A great piece by Sandeep Jauhar in Slate explores the effects of work hour limitations for medical residents on patient care. The article highlights trade-offs inherent in these policies. On the one hand, sleepy residents make more mistakes. On the other, work restrictions that reduce the total number of hours worked among all residents encourage the use of cross-cover mechanisms (the article talks a lot about night float) which may reduce the continuity of care. This, too, may adversely affect patient care if continuity is important. As Jauhar points out, the ultimate impact of work hour restrictions comes down to an empirical question, and the available evidence appears mixed.
The discontinuous introduction of residency work hour restrictions nationwide, as well as the random assignment of interns and residents to regular and night-float shifts, can be exploited to study the impact of both work hour restrictions as well as different cross-cover mechanisms. With such a transparent identification strategy available, I'm surprised that only two major studies have been done on this issue (even more so since the meta-evidence is inconclusive). Perhaps it is difficult to find data on outcomes or on how the time of residents is allocated?
I'd be curious to start looking at some new data on this if anyone is interested.
2 comments:
Yeah, theres two main reasons that I see for why this type of study hasn't been done.
First, as you say, lack of necessary data. I think most work on this is done within a hospital where they collect data specifically for a given analysis, but do not have panel data across many hospitals and states. I read about some national residency work hours databases. They seem to have good data that could be used for this type of study, but they just post descriptive results online and describe the survey, without providing the actual dataset as a publicly available file.
Second, this type of study might be difficult even with access to necessary data, because of other quality improvement programs that may impact outcomes of interest directly or may moderate the impact of the work hour requirements. The Slate article, for example, talks about handoffs. I'd be worried that there are handoff programs in hospitals that would moderate the impact of the work hours on outcomes. Maybe if there was complete data on this topic, and one used a hospital fixed effect, and also knew something about other programs that may moderate this treatment effect, then it would be possible.
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