Cost Implications of ACGME's 2011 Changes to Resident Duty Hours and the Training Environment

BACKGROUND: In 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. OBJECTIVES: To 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. DESIGN: A 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. INTERVENTION: ACGME'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 $6.91million). 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. CONCLUSION: Implementation 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.