Study: Patient outcomes and care costs unaffected by residency work limits

Limiting residents' work hours has not affected the quality or cost of care internists provide when they begin practicing, according to a new study.

The study, a research paper in BMJ, looks at the impact of the 2003 reforms limiting residents to 80-hour workweeks and shifts of 30 consecutive hours. At the time, some hospital administrators and older physicians voiced concerns that the limits would deprive physicians of the amount of clinical experience required for medical practice.

(Subsequent reforms in 2011 further reduced residents’ shift lengths to 28 hours while limiting interns to shifts of 16 consecutive hours. In 2017 the limits on interns’ hours were partially reversed.)

The study compares patient outcomes and care costs among Medicare beneficiaries hospitalized between 2000 and 2012 and treated by first-year internists who finished their residency after 2006 (and were thus fully exposed to the work hour limits), with those treated by first-year internists who finished residency before 2006.

Outcome measures included 30-day mortality and 30-day readmission rate. For cost of care, researchers used Medicare Part B spending for a given hospital stay. Results for about 486,000 patients were included in the study.

To further account for national trends in outcomes and cost of care, the authors included a control group consisting of patients admitted during a given year and treated by a doctor who had completed residency 10 years earlier; for example, a patient admitted in 2002 whose doctor finished residency in 1992.

The results showed little statistical difference between the groups either in outcomes or costs of care. Thirty-day mortality rates for patients of first-year internists during the 2000-2006 and 2007-2012 periods were 10.6 percent and 9.6 percent, respectively, and 11.2 percent for 10th-year internists. Readmission rates for first-year internists were 20.4 percent for both the 2000-2006 and 2007-2012 groups, and 20.1 percent for 10th year internists.

Per-patient spending among first-year doctors was $1,161 in the 2000-2006 period and $1,267 in the 2007-2012 period, and $1,331 for the 10th-year internists.

The authors note that the team-based nature of most hospital care serves to mute the impact of a single physician on outcomes and costs is limited. Given that reality, they say, the study’s findings “might also serve as a justification for future training reforms, which should recognize that the role of individual physicians in delivering care is mitigated by the increasing role of teams and technological advances in how medical care is delivered.”