To summarize our findings, the ACGME residency work-hours reform could cost $673 million to $1.1 billion per year nationwide if excess resident work is transferred to nonphysician providers. Preventable adverse events appear far more expensive, costing teaching hospitals $3.6 billion and society $13.2 billion per year—and claiming over 20,000 lives. Reform strategies promoting these events will increase mortality and costs, even if personnel costs are nil. Because most economic effects of preventable adverse events occur after discharge,15
strategies using lower- and mid-level providers are more likely to be cost neutral for society than for teaching hospitals: a 5.1% to 8.5% decline in events would be needed from the societal perspective, while 18.5% to 30.9% would be from the teaching-hospital perspective.
Although patient safety was, ostensibly, the impetus for reform, prior efforts to limit resident work-hours have had mixed outcomes.44–47
This suggests that the success of reform may depend on the approach but, unfortunately, few studies have explored how to optimize clinical or educational outcomes under reform. One recent randomized trial added more residents to intensivecare unit teams, reducing weekly hours and shortening shifts, and substantially decreasing serious errors.47
Because of implications for physician supply and Balanced Budget Act caps on residency positions,48
hiring additional residents seems unfeasible nationwide. Changes in New York State surgery programs after 1998 illustrate the range of possibilities: half increased resident cross-coverage, 42% instituted a night-float system, 35% transferred work from junior residents to seniors, 14% recruited new residents or reassigned existing ones, 14% permitted nonteaching patients, 54% increased mid-level providers' roles, and 11% increased lower-level providers' roles.16
Several editorialists argue that, of these, transferring noneducational tasks to lower and mid-level providers would best promote resident education and patient safety.17–20
Two points support the hypothesis that this approach would benefit resident education. Eliminating menial tasks may alleviate stress,49
encouraging learning. More importantly, it should allow programs to reduce work-hours without affecting education. A recent metaanalysis found that residents working 84.5 hours weeks spend 29.5 hours in patient-care activities of marginal or no educational value.24
In contrast with substitution strategies, redistributing work among residents may encroach upon conference attendance, independent reading, and elective rotations.
If substitution best preserves education, would it also promote patient safety? Reform may reduce sleep deprivation,46
but discontinuity in care has a potentially larger effect on patient outcomes.50
Studies suggest alleviating fatigue might diminish error commission rates: one reform effort lowered medication errors by 29%,44
and a few studies found 20% to 100% more errors on postcall days.23
Most convincingly, the randomized trial mentioned above found that interns working 85-hour weeks slept less, had more than twice the attentional failures,46
and committed 35.9% more serious errors than those working 65-hour weeks.47
However, most errors are intercepted or happen to not cause harm. In that trial, more than half of the serious errors were intercepted. And while the interns working longer hours committed 56.6% more nonintercepted serious errors, injuries because of these errors (i.e., preventable adverse events) were unchanged. The study was not powered to address preventable adverse events47
but its results suggest that reducing sleep deprivation might prevent many errors and, possibly, a smaller number of adverse events.
Discontinuities of care appear potentially more dangerous than sleep deprivation: one study found that preventable adverse events climbed 500% on days that interns were cross-covering.50
Standardized sign-out mitigated this risk in a follow-up study and in the above trial.47,51
This suggests that preventable adverse events could rise under the ACGME reform if handoffs are not handled carefully because adding days off and limiting call must increase cross-coverage. In addition to standardizing sign-out, programs can mitigate discontinuity risks by minimizing the transfer of work among residents.
Substantial improvements in efficiency, perhaps via technological innovation, might reduce hours without shifting work among residents or to substitute providers. Today, however, curtailing residents' hours without redistributing the work seems likely to erode education, implicitly transfer work to attending physicians, or jeopardize patient care.
Even if substitution with nonphysician providers preserves education and quality of care, cost is a major drawback. Such strategies could cost up to $40,000 per resident annually and boost admission costs by $43.43 to $72.28 each. Teaching hospitals may be reluctant to undertake this expenditure without subsidies, particularly because their economic condition worsened after the Balanced Budget Act.48,52
Resident substitution would be much more appealing if it were cost neutral.
If reform succeeds at preventing adverse events, it could save teaching hospitals money through lower hospitalization costs or decreased litigation. The latter seems unlikely because malpractice claims follow only 1.5% of negligent adverse events (a subset of preventable ones)53
and neither adverse events nor negligence predict payments to claimants.54
Although lower hospitalization costs appear plausible, preventable adverse events must fall 18.5% to 30.9% to make substitution cost neutral for teaching hospitals; this magnitude reduction may not be attainable.
In contrast, a modest decline in preventable adverse events, 5.1% to 8.5%, might make resident substitution cost neutral for society. Reform strategies this effective could also save about 1,000 to 1,700 lives annually. The 56.6% decline in nonintercepted serious medical errors observed in the above trial 47
suggests that a modest decline in preventable adverse events might be achievable. Because substitution would still be cost increasing from a teaching-hospital perspective, government subsidies could be justifiable. Although not reintroduced to date in 2005,9
“The Patient and Physician Safety and Protection Act of 2003” did allocate funds for reform.13,14
The proposed legislation might increase federal graduate medical education payments by 7.6% to 12.5% relative to fiscal year 2002,48
assuming that personnel costs would be the same as under the ACGME policy.
Unfortunately, the quality of available data tempers the strength of our conclusions. First, we estimated pre-reform work-hours from 1998 New York State data—i.e., after reform; however, these estimates appear higher than 2001 AAMC data for first-year residents nationally.5,55
Second, we extrapolated an Internal Medicine substitution model29
to all specialties. Third, we arbitrarily transferred work to substitutes hour for hour when the actual effect on workload is unknown. Fourth, because negligent adverse event rates are similar at major teaching and nonteaching hospitals,56
we assumed that preventable adverse event rates would be too. Fifth, event costs may be higher at teaching hospitals, although we identified no literature addressing this. Sixth, we assumed that enforcement costs would be negligible, which is unlikely. Finally, we share the limitations of the Utah and Colorado study, which used implicit review methods to determine incremental event costs and omitted transportation, informal caregiving, and the friction costs of litigation.15
Our analysis was limited to monetary costs and mortality; we did not account for the potential effect of reducing adverse events on length and quality of life. Although this would not alter findings from the teaching-hospital perspective, it could affect those from the societal perspective. We did not have the data, however, to conduct cost-utility or cost-benefit analyses. Further, one study suggested that preventable adverse events may have a modest effect on length or quality of life.57