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Original Investigation
From the American Head and Neck Society
February 9, 2017

Association of Otolaryngology Resident Duty Hour Restrictions With Procedure-Specific Outcomes in Head and Neck Endocrine Surgery

Author Affiliations
  • 1Department of Otolaryngology–Head & Neck Surgery, University of Tennessee Health Science Center, Memphis
  • 2Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis
JAMA Otolaryngol Head Neck Surg. Published online February 9, 2017. doi:10.1001/jamaoto.2016.4182
Key Points

Question  What was the impact on surgery-specific outcomes following duty hour implementation for thyroid and parathyroid procedures in teaching hospitals with otolaryngology residents (THs-OTO)?

Findings  In this retrospective analysis of the National Inpatient Sample (2000-2002 vs 2006-2008), THs-OTO contributed a greater share of procedures (18% to 25%). With the earlier period serving as the reference, rates of recurrent laryngeal nerve (RLN) injury, postoperative hematoma, and hypoparathyroidism did not change; however, unintentional vessel lacerations increased and length of stay and mortality decreased.

Meaning  Although unintentional vessel lacerations increased, RLN injury, hematoma, and hypoparathyroidism did not change. Length of stay and mortality improved following duty hour restrictions.

Abstract

Importance  Graduate medical education has undergone a transformation from traditional long work hours to a restricted plan to allow adequate rest for residents. The initial goal of this restriction is to improve patient outcomes.

Objective  To determine whether duty hour restrictions had any impact on surgery-specific outcomes by analyzing complications following thyroid and parathyroid procedures performed before and after duty hour reform.

Design, Setting, and Participants  Retrospective cross-sectional analysis of the National Inpatient Sample (NIS).The NIS was queried for procedure codes associated with thyroid and parathyroid procedures for the years 2000 to 2002 and 2006 to 2008. Hospitals were divided based on teaching status into 3 groups: nonteaching hospitals (NTHs), teaching hospitals without otolaryngology programs (THs), and teaching hospitals with otolaryngology programs (THs-OTO).

Main Outcomes and Measures  Procedure-specific complication rates, length of stay, and mortality rates were collected. SAS statistical software (version 9.4) was used for analysis with adjustment using Charlson comorbidity index.

Results  Total numbers of head and neck endocrine procedures were 34 685 and 39 770 (a 14.7% increase), for 2000 to 2002 and 2006 to 2008, respectively. THs-OTO contributed a greater share of procedures in 2006 to 2008 (from 18% to 25%). With the earlier period serving as the reference, length of stay remained constant (2.1 days); however, total hospital charges increased (from $12 978 to $23 708; P < .001). Rates of postoperative hematoma (odds ratio [OR], 1.21; 95% CI, 1.06-1.38), hypoparathyroidism (OR, 1.27; 95% CI, 1.06-1.52), and unintentional vessel lacerations (OR, 1.36; 95% CI, 1.02-1.83) increased overall with NTHs (OR, 1.26; 95% CI, 1.04-1.52), THs (OR, 1.65; 95% CI, 1.15-2.37), and THs-OTO (OR, 1.98; 95% CI, 1.09-3.61) accounting for these differences, respectively. Overall mortality decreased (OR, 0.66; 95% CI, 0.47-0.94) following a decrease in the TH-OTO mortality rate (OR, 0.34; 95% CI, 0.12-0.93).

Conclusions and Relevance  While recurrent laryngeal nerve injury, hematoma formation, and hypoparathyroidism did not change, length of stay and mortality improved within THs-OTO following head and neck endocrine procedures after implementation of duty hour regulations. This finding refutes the concern that duty hour restrictions result in poorer overall outcomes. Less time available to develop technical competence may play a factor in some outcomes in lieu of recurrent laryngeal nerve injury increasing within THs and accidental injury to vessels, organs, or nerves and hypocalcemia increasing within THs-OTO. Furthermore, head and neck endocrine cases increased at THs with otolaryngology programs.

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