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Thursday, April 29, 2010

RAND-UCLA Study Sheds Light on Proposed Resident Duty Hour Limits


Report's Authors, AAFP Share Same Doubts About Further Restrictions

By Barbara Bein
A report from the nonprofit research organization RAND Corp. and the University of California, Los Angeles, or UCLA, says that new recommendations to further limit the work hours of medical residents would cost the nation's teaching facilities about $1.6 billion a year to hire additional personnel to fill in for residents coming off work shifts. That's a high price to pay for the uncertain effects that adopting the recommendations would have on reducing fatigue-related medical errors in many clinical settings, say Academy leaders and other medical education experts.
"This report confirms our concerns. Not only are (further restrictions) costly, but there also is no evidence that they will actually improve patient safety," AAFP President Ted Epperly, M.D., of Boise, Idaho, told AAFP News Now.

The RAND-UCLA study, "Cost Implications of Reduced Work Hours and Workloads for Resident Physicians," was published in the May 21 issue of the New England Journal of Medicine.

The new report comes five months after the Institute of Medicine, or IOM, recommendedthat continuous on-site duty periods for residents not exceed 16 hours unless a five-hour uninterrupted sleep period is provided between 10 p.m. and 8 a.m. Other recommendations proposed reducing residents' workloads and increasing the number of days they would have off each month.

The IOM's own estimate of the cost of shifting resident work to other clinicians was about $1.7 billion a year, more than the $1.6 billion a year estimated by the RAND-UCLA report, which expanded on the IOM's cost analysis by using published data to estimate labor costs associated with transferring excess work from residents to substitute clinicians.

Academy leaders have disagreed with many of the IOM recommendations, and the RAND researchers point to key reasons for those concerns.

"Adopting new restrictions on the work hours of physicians in training would impose a substantial new cost on the nation's 8,500 physician training programs," said lead author Teryl Nuckols, M.D., an internist at the David Geffen School of Medicine at UCLA and a RAND researcher, in a May 20 press release. "There is no obvious way to pay for these changes, so that's one major issue that must be addressed."

The RAND-UCLA report says teaching hospitals would have to make up for residents' shorter work hours by hiring other health care professionals, such as physician assistants, to do the work or by expanding the number of residency positions offered at teaching facilities.

Hiring additional clinicians would cost each major teaching hospital $3.2 million a year, according to RAND researchers. The other option to make up for residents' shorter work hours -- expanding the total number of residency positions offered -- would ease physician shortages in some specialties but would lead to oversupply in others, the report says.

Epperly echoed that latter perspective, saying that such a move could have the unintended effect of increasing the overall physician workforce in the same proportions as what he termed "our already out-of-balance workforce."

"More of the same workforce is not a solution, but only contributes to the problem," Epperly said. "We need to rebalance this workforce with a greater number of primary care physicians."

But perhaps the most significant question addressed by the RAND-UCLA study is whether reducing resident work hours would cut down on serious medical errors. The report's authors say that although one study of shorter shifts suggested that a 25 percent decrease in serious errors might be plausible in hospital intensive care units, overall, few errors cause patient injuries, and the effects of making such work hour changes could differ in other clinical settings.

Moreover, the additional patient hand-offs could actually increase the number of preventable adverse events, says the report, which concludes that "implementing the … IOM recommendations would be costly and their effectiveness is unknown. If highly effective, they could prevent patient harm at reduced or no cost from the societal perspective. However, net costs to teaching hospitals would remain high."

Epperly -- who is program director and CEO of the Family Medicine Residency of Idaho in Boise -- agreed. "We may be substituting shorter work periods on the residents' part with increased fragmentation of both patient care and (residents') educational experience," he said of the report's findings. "More frequent hand-offs of patient care have been associated with increased medical errors. Therefore, we may actually be making patient care more unsafe, instead of safer."

Epperly is scheduled to speak about the proposed duty hour restrictions during the Accreditation Council for Graduate Medical Education's National Congress on Duty Hours and the Learning Environment, June 11-12 in Chicago. Also speaking will be Marjorie Bowman, M.D., M.P.A., of Philadelphia, professor and chair of the University of Pennsylvania Health System Department of Family Medicine and Community Health.

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