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Table 1.  
Number of Hospitals Included Within Each Groupinga
Number of Hospitals Included Within Each Groupinga
Table 2.  
List of Procedure-Specific Head and Neck Endocrine Surgical Complications, ICD-9 CM Codes Included in the Analysis
List of Procedure-Specific Head and Neck Endocrine Surgical Complications, ICD-9 CM Codes Included in the Analysis
Table 3.  
Procedure-Specific Complications Compared Within the Study Period 2000-2002 Between the 3 Groups With NTHs as the Reference Group
Procedure-Specific Complications Compared Within the Study Period 2000-2002 Between the 3 Groups With NTHs as the Reference Group
Table 4.  
Procedure-Specific Complications Compared Within the Study Period 2006-2008 Between the 3 Groups With NTHs as the Reference Group
Procedure-Specific Complications Compared Within the Study Period 2006-2008 Between the 3 Groups With NTHs as the Reference Group
Table 5.  
Procedure-Specific Complications Compared Between the 2 Periods
Procedure-Specific Complications Compared Between the 2 Periods
1.
Biron  VL, Bang  H, Farwell  DG, Bewley  AF.  National trends and factors associated with hospital costs following thyroid surgery.  Thyroid. 2015;25(7):823-829.Google ScholarCrossref
2.
Fraser  WD.  Hyperparathyroidism.  Lancet. 2009;374(9684):145-158.PubMedGoogle ScholarCrossref
3.
Horne  JA, Reyner  LA.  Sleep related vehicle accidents.  BMJ. 1995;310(6979):565-567.PubMedGoogle ScholarCrossref
4.
Lockley  SW, Barger  LK, Ayas  NT, Rothschild  JM, Czeisler  CA, Landrigan  CP; Harvard Work Hours, Health and Safety Group.  Effects of health care provider work hours and sleep deprivation on safety and performance.  Jt Comm J Qual Patient Saf. 2007;33(11)(suppl):7-18.PubMedGoogle ScholarCrossref
5.
Marcus  CL, Loughlin  GM.  Effect of sleep deprivation on driving safety in housestaff.  Sleep. 1996;19(10):763-766.PubMedGoogle ScholarCrossref
6.
NCSDR/NHTSA Expert Panel on Driver Fatigue and Sleepiness. Drowsy Driving and Automobile Crashes. Washington, DC; National Center on Sleep Disorders Research and National Highway Traffic Safety Administration; 1997. https://www.nhlbi.nih.gov/files/docs/resources/sleep/drsy_drv.pdf. Accessed June 2016.
7.
Steele  MT, Ma  OJ, Watson  WA, Thomas  HA  Jr, Muelleman  RL.  The occupational risk of motor vehicle collisions for emergency medicine residents.  Acad Emerg Med. 1999;6(10):1050-1053.PubMedGoogle ScholarCrossref
8.
Zarebczan  B, McDonald  R, Rajamanickam  V, Leverson  G, Chen  H, Sippel  RS.  Training our future endocrine surgeons: a look at the endocrine surgery operative experience of US surgical residents.  Surgery. 2010;148(6):1075-1080.Google ScholarCrossref
9.
Monteiro  R, Mino  JS, Siperstein  AE.  Trends and disparities in education between specialties in thyroid and parathyroid surgery: an analysis of 55,402 NSQIP patients.  Surgery. 2013;154(4):720-728.PubMedGoogle ScholarCrossref
10.
Chambers  KJ, Bhattacharyya  N.  The increasing role of otolaryngology in the management of surgical thyroid disorders.  Laryngoscope. 2013;123(12):3239-3242.PubMedGoogle ScholarCrossref
11.
Babu  R, Thomas  S, Hazzard  MA,  et al.  Worse outcomes for patients undergoing brain tumor and cerebrovascular procedures following the ACGME resident duty-hour restrictions.  J Neurosurg. 2014;121(2):262-276.PubMedGoogle ScholarCrossref
12.
Dumont  TM, Tranmer  BI, Horgan  MA, Rughani  AI.  Trends in neurosurgical complication rates at teaching vs nonteaching hospitals following duty-hour restrictions.  Neurosurgery. 2012;71(5):1041-1046.PubMedGoogle ScholarCrossref
13.
Browne  JA, Cook  C, Olson  SA, Bolognesi  MP.  Resident duty-hour reform associated with increased morbidity following hip fracture.  J Bone Joint Surg Am. 2009;91(9):2079-2085.PubMedGoogle ScholarCrossref
14.
Hoh  BL, Neal  DW, Kleinhenz  DT, Hoh  DJ, Mocco  J, Barker  FG  II.  Higher complications and no improvement in mortality in the ACGME resident duty-hour restriction era: an analysis of more than 107,000 neurosurgical trauma patients in the Nationwide Inpatient Sample database.  Neurosurgery. 2012;70(6):1369-1381.Google ScholarCrossref
15.
Gopaldas  RR, Chu  D, Dao  TK,  et al.  Impact of ACGME work-hour restrictions on the outcomes of coronary artery bypass grafting in a cohort of 600,000 patients.  J Surg Res. 2010;163(2):201-209.PubMedGoogle ScholarCrossref
16.
Healthcare Cost and Utilization Project. Overview of HCUP. 2015. http://www.hcup-us.ahrq.gov/overview.jsp, 2015. Accessed June 2016.
17.
Vadera  S, Griffith  SD, Rosenbaum  BP,  et al.  National incidence of medication error in surgical patients before and after Accreditation Council for Graduate Medical Education duty-hour reform.  J Surg Ed. 2015;72(6):1209-1216.Google ScholarCrossref
18.
Babu  R, Thomas  S, Hazzard  MA,  et al.  Morbidity, mortality, and health care costs for patients undergoing spine surgery following the ACGME resident duty-hour reform: Clinical article.  J Neurosurg Spine. 2014;21(4):502-515.PubMedGoogle ScholarCrossref
19.
Vanderveen  K, Chen  M, Scherer  L.  Effects of resident duty-hours restrictions on surgical and nonsurgical teaching faculty.  Arch Surg. 2007;142(8):759-764.Google ScholarCrossref
20.
Coverdill  JE, Finlay  W, Adrales  GL,  et al.  Duty-hour restrictions and the work of surgical faculty: results of a multi-institutional study.  Acad Med. 2006;81(1):50-56.PubMedGoogle ScholarCrossref
21.
Karamanoukian  RL, Ku  JK, DeLaRosa  J, Karamanoukian  HL, Evans  GR.  The effects of restricted work hours on clinical training.  Am Surg. 2006;72(1):19-21.PubMedGoogle Scholar
22.
Immerman  I, Kubiak  EN, Zuckerman  JD.  Resident work-hour rules: a survey of residents’ and program directors’ opinions and attitudes.  Am J Orthop. 2007;36(12):E172-E179.Google Scholar
23.
Salim  A, Teixeira  PG, Chan  L,  et al.  Impact of the 80-hour workweek on patient care at a level I trauma center.  Arch Surg. 2007;142(8):708-712.Google ScholarCrossref
24.
Norby  K, Siddiq  F, Adil  MM, Haines  SJ.  The effect of duty hour regulations on outcomes of neurological surgery in training hospitals in the United States: duty hour regulations and patient outcomes.  J Neurosurg. 2014;121(2):247-261.PubMedGoogle ScholarCrossref
25.
Desai  SV, Feldman  L, Brown  L,  et al.  Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial.  JAMA Intern Med. 2013;173(8):649-655.PubMedGoogle ScholarCrossref
26.
Karam  M, Roberts-Klein  S, Shet  N, Chang  J, Feustel  P.  Bilateral hilar foci on 18F-FDG PET scan in patients without lung cancer: variables associated with benign and malignant etiology.  J Nucl Med. 2008;49(9):1429-1436.PubMedGoogle ScholarCrossref
27.
Bergenfelz  A, Jansson  S, Kristoffersson  A,  et al.  Complications to thyroid surgery: results as reported in a database from a multicenter audit comprising 3,660 patients.  Langenbecks Arch Surg. 2008;393(5):667-673.Google ScholarCrossref
28.
Bilimoria  KY, Chung  JW, Hedges  LV,  et al.  Development of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial protocol: a national cluster-randomized trial of resident duty hour policies.  JAMA Surg. 2016;151(3):273-281.PubMedGoogle ScholarCrossref
29.
Ahmed  N, Devitt  KS, Keshet  I,  et al.  A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes.  Ann Surg. 2014;259(6):1041-1053.PubMedGoogle ScholarCrossref
30.
Chang  YC, Chiao  CC.  Localization and functional mapping of AMPA receptor subunits in the developing rabbit retina.  Invest Ophthalmol Vis Sci. 2008;49(12):5619-5628.PubMedGoogle ScholarCrossref
31.
National Resident Matching Program. Results and Data: 2007 Main Residency Match. National Resident Matching Program; 2007. http://www.nrmp.org/wp-content/uploads/2013/08/resultsanddata2007.pdf. Accessed January 24, 2017.
32.
National Resident Matching Program. Results and Data: 2006 Main Residency Match. National Resident Matching Program; 2006. http://www.nrmp.org/wp-content/uploads/2013/08/resultsanddata2006.pdf. Accessed January 24, 2017.
33.
Andriole  DA, Schechtman  KB, Ryan  K, Whelan  A, Diemer  K.  How competitive is my surgical specialty?  Am J Surg. 2002;184(1):1-5.PubMedGoogle ScholarCrossref
34.
Lansford  CD, Fisher  SR, Ossoff  RH, Chole  RA.  Otolaryngology-head and neck surgery residency match: applicant survey.  Arch Otolaryngol Head Neck Surg. 2004;130(9):1017-1023.PubMedGoogle ScholarCrossref
35.
Cabrera-Muffly  C, Sheeder  J, Abaza  M.  State of the otolaryngology match: has competition increased since the “early” match?  Otolaryngol Head Neck Surg. 2015;152(5):838-842. PubMedGoogle ScholarCrossref
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Original Investigation
From the American Head and Neck Society
June 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. 2017;143(6):549-554. 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.

Introduction

Although surgery for benign thyroid disease can be performed in an outpatient surgery setting, thyroid disease still frequently requires an inpatient setting.1 Primary hyperparathyroidism is the most common cause of hypercalcemia and the third most common endocrine disorder.2 Owing to the importance of this disease burden, the training of individuals administering care to these patients should be periodically examined. Duty hour reform gives us a unique opportunity for such an examination.

The beginning of the 2005 academic calendar marked implementation of the initial Accreditation Council for Graduate Medical Education (ACGME) duty hour restrictions on all resident physicians. The overall goal was to achieve better patient outcomes by reducing resident fatigue and sleep deprivation. Cognitive and clinical performance declines associated with sleep deprivation could be avoided. Furthermore, personal safety issues, such as needle stick injuries and motor vehicle crashes, could be averted owing to these restrictions with more emphasis placed on resident quality of life.3-7

Otolaryngologists, general surgeons, and endocrine surgeons perform most head and neck endocrine surgical procedures. Which specialty performs more head and neck endocrine procedures as residents is up for debate,8,9 but it seems that otolaryngologists are now managing more surgical thyroid disorders.10 For 2015, general surgery graduates were required to log 8 of any endocrine procedures, while otolaryngology graduates were required to log 22 thyroid and parathyroid cases, suggesting an experiential difference between the specialties. While otolaryngology and general surgery residents are subject to duty hour restrictions, endocrine surgery is a 1-year fellowship following general surgery residency and is not subject to the same duty hour restrictions mandated by the ACGME.

Duty hour restrictions limit a resident to a 24-hour continuous workload with a 6-hour period of transition, every third night call, a 10-hour rest between duty periods, an 80-hour work week, and 1 in 7 days free of patient care responsibilities.11 Studies in neurosurgery, orthopedic surgery, and cardiac surgery programs have looked at outcomes using the National Inpatient Sample (NIS) database with mixed results.12-15 We aimed to characterize any differences in head and neck endocrine procedure-specific complications before and after duty hour reform within the NIS.

Methods

The NIS was developed by the Agency for Healthcare Research and Quality (AHRQ) specifically to analyze health care outcomes. This series of databases contains information regarding patient demographics, geographic region, diagnoses, procedures, length of stay (LOS), and hospital characteristics.16 The International Classification of Diseases, Ninth Revision, Clinical Modification(ICD-9-CM), procedure codes correlating to head and neck endocrine procedures were extracted, including unilateral thyroid lobectomy (code 06.2), other partial thyroidectomy (06.3), complete thyroidectomy (06.4), substernal thyroidectomy (06.5), excision of lingual thyroid (06.6), excision of thyroglossal duct or tract (06.7), and parathyroidectomy (06.8). These ICD-9-CM codes were compared before and after the duty hour restrictions took effect. The first period included the years 2000, 2001, and 2002, while the second included 2006, 2007, and 2008 (years 2003-2005 represent the time during which graduated implementation of duty hour restrictions took place).

A teaching status variable exists within the data set; however, this variable is divided only into nonteaching (NTHs) vs teaching hospitals without otolaryngology programs (THs). Previous studies failed to divide teaching hospitals into those with and without a specialty’s respective training program. In our investigation, we found most THs did not have otolaryngology residents. This discovery led to dividing the THs into 2 new groupings: THs and THs with otolaryngology residents (THs-OTO). To create these new groupings, we searched the websites of all known otolaryngology training programs to find the hospitals associated with these programs and sorted institutions based on state, city, and address to correlate with known otolaryngology training programs. Therefore, we then had 3 groupings: NTHs, THs, and THs-OTO. States that did not report hospital-specific information or did not report teaching status were omitted. A summary of those states and number of hospitals included can be found in Table 1.

Discharge weights are available within the database to calculate national estimates; however, these weights were not applied because multiple states were omitted in the hospital stratification process. SAS statistical software (version 9.4; SAS Institute Inc) was used to compare surgical complications individually (Table 2) using multivariate logistic regression for dichotomous variables and multivariate linear regression for continuous variables with significance at P < .05. Cost, LOS, and mortality were also studied. The Romano adaptation of the Charlson comorbidity index (CCI) was built into the analysis as a continuous variable to account for comorbidities (the CCI range was 0-7, while 80% were CCIs of 0-1). Those columns within the data set with fewer than 10 entries were omitted owing to the AHRQ limitations set forth in the Data Use Agreement. Exemption was obtained from the University of Tennessee institutional review board owing to this study’s analysis of preexisting public data.

Results
Comparison of NTHs, THs, and THs-OTO Within the Pre–Duty Hour Period (2000-2002)

Nonteaching facilities served as the control with hypoparathyroidism occurring less frequently in THs (odds ratio [OR], 0.64; 95% CI, 0.46-0.91) and hypocalcemia occurring less at THs-OTO (OR, 0.72; 95% CI, 0.62-0.83); however, recurrent laryngeal nerve (RLN) injury occurred more often at THs-OTO (OR, 2.14; 95% CI, 1.58-2.90) (Table 3). Hypocalcemia also occurred more often at THs (OR 1.12; 95% CI, 1.01-1.25). Median LOS and total charges were the same between NTHs, THs, and THs-OTO (2.12 vs 2.08 vs 2.13 days, respectively, and $12 852.98, $12 837.59, and $13 533.77, respectively). Overall, each point increase in CCI was associated with an increased risk for RLN injury (ORs 1.97; 95% CI, 1.75-2.22]), hypocalcemia (ORs 1.62; 95% CI, 1.41-1.86), hypoparathyroidism (ORs 1.52; 95% CI, 1.45-1.60), and mortality (OR, 3.37; 95% CI, 2.81-4.05).

Comparison of Post–Duty Hour Period (2006-2008)

Nonteaching facilities served as the control with no differences noted between NTH and TH. Hypoparathyroidism (OR, 0.68; 95% CI, 0.51-0.92) hypocalcemia (OR, 0.88; 95% CI, 0.79-0.98]), and mortality (OR, 0.33; 95% CI, 0.15-0.76) occurred less frequently at THs-OTO. Compared with NTH within this second period, THs-OTO had more RLN injury (OR, 1.38; 95% CI, 1.07-1.78) and accidental lacerations (OR, 2.03; 95% CI, 1.33-3.08) (Table 4). Median LOS was slightly less at THs-OTO than NTHs and THs (2.02 vs 2.12 vs 2.15 days, respectively). Median total charges were the same among NTHs, THs, and THs-OTO ($23 970.85, $23 389.84, and $23 574.45, respectively). Again, each point increase in CCI was associated with an increased risk for RLN injury (OR, 1.77; 95% CI, 1.62-1.94), hypocalcemia (OR, 1.44; 95% CI, 1.29-1.60), hypoparathyroidism (OR, 1.42; 95% CI, 1.36-1.44), and mortality (OR, 2.78; 95% CI, 2.35-3.30).

Comparisons Between the Duty Hour Periods (2000-2002 vs 2006-2008)

The total number of head and neck endocrine procedures was 34 685 for 2000 to 2002 and 39 770 for 2006 to 2008 (14.66% increase overall) with THs-OTO contributing a greater share of procedures in 2006 to 2008 (from 18% to 25%) (Table 5). Overall, there was an increase in the rate of hematomas (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) from 2000 to 2002, to 2006 to 2008. These overall increased frequencies corresponded with an increase in hematoma formation at NTHs (OR, 1.26; 95% CI, 1.04-1.52), an increase in hypoparathyroidism at THs (OR, 0.84; 95% CI, 0.75-0.94), and an increase in unintentional vessel lacerations at THs-OTO (OR, 1.98; 95% CI, 1.09-3.60). Furthermore, THs had an increase in rates of RLN injury (OR, 1.53; 95% CI, 1.11-2.10), but a decrease in rate of hypocalcemia (OR, 0.84 ; 95% CI, 0.75-0.94). Within THs-OTO, hypocalcemia (OR, 1.24; 95% CI, 1.06-1.45) increased. TH-OTO RLN injury did not change between the time periods (OR, 0.79; 95% CI, 0.59-1.07); however, when compared with NTHs in each time period, the OR decreased (from OR, 1.98; 95% CI, 1.46-2.68 in 2000 to 2002 to OR, 1.33; 95% CI, 1.03-1.72 in 2006 to 2008).

Overall mean charges increased from $12 978.29 to $23 708.11 (difference, $10 729.82; 95% CI, $10 312.66-$11 146.98) with consistent increases between each hospital type 9 (NTHs: from $12 852.98 to $23 970.85; difference, $11 117.87; 95% CI, $10 522.14-$11 713.60; THs: from $12 837.59 to $23 389.84; difference, $10 552.25; 95% CI, $9788.50-$11 316.00; THs-OTO: from $13 533.27 to $23 574.45; difference, $10 041.18; 95% CI, $9122.43-$10 959.93). Median LOS did not increase overall (2.1 days) but did show a decrease in THs-OTO (from 2.13 to 2.01 days; P < .002). Mortality rate decreased (OR, 0.66; 95% CI, 0.47-0.94), which corresponded to a decrease in mortality rate of procedures performed at THs-OTO (OR, 0.34; 95% CI, 0.12-0.93). Mortality rates for NTHs (0.02%) and THs (0.02%) remained the same.

Discussion

The ultimate goal of graduate medical education duty hour restrictions is to improve patient outcomes by reducing sleep deprivation and improving performance of residents in training.

Certain complications and LOS have been shown to increase after the implementation of duty hour restrictions,17 although this finding remains controversial.18 Some teaching programs believe the new standards are barriers to effective training19-21 with advocacy for loosening the restrictions, increasing the length of residency, or restructuring programs. Opponents of the duty hour restrictions fear that patient outcomes will deteriorate rather than improve as a result of residents taking less ownership of patients, less time caring for medically complex patients, and less time improving surgical skills.22 Our findings suggest that duty hour restrictions have not been associated with an overall deterioration in patient outcomes for head and neck endocrine procedures.

Although RLN injury at THs and hypocalcemia and unintentional lacerations to vessels, nerves, or organs at THs-OTO increased slightly and could indicate a decrease in surgical proficiency, these complications could be explained by better coding when a complication occurs. In addition, while medical comorbidity could be adjusted for using the CCI, adjustment for surgical complexity could not be made. Teaching hospitals with otolaryngology programs may represent tertiary referral otolaryngology centers with a higher degree of complexity comparatively and may account for slightly worse outcomes, including unintentional laceration. Furthermore, and most important for THs-OTO, hematoma formation and RLN injury did not increase while mortality and LOS actually improved. Other factors, such as possible increased attending oversight or concentration of head and neck endocrine procedures into THs, could account for some differences noted. Nonteaching hospitals were to serve as a control in this investigation were complications to remain constant; however, an increase in hematoma formation was noted. This finding is worrisome, but it is difficult to fully elucidate the factors leading to it.

The best advantage to using such a robust data set like the NIS is that the power of the study is increased compared with most retrospective reviews. Owing to this major advantage, many investigators have characterized the effect of duty hours on patient outcomes in trauma surgery,23 neurosurgery,24 medicine,25 and orthopedic surgery.13 These studies failed to divide THs into those with and without that specialty’s respective training program. This discovery led to dividing the THs into 2 new groupings: THs and THs-OTO. Even with this distinction, THs-OTO may also have general surgery training programs, thus combining outcomes from both specialties. Moreover, the THs may aggregate outcomes from general surgery trainees and private surgeons. However, such a large data set should still reflect differences between the training specialties.

Limitations

Large data sets come with several inherent limitations. Only ICD-9-CM procedure codes are used for the coding of procedures; Current Procedural Terminology codes are not found within the data set. Miscoding can occur within any data set that uses ICD-9-CM coding schema; however, miscoding should be present throughout the data set with relative consistency. The number of ancillary staff members, disposition issues following surgery- or patient-specific circumstances could not be assessed, nor could complications following discharge. Since the increase in some complications occurred after the duty hour restrictions took effect, sleep deprivation should not be associated to the same degree as previously; however, adherence to the duty hour policy by residents could not be assessed. There is no way to prove causation based on these findings but rather an association between the duty hour change and complications before and afterward.

Intraoperative nerve monitoring was not available until 2007 in the data sets owing to ICD-9-CM coding limitations (code 00.94 was not available prior to 2007); therefore, this variable could not be assessed in this study.26 Another confounder affecting rates of detection RLN injury and vocal cord paresis is the disparity in performing postoperative laryngoscopy between otolaryngologists and general surgeons. In a Scandinavian database study,27 routine laryngoscopy (which may be performed more often by otolaryngologists) was associated with a higher rate of vocal cord paresis suggesting an observation bias.

Two recent large-scale studies showed no better resident well-being following duty hour restrictions for general surgery residents: the FIRST trial28 and a systematic review29 of 135 articles pertaining to surgical resident duty hours. In addition, the FIRST trial demonstrated that a schedule with more flexible work hours was not inferior to the current mandated duty hour restrictions. These results may not be generalizable to otolaryngology residents.

Some opponents to the duty hour mandate question the ability of residents to perform the minimum number of key indicator procedures (22 thyroid and/or parathyroid procedures) and advocate lengthening otolaryngology residency to a 6-year program if these restrictions continue. An increase in intern time spent on otolaryngology service (from 3 months to 6 months) has already been realized. With steady otolaryngology applicant spots and match rate over the study period, (244 in 2000 vs 273 in 2008 [1.2% of all residency positions]),30-35 this study emphasizes that this key indicator procedure is concentrating into centers that have otolaryngology residents.

Conclusions

While RLN injury, hematoma formation, and hypoparathyroidism did not change, LOS, and mortality improved within THs-OTO following head and neck endocrine procedures after implementation of duty hour regulations. Although confounders within the NIS cannot be assessed, these findings refute 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 RLN injury increasing within TH and accidental injury to vessels, organs, or nerve and hypocalcemia increasing within THs-OTO. Furthermore, head and neck endocrine cases increased at THs-OTOs.

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Article Information

Corresponding Author: Merry Sebelik, MD, Department of Otolaryngology–Head & Neck Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Ste 420, Memphis, TN 38163 (msebelik@uthsc.edu).

Accepted for Publication: November 9, 2016.

Published Online: February 9, 2017. doi:10.1001/jamaoto.2016.4182

Author Contributions: Drs Wan and Sebelik had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Smith, Sebelik.
Concept and design: Smith, Sebelik.

Acquisition, analysis, or interpretation of data: Smith, Braden, Wan.

Drafting of the manuscript: Smith, Braden, Wan.

Critical revision of the manuscript for important intellectual content: Smith, Braden, Sebelik.

Statistical analysis: Smith, Wan.

Obtained funding: Sebelik.

Administrative, technical, or material support: Smith.

Supervision: Sebelik.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported.

Meeting Presentation: This article was presented as an oral presentation at the American Head and Neck Society Ninth International Conference on Head and Neck Cancer; July 16-20, 2016; Seattle, Washington.

References
1.
Biron  VL, Bang  H, Farwell  DG, Bewley  AF.  National trends and factors associated with hospital costs following thyroid surgery.  Thyroid. 2015;25(7):823-829.Google ScholarCrossref
2.
Fraser  WD.  Hyperparathyroidism.  Lancet. 2009;374(9684):145-158.PubMedGoogle ScholarCrossref
3.
Horne  JA, Reyner  LA.  Sleep related vehicle accidents.  BMJ. 1995;310(6979):565-567.PubMedGoogle ScholarCrossref
4.
Lockley  SW, Barger  LK, Ayas  NT, Rothschild  JM, Czeisler  CA, Landrigan  CP; Harvard Work Hours, Health and Safety Group.  Effects of health care provider work hours and sleep deprivation on safety and performance.  Jt Comm J Qual Patient Saf. 2007;33(11)(suppl):7-18.PubMedGoogle ScholarCrossref
5.
Marcus  CL, Loughlin  GM.  Effect of sleep deprivation on driving safety in housestaff.  Sleep. 1996;19(10):763-766.PubMedGoogle ScholarCrossref
6.
NCSDR/NHTSA Expert Panel on Driver Fatigue and Sleepiness. Drowsy Driving and Automobile Crashes. Washington, DC; National Center on Sleep Disorders Research and National Highway Traffic Safety Administration; 1997. https://www.nhlbi.nih.gov/files/docs/resources/sleep/drsy_drv.pdf. Accessed June 2016.
7.
Steele  MT, Ma  OJ, Watson  WA, Thomas  HA  Jr, Muelleman  RL.  The occupational risk of motor vehicle collisions for emergency medicine residents.  Acad Emerg Med. 1999;6(10):1050-1053.PubMedGoogle ScholarCrossref
8.
Zarebczan  B, McDonald  R, Rajamanickam  V, Leverson  G, Chen  H, Sippel  RS.  Training our future endocrine surgeons: a look at the endocrine surgery operative experience of US surgical residents.  Surgery. 2010;148(6):1075-1080.Google ScholarCrossref
9.
Monteiro  R, Mino  JS, Siperstein  AE.  Trends and disparities in education between specialties in thyroid and parathyroid surgery: an analysis of 55,402 NSQIP patients.  Surgery. 2013;154(4):720-728.PubMedGoogle ScholarCrossref
10.
Chambers  KJ, Bhattacharyya  N.  The increasing role of otolaryngology in the management of surgical thyroid disorders.  Laryngoscope. 2013;123(12):3239-3242.PubMedGoogle ScholarCrossref
11.
Babu  R, Thomas  S, Hazzard  MA,  et al.  Worse outcomes for patients undergoing brain tumor and cerebrovascular procedures following the ACGME resident duty-hour restrictions.  J Neurosurg. 2014;121(2):262-276.PubMedGoogle ScholarCrossref
12.
Dumont  TM, Tranmer  BI, Horgan  MA, Rughani  AI.  Trends in neurosurgical complication rates at teaching vs nonteaching hospitals following duty-hour restrictions.  Neurosurgery. 2012;71(5):1041-1046.PubMedGoogle ScholarCrossref
13.
Browne  JA, Cook  C, Olson  SA, Bolognesi  MP.  Resident duty-hour reform associated with increased morbidity following hip fracture.  J Bone Joint Surg Am. 2009;91(9):2079-2085.PubMedGoogle ScholarCrossref
14.
Hoh  BL, Neal  DW, Kleinhenz  DT, Hoh  DJ, Mocco  J, Barker  FG  II.  Higher complications and no improvement in mortality in the ACGME resident duty-hour restriction era: an analysis of more than 107,000 neurosurgical trauma patients in the Nationwide Inpatient Sample database.  Neurosurgery. 2012;70(6):1369-1381.Google ScholarCrossref
15.
Gopaldas  RR, Chu  D, Dao  TK,  et al.  Impact of ACGME work-hour restrictions on the outcomes of coronary artery bypass grafting in a cohort of 600,000 patients.  J Surg Res. 2010;163(2):201-209.PubMedGoogle ScholarCrossref
16.
Healthcare Cost and Utilization Project. Overview of HCUP. 2015. http://www.hcup-us.ahrq.gov/overview.jsp, 2015. Accessed June 2016.
17.
Vadera  S, Griffith  SD, Rosenbaum  BP,  et al.  National incidence of medication error in surgical patients before and after Accreditation Council for Graduate Medical Education duty-hour reform.  J Surg Ed. 2015;72(6):1209-1216.Google ScholarCrossref
18.
Babu  R, Thomas  S, Hazzard  MA,  et al.  Morbidity, mortality, and health care costs for patients undergoing spine surgery following the ACGME resident duty-hour reform: Clinical article.  J Neurosurg Spine. 2014;21(4):502-515.PubMedGoogle ScholarCrossref
19.
Vanderveen  K, Chen  M, Scherer  L.  Effects of resident duty-hours restrictions on surgical and nonsurgical teaching faculty.  Arch Surg. 2007;142(8):759-764.Google ScholarCrossref
20.
Coverdill  JE, Finlay  W, Adrales  GL,  et al.  Duty-hour restrictions and the work of surgical faculty: results of a multi-institutional study.  Acad Med. 2006;81(1):50-56.PubMedGoogle ScholarCrossref
21.
Karamanoukian  RL, Ku  JK, DeLaRosa  J, Karamanoukian  HL, Evans  GR.  The effects of restricted work hours on clinical training.  Am Surg. 2006;72(1):19-21.PubMedGoogle Scholar
22.
Immerman  I, Kubiak  EN, Zuckerman  JD.  Resident work-hour rules: a survey of residents’ and program directors’ opinions and attitudes.  Am J Orthop. 2007;36(12):E172-E179.Google Scholar
23.
Salim  A, Teixeira  PG, Chan  L,  et al.  Impact of the 80-hour workweek on patient care at a level I trauma center.  Arch Surg. 2007;142(8):708-712.Google ScholarCrossref
24.
Norby  K, Siddiq  F, Adil  MM, Haines  SJ.  The effect of duty hour regulations on outcomes of neurological surgery in training hospitals in the United States: duty hour regulations and patient outcomes.  J Neurosurg. 2014;121(2):247-261.PubMedGoogle ScholarCrossref
25.
Desai  SV, Feldman  L, Brown  L,  et al.  Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial.  JAMA Intern Med. 2013;173(8):649-655.PubMedGoogle ScholarCrossref
26.
Karam  M, Roberts-Klein  S, Shet  N, Chang  J, Feustel  P.  Bilateral hilar foci on 18F-FDG PET scan in patients without lung cancer: variables associated with benign and malignant etiology.  J Nucl Med. 2008;49(9):1429-1436.PubMedGoogle ScholarCrossref
27.
Bergenfelz  A, Jansson  S, Kristoffersson  A,  et al.  Complications to thyroid surgery: results as reported in a database from a multicenter audit comprising 3,660 patients.  Langenbecks Arch Surg. 2008;393(5):667-673.Google ScholarCrossref
28.
Bilimoria  KY, Chung  JW, Hedges  LV,  et al.  Development of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial protocol: a national cluster-randomized trial of resident duty hour policies.  JAMA Surg. 2016;151(3):273-281.PubMedGoogle ScholarCrossref
29.
Ahmed  N, Devitt  KS, Keshet  I,  et al.  A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes.  Ann Surg. 2014;259(6):1041-1053.PubMedGoogle ScholarCrossref
30.
Chang  YC, Chiao  CC.  Localization and functional mapping of AMPA receptor subunits in the developing rabbit retina.  Invest Ophthalmol Vis Sci. 2008;49(12):5619-5628.PubMedGoogle ScholarCrossref
31.
National Resident Matching Program. Results and Data: 2007 Main Residency Match. National Resident Matching Program; 2007. http://www.nrmp.org/wp-content/uploads/2013/08/resultsanddata2007.pdf. Accessed January 24, 2017.
32.
National Resident Matching Program. Results and Data: 2006 Main Residency Match. National Resident Matching Program; 2006. http://www.nrmp.org/wp-content/uploads/2013/08/resultsanddata2006.pdf. Accessed January 24, 2017.
33.
Andriole  DA, Schechtman  KB, Ryan  K, Whelan  A, Diemer  K.  How competitive is my surgical specialty?  Am J Surg. 2002;184(1):1-5.PubMedGoogle ScholarCrossref
34.
Lansford  CD, Fisher  SR, Ossoff  RH, Chole  RA.  Otolaryngology-head and neck surgery residency match: applicant survey.  Arch Otolaryngol Head Neck Surg. 2004;130(9):1017-1023.PubMedGoogle ScholarCrossref
35.
Cabrera-Muffly  C, Sheeder  J, Abaza  M.  State of the otolaryngology match: has competition increased since the “early” match?  Otolaryngol Head Neck Surg. 2015;152(5):838-842. PubMedGoogle ScholarCrossref
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