Department of Medicine, Milwaukee VAMC/ Medical College of Wisconsin, Milwaukee, WI 53295, USA.
J Gen Intern Med. 2011 Aug;26(8):907-19. doi: 10.1007/s11606-011-1657-1. Epub 2011 Mar 3.
The ACGME-released revisions to the 2003 duty hour standards.
To review the impact of the 2003 duty hour reform as it pertains to resident and patient outcomes.
Medline (1989-May 2010), Embase (1989-June 2010), bibliographies, pertinent reviews, and meeting abstracts.
We included studies examining the relationship between the pre- and post-2003 time periods and patient outcomes (mortality, complications, errors), resident education (standardized test scores, clinical experience), and well-being (as measured by the Maslach Burnout Inventory). We excluded non-US studies.
One rater used structured data collection forms to abstract data on study design, quality, and outcomes. We synthesized the literature qualitatively and included a meta-analysis of patient mortality.
Of 5,345 studies identified, 60 met eligibility criteria. Twenty-eight studies included an objective outcome related to patients; 10 assessed standardized resident examination scores; 26 assessed resident operative experience. Eight assessed resident burnout. Meta-analysis of the mortality studies revealed a significant improvement in mortality in the post-2003 time period with a pooled odds ratio (OR) of 0.9 (95% CI: 0.84, 0.95). These results were significant for medical (OR 0.91; 95% CI: 0.85, 0.98) and surgical patients (OR 0.86; 95% CI: 0.75, 0.97). However, significant heterogeneity was present (I(2) 83%). Patient complications were more nuanced. Some increased in frequency; others decreased. Outcomes for resident operative experience and standardized knowledge tests varied substantially across studies. Resident well-being improved in most studies.
Most studies were observational. Not all studies of mortality provided enough information to be included in the meta-analysis. We used unadjusted odds ratios in the meta-analysis; statistical heterogeneity was substantial. Publication bias is possible.
Since 2003, patient mortality appears to have improved, although this could be due to secular trends. Resident well-being appears improved. Change in resident educational experience is less clear.
ACGME 发布的对 2003 年工时标准的修订。
审查 2003 年工时改革对住院医师和患者结局的影响。
Medline（1989 年-2010 年 5 月）、Embase（1989 年-2010 年 6 月）、参考文献、相关综述和会议摘要。
我们纳入了研究住院医师和患者结局（死亡率、并发症、错误）、住院医师教育（标准化考试成绩、临床经验）和幸福感（用 Maslach 倦怠量表测量）的关系的研究。我们排除了非美国的研究。
一名评估员使用结构化数据收集表格提取研究设计、质量和结果的数据。我们对文献进行了定性综合分析，并对患者死亡率进行了 meta 分析。
在 5345 项研究中，有 60 项符合纳入标准。28 项研究纳入了与患者相关的客观结局；10 项评估了住院医师标准化考试成绩；26 项评估了住院医师手术经验。8 项评估了住院医师倦怠。对死亡率研究的 meta 分析显示，2003 年后死亡率显著改善，汇总优势比（OR）为 0.9（95%可信区间：0.84，0.95）。这些结果对内科（OR 0.91；95%可信区间：0.85，0.98）和外科患者（OR 0.86；95%可信区间：0.75，0.97）均有意义。然而，存在显著的异质性（I²83%）。患者并发症更为复杂。一些并发症的发生率增加，而另一些则减少。住院医师手术经验和标准化知识测试的结果在不同研究中差异很大。大多数研究显示住院医师的幸福感得到改善。
大多数研究为观察性研究。并非所有死亡率研究都提供了足够的信息纳入 meta 分析。我们在 meta 分析中使用了未经调整的优势比；统计学异质性很大。可能存在发表偏倚。
自 2003 年以来，患者死亡率似乎有所改善，尽管这可能是由于时间趋势的影响。住院医师的幸福感似乎有所改善。住院医师教育经验的变化则不太明确。
