Resident work hour restrictions may be costly for teaching hospitals

An analysis based on a computer model suggests that recent educational mandates that resident physicians work fewer hours may cost teaching hospitals hundreds of thousands of dollars - or more, if they replace surgical residents with other clinicians, according to a report in the April issue of Archives of Surgery.

"Teaching hospitals have relied heavily on their resident staff to meet their service needs," write the authors as background information in the article. "Nowhere has this been more prominent than in surgery, where trainees are traditionally expected to have a significant service responsibility in exchange for the privilege of participating in the operating room (OR), in effect, a contract to exchange service for training." New national requirements limiting the number of hours that residents can work went into effect in July 2003, forcing many teaching hospitals to restructure their staffing.

Christine C. Mitchell, M.S., and colleagues at Brigham and Women's Hospital and Harvard Medical School, Boston, constructed a computer model with multiple variables to predict future staffing requirements and costs for the surgery service at a teaching hospital over five years. "The model included seven major factors: number and work hours for each level of resident and fellow, moonlighter and physician extender; wages, fringe benefits and inflation rates; staffing type preference; volume and anticipated service growth; workflow efficiency savings; option to eliminate moonlighters; and option to use adjusted staffing ratios to project staffing needs," the authors write. The model was used to estimate the financial impact of four hypothetical scenarios on a surgical department with 20 residents and four fellows.

In scenario one, residents continue to work 80 hours per week, but must spend two to 20 of those hours receiving instruction rather than caring for patients. The potential cost of these changes over five years ranges from $113,000 (if two hours of resident time per week is replaced by the time of physician assistants) to more than $1.9 million (if 20 hours of care per week are provided by nurse practitioners instead of residents).

In scenario two, resident work hours are decreased to 75 or 60 per week, with 10 hours of that spent in instruction. If residents work 75 hours, with the remainder covered by physician assistants, five-year costs would be approximately $851,000; if residents work 60 hours per week and nurse practitioners are hired, costs increase to more than $2.9 million. Scenario three involves the same resident work hours but assumes that in the third year of the analysis, clinical efficiency increases by 10 percent. This improvement decreases the cost of replacing residents with nurse practitioners to $2.4 million (a savings of nearly $700,000) and of replacing residents with physician assistants or hospitalists, a savings of $350,000.

In scenario four, no efficiencies were achieved and the number of surgeries performed at the hospital increased. "In this case, even modest increases in surgical volume greatly magnified the expense of replacing resident clinical care with other providers, reaching as high as $6 million for the five-year period," the authors write.

"To use this model effectively as a decision-making tool, hospital leaders need to first reach a consensus on the ideal distribution of existing residents among programs and patient care locations," they conclude. "This consensus must be driven more by their institution's education mission and less by its service needs , from a staffing perspective, hospitals may have to view interns and residents as students rather than as an economical source of labor in a difficult reimbursement environment."

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