Sunday, December 26, 2010

Should Hospitalists or PAs Really Pick-up Slack of Residents' Reduced Hours?

In 2009, Duke University published research that concluded the reductions in resident hours proximately caused harm to patients
J Bone Joint Surg Am. 2009 Sep;91(9):2079-85.
Resident duty-hour reform associated with increased morbidity following hip fracture.
Browne JA, Cook C, Olson SA, Bolognesi MP.
Division of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710, USA.
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.

University Hospitals routinely utilize "hospitalists" that for all intents and purposes performs all duties (and more) of a resident.  Is that how the hospitals are protecting patients?  If so, how does that explain the fact that Duke Medical's research was performed in 2009 - when hospitalist usage was certainly in full swing.  

The Duke study fails to address the issue of how the lack of hospital hours for the residents effects their preparation to practice medicine.  That omission is significant.

Is this rationing of care to the elderly?  Is this "ObamaCare" by Duke Medical?

According to the Mayo Clinic, fall risks are substantially higher for the elderly.  What is the follow-up research by Dr. Michael Bolognesi?  

And the big question:

Why is Dr. Bolognesi  (and Duke University Medical) continuing to place DePuy ASR Hips into patients when he knows that patients are now (because the federal government reduced resident work hours) more likely to fall and die from hip fractures?  Money?

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