An article published in the Journal of Neurosurgery: Spine examines spine surgery outcomes when residents are present after the Accreditation Council for Graduate Medical Education implemented a resident duty-hour restriction in July 2003.
The researchers examined the Nationwide Inpatient Sample to evaluate how duty-hour restrictions impacted complications, mortality, length of stay and charges for patients who underwent spine surgery. Data was examined for patients who underwent spine surgery from 2000 to 2002 and then after the reform was enacted from 2005 to 2008.
There were 693,058 patients included in the study. The researchers found:
1. Complication rate was significantly higher post-reform than in the pre-duty hour restriction era. The overall complication rate was 8.6 percent; the post-reform complication rate was 8.7 percent, compared with 8.4 percent pre-reform.
2. The complication rates decreased in non-teaching hospitals from 8.2 percent pre-reform to 7.6 percent post-reform. However, at teaching hospitals the complication rate increased from 8.6 percent pre-reform to 9.6 percent post-reform.
3. The researchers conducted a difference-in-differences analysis to compare the change between teaching and non-teaching institutions and found teaching institutions had significantly larger complication rate increases in the post-reform era.
4. Overall mortality rate was 0.37 percent among spine surgery patients and there weren't significant differences from the pre- and post-reform periods. But the non-teaching hospital mortality rate significantly decreased — from 0.3 percent to 0.23 percent while it remained flat at teaching institutions at 0.46 percent.
5. The average length of stay was also impacted. Overall, length of stay was 4.2 days on average. The difference between teaching and non-teaching hospitals was:
• Pre-reform at non-teaching hospitals: 3.7 days
• Post-reform at non-teaching hospitals: 3.5 days
• Pre-reform at teaching hospitals: 4.7 days
• Post-reform at teaching hospitals: 4.8 days
6. Total patient chargers were significantly higher in the post-reform era. Pre-reform, the average charge was $40,000; in post-reform the charges were $69,000. However, the DID analysis didn't show significant difference between charge changes at teaching and non-teaching hospitals.
"The implementation of duty-hour restrictions was associated with an increased risk of postoperative complications for patients undergoing spine surgery," concluded the study authors. "Therefore, contrary to its intended purpose, duty-hour reform may have resulted in worse patient outcomes."
However, there were several other factors impacting the spine field between 2000 and 2008. From 1998 to 2008, spinal fusions increased 137 percent — significantly more than other orthopedic procedures performed on the same patient population. There are many reasons for the increase, including more fellowship-trained spine surgeons in new regions of the country and surgical technology advancement.