volpp and landrigan - jama 2008 - building evidence based work schedules

Upload: ariascf

Post on 30-May-2018

217 views

Category:

Documents


0 download

TRANSCRIPT

  • 8/14/2019 Volpp and Landrigan - JAMA 2008 - Building Evidence Based Work Schedules

    1/4

    current as of November 20, 2008.Online article and related content

    http://jama.ama-assn.org/cgi/content/full/300/10/1197

    . 2008;300(10):1197-1199 (doi:10.1001/jama.300.10.1197)JAMA

    Kevin G. Volpp; Christopher P. Landrigan

    Principles and Best EvidenceBuilding Physician Work Hour Regulations From First

    Correction Contact me if this article is corrected.

    Citations Contact me when this article is cited.

    Topic collections

    Contact me when new articles are published in these topic areas.ErrorEducation; Quality of Care; Evidence-Based Medicine; Patient Safety/ MedicalMedical Practice; Academic Medical Centers; Law and Medicine; Medical

    the same issueRelated Articles published in

    . 2008;300(10):1146.JAMAVineet M. Arora et al.Shift Duration, and Participation in Educational ActivitiesAssociation of Workload of On-Call Medical Interns With On-Call Sleep Duration,

    http://pubs.ama-assn.org/misc/[email protected]

    http://jama.com/subscribeSubscribe

    [email protected]/E-prints

    http://jamaarchives.com/alertsEmail Alerts

    at Harvard University on November 20, 2008www.jama.comDownloaded from

    http://jama.ama-assn.org/cgi/content/full/300/10/1197http://jama.ama-assn.org/cgi/content/full/300/10/1197http://jama.ama-assn.org/cgi/content/full/300/10/1197http://jama.ama-assn.org/cgi/alerts/ctalert?alertType=correction&addAlert=correction&saveAlert=no&correction_criteria_value=300/10/1197http://jama.ama-assn.org/cgi/alerts/ctalert?alertType=correction&addAlert=correction&saveAlert=no&correction_criteria_value=300/10/1197http://jama.ama-assn.org/cgi/alerts/ctalert?alertType=citedby&addAlert=cited_by&saveAlert=no&cited_by_criteria_resid=jama;300/10/1197http://jama.ama-assn.org/cgi/alerts/ctalert?alertType=citedby&addAlert=cited_by&saveAlert=no&cited_by_criteria_resid=jama;300/10/1197http://jama.ama-assn.org/cgi/alerts/collalerthttp://jama.ama-assn.org/cgi/alerts/collalerthttp://jama.ama-assn.org/cgi/alerts/collalerthttp://jama.ama-assn.org/cgi/content/short/300/10/1146http://jama.ama-assn.org/cgi/content/short/300/10/1146http://jama.ama-assn.org/cgi/content/short/300/10/1146http://jama.ama-assn.org/cgi/content/short/300/10/1146http://jama.ama-assn.org/cgi/content/short/300/10/1146http://pubs.ama-assn.org/misc/permissions.dtlhttp://pubs.ama-assn.org/misc/permissions.dtlhttp://pubs.ama-assn.org/misc/permissions.dtlhttp://jama.com/subscribehttp://jama.com/subscribehttp://jama.com/subscribemailto:[email protected]:[email protected]:[email protected]://jamaarchives.com/alertshttp://jamaarchives.com/alertshttp://jamaarchives.com/alertshttp://jama.ama-assn.org/http://jama.ama-assn.org/http://jama.ama-assn.org/http://jama.ama-assn.org/mailto:[email protected]://jamaarchives.com/alertshttp://pubs.ama-assn.org/misc/permissions.dtlhttp://jama.com/subscribehttp://jama.ama-assn.org/cgi/content/short/300/10/1146http://jama.ama-assn.org/cgi/alerts/collalerthttp://jama.ama-assn.org/cgi/alerts/ctalert?alertType=citedby&addAlert=cited_by&saveAlert=no&cited_by_criteria_resid=jama;300/10/1197http://jama.ama-assn.org/cgi/alerts/ctalert?alertType=correction&addAlert=correction&saveAlert=no&correction_criteria_value=300/10/1197http://jama.ama-assn.org/cgi/content/full/300/10/1197
  • 8/14/2019 Volpp and Landrigan - JAMA 2008 - Building Evidence Based Work Schedules

    2/4

    COMMENTARY

    Building Physician Work Hour RegulationsFrom First Principles and Best EvidenceKevin G. Volpp, MD, PhD

    Christopher P. Landrigan, MD, MPH

    IN 2003, PASSAGE OF THE ACCREDITATION COUNCIL FORGraduate Medical Education(ACGME) work hour stan-dards marked the first time that work hours for physi-cians in training were regulated throughout the United

    States. Five years later, the medical profession stands at acritical juncture. At the request of Congress, the Agency for

    Healthcare Research and Quality has sponsored an Insti-tute of Medicine committee to review the evidence on therelationshipbetween residents workhours and patient safetyand to develop recommendations for improvement.1

    There is increasing evidence that resident sleep depriva-tion endangers patients and residents,2-5 but studies have notshown consistent benefit from implementation of the cur-rent ACGME standards. No changes in mortality were foundin national studies of surgical patients.6-8 Some reductionsin mortality were observed for medical patients at VeteransAdministration hospitals8 and in a cohort of nonVeteransAdministration hospitals,6 although not in a larger popula-tion of medical patients covered by Medicare.7

    Thelack of consistent improvements may be dueto severalfactors. First, there areflaws in thedesignof the intervention.TheACGME standards continue to allow trainees to work 30consecutive hours, a duration repeatedly demonstrated to behazardousboth in laboratory studies andinstudiesof traineesworkinginhospitalsettings.2-5Second,compliancewiththestan-dardsmaybesuboptimal.9 Third,benefitsfromreducedfatiguemight beoffsetby worsened continuityof patientcare,particu-larly in hospitals in which robust systems for ensuring high-quality transitions in care have not been implemented.

    In this article, we propose priorities that should guide themedical community in developing specific alternatives forphysicianwork hour regulation, if the objectives are to maxi-mize patient and physician safety while preserving the best

    possible training for physicians.

    Guiding Principles

    Several principles should be considered important aspects ofany further modification of resident duty hours to improvepatient safety. An important overriding notion is to be wary

    of statusquo bias.Defaults oftenfavor an inferior statusquo,10

    with the lack of definitive evidenceabout alternativesused asa reason to retain an establishedapproacheven when it seemslikelythatalternativeswouldperformbetter.Currentdutyhourstandards are strongly tied to traditional extended duty (on-call) shifts in academic medical centers. Emerging data onthe hazards of these shifts, however, suggest it would be use-ful to consider entirely novel scheduling systems. Lean pro-duction principles from Toyota applied to medical settingsintimate that the traditional approach of admitting patients

    to teams in boluses every third or fourth night may be less de-sirable than evening the workload through daily admissions.Schedule reform, like any other therapeutic intervention,shouldbe well founded in scientificprinciples andusethe bestavailable scientific evidence to devise an optimal system.

    Rigorously Study Alternatives for Work Hour Reduc-tion. Not enough is known for anyone alternative to be uni-versally embraced as the optimal approach to duty hourreduction in all settings. It is important that any changesbe critically assessed, with a premium placed on designinginterventions to allow careful evaluation of their relativecostsand benefits. There are myriad ways that the risks of per-formance decrements caused by sleep deprivation and cir-

    cadian misalignment could be addressed while concur-rently dealing with concerns about continuity, workload,and other factors that bear on safety. Evidence exists re-garding some of these approaches, but others require fur-ther study with examination in different specialties:

    1. Moving to a 16- to 18-hour shift limit. Eliminating 24-hour shifts has been found to improve patient safety in in-tensive care units.2 Further evaluation across clinical set-tings would be informative.

    2. Implementing mandatory overnight sleep programs thatallow residents sufficient protected time when they are attheir circadian nadirs. Studies of voluntary overnight napprograms have led to only modest sleep increases. Evalua-

    tion of the potential benefits of fully protecting sleeping in-terns for 6 to 8 hours would be valuable.

    See also p 1146.

    Author Affiliations: Center for Health Equity Research and Promotion, VeteransAdministration Hospital, Philadelphia, and Department of Medicine, Universityof Pennsylvania School of Medicine, Philadelphia (Dr Volpp); and Brighamand Womens Hospital and Harvard Medical School, Boston, Massachusetts(Dr Landrigan).Corresponding Author: Kevin G. Volpp,MD, PhD, Universityof Pennsylvania Schoolof Medicine andthe Wharton School, 1232 Blockley Hall, 423GuardianDr, Phila-delphia, PA 19104-6021 ([email protected]).

    2008 American Medical Association. All rights reserved. (Reprinted) JAMA, September 10, 2008Vol 300, No. 10 1197

    at Harvard University on November 20, 2008www.jama.comDownloaded from

    http://jama.ama-assn.org/http://jama.ama-assn.org/http://jama.ama-assn.org/http://jama.ama-assn.org/
  • 8/14/2019 Volpp and Landrigan - JAMA 2008 - Building Evidence Based Work Schedules

    3/4

    3. Rotating shifts in a clockwise manner that allows foreasier circadian adjustment.

    4. Scheduling shorter shifts but allowing for substantialshift overlap to minimize discontinuity of care.

    5. Redesigning the flow of patients and assignment toteams to even workflow over time (eg, admitting 1-2 pa-

    tients per day as opposed to boluses every call cycle).Some of these approaches could be attempted con-currently, and other approaches are also possible. Ran-domized trials comparing the effectiveness and cost-effectiveness of any approach against the status quo wouldbe of particular value. If further modifications are made toexisting ACGME duty hour standards, randomization oftraining programs to different approaches for work hour re-form should be considered.

    Measure Outcomes Related to Resident Education. In-sufficient data exist on how duty hour reform affects train-ing. Although residents case volume experience might bediminished in some settings with reduction of work hours,better-rested residents might also learn more efficiently be-

    cause sleep-deprived individuals have impaired consolida-tion of memory.11 Systematic assessment is needed of theeffects of different work hour reduction strategies on long-term educational outcomes.

    Improve Sign-Out Procedures. The days of haphaz-ard sign-outs scribbled on pieces of paper should long beover, but they are not. Errors caused by handoffs betweenclinicians are a major concern with duty hour regulation anda potential barrier to use of shorter shifts. Pilot studies havesuggested these risks can be significantly reduced throughthe use of structured computerized sign-out tools.12 Signifi-cant efforts in this area couldsubstantially improve thesafetyof the health care system regardless of which approach to

    duty hour reform is taken.Eliminate or Minimize Situations in Which Residents

    Work 24 to 30 Continuous Hours. Strong and consistentrelationships between sleep deprivation and impaired per-formance have been well documented.After 24 hours of con-tinuous wakefulness, impairments in performance are simi-lar to those induced by a blood alcohol level of 0.10%.13 Inone study, residents working 24-hour shifts made 36%moreserious medical errors and 460% more serious diagnosticerrorsthan those working 16-hour or shorter shifts.2 Twenty-four-hour shifts were also associated with a 61% increasein the odds of sustaining a needle stick or other sharp in-jury5 anda doublingin therisk of motor vehicle crashes while

    driving home from work.

    4

    In a meta-analysis of 60 studiesof sleep deprivation and performance, residents clinical per-formance after 24 hours awake decreased 1.5 SDs to ap-proximately the seventh percentile of their mean rested per-formance.3 Compared with interns workingno 24-hour shiftsin a month, interns working 5 or more such shifts reportedmaking 7 times as many fatigue-related medical errors thatharm patients and 4 times as many fatigue-related medicalerrors that result in death.14

    These statistics raise serious concerns about the safety of24- to 30-hour continuous shifts for both patients and resi-dents.

    Improve Monitoring of Standards. There is no centralrepository for information on compliance with the ACGMEduty hour standards besides the ACGME, and there are

    reasons to questionwhether residents voluntarilyreport non-compliance to a regulatory agency. A third-party mecha-nism for monitoring and enforcement withadequate whistle-blower protection, such as that provided by the FederalAviation Administration for aviation safety reports, wouldgreatly enhance the ability to ascertain compliance and ef-fectiveness of future work hour improvement efforts.

    Increase Flexibility for Implementation and Enforce-ment. The ACGME Committee on Innovation has beenworking to change the accreditation process from a bluntstick based approve/disapprove approach, in which theonly means of enforcing standards is to threaten removalof accreditation (a step unlikely to be taken with any regu-larity), to one in which there is more flexibility to offer gra-

    dated rewards to programs achieving excellence on a vari-ety of dimensions. Such efforts by the ACGME or otherregulatory bodies to increase the flexibility of enforcementmethods are important and should be accelerated.

    Recognize the Importance of Supervision and Work In-tensity. The Bell Commission reports on the Libby Zion lawsemphasized that supervision is an essential element for im-proving quality of care among patients receiving care by phy-sicians in training. In addition, if inadequate staffing is inplace, reduction in resident work hours will lead to a re-duction in the number of clinicians available in the hospi-tal at any given time, overburdening those residents whoremain on duty unless fewer patients are assigned to resi-

    dents. With inadequate supervision or insufficient addi-tion of support staff and physician extenders, conscien-tious residents will try to fit more work into less time.Recognizing the importance of these 2 elements and prop-erly designing new staffing plans and supervision patternsthat address these issues and acknowledge the effect of dif-ferent systems on attending physicians and fellows will beimportant to optimize the ability of any proposed duty hourschedule to lead to better patient outcomes.

    Align Incentives for Payment With Desired Objectives.In 2007, Medicare spent about $2.8 billion on direct medi-cal education and $5.7 billion on indirect medical educa-tion, or about $110 000 per resident in the United States.15

    However, the ACGME duty hour standards have been ex-perienced by teaching hospitals as an unfunded mandate.Properly addressing duty hour reform by reducing the work-load of residents andassigningsome of the workload to otherclinicians requires resources. Support for this shouldbe con-sidered. In addition, the ideal duty hour standard would in-clude financial incentives for payers that would support andsustain duty hour standards or related objectives as part ofpay for performance. Tying some portion of ongoing reim-

    COMMENTARY

    1198 JAMA, September 10, 2008Vol 300, No. 10 (Reprinted) 2008 American Medical Association. All rights reserved.

    at Harvard University on November 20, 2008www.jama.comDownloaded from

    http://jama.ama-assn.org/http://jama.ama-assn.org/http://jama.ama-assn.org/http://jama.ama-assn.org/
  • 8/14/2019 Volpp and Landrigan - JAMA 2008 - Building Evidence Based Work Schedules

    4/4

    bursement for direct medical education and indirect medi-cal education to performance on clinical or educational out-comes or metrics such as resident safety andcompliance withduty hour standards would likely effect change and encour-age significant innovation among residency programs andhealth systems nationally. A system of positive and nega-

    tive incentives that uses existing pools of money could bedesigned to reward programs that performed well on thesemeasures. An incentive-based approach, in contrastto a regu-latory approach, would also encourage programs to be in-novative in determining ways to outperform current stan-dards as opposed to simply strivingto meet existing standardsfor performance.

    Conclusion

    There is opportunity to improve the safety of teaching hos-pitals through modification of resident work hours. As in2003, the Institute of Medicine committee, ACGME, andothers are coming under increasing pressure to move for-ward. A major barrier to informed decision making is that

    there is insufficient evidence on the effectiveness and cost-effectiveness of different alternatives. However, the ab-sence of conclusive data on the perfect solution should notstymie further reformefforts, because the hazards of the sta-tus quo have become apparent. Keeping the 8 principles de-scribed above in mind, duty hour regulation can move for-ward, even in the absence of perfect data, in ways that willbe more likely to help than to harm patients.

    Financial Disclosures: Dr Landrigan is a paid employee of Brigham and WomensHospital and Childrens Hospital Boston, both of which employ interns and resi-dents. He has served as a paid consultant to the District Health Boards of NewZealand, providingrecommendation on how to improve the scheduling and work-ing conditions for junior physicians in New Zealand; the Institute of HealthcareImprovement to develop plans for a national epidemiologic patient safety study;and Vital Issues in Medicine, developing an educational course for physicians on

    shift work disorder; this work was supported by a grant from Cephalon Inc to Vi-tal Issues in Medicine. In addition, Dr Landrigan has received monetary awards,honoraria, and travel reimbursement from multiple academic and professional

    organizations for delivering lectures on sleep deprivation, resident performance,and safety. Dr Volpp is an employee of the Veterans Administration and the Uni-versity of Pennsylvania, both of which employ interns and residents.Funding/Support: This work was supported by grants VA HSR&D IIR 04.202.1(from the Veterans Administration), R01 HL082637 (National Heart, Lung,and Blood Institute), and U18 HS15906 (Agency for Healthcare Research andQuality).Role of the Sponsors: The funders had no role in the preparation, review, orapproval of the manuscript.

    REFERENCES

    1. Instituteof Medicine. Optimizinggraduatemedicaltrainee (resident)hours andwork schedules to improvepatient safety.http://www.iom.edu/CMS/3809/48553.aspx. Accessed May 16, 2008.2. LandriganCP, Rothschild JM,CroninJW, et al.Effectof reducing interns workhours on serious medical errors in intensive care units. N Engl J Med. 2004;351(18):1838-1848.3. Philibert I. Sleep loss and performance in residents and nonphysicians: a meta-analytic examination. Sleep. 2005;28(11):1392-1402.4. Barger LK, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motorvehicle crashes among interns. N Engl J Med. 2005;352(2):125-134.5. Ayas NT, Barger LK, Cade BE, et al. Extended work duration and the risk ofself-reported percutaneous injuries in interns. JAMA. 2006;296(9):1055-1062.6. Shetty KD, Bhattacharya J. Changes in hospital mortality associated with resi-dency work-hour regulations. Ann Intern Med. 2007;147(2):73-80.7. Volpp KG, Rosen AK, RosenbaumPR, et al. Mortalityamong hospitalizedMedi-

    care beneficiaries in the first 2 years following ACGME resident duty hour reform.JAMA. 2007;298(9):975-983.8. Volpp KG, Rosen AK, Rosenbaum PR, et al. Mortality among patients in VAhospitals in the first 2 years following ACGME resident duty hour reform. JAMA.2007;298(9):984-992.9. Landrigan CP, Barger LK, Cade BE, Ayas NT, Czeisler CA. Interns compliancewith Accreditation Councilfor Graduate MedicalEducation work-hour limits.JAMA.2006;296(9):1063-1070.10. Halpern SD, Ubel PA, Asch DA. Harnessing the power of default options toimprove health care. N Engl J Med. 2007;357(13):1340-1344.11. Stickgold R. Sleep-dependent memory consolidation. Nature. 2005;437(7063):1272-1278.12. Petersen LA, Orav EJ, Teich JM, ONeil AC. Using a computerized sign-outprogram to improve continuity of inpatient care and prevent adverse events.Jt Comm J Qual Improv. 1998;24(2):77-87.13. DawsonD, ReidK. Fatigue, alcoholand performance impairment. Nature. 1997;388(6639):235.14. Barger LK, Ayas NT, Cade BE, et al. Impact of extended-duration shifts onmedical errors, adverse events, and attentional failures. PLoS Med. 2006;3

    (12):e487.15. CMS Office of the Actuary. CBOs March 2008 baseline: Medicare. http://cbo.gov/budget/factsheets/2008b/medicare.pdf. Accessed July 17, 2008.

    COMMENTARY

    2008 American Medical Association. All rights reserved. (Reprinted) JAMA, September 10, 2008Vol 300, No. 10 1199

    at Harvard University on November 20, 2008www.jama.comDownloaded from

    http://jama.ama-assn.org/http://jama.ama-assn.org/http://jama.ama-assn.org/http://jama.ama-assn.org/