Implementation of 2011 Duty Hours Regulations through a Workload Reduction Strategy and Impact on Residency Training

BACKGROUND: Training programs have implemented the 2011 ACGME duty hour regulations (DHR) using “workload compression” (WLC) strategies, attempting to fit similar clinical responsibilities into fewer working hours, or workload reduction (WLR) approaches, reducing the number of patient encounters per trainee. Many have expressed concern that these strategies could negatively impact patient care and learner outcomes. OBJECTIVE: This study evaluates the medical knowledge and clinical impact of a WLR intervention in a single institution. DESIGN & PARTICIPANTS: Nonrandomized intervention study with comparison to a historical control study among 58 PGY-1 internal medicine trainees in the 2 years after duty hour implementation [exposure cohort (EC), 7/1/2011–6/30/2013], compared to 2 years before implementation [comparison cohort (CC), 7/1/2009–6/30/2011]. MAIN MEASURES: Process outcomes were average inpatient encounters, average new inpatient admissions, and average scheduled outpatient encounters per PGY-1 year. Performance outcomes included trainee inpatient and outpatient days on service, In-Training Examination (ITE) scores as an objective surrogate of medical knowledge, Case-Mix Index (CMI), and quality of care measures (30-day readmission rate, 30-day mortality rate, and average length of stay). KEY RESULTS: Baseline characteristics and average numbers of inpatient encounters per PGY-1 class were similar between the EC and CC. However, the EC experienced fewer new inpatient admissions (157.47 ± 40.47 vs. 181.72 ± 25.45; p < 0.01), more outpatient encounters (64.80 ± 10.85 vs. 56.98 ± 6.59; p < 0.01), and had similar ITE percentiles (p = 0.58). Patients of similar complexity cared for by the EC also had a greater reduction in readmissions (21.21 % to 19.08 %; p < 0.01) than the hospital baseline (12.07 to 11.14 %; p < 0.01). CONCLUSIONS: Our WLR resulted in a small decrease in the average number of new inpatient admissions and an increase in outpatient encounters. ITE and care quality outcomes were maintained or improved. While there is theoretical concern that reducing PGY-1 inpatient admissions volumes may negatively impact education and clinical care measures, this study found no evidence of such a trade-off.