D ATA D R I V E N . P O L I C Y F O C U S E D LDI ResearchBRIEF Research to Improve the Nation’s Health System 2020 . No. 3 DUTY HOUR REFORM AND THE OUTCOMES OF PATIENTS TREATED BY NEW SURGEONS Evaluating a New Paradigm in Surgical Training Rachel R. Kelz, Bijan A. Niknam, Morgan M. Sellers, James E. Sharpe, Paul R. Rosenbaum, Alexander S. Hill, Hong Zhou, Lauren L. Hochman, Karl Y. Bilimoria, Kamal Itani, Patrick S. Romano, and Jeffrey H. Silber. Annals of Surgery — April 2020 KEYFINDINGS Despite concerns that duty hour reform might adversely affect the performance of new surgeons, this national study found no impact on patient outcomes, including 30-day mortality rates, failure-to-rescue, length of stay, and use of intensive care units. These findings should allay fears that reduced work hours during residency would produce surgeons less prepared for practice than their more experienced colleagues. THE QUESTION In 2003, the Accreditation Council for Graduate Medical Education of new surgeons (compared to their more experienced colleagues) transformed surgical training—and stirred controversy—by changed over two periods: 1999-2003 (pre-reform) and 2009-2013 implementing reforms to resident duty hours. Among other changes, (post-reform). Patients of new surgeons (defined as practicing less than the restructured residency experience produced a net loss of 6-12 three years) were matched by hospital and operation with patients of months of clinical training (as a result of reduced work hours). Some experienced surgeons (practicing greater than 10 years) in both periods; program directors, experienced surgeons, and trainees themselves only the new surgeons in the later period had been trained after duty questioned whether these changes would affect the development of hour reform. More than 2,500 new/experienced surgeons were paired surgical skills, judgment, and autonomy. To date, studies of duty hour in the traditional era, and compared to nearly 1,900 new/experienced reform have largely focused on its impact on residents during training surgeons in the modern era. and on patients in academic medical centers. This study assesses the The question under study was whether the known gap in outcomes impact of duty hour reform on the performance of new surgeons after between new and experienced surgeons changed after duty their transition to independent practice. hour reform. To find out, the authors compared 30-day mortality, The authors use a novel approach to account for potential changes readmissions, failure-to-rescue (death after developing a complication), over time in surgical performance that might be unrelated to duty and other outcomes in Medicare patients of general and orthopedic hour reform. The study looks at whether the relative performance surgeons practicing in more than 1,400 hospitals nationwide. COLONIAL PENN CENTER | 3641 LOCUST WALK | PHILADELPHIA, PA 19104-6218 | LDI.UPENN.EDU | P: 215-898-5611 | F: 215-898-0229 | @PENNLDI ResearchBRIEF LDI THE FINDINGS THE IMPLICATIONS The 30-day mortality rates of new surgeons were slightly higher than This is the first national study to address concerns about the impact experienced surgeons in both training eras, but significantly higher only of duty hour reform on the performance of new surgeons. By using in the traditional era (7.0% vs. 6.3%). Importantly, the paired differences contemporaneous experienced surgeons as controls, the authors over the two periods did not change significantly in terms of 30-day address controversy surrounding the new educational model’s impact mortality, 30-day failure-to-rescue, 30-day readmissions and death, ICU on patient outcomes. The study’s findings provide reassurance that use, or length of stay. However, the paired differences indicated that patient outcomes did not suffer when surgical training was restructured. patients of new surgeons trained in the modern era required increased To our knowledge, this is the first study to use the patient outcomes anesthesia time (+9 minutes), experienced higher odds of prolonged of practicing surgeons to measure changes in surgical training. stay (+8%), and higher 30-day resource costs (+$255, in 2013 dollars). These methods can be a template for evaluating the impact of other The authors note that an emphasis on reducing readmissions in the educational reforms across medical specialties. modern era may encourage physicians to prolong length of stay. The results were similar for general and orthopedic surgeons, with a THE STUDY notable exception. Patients of new general surgeons trained in the modern era had relatively lower 30-day readmissions or death (-14%). The authors identified nearly 1.5 million fee-for-service Medicare However, this reflects a slight increase in 30-day readmissions among beneficiaries aged 65.5 or older who underwent general or orthopedic experienced surgeons across training eras, rather than a change in the surgery (requiring an incision) in two time frames: 1999-2003 and rate of readmissions among new surgeons in the modern era. 2009-2013. They identified the operating physician for each patient using the Medicare Part B file. For patients with multiple qualifying surgeries, an operation was chosen randomly, so that each patient was included only once. No significant difference in relative performance of new and They divided surgeons into four groups based on training era (before experienced surgeons from traditional to modern era or after reform) and experience level (new or experienced). Surgeons trained before reform completed their entire residency prior to reform 8% and began independent practice between 1999 and 2003. Surgeons trained after reform entered independent practice between 2009 and 7% 2013. “New” physicians had less than three years of independent practice, and “experienced” ones had ten or more years of independent practice. 30-DAY MORTALITY RATE 6% 5% In each training era, new and experienced surgeons operating in the same hospital were paired for this “difference in differences” analysis. 4% This resulted in 2,578 pairs in the pre-reform era and 1,820 pairs in the 3% post-reform era. Within each surgeon pair, the authors selected 10 patients of experienced surgeons and 10 patients of new surgeons for 2% analysis. The patients were matched by procedure, demographics, and 1% risk factors (such as comorbidities) that could contribute to differences 0% in outcomes. The primary outcome was 30-day mortality; other TRADITIONAL ERA MODERN ERA outcomes included 30-day readmissions, anesthesia time, length-of- stay, ICU usage, and 30-day resource-based costs. New Surgeons Experienced Surgeons Kelz RR, Niknam BA, Sellers MM, Sharpe JE, Rosenbaum PR, et al. Duty Figure 1. Matched 30-day mortality rates, new and experienced surgeons, Hour Reform and the Outcomes of Patients of New Surgeons. Annals of traditional and modern era. Surgery. 2020 Apr;271(4):599-605. LEAD AUTHOR DR. RACHEL KELZ Rachel R. Kelz, MD, MSCE, MBA, FACS is a Professor of Surgery at the Perelman School of Medicine at the University of Pennsylvania. She is an Endocrine Surgeon and cares for patients at the Hospital of the University of Pennsylvania. Dr. Kelz serves as the Vice Chair of Clinical Research within the Department of Surgery. Dr. Kelz is recognized as a leader in surgical education and was awarded the Lindback Foundation award for distinguished teaching by the Provost of the University of Pennsylvania. She serves as the Surgeon Champion for the National Surgical Quality Improvement Program at Penn. Her work in outcomes and education has recently merged, and she is focusing on innovative approaches to combine administrative data with chart abstraction to identify opportunities to improve surgical education and performance.