Cost implications of ACGME's 2011 changes to resident duty hours and the training environment.

backgroundIn July 2011, the Accreditation Council for Graduate Medical Education (ACGME) will implemented stricter duty-hour limits and related changes to the training environment. This may affect preventable adverse event (PAE) rates.

objectivesTo estimate direct costs under various implementation approaches, and examine net costs to teaching hospitals and cost-effectiveness to society across a range of hypothetical changes in PAEs.

designA decision-analytical model represented direct costs and PAE rates, mortality, and costs. DATA SOURCES: Published literature and publicly available data. TARGET POPULATION: Patients admitted to hospitals with ACGME-accredited programs. TIME HORIZON: One year. PERSPECTIVES: All teaching hospitals, major teaching hospitals, society.

interventionACGME's 2011 Common Program Requirements. OUTCOME MEASURES: Direct annual costs (all accredited hospitals), net cost (major teaching hospitals), cost per death averted (society). RESULTS OF BASE-ANALYSIS: Nationwide, duty-hour changes would cost $177 million annually if interns maintain current productivity, vs. up to $982 million if they transfer work to a mixture of substitutes; training-environment changes will cost $204 million. If PAEs decline by 7.2-25.8%, net costs to major teaching hospitals will be zero. If PAEs fall by 3%, the cost to society per death averted would be -$523,000 (95%-confidence interval: -$1.82 million to $685,000) to $2.44 million ($271,000 to $6.91 million). If PAEs rise, the policy will be cost-increasing for teaching hospitals and society. RESULTS OF SENSITIVITY ANALYSIS: The total direct annual cost nationwide would be up to $1.34 billion using nurse practitioners/physician assistants, $1.64 billion using attending physicians, $820 million hiring additional residents, vs. 1.42 billion using mixed substitutes. LIMITATIONS: The effect on PAEs is unknown. Data were limited for some model parameters.

conclusionImplementation decisions greatly affect the cost. Unless PAEs decline substantially, teaching hospitals will lose money. If PAEs decline modestly, the requirements might be cost-saving or cost-effective to society.