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Effect of work-hours regulations on intensive care unit mortality in United States teaching hospitals*

Prasad, Meeta MD; Iwashyna, Theodore J. MD, PhD; Christie, Jason D. MD, MSCE; Kramer, Andrew A. PhD; Silber, Jeffrey H. MD, PhD; Volpp, Kevin G. MD, PhD; Kahn, Jeremy M. MD, MS

doi: 10.1097/CCM.0b013e3181a93468
Clinical Investigations

Objectives: To examine the association of the resident work-hours reform with mortality for patients in medical and surgical intensive care units. The United States instituted restrictions on resident work-hours in July 2003. The clinical impact of this reform on critically ill patients is unknown.

Design: A retrospective cohort study, comparing mortality trends before and after July 1, 2003, in teaching and nonteaching hospitals.

Setting and Patients: The study included 230,151 adult patients admitted to 104 different intensive care units at 40 hospitals participating in the Acute Physiology and Chronic Health Evaluation IV clinical information system from July 1, 2001, to June 30, 2005.

Interventions: None.

Measurements and Main Results: The primary exposure was the date of admission, relative to the implementation of the work-hours regulations. The primary outcome was in-hospital mortality; a secondary outcome was intensive care unit mortality. The analysis included 79,377 patients in 12 academic hospitals; 73,580 patients in 12 community hospitals with residents; and 77,194 patients in 16 nonteaching hospitals. Risk-adjusted mortality improved in hospitals of all teaching levels during the study period. There were no significant differences in the mortality trends between hospitals of different teaching intensities, as demonstrated by nonsignificant interaction between time and teaching status (global test of interaction, p = .56).

Conclusions: There was a decrease in in-hospital mortality in intensive care unit patients during the years of observation. This decrease was not associated with hospital teaching status, suggesting no net positive or negative association of the resident work-hours regulations with a major patient-centered outcome.

From the Division of Pulmonary, Allergy, and Critical Care Medicine (MP, JDC, JMK), Department of Medicine, Center for Clinical Epidemiology and Biostatistics (MP, JDC, JMK), Departments of Pediatrics and Anesthesiology and Critical Care (JHS), Division of General Internal Medicine (KGV), Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA; Division of Pulmonary and Critical Care Medicine (TJI), Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Leonard Davis Institute of Health Economics (TJI, JHS, KGV, JMK), University of Pennsylvania, Philadelphia, PA; Cerner Corporation (AAK), Vienna, VA; Center for Outcomes Research (JHS), Children’s Hospital of Pennsylvania, Philadelphia, PA; Department of Health Care Systems (JHS, KGV), Wharton School, University of Pennsylvania, Philadelphia, PA; Veterans Administration Center for Health Equity Research and Promotion (KGV), Philadelphia, PA.

This study was supported, in part, by Grant T32 HL007891-10 from the National Institutes of Health (to MP).

The authors have not disclosed any potential conflicts of interest.

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© 2009 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins