More cuts in resident hours could be costly

Additional restrictions on medical residents' work hours could cost teaching hospitals about $1.6 billion each year, according to a study in the May 21 New England Journal of Medicine.

The study placed a price tag on recommendations made in a December 2008 Institute of Medicine report that were intended to further reduce fatigue-related medical errors and enhance the learning environment for residents. Among the recommendations were five-hour naps during extended shifts and 16-hour limits for shifts without naps.

The IOM's call for change beyond the 80-hour work week rule implemented in 2003 by the Accreditation Council for Graduate Medical Education has sparked controversy not only because of the expense but also because of the possible impact to the quality of residents' education.

"We have heard from students and residents that they are not supportive" of the proposed changes, said Joanne Conroy, MD, chief health care officer with the Assn. of American Medical Colleges. "They are concerned about the quality of their educational experiences."

Residents have three to seven years to learn specialties, and they fear that truncated shifts and the need to trim patient care time could detract from their training, Dr. Conroy said. Talk of expanding the number of years it would take to complete residencies has been met with dismay over the extra amount it would add to medical school costs, she added.

The ACGME is gathering written responses to the IOM recommendations and will host a meeting June 11-12 in Chicago to discuss them. A council task force will suggest possible work hour changes by July 2011.

The NEJM study, which was commissioned by the IOM to expand on a cost analysis included in the original report, provides additional information for the meeting.

In arriving at the $1.6 billion figure, researchers calculated the labor costs of implementing four of the IOM recommendations: adherence to the 80-hour work week; a five-hour nap during extended shifts; a 16-hour work limit for shifts without naps; and a reduced workload for residents. They estimated the labor costs for substituting other skilled workers for residents at 1,206 hospitals with ACGME-accredited programs. The expenses break down to $3.2 million per hospital each year, researchers said.

Safety concerns

Although increased patient safety is a driving force behind the work-hour changes, it is unknown if the adjustments would reduce preventable adverse events, researchers said.

A related editorial in the same NEJM issue said studies looking at this issue were inconclusive. Perhaps fatigue doesn't play as large a role in patient safety as does the increase in patient handoffs made necessary by more shift changes due to shortened hours, the editorial's authors wrote.

"Studies have shown that handoffs are associated with adverse patient outcomes, including increases in medical errors, the length of hospital stay and costs, since decisions are made by providers who are unfamiliar with the patient," wrote authors Melvin S. Blanchard, MD, associate professor of medicine, and Kenneth S. Polonsky, MD, chair of the department of medicine, both at Washington University School of Medicine, St. Louis; and David O. Meltzer, MD, PhD, associate professor of medicine at the University of Chicago's department of medicine.

The editorial authors urged the ACGME to require studies on the potential impact of the recommendations on preventable adverse events and how patient handoffs can be achieved safely. "The IOM committee urged rapid implementation of their recommendations. We strongly disagree," they wrote.

In an April letter to the ACGME, AAMC President Darrell G. Kirch, MD, and Executive Vice President Carol A. Aschenbrener, MD, noted, "There is very little solid evidence that links resident schedules to patient care outcomes." They recommend assessing "fitness for duty" as a better approach, since individual tolerances for sleep deprivation and long hours on duty can vary.

The American Medical Association, one of five member organizations of the ACGME, will continue to track the issue, wrote AMA Executive Vice President and Chief Executive Officer Michael D. Maves, MD, MBA, to Thomas Nasca, MD, executive director of ACGME.

Additional discussion on limits to residents' duty hours is scheduled during the June AMA Annual Meeting, Dr. Maves said.

The print version of this content appeared in the June 8, 2009 issue of American Medical News.

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