Work Hour Regulation for Physician Trainees: Educational and Clinical Outcomes

描述（由申请人提供）：研究生医学教育认证委员会（ACGME）于2003年制定了培训医生的工作时间规定，这是在卡车运输、航空和其他急性和慢性睡眠剥夺引起严重安全问题的职业实施类似规定很久之后。值班时间规定的影响一直存在争议。虽然有一些证据表明，这在短期内改善了死亡率结果，但对教育结果、长期临床结果的影响知之甚少，也不清楚值班时间改革在改善临床或教育结果方面产生的医院间差异的机制。在美国外科委员会、美国内科医学委员会、国家医学检查委员会、内科和外科项目主任协会以及美国医师学会的协助下，我们建议完成以下具体目标：通过对内科（IM）和普通外科（GS）的项目主任和住院医生进行全国性调查，通过对内科（IM）和普通外科住院医生项目样本进行定性实地调查，描述项目层面对值班时间改革和住院医生工作条件的行为反应的多样性和频率。2. 评估不同专业住院医师的教育成果（委员会分数）随时间变化与值班时间改革的关系。3. 研究临床结果（死亡率、抢救失败、延长住院时间的可能性、患者安全指标）在工作后改革的头两年之后是如何变化的。4. 检查教育和临床结果的变化与医院财务绩效、医师扩展员和护士人员配备水平以及在全国项目主任调查中确定的项目反应之间的关系。拟议的分析将是第一个将全国教育和临床结果数据汇总在一起的分析，并将帮助我们理解为什么培训医生的值班时间监管改革在改善教育和临床结果方面起作用（或不起作用）。这是一个重要的政策问题，因为作为改革主体的医生每年为数千万美国人提供医疗服务。2003年对接受培训的医生的值班时间的规定是为改善美国医院的病人安全所做的最重要的努力之一。这些法规如何影响患者的治疗结果、医生培训的质量，以及项目如何改善或维持患者的治疗结果和住院医师培训的质量，在很大程度上是未知的。在本研究中，我们将研究住院医师项目和医院如何应对值班时间改革，以及这些行为反应如何决定哪些住院医师项目和医院在教育和临床结果方面经历了相对的改善或恶化，这是考虑到数千万美国人从接受培训的医生那里接受护理的重要问题，这些医生是值班时间监管的主题。

DESCRIPTION (provided by applicant): Regulation of work hours for physicians in training was put in place by the Accreditation Council for Graduate Medical Education (ACGME) in 2003, long after similar regulations were implemented in trucking, aviation, and in other occupations where acute and chronic sleep deprivation raise significant concerns about safety. The impact of duty hour regulation has been controversial. While there is some evidence that this improved mortality outcomes in the short-term, little is known about the impact on educational outcomes, longer-term clinical outcomes, or the mechanisms creating inter-hospital differences in the effectiveness of duty hour reform in improving either clinical or educational outcomes. With assistance from the American Board of Surgery, the American Board of Internal Medicine, the National Board of Medical Examiners, the Association of Program Directors in Internal Medicine and Surgery, and the American College of Physicians, we propose to complete the following specific aims: 1. To describe the variety and frequency of program-level behavioral responses to duty hour reform and resident work conditions by conducting national surveys of program directors and residents in Internal Medicine (IM) and General Surgery (GS) informed by qualitative field work at a sample of IM and GS residency programs. 2. To assess how educational outcomes (board scores) have changed over time in conjunction with duty hour reform for residents in different specialties. 3. To examine how clinical outcomes (mortality, failure-to-rescue, probability of a prolonged length of stay, patient safety indicators) have changed over time beyond the first two years post-duty hour reform. 4. To examine the relationship between changes in educational and clinical outcomes and hospital financial performance, physician extender and nurse staffing levels, and program responses identified in the national survey of program directors. The proposed analysis will be the first to pull together national data on educational and clinical outcomes and will help us understand why duty hour regulation reform for physicians in training worked - or did not work - in terms of improving educational and clinical outcomes. This is an important policy question given that the physicians who are the subject of these reforms provide care to tens of millions of Americans each year. PUBLIC HEALTH RELEVANCE Regulation of duty hours for physicians in training in 2003 represented one of the most significant efforts ever undertaken to improve patient safety in American hospitals. It is largely unknown how these regulations affected patient outcomes, the quality of physician training, and how programs responded to improve or maintain patient outcomes and the quality of residency training. In this study, we will examine how residency programs and hospitals responded to the duty hour reform and how these behavioral responses determined which residency programs and hospitals experienced relative improvements or worsening in educational and clinical outcomes, important questions given that tens of millions of Americans receive care from the physicians in training who were the subject of the duty hour regulation.