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Resident Duty-Hour Reform Associated with Increased Morbidity Following Hip Fracture
James A. Browne, MD1; Chad Cook, PhD, MBA, PT2; Steven A. Olson, MD3; Michael P. Bolognesi, MD4
1 Division of Orthopaedic Surgery, DUMC Box 3000, Orange Zone, Duke Clinics Building, Trent Drive, Duke University Medical Center, Durham, NC 27710
2 Department of Surgery, Duke University Medical Center, DUMC Box 3907, Durham, NC 27710
3 Division of Orthopaedic Surgery, Department of Surgery, Duke University Medical Center, 2504 Duke South Blue Zone, Durham, NC 27710
4 Division of Orthopaedic Surgery, Department of Surgery, Duke University Medical Center, DUMC Box 3269, Room 5316, Duke Clinics Building, Durham, NC 27710
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from commercial entities (Zimmer, DePuy, and Wright Medical).
A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM/DVD (call our subscription department, at 781-449-9780, to order the CD-ROM or DVD).
Investigation performed at the Division of Orthopaedic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Sep 01;91(9):2079-2085. doi: 10.2106/JBJS.H.01240
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Background: The Accreditation Council for Graduate Medical Education implemented resident duty-hour reform for orthopaedic resident surgeons in the United States on July 1, 2003. This study sought to determine whether the change in duty-hour regulations was associated with relative changes in mortality and morbidity for patients with a hip fracture treated in hospitals with and without resident teaching involved in the delivery of medical care.

Methods: The Nationwide Inpatient Sample database was used to identify 48,430 patients treated for hip fracture during the years of 2001 to 2002, before resident duty-hour reform, and the years of 2004 to 2005 after reform. Logistic regression was used to examine the change in morbidity and mortality in nonteaching compared with teaching hospitals before and after the reform, adjusting for patient characteristics and comorbidities.

Results: An increase in the overall incidence of perioperative morbidity was observed in both teaching and nonteaching hospitals, suggesting a general increase in the severity of illness of the patients with a hip fracture. A significant increase in the rate of change in the incidence of perioperative pneumonia, hematoma, transfusion, renal complications, nonroutine discharge, costs, and length of stay was seen in patients who underwent treatment for a hip fracture in the years after the resident duty-hour reforms at teaching institutions. Resident duty-hour reform was not associated with an increase in mortality.

Conclusions: Resident duty-hour reform was associated with an accelerated rate of increasing patient morbidity following treatment of hip fractures in teaching institutions. Further research into this concerning finding is needed.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    James A. Browne, MD
    Posted on October 22, 2009
    Dr. Browne and colleagues respond to Mr. O'Neill
    Mayo Clinic

    We thank Mr. O’Neill for his interest in our paper and for sharing his own perspective on duty-hour restrictions. We agree that the delivery of healthcare is a complex process and that patient care depends on many variables.

    While interesting, the assertion that residents now have more time and energy to document co-morbidities and complications for their patients is pure speculation. Conversely, one could also theorize that resident physicians, in an attempt to maximize time involved in patient care and their operative experience, are neglecting their administrative duties in order to satisfy their work-hour restrictions. Given the constraints of the 80-hour work week, residents could be expected to spend a lower percentage of their time on documentation to optimize other aspects of their training. By this logic, one would expect the rate of documented complications to decline.

    We prefer to base our argument on the available evidence. There is no data, to our knowledge, that supports an improvement in documentation habits of residents when duty hour restrictions are imposed. However, the increased number of resident handoffs following duty hour reform has been well documented (1). Multiple studies have demonstrated deficits in communication and information transfer leading to adverse patient outcomes (2-6). The available evidence clearly supports the assertion that transfers of patient care from one physician to another may be associated with an adverse event. Needless to say, our particular study methodology was not structured to allow us to look at this specific factor as it relates to the observed complications, so we are left to extrapolate from other available studies.

    Furthermore, we believe that it is highly unlikely that hospitals in the United States would rely exclusively on resident documentation to determine the final reporting of complications. Reimbursement is largely dependent upon accurate coding and documentation. At our institution, the coding for final discharge diagnoses and coding of co-morbidities and complications is completed by a group of individuals who specialize in this activity, and does not rely on a single resident’s documentation for accuracy. Perhaps secondary to differences in the reimbursement systems, the National Health Service in the United Kingdom may not be analogous to the U.S. healthcare system in the role of resident physicians and documentation. The American College of Surgeons has been explicit in stating that it is inappropriate for teaching hospitals to rely upon residents to perform tasks that are not directly related to either education or patient care (7).

    The issue of duty hours and patient care is both complex and important. We acknowledge the limitations of using an administrative database in our study. It is our hope that this preliminary study will lead to a critical review of this issue in the interest of patient care and encourage other investigators to find data from the U.S. healthcare system that confirm or refute our observations.


    1. Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. 2006;1:257-66.

    2. Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121:866-72.

    3. Arora V, Kao J, Lovinger D, Seiden SC, Meltzer D. Medication discrepancies in resident sign-outs and their potential to harm. J Gen Intern Med. 2007;22:1751-5.

    4. Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of inadequate sign-out for patient care. Arch Intern Med. 2008;168:1755-60.

    5. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14:401-7.

    6. Okie S. An elusive balance--residents' work hours and the continuity of care. N Engl J Med. 2007;356:2665-7.

    7. American College of Surgeons. Statement on residency work hours. http://www.facs.org/fellows_info/statements/st-39.html. Accessed 2009 Oct 21.

    Barry J. O'Neill
    Posted on October 08, 2009
    Resident Duty Hour Reform Associated with Increased Recording of Morbidity Following Hip Fracture
    Limerick Regional Hospitals, Ireland

    To the Editor:

    As an orthopaedic trainee who was employed by the National Health Service in the United Kingdom when the European Working Time Directive was implemented, I can sympathize entirely with the motivational factors behind the recent study by Browne et al (1). The number of training hours lost to trainees in the 'interests' of trainee well-being, with (in the UK system at least) little or no flexibility and no allowance for trainee discretion, is frustrating in the extreme. So I have to applaud Browne et al. on their attempt to highlight some of the problems that the new restrictions have produced.

    I would however, raise a point that I think has been entirely overlooked in this particular study. The methodology of the study states that data were collected from the Nationwide Inpatient Sample (NIS), which is simply a summary of recorded discharge data. The authors use this system to highlight an increase in the incidence of pneumonia, hematoma, transfusion, and renal complications. They go on to say that, "consistent with our results, some recent studies have suggested that limiting work hours has had an adverse impact on patient outcome". The suggestion is that an increased number of hand-offs and an increase in the number of clinicians caring for each patient, have resulted in an increase in post-surgical complications such as pneumonia, hematoma, transfusion, and renal complications. In my experience, patients who develop these particular complications do so because of a variety of factors, and to suggest that an increase in the incidence of these complications is related to the new restricted working hours seems a bit simplistic.

    I would put it to Browne et al., that the incidence of these complications has in fact not changed significantly since the introduction of the resident duty hour reform, but that the resident duty hour reform has simply resulted in an increase in the documentation of complications on discharge summaries logged in the NIS. Put simply, residents now have more time and more energy at the end of a shift to complete their documentation fully and to record complications on discharge summaries that previously may not have been documented at all.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.


    1. Browne JA, Cook C, Olson SA, Bolognesi MP. Resident duty-hour reform associated with increased morbidity following hip fracture. J Bone Joint Surg Am. 2009;91:2079-85.

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