What Was the Impact of the 2003 ACGME Duty‐Hour Rules? Patient Safety, Resident Education, and Resident Well‐Being

Background:

In July 2003, the Accreditation Council for Graduate Medical Education implemented duty‐hour rules for all U.S. residents. In December 2008, the Institute of Medicine released a report urging additional restrictions. The issues at stake are patient safety, resident education, and resident well‐being. Given that 6 years have elapsed since the initial rules, we undertook a systematic review of the literature to determine what progress has been made toward improving these outcomes.

Methods:

We developed an electronic search strategy in Medline and Embase in consultation with research librarians. Because this was part of a larger project, we included the years 1989–2009. We reviewed the resulting abstracts for inclusion based on whether they represented research and were on a relevant topic relevant. Articles corresponding to the included abstracts were reviewed in detail for inclusion. For this project, included articles had to be from the United States and had to contain data collected after the 2003 duty‐hour rules went into effect. To assess study quality, the previously validated Medical Education Research Quality Index (MERSQI) was used. Abstracted data were entered into a secure Web‐based database.

Results:

The search yielded 4805 articles. Of those, 1809 abstracts were reviewed in further detail. We identified 158 studies on the impact of the 2003 duty‐hour rules. The main findings were related to patient safety, resident education, and resident well‐being. Fifteen studies assessed mortality in medical or surgical patients. Several studies showed improvement in mortality in the post–duty hour time period. The others showed no change. In the sole exception, a subset of patients with stroke had worsened mortality. The 19 studies assessing complications in the post‐duty hour period had mixed results, with about the same number of studies showing improvements as showed worsening. For resident education, standardized test scores seemed to mostly remain unchanged in the post–duty hour time period, Operative experience was much more variable, with many studies reporting decreased operative experience. No internal medicine studies of experience have been done. Finally, resident well‐being, as measured by burnout, appears to have improved in the post–duty hour rule period.

Conclusions:

The 2003 duty‐hour rules appear to have had an impact on patients and residents. Mortality seems to have improved or at worst, not changed. The impact on complications is mixed and should be assessed more thoroughly. The impact on resident education, especially in terms of operative experience is worrisome, but well‐being appears to have improved. More work is needed to delineate the variability in the outcomes of patient complications and resident experience. Overall, the impact of the duty‐hour rules appears to have been positive.

Author Disclosure:

K. Fletcher, VA, research funding, NCI, research funding, ACGME, research funding; V. Arora, ACGME, research funding; AHRQ, research funding; NIA, research funding; D. Reed, ACGME, research funding, ABIM, research funding.