Association between end-of-rotation resident transition in care and mortality among hospitalized patients

Joshua L. Denson, Ashley Jensen, Harry S. Saag, Binhuan Wang, Yixin Fang, Leora I. Horwitz, Laura Evans, Scott Sherman

Research output: Contribution to journalArticle

Abstract

Importance Shift-to-shift transitions in care among house staff are associated with adverse events. However, the association between end-of-rotation transition (in which care of the patient is transferred) and adverse events is uncertain. OBJECTIVE To examine the association of end-of-rotation house staff transitions with mortality among hospitalized patients. DESIGN, SETTING, AND PARTICIPANTS Retrospective multicenter cohort study of patients admitted to internal medicine services (N = 230 701) at 10 university-affiliated US Veterans Health Administration hospitals (2008-2014). EXPOSURES Transition patients (defined as those admitted prior to an end-of-rotation transition who died or were discharged within 7 days following transition) were stratified by type of transition (intern only, resident only, or intern + resident) and compared with all other discharges (control). An alternative analysis comparing admissions within 2 days before transition with admissions on the same 2 days 2 weeks later was also conducted. MAIN OUTCOMES AND MEASURES The primary outcome was in-hospital mortality. Secondary outcomes included 30-day and 90-day mortality and readmission rates. A difference-in-difference analysis assessed whether outcomes changed after the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations. Adjustments included age, sex, race/ethnicity, month, year, length of stay, comorbidities, and hospital. RESULTS Among 230 701 patient discharges (mean age, 65.6 years; men, 95.8%; median length of stay, 3.0 days), 25 938 intern-only, 26 456 resident-only, and 11 517 intern + resident end-of-rotation transitions occurred. Overall mortality was 2.18% in-hospital, 9.45% at 30 days, and 14.43% at 90 days. Adjusted hospital mortality was significantly greater in transition vs control patients for the intern-only and intern + resident groups, but not for the resident-only group. Adjusted 30-day and 90-day mortality rates were greater in all transition vs control comparisons. Duty hour changes were associated with greater adjusted hospital mortality for transition patients in the intern-only and intern + resident groups than for controls (intern-only: odds ratio [OR], 1.11 [95% CI, 1.02-1.21]; intern + resident: OR, 1.17 [95% CI, 1.02-1.34]). The alternative analyses did not demonstrate any significant differences in mortality between transition and control groups. CONCLUSIONS AND RELEVANCE Among patients admitted to internal medicine services in 10 Veterans Affairs hospitals, end-of-rotation transition in care was associated with significantly higher in-hospital mortality in an unrestricted analysis that included most patients, but not in an alternative restricted analysis. The association was stronger following institution of ACGME duty hour regulations.

Original languageEnglish (US)
Pages (from-to)2204-2213
Number of pages10
JournalJAMA - Journal of the American Medical Association
Volume316
Issue number21
DOIs
StatePublished - Dec 6 2016

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Hospital Mortality
Mortality
Graduate Medical Education
Patient Transfer
Accreditation
Internship and Residency
Internal Medicine
Length of Stay
Odds Ratio
Veterans Health
Veterans Hospitals
United States Department of Veterans Affairs
Control Groups
Patient Discharge
Multicenter Studies
Comorbidity
Patient Care
Cohort Studies
Transitional Care

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Association between end-of-rotation resident transition in care and mortality among hospitalized patients. / Denson, Joshua L.; Jensen, Ashley; Saag, Harry S.; Wang, Binhuan; Fang, Yixin; Horwitz, Leora I.; Evans, Laura; Sherman, Scott.

In: JAMA - Journal of the American Medical Association, Vol. 316, No. 21, 06.12.2016, p. 2204-2213.

Research output: Contribution to journalArticle

Denson, Joshua L. ; Jensen, Ashley ; Saag, Harry S. ; Wang, Binhuan ; Fang, Yixin ; Horwitz, Leora I. ; Evans, Laura ; Sherman, Scott. / Association between end-of-rotation resident transition in care and mortality among hospitalized patients. In: JAMA - Journal of the American Medical Association. 2016 ; Vol. 316, No. 21. pp. 2204-2213.
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abstract = "Importance Shift-to-shift transitions in care among house staff are associated with adverse events. However, the association between end-of-rotation transition (in which care of the patient is transferred) and adverse events is uncertain. OBJECTIVE To examine the association of end-of-rotation house staff transitions with mortality among hospitalized patients. DESIGN, SETTING, AND PARTICIPANTS Retrospective multicenter cohort study of patients admitted to internal medicine services (N = 230 701) at 10 university-affiliated US Veterans Health Administration hospitals (2008-2014). EXPOSURES Transition patients (defined as those admitted prior to an end-of-rotation transition who died or were discharged within 7 days following transition) were stratified by type of transition (intern only, resident only, or intern + resident) and compared with all other discharges (control). An alternative analysis comparing admissions within 2 days before transition with admissions on the same 2 days 2 weeks later was also conducted. MAIN OUTCOMES AND MEASURES The primary outcome was in-hospital mortality. Secondary outcomes included 30-day and 90-day mortality and readmission rates. A difference-in-difference analysis assessed whether outcomes changed after the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations. Adjustments included age, sex, race/ethnicity, month, year, length of stay, comorbidities, and hospital. RESULTS Among 230 701 patient discharges (mean age, 65.6 years; men, 95.8{\%}; median length of stay, 3.0 days), 25 938 intern-only, 26 456 resident-only, and 11 517 intern + resident end-of-rotation transitions occurred. Overall mortality was 2.18{\%} in-hospital, 9.45{\%} at 30 days, and 14.43{\%} at 90 days. Adjusted hospital mortality was significantly greater in transition vs control patients for the intern-only and intern + resident groups, but not for the resident-only group. Adjusted 30-day and 90-day mortality rates were greater in all transition vs control comparisons. Duty hour changes were associated with greater adjusted hospital mortality for transition patients in the intern-only and intern + resident groups than for controls (intern-only: odds ratio [OR], 1.11 [95{\%} CI, 1.02-1.21]; intern + resident: OR, 1.17 [95{\%} CI, 1.02-1.34]). The alternative analyses did not demonstrate any significant differences in mortality between transition and control groups. CONCLUSIONS AND RELEVANCE Among patients admitted to internal medicine services in 10 Veterans Affairs hospitals, end-of-rotation transition in care was associated with significantly higher in-hospital mortality in an unrestricted analysis that included most patients, but not in an alternative restricted analysis. The association was stronger following institution of ACGME duty hour regulations.",
author = "Denson, {Joshua L.} and Ashley Jensen and Saag, {Harry S.} and Binhuan Wang and Yixin Fang and Horwitz, {Leora I.} and Laura Evans and Scott Sherman",
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T1 - Association between end-of-rotation resident transition in care and mortality among hospitalized patients

AU - Denson, Joshua L.

AU - Jensen, Ashley

AU - Saag, Harry S.

AU - Wang, Binhuan

AU - Fang, Yixin

AU - Horwitz, Leora I.

AU - Evans, Laura

AU - Sherman, Scott

PY - 2016/12/6

Y1 - 2016/12/6

N2 - Importance Shift-to-shift transitions in care among house staff are associated with adverse events. However, the association between end-of-rotation transition (in which care of the patient is transferred) and adverse events is uncertain. OBJECTIVE To examine the association of end-of-rotation house staff transitions with mortality among hospitalized patients. DESIGN, SETTING, AND PARTICIPANTS Retrospective multicenter cohort study of patients admitted to internal medicine services (N = 230 701) at 10 university-affiliated US Veterans Health Administration hospitals (2008-2014). EXPOSURES Transition patients (defined as those admitted prior to an end-of-rotation transition who died or were discharged within 7 days following transition) were stratified by type of transition (intern only, resident only, or intern + resident) and compared with all other discharges (control). An alternative analysis comparing admissions within 2 days before transition with admissions on the same 2 days 2 weeks later was also conducted. MAIN OUTCOMES AND MEASURES The primary outcome was in-hospital mortality. Secondary outcomes included 30-day and 90-day mortality and readmission rates. A difference-in-difference analysis assessed whether outcomes changed after the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations. Adjustments included age, sex, race/ethnicity, month, year, length of stay, comorbidities, and hospital. RESULTS Among 230 701 patient discharges (mean age, 65.6 years; men, 95.8%; median length of stay, 3.0 days), 25 938 intern-only, 26 456 resident-only, and 11 517 intern + resident end-of-rotation transitions occurred. Overall mortality was 2.18% in-hospital, 9.45% at 30 days, and 14.43% at 90 days. Adjusted hospital mortality was significantly greater in transition vs control patients for the intern-only and intern + resident groups, but not for the resident-only group. Adjusted 30-day and 90-day mortality rates were greater in all transition vs control comparisons. Duty hour changes were associated with greater adjusted hospital mortality for transition patients in the intern-only and intern + resident groups than for controls (intern-only: odds ratio [OR], 1.11 [95% CI, 1.02-1.21]; intern + resident: OR, 1.17 [95% CI, 1.02-1.34]). The alternative analyses did not demonstrate any significant differences in mortality between transition and control groups. CONCLUSIONS AND RELEVANCE Among patients admitted to internal medicine services in 10 Veterans Affairs hospitals, end-of-rotation transition in care was associated with significantly higher in-hospital mortality in an unrestricted analysis that included most patients, but not in an alternative restricted analysis. The association was stronger following institution of ACGME duty hour regulations.

AB - Importance Shift-to-shift transitions in care among house staff are associated with adverse events. However, the association between end-of-rotation transition (in which care of the patient is transferred) and adverse events is uncertain. OBJECTIVE To examine the association of end-of-rotation house staff transitions with mortality among hospitalized patients. DESIGN, SETTING, AND PARTICIPANTS Retrospective multicenter cohort study of patients admitted to internal medicine services (N = 230 701) at 10 university-affiliated US Veterans Health Administration hospitals (2008-2014). EXPOSURES Transition patients (defined as those admitted prior to an end-of-rotation transition who died or were discharged within 7 days following transition) were stratified by type of transition (intern only, resident only, or intern + resident) and compared with all other discharges (control). An alternative analysis comparing admissions within 2 days before transition with admissions on the same 2 days 2 weeks later was also conducted. MAIN OUTCOMES AND MEASURES The primary outcome was in-hospital mortality. Secondary outcomes included 30-day and 90-day mortality and readmission rates. A difference-in-difference analysis assessed whether outcomes changed after the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations. Adjustments included age, sex, race/ethnicity, month, year, length of stay, comorbidities, and hospital. RESULTS Among 230 701 patient discharges (mean age, 65.6 years; men, 95.8%; median length of stay, 3.0 days), 25 938 intern-only, 26 456 resident-only, and 11 517 intern + resident end-of-rotation transitions occurred. Overall mortality was 2.18% in-hospital, 9.45% at 30 days, and 14.43% at 90 days. Adjusted hospital mortality was significantly greater in transition vs control patients for the intern-only and intern + resident groups, but not for the resident-only group. Adjusted 30-day and 90-day mortality rates were greater in all transition vs control comparisons. Duty hour changes were associated with greater adjusted hospital mortality for transition patients in the intern-only and intern + resident groups than for controls (intern-only: odds ratio [OR], 1.11 [95% CI, 1.02-1.21]; intern + resident: OR, 1.17 [95% CI, 1.02-1.34]). The alternative analyses did not demonstrate any significant differences in mortality between transition and control groups. CONCLUSIONS AND RELEVANCE Among patients admitted to internal medicine services in 10 Veterans Affairs hospitals, end-of-rotation transition in care was associated with significantly higher in-hospital mortality in an unrestricted analysis that included most patients, but not in an alternative restricted analysis. The association was stronger following institution of ACGME duty hour regulations.

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