National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training

There were no significant subgroup effects for death or serious complications according to risk of death or serious complications (highest quartile vs. lower three quartiles of patients).

“There were no significant subgroup effects for death or serious complications according to type of surgery (emergency vs. elective), risk of death or serious complications (highest quartile vs. lower three quartiles of patients), or surgical setting (inpatient vs. outpatient) (Table S13 in the Supplementary Appendix).”

There were no significant subgroup effects for death or serious complications according to type of surgery (emergency vs. elective).

“There were no significant subgroup effects for death or serious complications according to type of surgery (emergency vs. elective), risk of death or serious complications (highest quartile vs. lower three quartiles of patients), or surgical setting (inpatient vs. outpatient) (Table S13 in the Supplementary Appendix).”

Noninferiority was not established for renal failure.

“There was no significant difference between study groups with respect to failure to rescue and renal failure, but the upper boundary of the 92% confidence interval exceeded the margin; therefore, noninferiority was not established for these outcomes.”

Flexible policies were noninferior to standard policies with respect to unplanned reoperation.

“With respect to secondary outcomes, flexible policies were noninferior to standard policies with respect to serious complications, any complication, unplanned reoperation, sepsis, surgicalsite infection, and urinary tract infection in unadjusted and adjusted models (Fig. 1).”

Noninferiority was not established for failure to rescue.

“There was no significant difference between study groups with respect to failure to rescue and renal failure, but the upper boundary of the 92% confidence interval exceeded the margin; therefore, noninferiority was not established for these outcomes.”

All results were robust with respect to variations in modeling specifications and the inclusion of additional covariates for patients, hospitals, or both.

“All results were robust with respect to variations in modeling specifications and the inclusion of additional covariates for patients, hospitals, or both.”

The upper boundaries of the 92% confidence intervals from unadjusted and adjusted analyses of the 30-day rate of postoperative pneumonia coincided exactly with the noninferiority margin.

“The upper boundaries of the 92% confidence intervals from unadjusted and adjusted analyses of the 30-day rate of postoperative pneumonia coincided exactly with the noninferiority margin.”

The rate of death or serious complications did not differ significantly between study groups (9.1% in the flexible-policy group and 9.0% in the standard-policy group, P = 0.92).

“The rate of death or serious complications did not differ significantly between study groups (9.1% in the flexible-policy group and 9.0% in the standard-policy group, P = 0.92).”

Flexible policies were deemed noninferior to standard policies with respect to death or serious complications.

“The upper boundaries of the 92% confidence interval from both unadjusted and adjusted models were greater than 1.00 but less than the noninferiority margin odds ratio of 1.15; thus, flexible policies were deemed to be noninferior to standard policies with respect to death or serious complications.”

Flexible policies were noninferior to standard policies with respect to surgical-site infection.

“With respect to secondary outcomes, flexible policies were noninferior to standard policies with respect to serious complications, any complication, unplanned reoperation, sepsis, surgicalsite infection, and urinary tract infection in unadjusted and adjusted models (Fig. 1).”

Flexible policies were noninferior to standard policies with respect to sepsis.

“With respect to secondary outcomes, flexible policies were noninferior to standard policies with respect to serious complications, any complication, unplanned reoperation, sepsis, surgicalsite infection, and urinary tract infection in unadjusted and adjusted models (Fig. 1).”

There were no significant subgroup effects for death or serious complications according to surgical setting (inpatient vs. outpatient).

“There were no significant subgroup effects for death or serious complications according to type of surgery (emergency vs. elective), risk of death or serious complications (highest quartile vs. lower three quartiles of patients), or surgical setting (inpatient vs. outpatient) (Table S13 in the Supplementary Appendix).”

Flexible policies were noninferior to standard policies with respect to serious complications.

“With respect to secondary outcomes, flexible policies were noninferior to standard policies with respect to serious complications, any complication, unplanned reoperation, sepsis, surgicalsite infection, and urinary tract infection in unadjusted and adjusted models (Fig. 1).”

Residents in flexible-policy programs were not significantly more likely than those in standard-policy programs to be dissatisfied with overall well-being.

“or overall well-being (14.9% and 12.0%, respectively; P = 0.10; odds ratio, 1.31; 95% CI, 0.99 to 1.74; P = 0.06)”

There was no significant difference between study groups with respect to renal failure.

“There was no significant difference between study groups with respect to failure to rescue and renal failure, but the upper boundary of the 92% confidence interval exceeded the margin; therefore, noninferiority was not established for these outcomes.”

There was no significant difference between study groups with respect to failure to rescue.

“There was no significant difference between study groups with respect to failure to rescue and renal failure, but the upper boundary of the 92% confidence interval exceeded the margin; therefore, noninferiority was not established for these outcomes.”

Flexible policies were noninferior to standard policies with respect to urinary tract infection.

“With respect to secondary outcomes, flexible policies were noninferior to standard policies with respect to serious complications, any complication, unplanned reoperation, sepsis, surgicalsite infection, and urinary tract infection in unadjusted and adjusted models (Fig. 1).”

Residents in flexible-policy programs were not significantly more likely than those in standard-policy programs to be dissatisfied with overall education quality.

“residents in flexible-policy programs were not significantly more likely than those in standard-policy programs to be dissatisfied (very dissatisfied or dissatisfied vs. neutral, satisfied, or very satisfied) with overall education quality (11.0% in the flexible-policy group and 10.7% in the standard-policy group, P = 0.86; odds ratio for the flexible-policy group, 1.08; 95% CI, 0.77 to 1.52; P =”

ABSITE survey data were obtained for a total of 4330 general surgery residents in 117 FIRST Trial programs.

“ABSITE survey data were obtained for a total of 4330 general surgery residents who were undergoing training in 117 FIRST Trial programs (2110 residents in the flexible-policy group and 2220 in the standard-policy group).”

Flexible policies were noninferior to standard policies with respect to any complication.

“With respect to secondary outcomes, flexible policies were noninferior to standard policies with respect to serious complications, any complication, unplanned reoperation, sepsis, surgicalsite infection, and urinary tract infection in unadjusted and adjusted models (Fig. 1).”

Residents in the flexible-policy group were less likely than those in the standard-policy group to report handing off active patient issues (32.0% vs. 46.3%, P<0.001).

“or handing off active patient issues (32.0% vs. 46.3%,P<0.001).”

Residents under flexible policies were more likely than those under standard policies to perceive negative effects of duty-hour policies on personal activities.

“Residents under flexible policies were less likely than those under standard policies to perceive negative effects of duty-hour policies on multiple aspects of patient safety, continuity of care, professionalism, and resident education but were more likely to perceive negative effects on personal activities.”

Residents under flexible policies were less likely than those under standard policies to perceive negative effects of duty-hour policies on multiple aspects of patient safety, continuity of care, professionalism, and resident education.

“Residents under flexible policies were less likely than those under standard policies to perceive negative effects of duty-hour policies on multiple aspects of patient safety, continuity of care, professionalism, and resident education but were more likely to perceive negative effects on personal activities.”

Flexible-policy residents were more likely than standard-policy residents to be dissatisfied with time for rest (odds ratio, 1.41; 95% CI, 1.06 to 1.89; P = 0.02).

“but were more likely to be dissatisfied with time for rest (odds ratio, 1.41; 95% CI, 1.06 to 1.89; P = 0.02)”

There were no significant differences between the standard-policy and flexible-policy groups in resident-reported primary outcomes in subgroups defined according to resident sex, program geographic region, or program type.

“There were no significant differences between the standardpolicy and flexible-policy groups in our residentreported primary outcomes in subgroups defined according to resident sex, program geographic region, or program type (Table S19 in the Sup-”

There was no significant difference between study groups regarding resident satisfaction with the duty-hour regulations of their program (odds ratio, 0.99; 95% CI, 0.71 to 1.40; P = 0.97).

“There was no significant difference between study groups regarding resident satisfaction with the duty-hour regulations of their program (odds ratio, 0.99; 95% CI, 0.71 to 1.40; P = 0.97).”

There were no significant differences between study groups in resident-reported perception of the effect of fatigue on personal or patient safety.

“There were no significant differences between study groups in resident-reported perception of the effect of fatigue on personal or patient safety.”

There was no significant difference between the standard-policy and flexible-policy groups with respect to residents' satisfaction regarding their overall well-being and education.

“There was also no significant difference between the standard-policy and flexible-policy groups with respect to residents' satisfaction regarding their overall well-being and education.”

Residents' satisfaction regarding their overall well-being and education quality was similar in the flexible-policy and standard-policy groups.

“Residents' satisfaction regarding their overall well-being and education quality was similar in the flexible-policy and standard-policy groups.”

Flexible-policy residents were significantly less likely than standard-policy residents to miss an operation at least once in the past month (29.9% vs. 42.0%, P<0.001; odds ratio, 0.56; 95% CI, 0.45 to 0.69; P<0.001).

“In analyses of breaks in continuity of care, flexible-policy residents were significantly less likely than standard-policy residents to leave during an operation (7.0% vs. 13.2%,P<0.001; odds ratio, 0.46; 95% CI, 0.32 to 0.65; P<0.001), miss an operation (29.9% vs. 42.0%,P<0.001; odds ratio, 0.56; 95% CI, 0.45 to 0.69; P<0.001), or hand off an active patient care issue (32.0% vs. 46.3%,P<0.001;”

Residents in the flexible-policy group were less likely than those in the standard-policy group to report leaving during an operation (7.0% vs. 13.2%, P<0.001).

“Residents in the flexible-policy group were less likely than those in the standard-policy group to report leaving during an operation (7.0% vs. 13.2%,P<0.001)”

Flexible-policy residents were significantly less likely than standard-policy residents to hand off an active patient care issue at least once in the past month (32.0% vs. 46.3%, P<0.001; odds ratio, 0.53; 95% CI, 0.45 to 0.63; P<0.001).

“In analyses of breaks in continuity of care, flexible-policy residents were significantly less likely than standard-policy residents to leave during an operation (7.0% vs. 13.2%,P<0.001; odds ratio, 0.46; 95% CI, 0.32 to 0.65; P<0.001), miss an operation (29.9% vs. 42.0%,P<0.001; odds ratio, 0.56; 95% CI, 0.45 to 0.69; P<0.001), or hand off an active patient care issue (32.0% vs. 46.3%,P<0.001;”

Flexible-policy residents were significantly less likely than standard-policy residents to be dissatisfied with the quality and ease of handoffs and transitions in care (odds ratio, 0.69; 95% CI, 0.52 to 0.92; P = 0.01).

“Flexible-policy residents were significantly less likely than standard-policy residents to be dissatisfied with continuity of care (odds ratio, 0.44; 95% CI, 0.32 to 0.60; P<0.001) and with the quality and ease of handoffs and transitions in care (odds ratio, 0.69; 95% CI, 0.52 to 0.92; P = 0.01)”

Residents in programs with flexible duty-hour policies (as compared with current ACGME duty-hour restrictions) noted numerous benefits with respect to nearly all aspects of patient safety, continuity of care, surgical training, and professionalism.

“Similarly, we found that residents in programs with flexible duty-hour policies (as compared with current ACGME duty-hour restrictions) noted numerous benefits with respect to nearly all aspects of patient safety, continuity of care, surgical training, and professionalism.”

There were no significant differences between the standard-policy and flexible-policy groups in primary outcomes in the subgroup defined according to postgraduate year (first vs. second and third vs. fourth and fifth).

“There were also no significant differences between the standard-policy and flexible-policy groups in the primary outcomes in the subgroup defined according to postgraduate year (first vs. second and third vs. fourth and fifth) (Table S19 in the Supplementary Appendix).”

Flexible-policy residents were significantly less likely than standard-policy residents to leave during an operation at least once in the past month (7.0% vs. 13.2%, P<0.001; odds ratio, 0.46; 95% CI, 0.32 to 0.65; P<0.001).

“In analyses of breaks in continuity of care, flexible-policy residents were significantly less likely than standard-policy residents to leave during an operation (7.0% vs. 13.2%,P<0.001; odds ratio, 0.46; 95% CI, 0.32 to 0.65; P<0.001), miss an operation (29.9% vs. 42.0%,P<0.001; odds ratio, 0.56; 95% CI, 0.45 to 0.69; P<0.001), or hand off an active patient care issue (32.0% vs. 46.3%,P<0.001;”

Flexible-policy residents were significantly less likely than standard-policy residents to be dissatisfied with continuity of care (odds ratio, 0.44; 95% CI, 0.32 to 0.60; P<0.001).

“Flexible-policy residents were significantly less likely than standard-policy residents to be dissatisfied with continuity of care (odds ratio, 0.44; 95% CI, 0.32 to 0.60; P<0.001)”

Study group was not associated with resident-reported frequency at which fatigue affected either patient safety or personal safety.

“Study group was also not associated with resident-reported frequency at which fatigue affected either patient safety or personal safety (Table 3).”

There were no significant differences between the standard-policy and flexible-policy groups in outcomes for subgroups that may be more sensitive to differences in duty-hour policies, including high-risk patients, inpatient surgeries, and emergency cases.

“Moreover, there were no significant differences between the standard-policy and flexible-policy groups in outcomes for subgroups that may be more sensitive to differences in duty-hour policies, 8,48 including high-risk patients, inpatient surgeries, and emergency cases.”

There was no significant difference in satisfaction with duty-hour policies between the study groups.

“There was also no significant difference in satisfaction with duty-hour policies between the study groups.”

Flexible-policy residents were more likely to perceive negative effects of duty-hour policies on resident outcomes that depended on time away from the hospital, such as case preparation after work, research participation, time with family and friends, time for extracurricular activities, rest, and health (all odds ratios >1.00, P<0.001 for all comparisons).

“However, flexible-policy residents were more likely to perceive negative effects of duty-hour policies on resident outcomes that depended on time away from the hospital, such as case preparation after work, research participation, time with family and friends, time for extracurricular activities, rest, and health (all odds ratios >1.00, P<0.001 for all comparisons).”

The study groups were well balanced with respect to a broad range of program, hospital, patient, and resident characteristics.

“The study groups were well balanced with respect to a broad range of program, hospital, patient, and resident characteristics (Table 2).”

Patient-level data were obtained from ACS NSQIP, a validated system for collection of high-quality clinical data to measure surgical outcomes.

“Patient-level data on patient characteristics, coexisting conditions, operative details, and surgical outcomes were obtained for general surgery cases from ACS NSQIP, a validated system developed in the 1990s for collection of high-quality clinical data to measure surgical outcomes; the system has been described extensively elsewhere.33,35,42”

• cites [33] 33. American College of Surgeons Na- tional Surgical Quality Improvement Pro- gram (ACS NSQIP) (http://site .acsnsqip .org).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [35] 35. Cohen ME, Ko CY, Bilimoria KY, et al. Optimizing ACS NSQIP modeling for evaluation of surgical quality and risk: patient risk adjustment, procedure mix adjustment, shrinkage adjustment, and sur- gical focus. J Am Coll Surg 2013; 217(2): 336-46.e1. sourceNot checked — no full text of the source
• cites [42] 42. The American Board of Surgery In- Training Exam (ABSITE) (http://www .absurgery .org/ default .jsp?examoffered_gs).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The primary patient outcome was based on the ACS NSQIP composite outcome measure of the 30-day rate of postoperative death or serious complications, which is based on a National Quality Forum-endorsed metric (NQF#0697).

“Our primary patient outcome was based on the ACS NSQIP composite outcome measure of the 30-day rate of postoperative death or serious complications, which is based on a National Quality Forum-endorsed metric (NQF#0697).36,37”

• cites [36] 36. Merkow RP, Hall BL, Cohen ME, et al. Validity and feasibility of the American College of Surgeons colectomy composite outcome quality measure. Ann Surg 2013; 257: 483-9. sourceNot checked — no full text of the source
• cites [37] 37. American College of Surgeons Na- tional Surgical Quality Improvement Pro- gram semiannual report: January 2015. Chicago: American College of Surgeons.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Minimum sample sizes of 90 programs (45 per group) with an average of 1.1 hospitals per program and an average of 950 patients per hospital would be necessary to obtain 80% power at an alpha level of 0.05.

“we estimated that minimum sample sizes of 90 programs (45 per group) with an average of 1.1 hospitals per program and an average of 950 patients per hospital would be necessary to obtain 80% power at an alpha level of 0.05”

In surgical settings, most studies have shown no difference or a worsening in patient postoperative outcomes and resident education after duty-hour reforms.

“In surgical settings, most studies have shown no difference or a worsening in patient postoperative outcomes and resident education after duty-hour reforms.3,6,7,[13][14][15][18][19][20][21]”

• cites [3] 3. Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. Washington, DC: National Acade- mies Press, 2008.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [6] 6. Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resi- dent duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg 2014; 259: 1041-53. sourceNot checked — no full text of the source
• cites [7] 7. Philibert I, Nasca T, Brigham T, Sha- piro J. Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex rela- tionships? Annu Rev Med 2013; 64: 467-83. sourceNot checked — no full text of the source

A noninferiority margin was specified before trial initiation as an absolute difference of 1.25 percentage points (13% relative difference, corresponding to a noninferiority margin odds ratio of 1.15).

“A noninferiority margin was specified before trial initiation as an absolute difference of 1.25 percentage points (13% relative difference, which corresponds to a noninferiority margin odds ratio of 1.15) on the basis of examination of the empirical distribution of hospital-level 30-day rates of death or serious complications, intracluster correlations, and power calculations.31,32”

• cites [31] 31. The Flexibility in Duty Hour Require- ments for Surgical Trainees Trial study protocol and statistical analysis plan (http://www .thefirsttrial .org/ Documents/ FIRSTTRIAL_StatisticalAnalysisPlan_ Updated03NOV2015 .pdf).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [32] 32. 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 2015 December 30 (Epub ahead of print).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Programs and their hospital affiliates were randomly assigned as clusters within strata to one of two study groups.

“Programs and their hospital affiliates were then randomly assigned as clusters within strata to one of two study groups.39”

• cites [39] 39. Bilimoria KY, Hoyt DB, Lewis F. Mak- ing the case for investigating flexibility in duty hour limits for surgical residents. JAMA Surg 2015; 150: 503-4.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The level of statistical significance for final analyses of patient outcomes was adjusted to 0.04 because one midpoint interim analysis was performed.

“Because one midpoint interim analysis was performed for data and safety monitoring purposes, the level of statistical significance for our final analyses of only patient outcomes was adjusted to 0.04 in order to maintain an overall significance level for the entire trial of 0.05.31,32,44”

• cites [31] 31. The Flexibility in Duty Hour Require- ments for Surgical Trainees Trial study protocol and statistical analysis plan (http://www .thefirsttrial .org/ Documents/ FIRSTTRIAL_StatisticalAnalysisPlan_ Updated03NOV2015 .pdf).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [32] 32. 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 2015 December 30 (Epub ahead of print).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [44] 44. Piaggio G, Elbourne DR, Pocock SJ, Evans SJ, Altman DG. Reporting of non- inferiority and equivalence randomized trials: extension of the CONSORT 2010 statement. JAMA 2012; 308: 2594-604. sourceNot checked — no full text of the source

Evidence from large, prospective, randomized trials to inform duty-hour regulations is currently lacking.

“Evidence from large, prospective, randomized trials to inform duty-hour regulations is currently lacking.3,6,7”

• cites [3] 3. Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. Washington, DC: National Acade- mies Press, 2008.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [6] 6. Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resi- dent duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg 2014; 259: 1041-53. sourceNot checked — no full text of the source
• cites [7] 7. Philibert I, Nasca T, Brigham T, Sha- piro J. Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex rela- tionships? Annu Rev Med 2013; 64: 467-83. sourceNot checked — no full text of the source

Patient care and resident education can be compromised by interruptions in continuity of care (i.e., handoffs).

“Patient care and resident education can be compromised by interruptions in continuity of care (i.e., handoffs) [22][23][24]”

• cites [22][23][24]Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

These findings suggest that flexible duty-hour policies appear to be safe for patient care.

“Thus, these find-ings suggest that flexible duty-hour policies appear to be safe for patient care.”

Results of per-protocol, as-treated, and instrumental-variables analyses were highly consistent with intention-to-treat results for patient and resident outcomes.

“Thus, results of per-protocol, as-treated, and instrumental-variables analyses were highly consistent with intention-to-treat results for patient and resident outcomes (Tables S14 through S18 and S20 through S24 in the Supplementary Appendix).”

This national, prospective, randomized trial showed that flexible, less-restrictive duty-hour policies for surgical residents were noninferior to standard ACGME duty-hour policies with respect to the primary patient outcome of the 30-day rate of postoperative death or serious complications.

“This national, prospective, randomized trial showed that flexible, less-restrictive duty-hour policies for surgical residents were noninferior to standard ACGME duty-hour policies with respect to our primary patient outcome of the 30day rate of postoperative death or serious complications.”

Overall program-level adherence to study-group conditions was 98% (97% in the standard-policy group and 100% in the flexible-policy group).

“Overall program-level adherence to study-group conditions was 98% (97% in the standard-policy group and 100% in the flexible-policy group) (Tables S4 and S5 in the Supplementary Appendix).”

The authors were unable to collect data on medication errors and other potentially resident-sensitive outcomes.

“Although postoperative complications are the ultimate outcomes that must be assessed for any change in surgical duty-hour policies, we were unable to collect data on medication errors and other potentially resident-sensitive outcomes.”

The alpha level was adjusted to 0.04 for the final analysis to account for interim analysis (overall trial alpha 0.05).

“To account for interim analysis, the alpha level was adjusted to 0.04 for the final analysis (alpha level for the overall trial, 0.05).”

As compared with standard duty-hour policies, flexible, less-restrictive duty-hour policies for surgical residents were associated with no significant difference in residents' satisfaction with overall well-being and education quality.

“As compared with standard duty-hour policies, flexible, less-restrictive duty-hour policies for surgical residents were associated with noninferior patient outcomes and no significant difference in residents' satisfaction with overall well-being and education quality.”

The finding of noninferior patient outcomes under flexible, less-restrictive duty-hour policies as compared with standard duty-hour policies for most postoperative outcomes examined is consistent with the results of previous studies.

“Our finding of noninferior patient outcomes under flexible, less-restrictive duty-hour policies as compared with standard duty-hour policies for most postoperative outcomes examined is consistent with the results of previous studies.6,7,[13][14][15][18][19][20][21]”

• cites [6] 6. Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resi- dent duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg 2014; 259: 1041-53. sourceNot checked — no full text of the source
• cites [7] 7. Philibert I, Nasca T, Brigham T, Sha- piro J. Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex rela- tionships? Annu Rev Med 2013; 64: 467-83. sourceNot checked — no full text of the source
• cites [13][14][15][18][19][20][21]Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Flexible duty-hour policies for surgical residents were noninferior to current ACGME duty-hour policies with respect to patient outcomes.

“In conclusion, flexible duty-hour policies for surgical residents were noninferior to current ACGME duty-hour policies with respect to patient outcomes.”

All results were robust with respect to minor variations in modeling specifications.

“All results were robust with respect to minor variations in modeling specifications.”

As compared with standard duty-hour policies, flexible, less-restrictive duty-hour policies for surgical residents were associated with noninferior patient outcomes.

“As compared with standard duty-hour policies, flexible, less-restrictive duty-hour policies for surgical residents were associated with noninferior patient outcomes and no significant difference in residents' satisfaction with overall well-being and education quality.”