Impact of resident work hour rules on errors and quality

描述(由申请人提供)：医学研究生教育认证委员会(ACGME)发布了2003年7月1日生效的规则，该规则影响了所有专业由ACGME认证的所有住院医师项目的值班时间。这些规则代表着自2000年医学研究所发表《人类的错误》以来，国家为减少医疗差错所做的最大努力，并将直接影响美国44%在教学医院接受护理的患者所获得的医疗保健。通过减少睡眠剥夺，这些规定可能会对患者的安全和护理质量产生有益影响，但护理连续性的恶化可能会抵消其中的一些好处。该项目将利用通过联邦医疗保险获得的国家数据和包括AHRQ质量指标在内的预先验证的质量衡量标准，评估值班时间规则对患者安全和护理质量的影响。该项目的主要目的是比较教学医院和非教学医院在实施ACGME工作时间规则之前和之后的死亡率和抢救失败(并发症后死亡)的变化。研究的诊断将包括所有因普通外科、骨科或血管手术入院的患者，以及急性心肌梗死、胃肠道出血或中风的内科诊断。次要目的是检查AHRQ患者安全指标(PSI)在规则更改前后的差异，并研究教学医院和非教学医院的住院时间(LOS)、延长住院时间的可能性和有条件的住院时间(一旦住院时间延长)是如何变化的。这项研究将基于从联邦医疗保险的MEDPAR数据集中收集的大约1600万手术和内科入院病例，这些数据涵盖1999-2003年(规则修改前)和2003-2005年(规则修改后)。我们将使用多时间序列设计，将非教学医院作为教学医院的对照，并将根据医院对住院医生的依赖(住院人数/床位比)、计划类型和规模以及医院的基线财务状况来研究影响的差异。这项研究将有能力检测这些结果中非常微小的差异，并将能够最终测试值班时间改革是否改善(或可能恶化)患者的安全和护理质量。这项研究的结果将是未来通过住院医生工作时间改革减少教学医院差错的任何努力的核心。

DESCRIPTION (provided by the applicant): The Accreditation Council for Graduate Medical Education (ACGME) released rules effective July 1, 2003 that affected duty hours for all ACGME-accredited residency programs in all specialties. These rules represent the largest national effort to reduce medical errors since the publication of the Institute of Medicine's To Err is Human in 2000 and will directly impact the health care received by the 44% of patients cared for in teaching hospitals in the United States. By reducing sleep deprivation, the rules will likely have beneficial effects on patient safety and quality of care, but worsened continuity of care may counterbalance some of these benefits. This project will evaluate the effect of the duty hour rules on patient safety and quality of care, utilizing national data available though Medicare and pre-validated measures of quality including the AHRQ Quality Indicators. The primary aims of the project are to compare changes in the rate of mortality and failure-to-rescue (death after complications) in teaching hospitals and non-teaching hospitals before and after implementation of the ACGME work hour rules. Diagnoses studied will include all patients admitted for general, orthopedic, or vascular surgery and medical diagnoses of acute myocardial infarction, gastrointestinal bleeding, or stroke. The secondary aims are to examine differences in AHRQ Patient Safety Indicators (PSIs) before and after the rule change and to study how length of stay (LOS), the probability of a prolonged length of stay, and conditional length of stay (LOS once a stay is prolonged) changed in teaching vs. non-teaching hospitals. The study will be based on approximately 16 million surgical and medical admissions collected from the Medicare's MEDPAR data set spanning the years 1999-2003 (before the rule change) and 2003-2005 (after the rule change). We will use a multiple time series design with non-teaching hospitals as a control for teaching hospitals and will examine how effects differ in accordance with hospital dependence on residents (resident/bed ratio), program type and size, and hospitals' baseline financial status. The study will be powered to detect very small differences in these outcomes and will be able to test definitively whether the duty hour reform improved (or possibly worsened) patient safety and quality of care. Results from this study will be central to any future efforts to reduce errors in teaching hospitals through resident work hour reform.