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The impact of resident duty hour reform on hospital readmission rates
Volpp KG, Silber J, Wang Y, Even-Shoshan O, Halenar M, Bellini L, Romano P, Zhu J, Press M, Rosen A, Itani K, Loveland S, Hanchate HD, Borzecki A. The impact of resident duty hour reform on hospital readmission rates. Paper presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 28; Minneapolis, MN.
Background: A key goal of resident duty hour reform by the Accreditation Council for Graduate Medical Education (ACGME) in 2003 was to improve patient outcomes. Prior research has demonstrated little to no impact of this reform on a variety of outcome measures. The effect on hospital readmission rates, which may have been particularly influenced by disruptions in continuity of care that resulted from the reform, is unknown. The objective of this study was to assess whether resident duty hour reform led to a relative improvement or worsening of readmission rates among Medicare patients in hospitals of different teaching intensity.
Methods: Observational study of all unique Medicare patients (n = 8,282,802) admitted to short-term acute-care nonfederal hospitals between July 1, 2000 and June 30, 2005 with principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, stroke or a DRG classification of general, orthopedic, or vascular surgery. We utilized difference-in-differences analysis and fixed effects logistic regression to examine the change in the odds of readmission in more versus less teaching-intensive hospitals before and after the duty hour reform, adjusting for patient comorbidities, age, sex, admission source, common time trends, and hospital. Primary outcomes were 30-day all-cause readmission, all-cause readmission or death within 30 days of discharge, and all-cause readmission or death within 30 days of admission.
Results: In medical and surgical patients, no significant relative increases or decreases in the odds of readmission were observed in more versus less teaching-intensive hospitals in either the first or second year following the reform. For the combined medical group, postreform year 1 odds ratio (OR) = 0.99, 95% confidence interval (0.94-1.03), and postreform year 2 OR = 0.99 (0.95-1.04). For the combined surgical group, postreform year 1 OR = 1.03 (0.98-1.08) and postreform year 2 OR = 1.02 (0.98-1.07). The findings for the other outcomes-readmission or death within 30 days of discharge and readmission or death within 30 days of admission-were qualitatively similar. Our results remained unchanged after the following stability analyses: excluding patients admitted to hospitals in New York State, expanding the inclusion criteria for index admissions, adjusting for patients discharged against medical advice, and removing the adjustments for comorbidity, hospital transfer, and nursing home admission source.
Conclusions: Teaching hospital readmission rates neither improved nor worsened in association with ACGME duty hour reform. These findings were robust to the use of composite measures of readmission and mortality and were insensitive to changes in patient selection and alterations in severity adjustment. Therefore, any potential adverse consequences of resident duty hour reform on continuity of care did not result in observable changes in readmission rates. This finding adds to the evidence that the reform in 2003 did not generally improve or worsen patient outcomes. More substantial duty hour limitations, as currently proposed, may have more beneficial or more deleterious effects on patient outcomes.