Early impact of the 2011 ACGME duty hour regulations on surgical outcomes
Open accessAbstract
Background In 2011, the Accreditation Council for Graduate Medical Education (ACGME) implemented additional restrictions on resident work hours. Although the impact of these restrictions on the education of surgical trainees has been examined, the effect on patient safety remains poorly understood.Methods We used national Medicare Claims data for patients undergoing general (n = 1,223,815) and vascular (n = 475,262) surgery procedures in the 3 years preceding the duty hour changes (January, 2009-June, 2011) and the 18 months thereafter (July, 2011-December, 2012). Hospitals were stratified into quintiles by teaching intensity using a resident to bed ratio. We utilized a difference-in-differences analytic technique, using nonteaching hospitals as a control group, to compare risk-adjusted 30-day mortality, serious morbidity, readmission, and failure to rescue (FTR) rates before and after the duty hour changes.Results After duty hour reform, no changes were seen in the measured outcomes when comparing teaching with nonteaching hospitals. Even when stratifying by teaching intensity, there were no differences. For example, at the highest intensity teaching hospitals (resident/bed ratio of ≥ 0.6), mortality rates before and after the duty hour changes were 4.2% and 4.0%, compared with 4.7% and 4.4% for nonteaching hospitals (relative risk [RR], 0.98; 95% CI, 0.89-1.07). Similarly, serious complication (RR, 1.02; 95% CI, 0.98-1.06), FTR (RR, 0.95; 95% CI, 0.87-1.04), and readmission (odds ratio, 1.00; 95% CI, 0.96-1.03) rates were unchanged.Conclusion In Medicare beneficiaries undergoing surgery at teaching hospitals, outcomes have not improved since the 2011 ACGME duty hour regulations.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Prior retrospective studies using administrative data concluded that the 16-hour 2011 ACGME work-hour limit did not appreciably impact hospital-level mortality or process of care measures.
“In addition to these two trials, prior retrospective studies using administrative data similarly concluded that the 16 hours 2011 ACGME work-hour limit did not appreciably impact hospital-level mortality or process of care measures,16 18 28”
From National improvements in resident physician-reported patient safety after limiting first-year resident physicians’ extended duration work shifts: a pooled analysis of prospective cohort studies (2023) · cites this paper as [28]
The Methods and Discussion (page not provided) describe a retrospective analysis of Medicare administrative data and report no change in measured surgical patient outcomes after the 2011 regulations, including 30-day mortality. The paper identifies the 16-hour limit as applying to first-year residents, but its listed outcomes do not include process-of-care measures; it also evaluates the regulations as a whole rather than isolating that limit. (LLM, conf=0.87)
Experimental — accuracy not yet measured
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Comorbidity measures for use with administrative data.
Elixhauser, A., Steiner, C., Harris, D. R., & Coffey, R. M. (1998) · Medical Care · doi:10.1097/00005650-199801000-00004 · Cited by 9,921 · see citing works
Effect of Reducing Interns' Work Hours on Serious Medical Errors in Intensive Care Units
Landrigan, C. P., Rothschild, J. M., Cronin, J. W., Kaushal, R., Burdick, E., Katz, J. T., Lilly, C. M., Stone, P. H., Lockley, S. W., Bates, D. W., et al. (2004) · New England Journal of Medicine · doi:10.1056/nejmoa041406 · Cited by 1,760 · see citing works
Complications, Failure to Rescue, and Mortality With Major Inpatient Surgery in Medicare Patients
Ghaferi, A. A., Birkmeyer, J. D., & Dimick, J. B. (2009) · Annals of Surgery · doi:10.1097/sla.0b013e3181bef697 · Cited by 809 · see citing works
Self-citationThe New Recommendations on Duty Hours from the ACGME Task Force
Nasca, T. J., Day, S. H., & Amis, E. S. (2010) · New England Journal of Medicine · doi:10.1056/nejmsb1005800 · Cited by 556 · see citing works
Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures
Barger, L. K., Ayas, N. T., Cade, B. E., Cronin, J. W., Rosner, B., Speizer, F. E., & Czeisler, C. A. (2006) · PLoS Medicine · doi:10.1371/journal.pmed.0030487 · Cited by 533 · see citing works
New Requirements for Resident Duty Hours
Philibert, I. (2002) · JAMA · doi:10.1001/jama.288.9.1112 · Cited by 531 · see citing works
Ahmed, N., Devitt, K. S., Keshet, I., Spicer, J., Imrie, K., Feldman, L., Cools-Lartigue, J., Kayssi, A., Lipsman, N., Elmi, M., et al. (2014) · Annals of Surgery · doi:10.1097/sla.0000000000000595 · Cited by 516 · see citing works
Resident Duty Hours: Enhancing Sleep, Supervision, and Safety
Ulmer, C. C., Wolman, D. M., & Johns, M. M. E. (2009) · Cited by 481 · see citing works
Identifying Complications of Care Using Administrative Data
Iezzoni, L. I., Daley, J., Heeren, T., Foley, S. M., Fisher, E. S., Duncan, C. C., Hughes, J. S., & Coffman, G. A. (1994) · Medical Care · doi:10.1097/00005650-199407000-00004 · Cited by 454 · see citing works
The Impact of the 80-Hour Resident Workweek on Surgical Residents and Attending Surgeons
Hutter, M. M., Kellogg, K. C., Ferguson, C. M., Abbott, W. M., & Warshaw, A. L. (2006) · Annals of Surgery · doi:10.1097/01.sla.0000220042.48310.66 · Cited by 397 · see citing works
Sleep Loss and Performance in Residents and Nonphysicians: A Meta-Analytic Examination
Philibert, I. (2005) · Sleep · doi:10.1093/sleep/28.11.1392 · Cited by 361 · see citing works
Allison, J. J. (2000) · JAMA · doi:10.1001/jama.284.10.1256 · Cited by 342 · see citing works
Volpp, K. G., Rosen, A. K., Rosenbaum, P. R., Romano, P. S., Even-Shoshan, O., Wang, Y., Bellini, L., Behringer, T., & Silber, J. H. (2007) · JAMA · doi:10.1001/jama.298.9.975 · Cited by 325 · see citing works
Taylor, D. H., Whellan, D. J., & Sloan, F. A. (1999) · New England Journal of Medicine · doi:10.1056/nejm199901283400408 · Cited by 300 · see citing works
Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time
Cohen, M. E., Liu, Y., Ko, C. Y., & Hall, B. L. (2015) · Annals of Surgery · doi:10.1097/sla.0000000000001192 · Cited by 268 · see citing works
Desai, S. V., Feldman, L., Brown, L., Dezube, R., Yeh, H.-C., Punjabi, N., Afshar, K., Grunwald, M. R., Harrington, C., Naik, R., et al. (2013) · JAMA Internal Medicine · doi:10.1001/jamainternmed.2013.2973 · Cited by 235 · see citing works
Volpp, K. G., Rosen, A. K., Rosenbaum, P. R., Romano, P. S., Even-Shoshan, O., Canamucio, A., Bellini, L., Behringer, T., & Silber, J. H. (2007) · JAMA · doi:10.1001/jama.298.9.984 · Cited by 228 · see citing works
Volpp, K. G. M., Rosen, A. K., & Rosenbaum, P. R. (2008) · Journal of Vascular Surgery · doi:10.1016/j.jvs.2007.11.035 · Cited by 223 · see citing works
Moonesinghe, R., Lowery, J., Shahi, N. N., Millen, A., & Beard, J. D. (2011) · BMJ · doi:10.1136/bmj.d1580 · Cited by 223 · see citing works
Dimick, J. B., Nicholas, L. H., Ryan, A. M., Thumma, J. R., & Birkmeyer, J. D. (2013) · JAMA · doi:10.1001/jama.2013.755 · Cited by 219 · see citing works
Self-citationTaylor, D., Whellan, & Sloan (1999) · DigitalGeorgetown (Georgetown University Library) · Cited by 203 · see citing works
Effects of the 2011 Duty Hour Reforms on Interns and Their Patients
Sen, S., Kranzler, H. R., Didwania, A. K., Schwartz, A. C., Amarnath, S. R., Kolars, J. C., Dalack, G. W., Nichols, B., & Guille, C. (2013) · JAMA Internal Medicine · doi:10.1001/jamainternmed.2013.351 · Cited by 157 · see citing works
Rajaram, R., Chung, J. W., Jones, A. T., Cohen, M. E., Dahlke, A. R., Ko, C. Y., Tarpley, J. L., Lewis, F. R., Hoyt, D. B., & Bilimoria, K. Y. (2014) · JAMA · doi:10.1001/jama.2014.15277 · Cited by 139 · see citing works
Fletcher, K. E., Reed, D. A., & Arora, V. M. (2011) · Journal of General Internal Medicine · doi:10.1007/s11606-011-1657-1 · Cited by 124 · see citing works
Revisiting Duty-Hour Limits — IOM Recommendations for Patient Safety and Resident Education
Iglehart, J. K. (2008) · New England Journal of Medicine · doi:10.1056/nejmp0808736 · Cited by 115 · see citing works
Patel, M. S., Volpp, K. G., Small, D. S., Hill, A. S., Even-Shoshan, O., Rosenbaum, L., Ross, R. N., Bellini, L., Zhu, J., & Silber, J. H. (2014) · JAMA · doi:10.1001/jama.2014.15273 · Cited by 113 · see citing works
The 80-Hour Resident Workweek Does Not Adversely Affect Patient Outcomes or Resident Education
de Virgilio, C., Yaghoubian, A. T., Lewis, R. J., Stabile, B. E., & Putnam, B. A. (2006) · Current Surgery · doi:10.1016/j.cursur.2006.03.006 · Cited by 100 · see citing works
Drolet, B. C., Sangisetty, S., Tracy, T. F., & Cioffi, W. G. (2013) · JAMA Surgery · doi:10.1001/jamasurg.2013.169 · Cited by 90 · see citing works
Bilimoria, K. Y., Chung, J. W., Hedges, L. V., Dahlke, A. R., Love, R., Cohen, M. E., Tarpley, J., Mellinger, J., Mahvi, D. M., Kelz, R. R., et al. (2016) · JAMA Surgery · doi:10.1001/jamasurg.2015.4990 · Cited by 87 · see citing works
Effect of the 16-Hour Work Limit on General Surgery Intern Operative Case Volume
Schwartz, S. I., Galante, J. M., Kaji, A. H., Dolich, M. O., Easter, D. W., Melcher, M. L., Patel, K., Reeves, M. E., Salim, A., Senagore, A. J., et al. (2013) · JAMA Surgery · doi:10.1001/jamasurg.2013.2677 · Cited by 64 · see citing works
Resident education in 2011: Three key challenges on the road ahead
Eaton, E. G. V., Tarpley, J. L., Solórzano, C. C., Cho, C. S., Weber, S. M., & Termuhlen, P. M. (2011) · Surgery · doi:10.1016/j.surg.2010.11.007 · Cited by 45 · see citing works
Lee, D. Y., Myers, E. A., Rehmani, S. S., Wexelman, B. A., Ross, R. E., Belsley, S. S., McGinty, J. J., & Bhora, F. Y. (2012) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2012.08.005 · Cited by 37 · see citing works
Bilimoria, K. Y., Quinn, C. M., Dahlke, A. R., Kelz, R. R., Shea, J. A., Rajaram, R., Love, R. R., Kreutzer, L., Biester, T. W., Yang, A. D., et al. (2016) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2016.10.046 · Cited by 35 · see citing works
Nguyen, N., & Sheingold, S. H. (2011) · Medicare & Medicaid Research Review · doi:10.5600/mmrr.001.04.a01 · Cited by 24 · see citing works
Surgery Resident Education 1986–2008: Effort, Respect, and Advocacy
Doherty, G. M. (2008) · World Journal of Surgery · doi:10.1007/s00268-008-9735-1 · Cited by 10 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
Sewell, J. L., Boscardin, C., Young, J. Q., ten Cate, O., & O’Sullivan, P. (2017) · Academic Medicine · doi:10.1097/acm.0000000000001690 · Cited by 66 · see citing works
Saliba, A. N., Taher, A. T., Tamim, H., Harb, A., Mailhac, A. C., Radwan, A., & Jamali, F. R. (2015) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2015.10.011 · Cited by 65 · see citing works
Burke, J., Downey, C. L., & Almoudaris, A. M. (2022) · PubMed · doi:10.1097/pts.0000000000000720 · Cited by 60 · see citing works
Factors That Affect Medical Students' Perception and Impression of a Plastic Surgery Program
Zuo, K. J., Retrouvey, H., & Wanzel, K. R. (2018) · Annals of Plastic Surgery · doi:10.1097/sap.0000000000001525 · Cited by 48 · see citing works
Awan, M., Zagales, I., McKenney, M. G., Kinslow, K., & Elkbuli, A. (2021) · Journal of surgical education · doi:10.1016/j.jsurg.2021.06.001 · Cited by 40 · see citing works
Grover, B. T., & Kothari, S. N. (2015) · Surgical Clinics of North America · doi:10.1016/j.suc.2015.09.003 · Cited by 41 · see citing works
Yamamoto, S., Tanaka, P. P., Vested, M., & Macario, A. (2017) · Cureus · doi:10.7759/cureus.1060 · Cited by 38 · see citing works
Weaver, M. D., Landrigan, C. P., Sullivan, J. P., O'Brien, C. S., Qadri, S., Viyaran, N., Czeisler, C. A., & Barger, L. K. (2023) · BMJ Quality & Safety · doi:10.1136/bmjqs-2021-014375 · Cited by 35 · see citing works
“…concluded that the 16 hours 2011 ACGME work-hour limit did not appreciably impact hospital-level mortality or process of care measures, 16 18 28 but like FIRST and iCOMPARE , these studies relied on process and outcome measures that were relatively insensitive and lacked a direct connection…”
Rajaram, R., Chung, J. W., Cohen, M. E., Dahlke, A. R., Yang, A. D., Meeks, J. J., Ko, C. Y., Tarpley, J. L., Hoyt, D. B., & Bilimoria, K. Y. (2015) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2015.06.010 · Cited by 33 · see citing works
Hospital Costs Related to Early Extubation After Infant Cardiac Surgery
McHugh, K. E., Mahle, W. T., Hall, M., Scheurer, M. A., Moga, M.-A., Triedman, J. K., Nicolson, S. C., Amula, V., Cooper, D. S., Schamberger, M. S., et al. (2018) · The Annals of Thoracic Surgery · doi:10.1016/j.athoracsur.2018.10.019 · Cited by 31 · see citing works
Exploring Qualitative Perspectives on Surgical Resident Training, Well-Being, and Patient Care
Kreutzer, L., Dahlke, A. R., Love, R. R., Ban, K. A., Yang, A. D., Bilimoria, K. Y., & Johnson, J. K. (2016) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2016.10.041 · Cited by 26 · see citing works
The “July effect” in total shoulder arthroplasty
Rao, A. J., Bohl, D. D., Frank, R. M., Cvetanovich, G. L., Nicholson, G. P., & Romeo, A. A. (2016) · Journal of Shoulder and Elbow Surgery · doi:10.1016/j.jse.2016.09.043 · Cited by 22 · see citing works
Anesthesiology Resident Night Float Duty Alters Sleep Patterns
Dunn, L. K., Kleiman, A. M., Forkin, K. T., Bechtel, A. J., Collins, S. R., Potter, J. F., Kaperak, C. J., Tsang, S., Huffmyer, J. L., & Nemergut, E. C. (2019) · Anesthesiology · doi:10.1097/aln.0000000000002806 · Cited by 21 · see citing works
A primer on medical education in the United States through the lens of a current resident physician.
Mowery, Y. M. (2015) · Europe PMC (PubMed Central) · doi:10.3978/j.issn.2305-5839.2015.10.19 · Cited by 20 · see citing works
Weaver, M. D., Sullivan, J. P., Landrigan, C. P., & Barger, L. K. (2023) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/j.jcjq.2023.06.014 · Cited by 18 · see citing works
Middleton, R. M., Vo, A., Ferguson, J. Y., Judge, A., Alvand, A., Price, A. J., & Rees, J. L. (2017) · Arthroscopy The Journal of Arthroscopic and Related Surgery · doi:10.1016/j.arthro.2016.10.025 · Cited by 16 · see citing works
Fatigue and training of obstetrics and gynaecology trainees in Australia and New Zealand
Tucker, P. E., Cohen, P. A., Bulsara, M. K., & Acton, J. N. (2017) · Australian and New Zealand Journal of Obstetrics and Gynaecology · doi:10.1111/ajo.12604 · Cited by 16 · see citing works
Restrictions on surgical resident shift length does not impact type of medical errors
Anderson, J. E., Goodman, L. F., Jensen, G. W., Salcedo, E. S., & Galante, J. M. (2017) · Journal of Surgical Research · doi:10.1016/j.jss.2016.12.038 · Cited by 14 · see citing works
A primer on medical education in the United States through the lens of a current resident physician.
Mowery, Y. M. (2015) · PubMed Central · doi:10.3978/j.issn.2072-1439.2015.10.05 · Cited by 12 · see citing works
Working hours of obstetrics and gynaecology trainees in Australia and New Zealand
Acton, J. N., Tucker, P. E., Bulsara, M. K., & Cohen, P. A. (2017) · Australian and New Zealand Journal of Obstetrics and Gynaecology · doi:10.1111/ajo.12605 · Cited by 11 · see citing works
McInnes, C. W., Vorstenbosch, J., Chard, R., Logsetty, S., Buchel, E. W., & Islur, A. (2018) · Plastic Surgery · doi:10.1177/2292550317749512 · Cited by 10 · see citing works
The impact of shortening shifts of physicians during their residency on patients and physicians
Daitch, V., Poran, I., & Leibovici, L. (2025) · Israel Journal of Health Policy Research · doi:10.1186/s13584-025-00715-2 · Cited by 6 · see citing works
Moura, F. S., Moura, E. I. D. M., & de Novais, M. A. P. (2018) · Revista Brasileira de Medicina do Trabalho · doi:10.5327/z1679443520180294 · Cited by 6 · see citing works
Marwaha, J. S., Drolet, B. C., Maddox, S. S., & Adams, C. A. (2016) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2016.01.009 · Cited by 5 · see citing works
Chi, D., Chen, A. D., Wu, W. W., Chattha, A. S., Lee, B. T., & Lin, S. J. (2023) · Plastic & Reconstructive Surgery Global Open · doi:10.1097/gox.0000000000004820 · Cited by 4 · see citing works
2011 ACGME Duty Hour Limits had No Association With Breast Reconstruction Complications
Simpson, A. M., Kwok, A. C., Collier, W., Kim, J., Veith, J., & Agarwal, J. P. (2019) · Journal of Surgical Research · doi:10.1016/j.jss.2019.09.058 · Cited by 4 · see citing works
Coverdill, J. E., Alseidi, A. A., Borgstrom, D. C., Dent, D. L., Dumire, R. D., Fryer, J. P., Hartranft, T. H., Holsten, S. B., Nelson, M. T., Shabahang, M. M., et al. (2017) · The American Journal of Surgery · doi:10.1016/j.amjsurg.2017.08.053 · Cited by 3 · see citing works
How the ACGME Work-Hour Restrictions Have Affected Orthopedic Residents
Saltzman, B. M., & Frank, J. M. (2017) · Orthopedics · doi:10.3928/01477447-20161227-01 · Cited by 3 · see citing works
Lark, M. E., Airhart, A. E., Miller, P. M., Chung, J. W., & Bilimoria, K. Y. (2025) · Journal of Graduate Medical Education · doi:10.4300/jgme-d-25-00784.1 · Cited by 2 · see citing works
Liu, B. J., Ordon, M. H., Bodley, J., Liu, G., & Kroft, J. (2018) · Journal of Obstetrics and Gynaecology Canada · doi:10.1016/j.jogc.2018.02.001 · Cited by 1 · see citing works
Damewood, R. B., Morris, J. B., Mellinger, J. D., Friedell, M. L., Borman, K. R., Dent, D. L., Schenarts, P. J., & Jarman, B. T. (2016) · Journal of surgical education · doi:10.1016/j.jsurg.2016.03.002
The Effect of Resident Training in the Operating Room
Gas, B. L. (2017)
The Physician Trainee Environment and its Associated Effects on Trainees and their Patients
Osborne, R. (2018) · TSpace (University of Toronto)
The Impact of Duty Hour Restrictions on Orthopedic Surgical Training
Ridge, I., Graf, A., & Suh, N. (2025) · Hand Clinics · doi:10.1016/j.hcl.2024.12.014
Hospital factors associated with failure to rescue after surgery: meta-analysis
Wells, C. I., Boppana, S. A., Varghese, C., Xu, W., O’Grady, G., & Bissett, I. P. (2026) · BJS Open · doi:10.1093/bjsopen/zrag086
- Authors
- Scally, C. P., Ryan, A. M., Thumma, J. R., Gauger, P. G., & Dimick, J. B.
- Affiliations
- University of Michigan (US)
- Corresponding author
- Scally, Christopher P.
- Venue
- Surgery
- Publisher
- Elsevier BV
- Published
- 2015-12
- Volume
- 158
- Issue
- 6
- Pages
- 1453-1461
- ISSN
- 0039-6060 (ISSN-L)
- PMC
- PMC4637214
- OpenAlex
- W993693568
- Cited by
- 36
- References
- 35
- Citations by year
- 2026: 1 · 2025: 3 · 2023: 2 · 2022: 2 · 2021: 1 · 2020: 1 · 2019: 2 · 2018: 6 · 2017: 9 · 2016: 4 · 2015: 5
- FWCI
- 7.77
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Surgery (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute on Aging (R01AG039434, 5T32CA009672-23)
- National Cancer Institute (R01AG039434, 5T32CA009672-23)
- Topics
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Innovations in Medical Education
- Keywords
- resident work hour restrictions, surgical outcomes, patient safety, teaching hospitals, 30-day mortality, hospital readmission, failure to rescue, Medicare beneficiaries, general surgery, vascular surgery
- MeSH terms
- Accreditation, Aged, Education, Medical, Graduate, Female, Medicare, Hospitals, Teaching, Humans, Insurance Benefits, Internship and Residency, Male, Patient Readmission, Personnel Staffing and Scheduling, Retrospective Studies, General Surgery, United States, Work Schedule Tolerance, Workload, Treatment Outcome, Hospital Mortality, Outcome Assessment, Health Care
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
