Impact of resident work hour rules on errors and quality

描述（由申请人提供）：研究生医学教育认证委员会（ACGME）发布了2003年7月1日生效的规则，该规则影响了所有ACGME认证的所有专业住院医师项目的工作时间。这些规定代表了自2000年医学研究所出版《人孰能无过》以来，国家为减少医疗事故所做的最大努力，并将直接影响到美国教学医院44%的患者所接受的医疗保健。通过减少睡眠剥夺，这些规则可能会对患者的安全和护理质量产生有益的影响，但恶化的护理连续性可能会抵消其中的一些好处。本项目将评估值班时间规则对患者安全和护理质量的影响，利用通过医疗保险和包括AHRQ质量指标在内的预先验证的质量措施可获得的国家数据。该项目的主要目的是比较教学医院和非教学医院的死亡率和抢救失败率（并发症后死亡）的变化。研究的诊断将包括所有接受普通、骨科或血管手术的患者，以及急性心肌梗死、胃肠道出血或中风的医学诊断。次要目的是检查规则变更前后AHRQ患者安全指标（psi）的差异，并研究教学医院与非教学医院的住院时间（LOS）、延长住院时间的概率和有条件的住院时间（一旦延长住院时间）的变化情况。这项研究将基于1999-2003年（规则改变前）和2003-2005年（规则改变后）从医疗保险的MEDPAR数据集中收集的大约1600万例手术和医疗入院病例。我们将使用非教学医院的多时间序列设计作为教学医院的对照，并将根据医院对居民的依赖程度（居民/床位比例）、项目类型和规模以及医院的基线财务状况来检查效果的差异。这项研究将有助于发现这些结果的微小差异，并将能够明确地测试值班时间改革是否改善（或可能恶化）了患者的安全和护理质量。本研究的结果将为今后通过住院医师工作时间改革减少教学医院差错的工作提供重要依据。

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.