Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients.
Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients.
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DOI：
10.1001/jama.2014.15273
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发表时间：
2014-12-10
期刊：
影响因子：
--
通讯作者：
Silber JH
中科院分区：
文献类型：
--
作者：
Patel MS;Volpp KG;Small DS;Hill AS;Even-Shoshan O;Rosenbaum L;Ross RN;Bellini L;Zhu J;Silber JH
与2011年研究生医学教育认证理事会（ACGME）工作时间改革相关的患者结局尚未在国家层面进行评估。评估2011年ACGME值班时间改革与死亡率和再入院率的相关性。对主要医学诊断为急性心肌梗死、卒中、胃肠道出血或充血性心力衰竭或诊断相关组分类为普通、骨科或血管手术的短期、急性护理、非联邦医院（n = 3104）的Medicare患者入院（2790356例患者中6384273例入院）的观察性研究。在这些医院中，96所（3.1%）是非常重要的教学，138所（4.4%）是主要教学，442所（14.2%）是次要教学，443所（14.3%）是非常次要教学，1985所（64.0%）是非教学。住院医师与床位比率作为医院教学强度的连续性衡量指标。比较值班时间改革前（2009年7月1日-2011年6月30日）和改革后（2011年7月1日-2012年6月30日），在强化程度较高的教学医院与强化程度较低的教学医院中的患者的30天全部位死亡率和30天全因再入院率的变化，调整患者合并症、时间趋势和医院部位。在当值时间改革前的两年，共有4 325 854人入院，其中288 422人死亡，602 380人再次入院。在改革后的第一年，占教学医院的强度，有2 058 419人入院，133 547人死亡，272 938人再次入院。考虑到教学医院强度，在合并医疗条件（比值比[OR]，1.00; 95%CI，0.96-1.03）、合并手术类别（OR，0.99; 95%CI，0.94-1.04）或任何单独医疗条件或手术类别的死亡率方面，没有显著的改革后差异。合并内科疾病（OR，1.00; 95% CI，0.97-1.02）或合并手术类别（OR，1.00; 95% CI，0.98-1.03）的再入院率在治疗后无显著差异。对于卒中的医疗状况，在治疗后阶段再入院的几率更高（OR，1.06; 95%CI，1.001-1.13）。然而，敏感性分析并不支持这一发现，并且任何其他个体疾病或手术类别的再入院率在改革后没有显著差异。在医疗保险受益人中，在实施2011年ACGME工时改革后的一年中，与实施前2年的住院患者相比，在较密集的教学医院住院患者的30天死亡率或30天全因再入院率的变化无显著差异。
Patient outcomes associated with the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms have not been evaluated at a national level. To evaluate the association of the 2011 ACGME duty hour reforms with mortality and readmissions. Observational study of Medicare patient admissions (6 384 273 admissions from 2 790 356 patients) to short-term, acute care, nonfederal hospitals (n = 3104) with principal medical diagnoses of acute myocardial infarction, stroke, gastrointestinal bleeding, or congestive heart failure or a Diagnosis Related Group classification of general, orthopedic, or vascular surgery. Of the hospitals, 96 (3.1%) were very major teaching, 138 (4.4%) major teaching, 442 (14.2%) minor teaching, 443 (14.3%) very minor teaching, and 1985 (64.0%) nonteaching. Resident-to-bed ratio as a continuous measure of hospital teaching intensity. Change in 30-day all-location mortality and 30-day all-cause readmission, comparing patients in more intensive relative to less intensive teaching hospitals before (July 1, 2009–June 30, 2011) and after (July 1, 2011–June 30, 2012) duty hour reforms, adjusting for patient comorbidities, time trends, and hospital site. In the 2 years before duty hour reforms, there were 4 325 854 admissions with 288 422 deaths and 602 380 readmissions. In the first year after the reforms, accounting for teaching hospital intensity, there were 2 058 419 admissions with 133 547 deaths and 272 938 readmissions. There were no significant postreform differences in mortality accounting for teaching hospital intensity for combined medical conditions (odds ratio [OR], 1.00; 95% CI, 0.96–1.03), combined surgical categories (OR, 0.99; 95% CI, 0.94–1.04), or any of the individual medical conditions or surgical categories. There were no significant postreform differences in readmissions for combined medical conditions (OR, 1.00; 95% CI, 0.97–1.02) or combined surgical categories (OR, 1.00; 95% CI, 0.98–1.03). For the medical condition of stroke, there were higher odds of readmissions in the postreform period (OR, 1.06; 95% CI, 1.001–1.13). However, this finding was not supported by sensitivity analyses and there were no significant postreform differences for readmissions for any other individual medical condition or surgical category. Among Medicare beneficiaries, there were no significant differences in the change in 30-day mortality rates or 30-day all-cause readmission rates for those hospitalized in more intensive relative to less intensive teaching hospitals in the year after implementation of the 2011 ACGME duty hour reforms compared with those hospitalized in the 2 years before implementation.
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