Morbidity, mortality, and health care costs for patients undergoing spine surgery following the ACGME resident duty-hour reform

Clinical article

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Object

The Accreditation Council for Graduate Medical Education (ACGME) implemented resident duty-hour restrictions on July 1, 2003, in concern for patient and resident safety. Whereas studies have shown that duty-hour restrictions have increased resident quality of life, there have been mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay (LOS), and charges in patients who underwent spine surgery.

Methods

The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, LOS, and charges by comparing the prereform (2000–2002) and postreform (2005–2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method.

Results

A total of 693,058 patients were included in the study. The overall complication rate was 8.6%, with patients in the postreform era having a significantly higher rate than those in the pre–duty-hour restriction era (8.7% vs 8.4%, p < 0.0001). Examination of hospital teaching status revealed complication rates to decrease in nonteaching hospitals (8.2% vs 7.6%, p < 0.0001) while increasing in teaching institutions (8.6% vs 9.6%, p < 0.0001) in the duty-hour reform era. The DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching institutions to had a significantly greater increase in complications during the postreform era (p = 0.0002). The overall mortality rate was 0.37%, with no significant difference between the pre– and post–duty-hour eras (0.39% vs 0.36%, p = 0.12). However, the mortality rate significantly decreased in nonteaching hospitals in the postreform era (0.30% vs 0.23%, p = 0.0008), while remaining the same in teaching institutions (0.46% vs 0.46%, p = 0.75). The DID analysis to compare the changes in mortality between groups revealed that the difference between the effects approached significance (p = 0.069). The mean LOS for all patients was 4.2 days, with hospital stay decreasing in nonteaching hospitals (3.7 vs 3.5 days, p < 0.0001) while significantly increasing in teaching institutions (4.7 vs 4.8 days, p < 0.0001). The DID analysis did not demonstrate the magnitude of change for each group to differ significantly (p = 0.26). Total patient charges were seen to rise significantly in the post–duty-hour reform era, increasing from $40,000 in the prereform era to $69,000 in the postreform era. The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.55).

Conclusions

The implementation of duty-hour restrictions was associated with an increased risk of postoperative complications for patients undergoing spine surgery. Therefore, contrary to its intended purpose, duty-hour reform may have resulted in worse patient outcomes. Additional studies are needed to evaluate strategies to mitigate these effects and assist in the development of future health care policy.

Abbreviations used in this paper:ACGME = Accreditation Council for Graduate Medical Education; CCI = Charlson Comorbidity Index; DID = difference-in-differences; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; LOS = length of stay; MI = myocardial infarction; NIS = Nationwide Inpatient Sample.

Object

The Accreditation Council for Graduate Medical Education (ACGME) implemented resident duty-hour restrictions on July 1, 2003, in concern for patient and resident safety. Whereas studies have shown that duty-hour restrictions have increased resident quality of life, there have been mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay (LOS), and charges in patients who underwent spine surgery.

Methods

The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, LOS, and charges by comparing the prereform (2000–2002) and postreform (2005–2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method.

Results

A total of 693,058 patients were included in the study. The overall complication rate was 8.6%, with patients in the postreform era having a significantly higher rate than those in the pre–duty-hour restriction era (8.7% vs 8.4%, p < 0.0001). Examination of hospital teaching status revealed complication rates to decrease in nonteaching hospitals (8.2% vs 7.6%, p < 0.0001) while increasing in teaching institutions (8.6% vs 9.6%, p < 0.0001) in the duty-hour reform era. The DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching institutions to had a significantly greater increase in complications during the postreform era (p = 0.0002). The overall mortality rate was 0.37%, with no significant difference between the pre– and post–duty-hour eras (0.39% vs 0.36%, p = 0.12). However, the mortality rate significantly decreased in nonteaching hospitals in the postreform era (0.30% vs 0.23%, p = 0.0008), while remaining the same in teaching institutions (0.46% vs 0.46%, p = 0.75). The DID analysis to compare the changes in mortality between groups revealed that the difference between the effects approached significance (p = 0.069). The mean LOS for all patients was 4.2 days, with hospital stay decreasing in nonteaching hospitals (3.7 vs 3.5 days, p < 0.0001) while significantly increasing in teaching institutions (4.7 vs 4.8 days, p < 0.0001). The DID analysis did not demonstrate the magnitude of change for each group to differ significantly (p = 0.26). Total patient charges were seen to rise significantly in the post–duty-hour reform era, increasing from $40,000 in the prereform era to $69,000 in the postreform era. The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.55).

Conclusions

The implementation of duty-hour restrictions was associated with an increased risk of postoperative complications for patients undergoing spine surgery. Therefore, contrary to its intended purpose, duty-hour reform may have resulted in worse patient outcomes. Additional studies are needed to evaluate strategies to mitigate these effects and assist in the development of future health care policy.

In concern for patient and resident safety, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions for resident physicians on July 1, 2003.1,2 These changes limited resident hours to 80 hours per week averaged over 4 weeks, with 1 in 7 days free of patient care duties.2 Other restrictions included a 24-hour limit on continuous duty in addition to 6 more hours for transfer of care and educational activities, a minimum of 10 hours of rest between duty periods, and in-hospital call no more frequently than every third night.

Many studies have shown that resident fatigue and sleep deprivation significantly affect cognitive functioning and clinical performance.3,14,21,26,33 Additionally, loss of sleep and extended work-hour shifts have been demonstrated to decrease resident quality of life and increase the risk of accidents such as motor vehicle crashes and percutaneous injuries.4–6,19,20,22 Whereas the implementation of duty-hour restrictions has increased resident quality of life, the effect on patient outcome is unclear.10,16,24,32 Although some studies have demonstrated an improvement in mortality and morbidity, many show either no change or significantly worse outcomes.7,9,11,12,15,27,34–36 As a result of work-hour restrictions, there has been an increase in the number of resident handoffs, disrupting the continuity of care and potentially increasing errors due to miscommunication.23,25 Additionally, there is increased concern for resident clinical experience due to the decrease in working hours.13,16,17

Spine surgery is one of the most common procedures performed and accounts for a significant percentage of health care expenditures in the US. We have therefore evaluated the effect of duty-hour restrictions on morbidity and mortality rates in patients undergoing spinal procedures. Additionally, whereas studies have primarily evaluated patient outcomes, we have also examined the effect of work-hour restrictions on patient length of stay (LOS) and health care costs, because it is imperative that policy be guided not only by patient outcomes but also by its impact on the health care system.

Methods

Study Source and Sample

Patient-related characteristics, hospital details, and the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure and diagnosis codes were obtained from the Nationwide Inpatient Sample (NIS) database. Patients with a range of spinal diseases were selected using ICD-9-CM codes (n = 693,058). Table 1 lists the ICD-9-CM procedures and diagnosis codes used. Spine patients were defined as those who underwent removal of a foreign body, reopening of laminectomy site, exploration and decompression of the spinal canal, excision of a lesion of the spinal cord or meninges, repair of meningocele or myelomeningocele, repair of a vertebral fracture, insertion or removal/revision of a spinal shunt, implantation or replacement of spinal neurostimulator leads, spinal fusion or refusion, insertion/removal of artificial spinal disc prosthesis, and insertion/removal of interspinous, pedicle-based stabilization, or facet replacement devices.

TABLE 1:

The ICD-9-CM diagnosis and procedure codes used for this study*

ICD-9-CM CodeDescription
procedure
 03.01removal of foreign body from spinal canal
 03.02reopening of laminectomy site
 03.09exploration and decompression of spinal canal
 03.4excision or destruction of lesion of spinal cord or spinal meninges
 03.51excision or destruction of lesion of spinal cord or spinal meninges
 03.52repair of spinal myelomeningocele
 03.53repair of vertebral fracture
 03.71, 03.72, 03.79spinal shunt
 03.93, 03.94implantation or replacement of spinal neurostimulator leads
 03.97, 03.98revision/removal of spinal shunt
 81.00–.08spinal fusion
 81.30–.39refusion of spine
 81.62–.64fusion of vertebrae
 84.59–.69insertion/removal of artificial spinal disc prosthesis
 84.80–.85insertion/removal of interspinous device, pedicle-based stabilization device, or facet replacement device
complication diagnosis
 998.2, E870.0accidental puncture or laceration
 998.1, 998.11–.13hematoma (intraoperative or postoperative)
 997.0, 997.00, 997.01, 997.09medical care or postoperative nervous system complications
 997.3postoperative respiratory complications
 998.4foreign body inadvertently left in wound
 999.9therapeutic misadventure, NEC
 998.9therapeutic misadventure, surgical treatment
 977.9wrong substance given or taken in error
 997.1, 410.0–.9, 998.0cardiac complications, acute myocardial infarction
 415.1respiratory complications, pulmonary embolism
 997.2peripheral vascular complications
 998.3, 998.31, 998.32, 998.83complication of operative wound
 998.5, 999.3, 998.51, 998.59postoperative infection
 998.8, 998.89other specified complications
 349.0, 998.6cerebrospinal fluid leak
 954.0injury to cervical sympathetic nerves
 787.2dysphagia
 478.30–.34, 784.4hoarseness due to paralysis of vocal cords
 900.00–.03, 900.82, 900.89, 900.9, 997.02carotid or vertebral injury
 E878.8, E878.9other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation

NEC = not elsewhere classified.

Select years were chosen to evaluate the restriction of resident work hours implemented nationally in July 2003. Patients admitted between January 1, 2000, and December 31, 2002, were chosen to represent the pre–duty-hour restriction population. Post–duty-hour restriction included admissions from January 1, 2005, to December 31, 2008. The years 2003 and 2004 were excluded because this is believed to be a transitional period for the implementation of work-hour restrictions.

Analysis of Covariates

The multivariate analyses accounted for both patient and hospital covariates. Patient variables included age at admission, sex, primary payer status, patient median income, and Charlson Comorbidity Index (CCI), a measure of the burden of comorbidities. Hospital variables included hospital bed size, hospital location and region, continuous hospital discharges, and hospital teaching status.

Main Outcome Measures

The primary outcomes in this study were perioperative mortality and complications. Complications included an accidental puncture or laceration, intra- or postoperative hematoma, medical care or postoperative nervous system complication, postoperative respiratory complications such as pulmonary embolism, cardiac complications such as acute myocardial infarction (MI), a foreign body inadvertently left in the wound, misadministration of medication, peripheral vascular complications, complications of the operative wound, postoperative infection, CSF leak, carotid or vertebral injury, and/or injury to cranial or sympathetic nerves (Table 1). We also examined the LOS and inpatient costs inflated to 2009 dollars with the Consumer Price Index. All outcome measures were compared between patients in the pre– and post–duty-hour restriction eras to evaluate the impact of work-hour restrictions on patient outcome.

Statistical Analysis

The policy change to restrict resident work hours can be modeled with a quasi-experimental method, often referred to as the difference-in-differences (DID) method. The method compares the differences in outcomes before and after an intervention in 2 groups. One group acts as a control and is assumed to be unaffected by the intervention. The primary analysis for this study tested the association of time period (before and after duty-hour restrictions) with 4 different outcomes, using nonteaching hospitals as a control. This was performed for all outcomes to evaluate the differences in risk change between nonteaching and teaching hospitals.

A generalized linear mixed-effects model was constructed for each of the 4 outcomes: mortality, binary complications, LOS in days, and continuous patient charges. Mortality and complications used a logit link function, LOS used a Poisson link, and patient charges used a lognormal link to adjust for the structure and distribution of the outcomes. Each model included continuous age at admission, hospital discharges, and time of admission in years and months. Categorical covariates included sex, CCI, primary payer status, patient median income, hospital bed size, hospital location, hospital region, hospital teaching status, and a time period indicator for pre– and post–work-hour restrictions. To adjust for the correlation between patients from the same hospital, a random intercept was included in all models. Finally, an interaction between teaching status and time period was included. These models therefore account for trends in patient and hospital characteristics that may affect outcomes. The DID analysis recognizes these trends and tests if they differ between treatment and control groups, thereby controlling changes in outcomes due to hidden covariates.

This method accounts for improvements in the standard of care and natural rises in health care cost by assuming a common linear trend across time. Models were constructed with the SAS GLIMMIX procedure, version 9.3. Reported p values were calculated from a t-test for continuous variables and Pearson chi-square test for categorical variables. All analyses were conducted using SAS 9.3 (SAS Institute).

Results

Patient Cohorts

A total of 693,058 patients met the inclusion criteria and were included in the analysis, consisting of 258,844 patients (37.3%) from the pre–duty-hour restriction era and 434,214 (62.7%) from the duty-hour restriction era (Table 2). Patients treated at nonteaching hospitals included 115,207 (37.5%) in the pre–duty-hour restriction era and 191,695 (62.5%) in the reform era (Table 3). The teaching institution cohort consisted of 385,958 patients (pre–duty-hour restrictions: 143,482; post–duty-hour restrictions: 242,476) (Table 4).

TABLE 2:

Characteristics and outcomes of all patients with spine surgery, stratified by time period*

CharacteristicPrereform; 2000–2002Postreform; 2005–2008Test Statisticp Value
total no.258,844 (100.0)434,214 (100.0)
age in yrs at admission−32.79<0.0001
 mean ± SD53.1 ± 16.8554.5 ± 16.52
 median (IQR)52.0 (42.0–66.0)55.0 (44.0–67.0)
no. female133,224 (51.47)227,053 (52.29)60.51<0.0001
CCI4,774.06<0.0001
 0193,514 (74.76)290,667 (66.94)
 147,292 (18.27)99,186 (22.84)
 213,625 (5.26)30,992 (7.14)
 ≥34,413 (1.70)13,369 (3.08)
bed size254.71<0.0001
 small28,196 (10.90)57,611 (13.27)
 medium59,837 (23.13)91,979 (21.18)
 large170,656 (65.97)284,581 (65.55)
hospital location1,086.52<0.0001
 rural14,831 (5.73)17,405 (4.01)
 urban243,858 (94.27)416,766 (95.99)
hospital region143.27<0.0001
 Northeast40,169 (15.52)67,208 (15.48)
 Midwest57,216 (22.10)103,510 (23.84)
 South105,425 (40.73)174,896 (40.28)
 West56,034 (21.65)88,600 (20.40)
total discharges in 100s−65.96<0.0001
 mean ± SD212.1 ± 128.39234.8 ± 170.72
 median (IQR)192.6 (115.4–279.8)208.1 (119.0–295.7)
primary payer2,187.95<0.0001
 Medicare75,812 (29.34)141,882 (32.77)
 Medicaid12,922 (5.00)24,997 (5.77)
 private insurance130,494 (50.50)213,904 (49.40)
 self-pay3,596 (1.39)7,047 (1.63)
 no charge285 (0.11)815 (0.19)
 other35,301 (13.66)44,320 (10.24)
median income58,995.74<0.0001
 low9,487 (3.75)94,335 (22.25)
 low to middle53,925 (21.30)111,654 (26.34)
 middle to high68,306 (26.98)113,136 (26.69)
 high121,414 (47.96)104,821 (24.73)
died in hospital997 (0.39)1,574 (0.36)2.350.1249
total w/ complications21,757 (8.41)37,900 (8.73)21.50<0.0001
complication count2.900.0888
 0237,087 (91.59)396,314 (91.27)
 117,635 (6.81)32,736 (7.54)
 23,457 (1.34)4,353 (1.00)
 ≥3665 (0.26)811 (0.19)
LOS in days14.05<0.0001
 mean ± SD4.3 ± 6.234.2 ± 6.65
 median (IQR)3.0 (2.0–5.0)3.0 (1.0–5.0)
adjusted charges in $1000s−173.83<0.0001
 mean ± SD40.0 ± 46.4569.0 ± 72.35
 median (IQR)27.4 (16.6–47.4)49.5 (27.7–85.2)

Unless otherwise indicated, the values are expressed as number of cases, with percentages in parentheses, throughout the tables. Not all information was available in all cases, so the denominators vary. IQR = interquartile range.

TABLE 3:

Characteristics and outcomes of patients with spine surgery at nonteaching hospitals, stratified by time period

CharacteristicPrereform; 2000–2002Postreform; 2005–2008Test Statisticp Value
total no.115,207 (100.0)191,695 (100.0)
age in yrs at admission−32.79<0.0001
 mean ± SD54.6 ± 15.6856.1 ± 15.06
 median (IQR)53.0 (43.0–67.0)56.0 (46.0–67.0)
no. female59,397 (51.56)100,911 (52.64)44.12<0.0001
CCI2,062.96<0.0001
 086,232 (74.85)128,315 (66.94)
 121,331 (18.52)45,018 (23.48)
 25,783 (5.02)13,004 (6.78)
 ≥31,861 (1.62)5,358 (2.80)
bed size2,173.56<0.0001
 small6,658 (5.78)24,136 (12.59)
 medium26,382 (22.90)39,976 (20.85)
 large82,167 (71.32)127,583 (66.56)
hospital location888.78<0.0001
 rural11,571 (10.04)13,426 (7.00)
 urban103,636 (89.96)178,269 (93.00)
hospital region0.610.4362
 Northeast11,758 (10.21)18,584 (9.69)
 Midwest18,504 (16.06)32,431 (16.92)
 South55,350 (48.04)92,254 (48.13)
 West29,595 (25.69)48,426 (25.26)
total discharges in 100s−65.96<0.0001
 mean ± SD150.4 ± 80.90153.3 ± 95.27
 median (IQR)143.1 (89.8–202.2)139.1 (78.6–214.2)
primary payer995.58<0.0001
 Medicare36,455 (31.70)67,551 (35.38)
 Medicaid4,436 (3.86)7,588 (3.97)
 private insurance55,016 (47.84)91,127 (47.72)
 self-pay1,381 (1.20)2,322 (1.22)
 no charge109 (0.09)220 (0.12)
 other17,605 (15.31)22,134 (11.59)
median income28,126.56<0.0001
 low3,783 (3.35)44,641 (23.87)
 low to middle26,944 (23.87)51,484 (27.53)
 middle to high31,588 (27.99)49,542 (26.50)
 high50,545 (44.79)41,316 (22.10)
died in hospital343 (0.30)450 (0.23)11.220.0008
total w/ complications9,425 (8.18)14,554 (7.59)34.62<0.0001
complication count191,695119.01<0.0001
 0105,782 (91.82)177,141 (92.41)
 17,592 (6.59)12,779 (6.67)
 21,532 (1.33)1,506 (0.79)
 ≥3301 (0.26)269 (0.14)
LOS14.05<0.0001
 mean ± SD3.7 ± 4.783.5 ± 4.74
 median (IQR)3.0 (1.0–4.0)2.0 (1.0–4.0)
adjusted charges in $1000s−173.83<0.0001
 mean ± SD38.1 ± 41.6365.3 ± 63.34
 median (IQR)26.4 (16.1–45.7)48.1 (26.9–82.3)
TABLE 4:

Characteristics and outcomes of patients with spine surgery at teaching hospitals, stratified by time period

CharacteristicPrereform; 2000–2002Postreform; 2005–2008Test Statisticp Value
total no.143,482 (100.0)242,476 (100.0)
age in yrs at admission−32.79<0.0001
 mean ± SD51.8 ± 17.6553.2 ± 17.49
 median (IQR)52.0 (41.0–65.0)54.0 (43.0–66.0)
no. female73,752 (51.40)126,120 (52.01)20.21<0.0001
CCI2,703.50<0.0001
 0107,160 (74.69)162,326 (66.95)
 125,941 (18.08)54,159 (22.34)
 27,832 (5.46)17,984 (7.42)
 ≥32,549 (1.78)8,007 (3.30)
bed size308.74<0.0001
 small21,538 (15.01)33,475 (13.81)
 medium33,455 (23.32)52,003 (21.45)
 large88,489 (61.67)156,998 (64.75)
hospital location195.06<0.0001
 rural3,260 (2.27)3,979 (1.64)
 urban140,222 (97.73)238,497 (98.36)
hospital region199.90<0.0001
 Northeast28,411 (19.80)48,624 (20.05)
 Midwest38,712 (26.98)71,078 (29.31)
 South49,920 (34.79)82,600 (34.07)
 West26,439 (18.43)40,174 (16.57)
total discharges in 100s−65.96<0.0001
 mean ± SD261.8 ± 137.62299.3 ± 188.72
 median (IQR)242.8 (164.7–342.2)259.9 (187.0–359.0)
primary payer1,191.44<0.0001
 Medicare39,306 (27.44)74,305 (30.71)
 Medicaid8,478 (5.92)17,408 (7.19)
 private insurance75,419 (52.65)122,770 (50.74)
 self-pay2,207 (1.54)4,725 (1.95)
 no charge176 (0.12)595 (0.25)
 other17,671 (12.34)22,177 (9.16)
median income31,217.46<0.0001
 low5,704 (4.07)49,654 (20.96)
 low to middle26,892 (19.19)60,168 (25.40)
 middle to high36,663 (26.16)63,593 (26.84)
 high70,869 (50.57)63,505 (26.80)
died in hospital654 (0.46)1,124 (0.46)0.100.7479
total w/ complications12,325 (8.59)23,343 (9.63)115.57<0.0001
complication count43.38<0.0001
 0131,157 (91.41)219,133 (90.37)
 110,037 (7.00)19,954 (8.23)
 21,924 (1.34)2,847 (1.17)
 ≥3364 (0.25)542 (0.22)
LOS14.05<0.0001
 mean ± SD4.7 ± 7.154.8 ± 7.79
 median (IQR)3.0 (2.0–5.0)3.0 (2.0–5.0)
adjusted charges in $1000s−173.83<0.0001
 mean ± SD41.6 ± 49.9671.9 ± 78.71
 median (IQR)28.2 (17.0–48.8)50.6 (28.3–87.5)

Complication Rates

The overall complication rate in all patients was 8.6%, with those in the postreform era having a significantly higher rate than those in the pre–duty-hour restriction era (8.7% vs 8.4%, p < 0.0001) (Table 2). Most cases with complications involved a single complication, with only 1.1% and 0.21% of patients having 2 and ≥ 3 complications. Examination of hospital teaching status revealed differences, with overall complication rates decreasing in nonteaching hospitals (8.2% vs 7.6%, p < 0.0001) while increasing in teaching institutions (8.6% vs 9.6%, p < 0.0001) in the duty-hour reform era (Tables 3 and 4).

The most common complications were accidental punctures or lacerations (2.4%), intraoperative or postoperative hematomas (1.3%), and postoperative nervous system complications (1.2%) (Table 5). Examination of patients admitted at nonteaching hospitals did not reveal an increase in any complications, with the incidence of 4 of the complications significantly decreasing in the postreform era (Table 6). However, in teaching institutions the incidence of 10 different complications significantly increased in the postreform era, with only 2 complications decreasing in incidence (postoperative respiratory and other specified complications) (Table 7).

TABLE 5:

Complication types in all patients with spine surgery, stratified by time period

ComplicationPrereform; 2000–2002Postreform; 2005–2008Test Statisticp Value
total21,757 (8.41)37,900 (8.73)21.50<0.0001
complication count3.390.0007
 mean ± SD0.1 ± 0.370.1 ± 0.35
accidental puncture or laceration5,712 (2.21)11,101 (2.56)83.85<0.0001
intraop or postop hematoma3,202 (1.24)6,133 (1.41)37.55<0.0001
medical care or postop nervous system2,818 (1.09)5,512 (1.27)44.61<0.0001
postop respiratory2,807 (1.08)3,439 (0.79)155.28<0.0001
foreign body inadvertently left in wound69 (0.03)100 (0.02)0.880.3496
therapeutic misadventure, NEC53 (0.02)192 (0.04)25.87<0.0001
therapeutic misadventure, surgical treatment22 (0.01)24 (0.01)2.160.1418
cardiac &/or acute MI1,766 (0.68)3,168 (0.73)5.140.0234
peripheral vascular172 (0.07)329 (0.08)1.950.1626
operative wound686 (0.27)1,418 (0.33)20.29<0.0001
postop infection2,164 (0.84)3,718 (0.86)0.790.3744
other specified3,047 (1.18)4,020 (0.93)101.51<0.0001
CSF leak563 (0.22)861 (0.20)2.920.0875
carotid or vertebral injury260 (0.10)510 (0.12)4.230.0398
injury to cervical sympathetic nerves5 (0.00)4 (0.00)1.280.2588
hoarseness due to vocal cord paralysis162 (0.06)370 (0.09)10.820.0010
dysphagia1,451 (0.56)2,723 (0.63)11.990.0005
TABLE 6:

Complication types in patients with spine surgery at nonteaching hospitals, stratified by time period

ComplicationPrereform; 2000–2000Postreform; 2005–2008Test Statisticp Value
total9,425 (8.18)14,554 (7.59)34.62<0.0001
complication count3.390.0007
 mean ± SD0.1 ± 0.370.1 ± 0.32
accidental puncture or laceration2,607 (2.26)4,515 (2.36)2.710.0996
intraop or postop hematoma1,427 (1.24)2,460 (1.28)1.150.2841
medical care or postop nervous system1,023 (0.89)1,723 (0.90)0.100.7571
postop respiratory1,240 (1.08)1,426 (0.74)92.35<0.0001
foreign body inadvertently left in wound32 (0.03)35 (0.02)2.990.0840
therapeutic misadventure, NEC24 (0.02)35 (0.02)0.250.6185
therapeutic misadventure, surgical treatment12 (0.01)10 (0.01)2.710.0995
cardiac &/or acute MI757 (0.66)1,109 (0.58)7.350.0067
peripheral vascular72 (0.06)108 (0.06)0.470.4951
operative wound234 (0.20)412 (0.21)0.480.4893
postop infection789 (0.68)1,273 (0.66)0.470.4950
other specified1,516 (1.32)1,706 (0.89)125.67<0.0001
CSF leak256 (0.22)353 (0.18)5.260.0218
carotid or vertebral injury91 (0.08)134 (0.07)0.810.3679
injury to cervical sympathetic nerves2 (0.00)1 (0.00)1.090.2975
hoarseness due to vocal cord paralysis43 (0.04)85 (0.04)0.850.3566
dysphagia637 (0.55)1,103 (0.58)0.640.4220
TABLE 7:

Complication types in patients with spine surgery at teaching hospitals, stratified by time period

ComplicationPrereform; 2000–2002Postreform; 2005–2008Test Statisticp Value
total12,325 (8.59)23,343 (9.63)115.57<0.0001
complication count3.390.0007
 mean ± SD0.1 ± 0.370.1 ± 0.37
accidental puncture or laceration3,102 (2.16)6,585 (2.72)112.98<0.0001
intraop or postop hematoma1,774 (1.24)3,673 (1.51)50.21<0.0001
medical care or postop nervous system1,792 (1.25)3,788 (1.56)62.09<0.0001
postop respiratory1,567 (1.09)2,013 (0.83)67.30<0.0001
foreign body inadvertently left in wound37 (0.03)65 (0.03)0.040.8506
therapeutic misadventure, NEC29 (0.02)157 (0.06)37.12<0.0001
therapeutic misadventure, surgical treatment10 (0.01)14 (0.01)0.210.6489
cardiac &/or acute MI1,009 (0.70)2,058 (0.85)24.21<0.0001
peripheral vascular100 (0.07)221 (0.09)4.990.0255
operative wound452 (0.32)1,006 (0.41)23.89<0.0001
postop infection1,375 (0.96)2,445 (1.01)2.300.1291
other specified1,531 (1.07)2,314 (0.95)11.610.0007
CSF leak307 (0.21)508 (0.21)0.090.7706
carotid or vertebral injury169 (0.12)376 (0.16)8.890.0029
injury to cervical sympathetic nerves3 (0.00)3 (0.00)0.420.5157
hoarseness due to vocal cord paralysis119 (0.08)285 (0.12)10.320.0013
dysphagia814 (0.57)1,620 (0.67)14.610.0001

Multivariate logistic regression of complications revealed that year of admission, age, CCI, primary payer, hospital location and region, number of hospital discharges, median income, and time period significantly impacted the likelihood of postoperative complications (Table 8). However, overall teaching status did not affect the likelihood of complications (p = 0.15). The analysis of the time period effect given teaching status revealed a significantly higher complication risk in teaching (OR 1.47; 95% CI 1.33–1.62; p < 0.0001) and nonteaching (OR 1.23; 95% CI 1.11–1.36; p < 0.0001) hospitals (Table 9). The DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching institutions had a significantly greater increase in complications during the postreform era than did nonteaching hospitals (p = 0.0002).

TABLE 8:

Multivariate logistic regression of complications for all patients with spine surgery

VariableTest Statistic (p value)OR (95% CI)
time in 1-yr increments65.1 (<0.0001)0.94 (0.92–0.95)
age in 10-yr increments128.6 (<0.0001)1.08 (1.06–1.09)
sex
 female1.3 (0.2478)reference
 male0.99 (0.97–1.01)
CCI
 0447.9 (<0.0001)reference
 11.17 (1.14–1.20)
 21.38 (1.33–1.43)
 ≥31.54 (1.45–1.63)
primary payer
 Medicare303.5 (<0.0001)reference
 Medicaid1.00 (0.95–1.06)
 private insurance0.79 (0.76–0.81)
 self-pay0.81 (0.74–0.88)
 no charge0.96 (0.72–1.27)
 other0.78 (0.74–0.81)
bed size
 small1.4 (0.4971)reference
 medium0.96 (0.87–1.07)
 large1.01 (0.90–1.13)
hospital location
 rural4.6 (0.0317)reference
 urban0.88 (0.79–0.99)
hospital region
 Northeast34.6 (<0.0001)reference
 Midwest0.99 (0.91–1.08)
 South0.90 (0.83–0.98)
 West1.15 (1.05–1.25)
hospital discharges in 100s4.3 (0.0387)1.00 (1.00–1.00)
median income
 low10.3 (0.0162)reference
 low to middle0.99 (0.96–1.03)
 middle to high1.00 (0.97–1.04)
 high0.96 (0.93–1.00)
teaching status
 nonteaching2.0 (0.1539)reference
 teaching0.97 (0.88–1.07)
time period
 prereform; 2000–200241.6 (<0.0001)reference
 postreform; 2005–20081.23 (1.11–1.36)
TABLE 9:

Effect of time period on complications, mortality, LOS, and patient charges

VariableOR or RR (95% CI)*p Value
complications
 time period effect given teaching1.47 (1.33–1.62)<0.0001
 time period effect given nonteaching1.23 (1.11–1.36)<0.0001
 interaction btwn time period & teaching status0.0002
mortality
 time period effect given teaching0.86 (0.65–1.14)0.3021
 time period effect given nonteaching0.72 (0.53–0.97)0.0330
 interaction btwn time period & teaching status0.0692
LOS
 time period effect given teaching0.99 (0.94–1.04)0.5707
 time period effect given nonteaching0.96 (0.92–1.01)0.0890
 interaction btwn time period & teaching status0.2622
patient charges
 time period effect given teaching1.07 (1.01–1.13)0.0281
 time period effect given nonteaching1.05 (0.99–1.11)0.1317
 interaction btwn time period & teaching status0.5531

For complications and mortality the first value denotes the odds ratio; for LOS and charges the first value denotes the relative risk.

Mortality Rate

The overall mortality rate was 0.37%, with no significant difference between the pre– and post–duty-hour restriction eras (0.39% vs 0.36%, p = 0.12) (Table 2). However, the mortality rate significantly decreased in nonteaching hospitals in the postreform era (0.30% vs 0.23%, p = 0.0008) while remaining the same in teaching institutions (0.46% vs 0.46%, p = 0.75) (Tables 3 and 4).

Multivariate logistic regression of mortality revealed that age, sex, CCI, primary payer type, hospital size and location, and teaching status were significant predictors of mortality (Table 10). Treatment in the postreform era did not affect the mortality risk (OR 0.81; 95% CI 0.61–1.06; p = 0.13). Evaluation of t he effect of duty-hour restrictions on nonteaching institutions revealed a significant decrease in mortality risk (OR 0.72; 95% CI 0.53–0.97; p = 0.033) (Table 9). However, this time period effect in teaching institutions did not result in a significant change in mortality risk (OR 0.86; 95% CI 0.65–1.14; p = 0.30). The DID analysis revealed that the difference between the effects approached significance (p = 0.069).

TABLE 10:

Multivariate logistic regression for mortality in all patients with spine surgery

VariableTest Statistic (p value)OR (95% CI)
time in 1-yr increments1.1 (0.2931)0.98 (0.93–1.02)
age in 10-yr increments185.7 (<0.0001)1.45 (1.38–1.53)
sex
 female164.1 (<0.0001)reference
 male1.76 (1.61–1.91)
CCI
 0990.1 (<0.0001)reference
 11.81 (1.61–2.04)
 23.94 (3.45–4.50)
 ≥37.99 (6.97–9.16)
primary payer
 Medicare200.0 (<0.0001)reference
 Medicaid2.33 (1.95–2.78)
 private insurance0.86 (0.75–0.98)
 self-pay2.61 (1.96–3.46)
 no charge0.52 (0.07–3.90)
 other0.53 (0.41–0.69)
bed size
 small40.0 (<0.0001)reference
 medium1.63 (1.27–2.08)
 large2.25 (1.73–2.92)
hospital location
 rural13.6 (0.0002)reference
 urban1.66 (1.27–2.17)
hospital region
 Northeast34.5 (<0.0001)reference
 Midwest0.59 (0.49–0.70)
 South0.78 (0.65–0.93)
 West0.76 (0.63–0.92)
hospital discharges in 100s0.1 (0.7499)1.00 (1.00–1.00)
median income
 low5.5 (0.1362)reference
 low to middle0.90 (0.80–1.03)
 middle to high0.91 (0.80–1.04)
 high0.84 (0.72–0.97)
teaching status
 nonteaching61.5 (<0.0001)reference
 teaching1.79 (1.55–2.07)
time period
 prereform; 2000–20022.3 (0.1294)reference
 postreform; 2005–20080.81 (0.61–1.06)

Length of Stay

The mean LOS for all patients was 4.2 days, with hospital stay decreasing in the postreform era (4.3 vs 4.2 days, p < 0.0001) (Table 2). Stratification by teaching status revealed that hospital stay only decreased in nonteaching hospitals (3.7 vs 3.5 days, p < 0.0001), while significantly increasing in teaching institutions (4.7 vs 4.8 days, p < 0.0001) (Tables 3 and 4).

Multivariate Poisson regression revealed that year of admission, age, primary payer type, CCI, hospital region, median income, and complication count significantly affected LOS (Table 11). Teaching status and treatment in the postreform era did not affect hospital stay. Analysis of the interaction of time period with nonteaching status revealed a decrease in LOS (RR 0.96; 95% CI 0.92–1.01; p = 0.089), although this only approached significance, whereas no significant change was seen in teaching institutions (RR 0.99; 95% CI 0.94–1.04; p = 0.57) (Table 9). The DID analysis did not demonstrate that the difference in the magnitude of change for each group differed significantly (p = 0.26).

TABLE 11:

Multivariate Poisson regression of LOS for all patients with spine surgery

VariableTest Statistic (p value)RR (95% CI)
time in 1-yr increments4.8 (0.0291)0.99 (0.99–1.00)
age in 10-yr increments23.6 (<0.0001)0.98 (0.98–0.99)
sex
 female3.6 (0.0568)reference
 male1.01 (1.00–1.03)
primary payer
 Medicare873.3 (<0.0001)reference
 Medicaid1.28 (1.23–1.33)
 private insurance0.82 (0.81–0.84)
 self-pay1.30 (1.20–1.41)
 no charge1.03 (0.75–1.42)
 other0.83 (0.81–0.85)
CCI
 02,695.0 (<0.0001)reference
 11.13 (1.12–1.15)
 21.54 (1.51–1.57)
 ≥32.07 (2.01–2.13)
bed size
 small3.0 (0.2245)reference
 medium1.00 (0.93–1.07)
 large1.05 (0.96–1.15)
hospital location
 rural0.7 (0.3935)reference
 urban0.97 (0.90–1.04)
hospital region
 Northeast24.8 (<0.0001)reference
 Midwest0.90 (0.84–0.95)
 South0.91 (0.85–0.97)
 West1.00 (0.94–1.06)
hospital discharges in 100s0.0 (0.9805)1.00 (1.00–1.00)
median income
 low51.8 (<0.0001)reference
 low to middle0.96 (0.95–0.98)
 middle to high0.95 (0.93–0.97)
 high0.94 (0.92–0.95)
complication count6,757.5 (<0.0001)1.65 (1.63–1.67)
teaching status
 nonteaching1.4 (0.2413)reference
 teaching1.04 (0.98–1.10)
time period
 prereform; 2000–20021.2 (0.2672)reference
 postreform; 2005–20080.98 (0.93–1.02)

Health Care Cost

Total patient charges were seen to rise significantly in the post–duty-hour reform era, increasing from $40,000 in the prereform era to $69,000 in the postreform era (Table 2). This effect occurred in both nonteaching and teaching hospitals (Tables 3 and 4). Multivariate log linear regression revealed that year of diagnosis, age, sex, primary payer type, CCI, hospital region, median income, complication count, and time period significantly affected patient charges (Table 12). Teaching status did not affect charges (β 1.01; 95% CI 0.96–1.08; p = 0.64).

TABLE 12:

Multivariate log-linear regression of adjusted patient charges for all patients with spine surgery

VariableTest Statistic (p value)Exp b (95% CI)
time in 1-yr increments328.8 (<0.0001)1.09 (1.08–1.10)
age in 10-yr increments583.4 (<0.0001)0.95 (0.95–0.95)
sex
 female105.0 (<0.0001)reference
 male0.97 (0.96–0.97)
primary payer
 Medicare241.0 (<0.0001)reference
 Medicaid1.09 (1.07–1.11)
 private insurance0.99 (0.97–1.01)
 self-pay1.12 (1.08–1.18)
 no charge0.95 (0.81–1.10)
 other1.04 (1.03–1.06)
CCI
 01,577.9 (<0.0001)reference
 11.07 (1.06–1.07)
 21.23 (1.21–1.24)
 ≥31.46 (1.43–1.49)
bed size
 small1.1 (0.5781)reference
 medium1.02 (0.97–1.08)
 large1.04 (0.96–1.13)
hospital location
 rural0.6 (0.4311)reference
 urban1.04 (0.95–1.14)
hospital region
 Northeast190.6 (<0.0001)reference
 Midwest1.05 (0.98–1.13)
 South1.08 (1.00–1.16)
 West1.63 (1.50–1.77)
hospital discharges in 100s3.5 (0.0622)1.00 (1.00–1.00)
median income
 low50.9 (<0.0001)reference
 low to middle0.99 (0.98–1.00)
 middle to high0.99 (0.98–1.00)
 high0.97 (0.96–0.98)
complications in 1-unit increments2,484.2 (<0.0001)1.36 (1.35–1.38)
teaching status
 nonteaching0.2 (0.6351)reference
 teaching1.01 (0.96–1.08)
time period
 prereform; 2000–20024.8 (0.0290)reference
 postreform; 2005–20081.06 (1.01–1.11)

Work-hour reform was not seen to affect patient hospital charges significantly in nonteaching hospitals (RR 1.05; 95% CI 0.99–1.11; p = 0.13) (Table 9). However, treatment in the postreform era in teaching institutions was associated with significantly higher patient charges (RR 1.07; 95% CI 1.01–1.13; p = 0.028). However, DID analysis did not demonstrate this difference to be significant (p = 0.55).

Trends in Surgical Complexity

To evaluate the trends in case complexity before and after duty-hour reform, the number of fusions and refusions performed at nonteaching and teaching hospitals was examined. In the prereform era, the average nonteaching hospital performed 47 fusions/refusions per year. In the postreform era, nonteaching hospitals performed an average of 55.5 such procedures, representing an 18.1% increase. Teaching institutions performed 274.6 fusions/refusions per year prior to duty-hour reform, with this increasing to 329.3 cases per year following reform. This represented a 19.9% increase.

Discussion

The implementation of duty-hour restrictions by the ACGME has been highly controversial, with many arguing that such changes have not only led to similar outcomes but may even adversely affect patient safety.8,28 This large study evaluating nearly 700,000 patients who underwent spine surgery has demonstrated that duty-hour reform results in increased complications. Although mortality rates, LOS, and patient charges also increased in teaching institutions in the postreform era, this difference was not found to be significant.

The effects of work-hour restrictions on patient outcome have been shown to be affected by patient population. Whereas an analysis of mortality rates among Medicare patients demonstrated similar outcomes in the pre– and post–duty-hour restriction eras, a similar analysis of patients in the Veterans Affairs health care system showed significantly decreased odds of mortality for medical patients but no risk reduction for surgical patients.34,35 Similarly, a study using the NIS database demonstrated significant improvements in mortality rates for medical patients but not for patients undergoing surgical procedures.29

These studies highlight the possibility that duty-hour reform may only improve outcomes in medical patients, while potentially increasing the risk of poor outcomes in surgical patients. Potential factors for these poor results in the field of surgery include reduced resident experience with managing acute complications, poorer operative skills due to less exposure, and increasing shiftwork mentality. However, evidence for the latter is unclear, with residents in some surgical specialties experiencing increasing operative volume, while others experience decreased or unchanged volume.30,31 Nonetheless, studies from various surgical specialties including cardiac, orthopedic, and neurological surgery have demonstrated worse outcomes in the duty-hour reform era.7,11,15

The analysis of spinal procedures provides unique insights into the effects of duty-hour reform on residents' clinical and surgical abilities. Unlike other neurosurgical subspecialties, spine surgery is often considered less complex and consists of more elective procedures. Because these patients tend to be less ill, postoperative complications may more accurately reflect the quality of postoperative care. Additionally, in our experience, the nature of spine surgeries allows for significant resident operative autonomy, frequently allowing them to perform the surgical exposure and insert instrumentation when indicated on 1 side of 2-sided procedures. Because residents may more directly influence the risk of intraoperative complications during spine surgeries, deterioration in operative skills and experience may be more apparent.

Evaluation of complications revealed a significantly greater increase in complications in the postreform era in teaching hospitals compared with nonteaching facilities (p = 0.0002). Analysis of complication type revealed that work-hour reform affected both resident surgical skills and postoperative management. Poorer surgical skills are reflected by the significant increases in the incidence of accidental punctures or lacerations, hematomas, carotid or vertebral injuries, hoarseness due to paralysis of vocal cords, and dysphagia in teaching institutions in the postreform era. None of these complications were seen to increase in nonteaching hospitals, indicating that a change in general care is not the cause of these increased complications. Also, the effects of resident errors in postoperative management were observed in the postreform era, with the incidences of medical care or postoperative nervous system complications, cardiac complications and/or acute MI, peripheral vascular complications, operative wound complications, and therapeutic misadventures significantly increasing in teaching institutions. The latter complication is most troubling, with the incidence of therapeutic misadventures tripling in the postreform era in teaching institutions (0.02% vs 0.06%, p < 0.0001), whereas no change was seen in nonteaching hospitals. These increases may be a reflection of increased patient handoffs and reduced clinical care experience.

Mortality rates were also seen to increase in teaching institutions compared with nonteaching hospitals, although this did not reach significance (p = 0.069). A significant decrease in mortality risk in nonteaching hospitals in the postreform era was observed (p = 0.033), consistent with improvements in the standard of care. In contrast, mortality risk did not decrease in teaching hospitals during this time (p = 0.30), suggesting that complications resulting in patient mortality may have increased, offsetting the benefit of improvements in surgical and postoperative care. Similarly, whereas improvements in the standard of care resulted in a trend toward decreasing hospital stay in nonteaching hospitals in the postreform era (p = 0.089), no such benefit was seen in teaching institutions (p = 0.57). Examination of patient hospital charges did not reveal an increase in nonteaching hospitals due to duty-hour reform (p = 0.13). However, an increase in patient charges in teaching hospitals was seen following duty-hour reform (p = 0.028). Although this may be due to increased patient complications, resulting in a prolonged LOS and increased hospital charges, the magnitude of the differences did not differ significantly.

In this study we have evaluated the effect of duty-hour reforms on the postoperative outcomes of a large cohort of patients who underwent spine surgery, and we have elucidated the potential causes for increased complications in the duty-hour reform era. However, this study has several limitations. First, as with all large administrative databases, miscoding may be present. Furthermore, changes in documentation that may affect the reporting of outcomes such as complications could not be evaluated and controlled for. Second, this study does not imply causality, but rather has demonstrated an association. Third, the NIS does not contain clinical variables such as patient neurological status, which may affect patient outcome and confound the results. Similarly, because we could not control for surgical complexity, teaching hospitals may be biased toward worse outcomes due to the presumed greater complexity of cases. However, we evaluated each hospital type individually and compared them using DID analysis. Because the patient population in teaching and nonteaching hospitals before and after duty-hour restrictions has probably remained relatively similar, the effect of changes in surgical complexity may be minimal. Also, due to advancements in medical and neurosurgical care, it is likely that both teaching and nonteaching hospitals have experienced an increase in surgical complexity. This is reflected in our analysis, which demonstrated a similar increase in the number of fusion/refusion procedures performed at teaching and nonteaching hospitals before and after duty-hour reform (teaching hospitals 19.9%, nonteaching hospitals 18.1%).

Furthermore, because the complication rates were similar for teaching and nonteaching hospitals prior to reform (8.6% vs 8.2%), the divergence in outcome following reform (9.6% vs 7.6%) suggests that differences and changes in case complexity are not a significant cause of the observed differences. Nonetheless, because ICD-9 codes cannot provide procedural details such as the type of spinal fusion, changes in case complexity cannot be excluded as a factor affecting the results. Finally, variables such as the number of residents, adherence to the duty-hour guidelines, and presence of ancillary clinical staff (nurse practitioners and physician assistants) are not present in the database and thus could not be controlled. Nonetheless, this study has evaluated a large cohort of patients who underwent spine surgery and has used rigorous statistical analyses to demonstrate significantly higher rates of complications in teaching institutions in the postreform era.

Conclusions

The implementation of duty-hour restrictions was associated with an increased risk of postoperative complications. Although not significantly different from nonteaching hospitals, increases in patient mortality rate, the LOS, and patient charges were observed in teaching institutions in the postreform era. These results suggest that contrary to the goals of the ACGME in enforcing duty-hour reform, this policy has resulted in worse patient outcomes and a greater burden on the health care system. Although duty-hour reform may have improved medical patients' outcomes, its overall negative effect on surgical patients warrants increased attention. Limiting a resident surgeon's clinical exposure may not only affect management and surgical exposure, but may also threaten the faculty-resident relationship, which is vital in the surgical apprenticeship structure. Without confidence in resident abilities, the development of surgical skills is likely to suffer. Additionally, although work-hour reform may have led to a decrease in resident surgeon skills, the true effect of these restrictions will only be realized when current faculty are replaced by those trained in the present system. Further changes in duty-hour reform policies should take note of the increased mortality and surgical complications following the implementation of a 50-hour work week limit in Switzerland.18 Additional studies are needed to evaluate strategies to mitigate the effects of reduced work hours and to assist in the development of future health care policy.

Disclosure

Dr. Isaacs is a consultant for NuVasive, and he has an ownership interest in SafeRay Spine LLC. He received support of a non–study-related clinical or research effort that he oversaw from NuVasive and the Orthopaedic Research and Education Foundation. He is a patent holder with LessRay, and he has direct stock ownership in Shapewire and VillaSpine.

Author contributions to the study and manuscript preparation include the following. Conception and design: Babu. Acquisition of data: Thomas. Analysis and interpretation of data: Lad, Babu, Thomas, Lokhnygina. Drafting the article: Babu. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Lad. Statistical analysis: Thomas, Lokhnygina. Administrative/technical/material support: Lad. Study supervision: Lad.

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    Schenarts PJAnderson Schenarts KDRotondo MF: Myths and realities of the 80-hour work week. Curr Surg 63:2692742006

  • 29

    Shetty KDBhattacharya J: Changes in hospital mortality associated with residency work-hour regulations. Ann Intern Med 147:73802007

  • 30

    Simien CHolt KDRichter TH: The impact of ACGME work-hour reforms on the operative experience of fellows in surgical subspecialty programs. J Grad Med Educ 3:1111172011

  • 31

    Simien CHolt KDRichter THWhalen TVCoburn MHavlik RJ: Resident operative experience in general surgery, plastic surgery, and urology 5 years after implementation of the ACGME duty hour policy. Ann Surg 252:3833892010

  • 32

    Stamp TTermuhlen PMiller SNolan DHutzel PGilchrist J: Before and after resident work hour limitations: an objective assessment of the well-being of surgical residents. Curr Surg 62:1171212005

  • 33

    Taffinder NJMcManus ICGul YRussell RCDarzi A: Effect of sleep deprivation on surgeons' dexterity on laparoscopy simulator. Lancet 352:11911998. (Letter)

  • 34

    Volpp KGRosen AKRosenbaum PRRomano PSEven-Shoshan OCanamucio A: Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. JAMA 298:9849922007

  • 35

    Volpp KGRosen AKRosenbaum PRRomano PSEven-Shoshan OWang Y: Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. JAMA 298:9759832007

  • 36

    Volpp KGRosen AKRosenbaum PRRomano PSItani KMBellini L: Did duty hour reform lead to better outcomes among the highest risk patients?. J Gen Intern Med 24:114911552009

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Article Information

Address correspondence to: Shivanand P. Lad, M.D., Ph.D., Division of Neurosurgery, Department of Surgery, Duke University, Box 3807, Durham, NC 27710. email: nandan.lad@duke.edu.

Please include this information when citing this paper: published online July 4, 2014; DOI: 10.3171/2014.5.SPINE13283.

© AANS, except where prohibited by US copyright law.

Headings

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    Schenarts PJAnderson Schenarts KDRotondo MF: Myths and realities of the 80-hour work week. Curr Surg 63:2692742006

  • 29

    Shetty KDBhattacharya J: Changes in hospital mortality associated with residency work-hour regulations. Ann Intern Med 147:73802007

  • 30

    Simien CHolt KDRichter TH: The impact of ACGME work-hour reforms on the operative experience of fellows in surgical subspecialty programs. J Grad Med Educ 3:1111172011

  • 31

    Simien CHolt KDRichter THWhalen TVCoburn MHavlik RJ: Resident operative experience in general surgery, plastic surgery, and urology 5 years after implementation of the ACGME duty hour policy. Ann Surg 252:3833892010

  • 32

    Stamp TTermuhlen PMiller SNolan DHutzel PGilchrist J: Before and after resident work hour limitations: an objective assessment of the well-being of surgical residents. Curr Surg 62:1171212005

  • 33

    Taffinder NJMcManus ICGul YRussell RCDarzi A: Effect of sleep deprivation on surgeons' dexterity on laparoscopy simulator. Lancet 352:11911998. (Letter)

  • 34

    Volpp KGRosen AKRosenbaum PRRomano PSEven-Shoshan OCanamucio A: Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. JAMA 298:9849922007

  • 35

    Volpp KGRosen AKRosenbaum PRRomano PSEven-Shoshan OWang Y: Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. JAMA 298:9759832007

  • 36

    Volpp KGRosen AKRosenbaum PRRomano PSItani KMBellini L: Did duty hour reform lead to better outcomes among the highest risk patients?. J Gen Intern Med 24:114911552009

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