NEJM: Limiting medical residents' hours could cost $1.6B annually

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New recommendations to limit the work hours of medical residents could cost U.S. teaching hospitals about $1.6 billion annually to hire additional personnel, according to a report published in the May 21 issue of the New England Journal of Medicine.

Although society may benefit if such changes reduce medical errors as intended, limiting trainee workloads would create a substantial new expense for academic medical centers.

"Adopting new restrictions on the work hours of physicians in training would impose a substantial new cost on the nation's 8,500 physician training programs," said lead author Teryl K. Nuckols, MD, an internist at the David Geffen School of Medicine at University of California at Los Angeles, and a researcher at RAND, a nonprofit research organization. "There is no obvious way to pay for these changes so that's one major issue that must be addressed."

In December 2008, the Institute of Medicine (IOM) released a report calling for revisions to medical residents' workloads to decrease the chances of fatigue-related medical errors and to enhance the learning environment. Recommendations included requiring prolonged shifts to include protected time for sleep, reducing to 16 hours the duration of time residents can work without protected time for sleep, reducing residents' workload and increasing the number of days residents must have off.

Graduate medical education programs traditionally have required residents to work long hours, often more than 100 hours per week, according to the researchers. Such training programs generally run three to seven years following medical school.

The study provided new details about the potential costs and clinical implications of the IOM recommendations, expanding upon a cost analysis described in the original report.

Should the recommendations be adopted, the researchers said that the teaching hospitals would need to make up for residents' shorter work hours by either hiring other providers such as physician assistants to do the work or by expanding the number of residency positions.

While adding residency slots could help ease physician shortages in some specialties, it also could lead to oversupply in others, according to the study. Researchers estimated that residency positions would need to grow by about 8 percent overall to meet staffing needs under the IOM recommendations.

"The trainees who are working more than the proposed limits would allow are not necessarily in the specialties where more physicians are needed," Nuckols said. "For example, pediatric residents work a lot of hours, but there is no evidence that there are too few pediatricians."

Researchers estimated that adopting the IOM's recommendations would cost each major teaching hospital about $3.2 million annually on average. That is higher than other proven quality improvement efforts for hospitals such as computerized physician order entry and medication barcoding systems. However, it would be less expensive than other proposals, such as requiring that there be one nurse for every four patients.

One study of shorter work shifts suggests that reducing resident work hours could cut serious medical errors by 25 percent in medical intensive care units. But few errors cause injury and the effects could be different in other clinical settings, according to the study. In addition, revising work rules could prompt other types of medical errors as the care of hospitalized patients is more-frequently handed from one provider to another.

Researchers said adopting the recommendations of the IOM report would be more expensive for teaching hospitals than a major revision of resident work hours adopted by training programs five years ago. Those rules reported that residents should not work more than an average of 80 hours per week, among other limits.

"Residency programs already have picked much of the low-hanging fruit by reducing the non-educational duties placed on residents," Nuckols said. "Further changes will require that hospitals hire professionals with high levels of training, such as nurse practitioners and physicians, and that will be expensive."

The IOM, under contract to the Agency for Healthcare Research and Quality (AHRQ), supported the study.