Is 80 the cost of saving lives? Reduced duty hours, errors, and cost.

As many JGIM readers are well aware, in July 2003 the Accreditation Council of Graduate Medical Education (ACGME) mandated that all residency training programs limit their residents' work week to 80 hours maximum, with no more than 30 hours of consecutive work, and 1 day off a week. Although some specialty's Residency Review Committees, Internal Medicine (JGIM) among them, had long required an “80 hours work week” for its trainees, the new mandate codified the 80 hours limit and enforced its application to 8,000 accredited programs, their more than 100,000 trainees, and by extension to the more than 16 million patients admitted to their care each year.1,2 In this edition of the Journal of General Internal Medicine, we have chosen to highlight an article that is one of the few papers to date which has explored the potential effects of resident duty hour reductions. The paper by Nuckols and Escarce3 in this issue of JGIM seeks to understand how the costs of adapting to the reduced hour work week might be offset by varying approaches to compensating for what, in essence, is a reduction in house staff availability of between 10% and 25%. In Nuckols' analysis, costs of adapting to work hours reductions are counterbalanced by lower rates of adverse events and cost savings in systems with fully rested caregivers.4 The author's main finding, that a potentially feasible amount of safety improvement may justify higher costs of adaptive responses to the reduction in work hours, is therefore based on sound logic and is defensible based on what is known about work hour reductions and how training programs are struggling to adapt. Is the connection between more rested residents and improved safety proven? A recent systematic review of the literature concluded that current evidence on patient safety was insufficient to inform the process of reducing resident duty hours.5 While the ACGME assumed that reducing duty hours would reduce fatigue and in turn reduce errors, the connection between better-rested trainees and error reduction is also poorly characterized. Some simulator studies have shown no difference in accuracy of procedures between sleep-deprived or rested physicians. Others suggest significant slowing or inefficiency in tasks for sleep-deprived residents.6 Although attentional failures, rolling eye movements caused by fatigue caught on electroencephalogram monitoring, and some preventable errors are higher when residents work greater than 24 hours, it is unknown if these reach the patient or influence outcomes.7,8 Nuckols' models suggest that a decrease in adverse events of 18.5% to 30.9% would be necessary (using the least expensive strategy of lower- and mid-level practitioners) in order for the reform to be cost-neutral for teaching hospitals. Although relative improvement in error rates between 18% and 30% have been noted with some interventions,9 the majority of quality improvement initiatives achieve only modest relative reductions. Absolute reductions in the 18% to 30% range have not been achieved even in the most effective strategies.10 What about costs? Nuckols appropriately chose to use estimates of costs for system change that were very conservative. For example, they assumed that reducing hours made other reform features possible at no additional cost, that reform did not affect length of stay or test ordering, that nonphysician substitutes for residents work at same speed, and that enforcement cost is negligible. Even under these conservative assumptions, the potential cost of adapting to the 80 hours work week is staggering—from $673 million to $1.1 billion annually nationwide. It appears likely that the actual costs of the 80 hours work week will be substantially higher. For example, one common organizational change to fulfill compliance is the development of an “uncovered” or a “nonteaching” service11 frequently staffed by attending physicians and mid-level practioners (N.P. and P.A.). Besides the cost of personnel, an uncovered service would incur short-term costs related to start-up (e.g., consultant costs, costs to redesign/renovate facilities for the uncovered service, as well as recruitment, hiring, and training costs), as well as ongoing costs related to managing an uncovered service. However, the fiscal and clinical implications of uncovered services or other adaptations to duty hour reductions are as yet unclear. Decreasing resident hours increases discontinuity of care by having additional cross-coverage models and handoffs that may in turn increase length of stay, the number of tests ordered, and in-hospital complications, all resulting in higher costs.12,13 Compliance monitoring is also costly. It is not uncommon to see faculty members with new titles such as “Duty Hours Director” both at the GME and Residency-level working with newly hired staff to ensure compliance. Residents may have to keep cards accounting for their time (minimal costs), use web sites such as http://www.80hours.com to maintain time sheets (moderate cost), or have more elaborate and costly systems which sense house staff IDs upon entering and leaving the hospital. Discontinuity, alluded to by Nuckols, is at the nexus of the challenges with the reduced hour mandates. Cross-coverage systems that allow residents to leave the hospital invariably increase the number of times a patient's information needs to be signed out. Each of these signouts provides an opportunity for a voltage drop in the information transferred, and subsequent potential for patient harm. Discontinuity does increase the chance of preventable adverse events,14 and was dealt with in the recent Harvard Work Hours, Health, and Safety Group through organizational efforts, a robust electronic signout system, and intensive training in signouts and team management. Importantly, this study focused on the self-contained environment of the intensive care unit, which generally has a limited number of teams and smaller number of signouts (albeit with complex information).8 Costs to support signout systems such as used in the Harvard study are uncharacterized elsewhere, but are also likely to be substantial. Computer signouts linked to hospital information systems can improve information transfer, but fewer than 5% of hospitals currently possess such a system, making it possible that short-term adaptations to residency work hours will increase errors until longer term technologic solutions can be put in place.15 Nuckols' results suggest that these 2 effects would make work hour reductions an even less favorable equation. There are other nonmonetary costs to the reduced duty hour mandates, costs not included in Nuckols' analysis but which are worth mention because they have been understudied and have potentially far-reaching effects. For the residents, the effect on education is still unknown. Are better-rested residents better learners, or is the push to leave the hospital within the allotted time impeding education? From a societal perspective, are we training physicians in a system that more accurately mirrors life after residency, or to be physicians where professionalism ends with the bell ringing the end of a shift. This is not to say that making all efforts to reduce sleep-related errors is an unworthy goal, but we await the emergence of a literature which describes the true effects of sleep deprivation and work-hour reduction on direct error rates, costs of care, and—most importantly—direct (rather than surrogate) patient outcomes. As the author points out, the timing of ACGME mandates was chosen to forestall governmental legislation. However, ACGME mandates are unfunded with noncompliance, leading to the loss of accreditation (and resultant loss of Medicare funding). Programs and teaching hospitals nationwide are making major structural, staffing, and information technology changes to come into compliance with these mandates at costs up to billions of dollars, but these costs are almost always borne by training programs, their hospitals, or medical school. Given the uncertain connection between work hour reductions and patient safety and the up-front and ongoing costs of compliance, supporting work hour reductions is an expensive fact of life for academic medical centers in the near-term. Over the long term, demonstrating the value of how hospitals adapt to work-hour reductions—whether technologic or organizational (e.g., uncovered services)—in terms of outcomes and safety will be the only counter to these costs. Which solutions will be most effective is unknown at this point, but it seems safe to say there are no silver bullets or single solutions to this extraordinarily complex question. The importance of improving patient safety while ensuring a well-trained resident workforce is clearly part of JGIM's core values. Duty hour reductions are in place and the period where its initial effects might be examined is passing, but equipoise for studies of work hours reduction adaptations could not be more acute. JGIM readers, with their focus on education, expertise in health services and outcomes research, and critical leadership roles in house staff training programs, are uniquely positioned to do the important work developing and evaluating new models of training,16JGIM welcomes the scholarly work that results from these investigations. The brave new world of residency is unfolding with many questions yet to be answered.