Department of Surgery, Warren Alpert Medical School, Brown University, Providence, RI.
Department of Surgery, Warren Alpert Medical School, Brown University, Providence, RI; Department of Surgery, Rhode Island Hospital, Providence, RI.
J Am Coll Surg. 2016 Jun;222(6):984-91. doi: 10.1016/j.jamcollsurg.2016.01.009. Epub 2016 Feb 22.
In 2011, the ACGME limited duty hours for residents. Although studies evaluating the 2011 policy have not shown improvements in general measures of morbidity or mortality, these outcomes might not reflect changes in specialty-specific practice patterns and secondary quality measures.
All trauma admissions from July 2009 through June 2013 at an academic Level I trauma center were evaluated for 5 primary outcomes (eg, mortality and length of stay), and 10 secondary quality measures and practice patterns (eg, operating room [OR] visits). All variables were compared before and after the reform (July 1, 2011). Piecewise regression was used to study temporal trends in quality.
There were 11,740 admissions studied. The reform was not strongly associated with changes in any primary outcomes except length of stay (7.98 to 7.36 days; p = 0.01). However, many secondary quality metrics changed. The total number of OR and bedside procedures per admission (6.72 to 7.34; p < 0.001) and OR visits per admission (0.76 to 0.91; p < 0.001) were higher in the post-reform group, representing an additional 9,559 procedures and 1,584 OR visits. Use of minor bedside procedures, such as laboratory and imaging studies, increased most significantly.
Although most major outcomes were unaffected, quality of care might have changed after the reform. Indeed, a consistent change in resource use patterns was manifested by substantial post-reform increases in measures such as bedside procedures and OR visits. No secondary quality measures exhibited improvements strongly associated with the reform. Several factors, including attending oversight, might have insulated major outcomes from change. Our findings show that some less-commonly studied quality metrics related to costs of care changed after the 2011 reform at our institution.
2011 年，ACGME 限制住院医师的工作时间。尽管评估 2011 年政策的研究并未显示发病率或死亡率等一般指标的改善，但这些结果可能无法反映专科特定实践模式和次要质量指标的变化。
对 2009 年 7 月至 2013 年 6 月在一家学术性一级创伤中心的所有创伤入院患者进行了 5 项主要结局（例如死亡率和住院时间）和 10 项次要质量措施和实践模式（例如手术室[OR]就诊）的评估。在改革前后（2011 年 7 月 1 日）比较了所有变量。分段回归用于研究质量的时间趋势。
共研究了 11740 例入院患者。改革与除住院时间（7.98 天至 7.36 天；p = 0.01）以外的任何主要结局的变化均无密切关系。然而，许多次要质量指标发生了变化。每例入院的 OR 和床边手术次数（6.72 次至 7.34 次；p < 0.001）和每例入院的 OR 就诊次数（0.76 次至 0.91 次；p < 0.001）在改革后组中更高，代表额外的 9559 次手术和 1584 次 OR 就诊。床边程序等次要程序，如实验室和影像学检查的使用增加最为显著。
尽管大多数主要结局没有受到影响，但改革后护理质量可能发生了变化。实际上，通过改革后床边程序和 OR 就诊等措施的大量增加，表现出资源使用模式的持续变化。没有次要质量指标表现出与改革密切相关的改善。包括主治医生监督在内的多种因素可能使主要结果免受改变。我们的研究结果表明，在我们的机构，与医疗成本相关的一些研究较少的质量指标在 2011 年改革后发生了变化。
