about drowsy and fatigued residents led the ACGME to restrict duty hours in 2003, with further limitations set in 2011. Under both sets of rules, residents may not work more than 80 hours a week or 24 hours in a row with some exceptions.

New York State implemented its own limits on duty hours in 1989 after the death of a patient in the care of sleep-deprived residents.

However, there have been concerns about the effect that shorter duty hours may have in terms of patient safety, with more patient hand-offs and less continuity of care.

To measure the effects of these restrictions on neurosurgery patients, Dr. Norby and her colleagues looked at data from the Nationwide Inpatient Sample (NIS) from 2000-2002 and from 2004-2006. They separated the patients according to whether they were in New York or elsewhere in the United States.

The proportion of patients who died in the hospital outside New York did not change significantly after the new rules went into effect. There was a small, statistically significant (P = .01) drop in the proportion of patients who went straight home, but that difference disappeared in a multivariate analysis, said Dr. Norby.

Before and after the ACGME restrictions went into effect, the New York patients had a lower rate of discharges to home than the group outside New York, but the difference was not statistically significant (P ≥ .1).

After the ACGME restrictions went into effect, the proportion of New York patients discharged to home dropped, but this change was also not statistically significant (P = .5).

The mortality rates among New York neurosurgery patients did not change significantly after the ACGME regulations (P = .8). Even before that, the mortality rate in New York was not statistically different from the rate outside New York (P = .5).

Table. Discharge Destinations for Neurosurgery Patients

Years Home (%) Long-term Care (%) Death (%) Other (%)
2000-2002 outside New York 84.1 12.7 3.0 0.2
2004-2006 outside New York 81.6 15.1 3.1 0.3
2000-2002 in New York 81.9 14.8 2.9 0.4
2004-2006 in New York 78.0 18.3 3.4 0.4

 

Dr. Norby said the results fit her own experiences as a resident. "One of the arguments is that people would be less tired and patients would have better outcomes. But there are more sign-offs and handoffs than before, so maybe there are more things that are missed."

The effect of the new rules might vary from one specialty to another, she said, noting that some studies in other settings, such as intensive care units, have found improvements in outcomes since the rules went into effect.

One limitation of the study is that different hospitals reported data to the NIS in different years, although the number of hospitals stayed constant, said Dr. Norby.

Cost in Experience

Asked to comment, Manish Aghi, MD, PhD, told Medscape Medical News that the work rules had resulted in residents getting less experience.

Dr. Aghi, who was not a part of this study, was a resident in 2003 and now supervises residents as an associate professor of neurosurgery at the University of California, San Francisco.

"I was early in my training when it went into effect," he said. "In the midst of my training I noticed there was a transition period and the volume of cases we got to see did drop. The residencies, in order to compensate for the work orders, expanded the number of residents. That allowed work flow to continue, but it further diluted the number of cases."

As for the care of patients, Dr. Aghi wondered if the study should have looked at other outcomes, such as length of stay.

"It's an interesting result, but if you're going to make an argument that we need to go back to more work hours, we're going to need deeper analysis," he said.

Dr. Norby and Dr. Aghi disclosed no relevant financial relationships.

Congress of Neurological Surgeons (CNS) 2013 Annual Meeting. Abstract #306. Presented October 21, 2013.

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