1. Impact of ACGME Duty Hour Rules on Prolonged Length of Stay Among Medicare and VA Patients Jeffrey H. Silber, MD, PhD Professor of Pediatrics, Anesthesiology and Critical Care, and Health Care Systems The University of Pennsylvania School of Medicine The Children’s Hospital of Philadelphia The Wharton School

2. Acknowledgments Kevin G. Volpp, MD, PhD Paul R. Rosenbaum, PhD Amy K. Rosen, PhD Patrick S. Romano, MD Kamal M.F. Itani, MD Liyi Cen, MS Lanyu Mi, MS Michael J. Halenar, BA Orit Even-Shoshan, MS Jeffrey H. Silber, M.D., PhD The University of Pennsylvania School of Medicine; The Wharton School, The Children’s Hospital of Philadelphia, The University of California, Davis, and Boston University; The U.S.Veterans Administration Hospitals in Philadelphia and Boston. Funding: NHLBI (R01 HL082637) and VA (IIR 04-202)

3. Motivation In 2003 the rules governing work hours for residents were changed on a national level In Previous work [JAMA 2007] we have reported on the influence of duty hour reform on mortality—finding little effect--no clear evidence of harm We now report on Prolonged Length of Stay (PLOS), a non-lethal outcome that may be associated with the change in resident work hour regulations

4. Overview We wished to utilize a measure that would reflect subtle problems that may occur from the change in resident work hour rules. Prolonged LOS (PLOS) may reflect subtle complications and inefficiencies in care that prolong stay These problems could potentially be a reflection of the change in resident duty hour regulations because: –Increased handoffs may increase errors in care leading to complications –Increased handoffs may increase inefficiencies in the early discharge of uncomplicated patients –More rested residents may increase efficiency and prevent errors that may lead to prolonged stays

5. Defining Prolonged LOS (PLOS) PLOS was first introduced by Silber and Rosenbaum et al. in HSR 1999 PLOS is based on the concept that for most admissions (conditions and procedures) there is a point in the hospitalization when “the longer you have stayed, the longer you will stay” signifying that some problem has occurred

6. Prolongation Point We can divide a hospital stay into two parts: Length of Stay (Days) Daily Rate of Discharge Prolongation Point Increasing discharge rate: More likely to go home as the patient stays longer Declining discharge rate: Less likely to go home as the patient stays longer

7. Silber, Rosenbaum et al. HSR 1999

8. Rate of Discharge 0.00 0.04 0.08 0.12 0.16 0.20 0.24 0.28 Days 05101520

9. Computing PLOS for AMI using the Hollander-Proschan Test Hospital DayNumber going homeHP T statisticT* 168378.3396E+14-90.58 2186978.4047E+1423.09 3276096.4994E+1480.59 4261663.8612E+1488.67 5205662.085E+1479.60 6162371.1544E+1472.71 7131876.5701E+1368.60 8109063.7849E+1364.99 987182.182E+1360.18 1072101.2897E+1356.72 1159727.6654E+1252.31 1247624.577E+1246.60

10. Prolongation Points and Percentage of Patients with Prolonged Hospital Stays by Conditions and Procedures (July 2002-June 2003) Prolongation Point Percent (Hosp. Day No.) Prolonged Conditions & Procedures Medicare VA Medicare VA Medical AMI3379.775.4 Stroke3378.976.4 GI Bleed3356.153.1 CHF3366.062.6 Surgical Lap Chole2266.657.5 R Hemicol.6665.771.9 Sigmoidectomy6672.574.0 O Chole5566.366.7 Total Knee4544.138.6 O Red Femur Fx w/ Int Fix4776.362.6 Total Hip4548.247.7 Exc Interverteb Disc2238.642.6 Res AAA6670.271.5 End Graft AA2344.855.7 AKA51481.644.6 Femoral-Pop Bypass6665.467.4 Toe Amp6756.961.1

11. The longer one stays, the longer one will stay

12. Types of PLOS Measures PLOS cost : Use LOS for death as it occurred PLOS outcomes : Use LOS for death as prolonged We used PLOS outcomes for this study, but results were stable using either definition

13. A Difference-in-Differences Study of PLOS ACGME Reform

14. Measuring Teaching Intensity We utilized the Resident-to-Bed Ratio as our measure of teaching intensity The RB ratio is defined as the total number of residents at a hospital divided by the hospital’s average daily census (ADC), as reported to Medicare using Medicare Cost Reports Typically, RB ratios are classified as follows: – RB = 0 (non-teaching) – 0<RB<0.05 (very minor teaching) –.05<RB<0.25 (minor teaching) –0.25<RB<0.6 (major teaching hospitals) –RB > 0.6 (very major teaching hospitals).

15. Risk Adjustment Methodology We performed Conditional Logistic Regression clustering on the individual hospital Risk adjustment was based on Elixhauser comorbidities, transfer-in status, age and sex, and principal procedure or condition We utilized a 6-month look-back to improve the sensitivity of the Elixhauser comorbidities

16. Patient Populations Medicare: MEDPAR data on all patients between ages 65 and 90 for Medical Conditions (AMI, CHF, Stroke, and GI bleeding) and Surgical Procedures (General Surgery, Orthopedics, and Vascular Surgery) for 2001-2005. VA data: Same years, ages, conditions, and procedures

17. RESULTS

18. Patient Characteristics by Diagnosis and Procedure (Medical) Age Mean No. of No. of Patients (mean) % Male Comorbidities Medicare VA Medicare VA Medicare VA Medicare VA AMI970,18432,17077.366.952991.92.0 Stroke933,22525,38578.468.142982.11.9 GI Bleed763,76536,03578.566.944982.62.3 CHF1,196,29450,26678.669.744982.62.5

19. Patient Characteristics by Diagnosis and Procedure (Surgical) Age Mean No. of No. of Patients (mean) % Male Comorbidities Medicare VA Medicare VA Medicare VA Medicare VA Gen Surg Lap Chole298,1087,17475.860.439911.81.4 R Hemicol166,2836,50077.068.943982.22.0 Sigmoid103,9524,23275.964.840982.01.6 Chole83,1724,57676.464.451961.91.6 Ortho Surg Total Knee651,70813,65874.565.235961.51.1 O Red I/F Fem300,7133,85081.272.725972.32.1 Total Hip317,5618,15875.563.136961.51.1 Intervert Disc94,5777,05373.452.749951.40.8 Vascular Surg Resection AAA63,9952,52475.369.875992.01.9 Graft Abd Aorta43,8561,92776.371.3831002.11.9 AKA31,8901,68979.371.346993.93.1 Fem Pop Bypass25,3542,90773.561.560992.41.9 Toe Amp14,3782,17279.365.658993.52.6

20. Prolongation Points and Percentage of Patients with Prolonged Hospital Stays by Conditions and Procedures Prolongation Point Percent (Hosp. Day No.) Prolonged Conditions & Procedures Medicare VA Medicare VA Medical AMI3379.775.4 Stroke3378.976.4 GI Bleed3356.153.1 CHF3366.062.6 Surgical Lap Chole2266.657.5 R Hemicol.6665.771.9 Sigmoidectomy6672.574.0 O Chole5566.366.7 Total Knee4544.138.6 O Red Femur Fx w/ Int Fix4776.362.6 Total Hip4548.247.7 Exc Interverteb Disc2238.642.6 Res AAA6670.271.5 End Graft AA2344.855.7 AKA51481.644.6 Femoral-Pop Bypass6665.467.4 Toe Amp6756.961.1

21. Non-teaching (0)Very Minor/Minor (>0 & <.25) Major (>0.25& <0.6)Very Major (>0.6) Unadjusted Results (Medical)

22. Non-teaching (0)Very Minor/Minor (>0 & <.25) Major (>0.25& <0.6)Very Major (>0.6) Unadjusted Results (Surgical)

23. Odds of Prolonged Stay Post Duty Hour Reform in More vs. Less Teaching Intensive Hospitals Using Conditional Logistic Regression Controlling for Each Hospital RB ratio x post-reform year 1 Patient categories OR (95% CI) (Number of Cases Medicare/VA) Medicare VA Medical Conditions Stroke1.01 (0.92, 1.10)0.92 (0.66, 1.27) AMI1.01 (0.93, 1.10)0.96 (0.72, 1.29) GI Bleed1.06 (0.97, 1.16)1.26 (1.00, 1.58) a CHF0.99 (0.92, 1.06)1.11 (0.92, 1.35) Combined Medical1.01 (0.97, 1.05)1.07 (0.94, 1.20) Surgical Conditions General Surgery1.09 (0.99, 1.21)1.07 (0.79, 1.43) Orthopedic Surgery1.03 (0.96, 1.10)0.82 (0.61, 1.12) Vascular Surgery1.16 (1.00, 1.34)1.08 (0.66, 1.77) Combined Surgery1.04 (0.98, 1.09)0.94 (0.78, 1.14) a p<0.05

24. Odds of Prolonged Stay Post Duty Hour Reform in More vs. Less Teaching Intensive Hospitals Using Conditional Logistic Regression Controlling for Each Hospital RB ratio x post-reform year 2 Patient categories OR (95% CI) (Number of Cases Medicare/VA) Medicare VA Medical Conditions Stroke1.01 (0.92, 1.10)0.95 (0.69, 1.31) AMI1.06 (0.97, 1.15)0.96 (0.72, 1.28) GI Bleed1.09 (1.00, 1.20)1.08 (0.86, 1.36) CHF1.02 (0.95, 1.10)1.18 (0.97, 1.43) Combined Medical1.04 (0.99, 1.08)1.05 (0.93, 1.19) Surgical Conditions General Surgery0.94 (0.85, 1.05)1.02 (0.76, 1.36) Orthopedic Surgery0.94 (0.88, 1.01)1.04 (0.77, 1.41) Vascular Surgery1.21 (1.04, 1.40) a 1.16 (0.71, 1.91) Combined Surgery0.96 (0.91, 1.01)1.00 (0.83, 1.21) a p<0.05

25. Conclusions The change in duty hour rules did not have an overall effect on the probability of experiencing a prolonged stay In Medicare and VA systems, hospitals generally found ways to cope with any worsening of continuity of care associated with duty hour reform and by-and-large succeeded in avoiding the confusion and adverse consequences predicted by those opposed to the new regulations.

26. THE END