Effects on resident work hours, sleep duration, and work experience in a randomized order safety trial evaluating resident-physician schedules(ROSTERS)
Open accessAbstract
Study Objectives: We compared resident physician work hours and sleep in a multicenter clustered-randomized crossover clinical trial that randomized resident physicians to an Extended Duration Work Roster (EDWR) with extended-duration (≥24 hr) shifts or a Rapidly Cycling Work Roster (RCWR), in which scheduled shift lengths were limited to 16 or fewer consecutive hours. Methods: Three hundred two resident physicians were enrolled and completed 370 1 month pediatric intensive care unit rotations in six US academic medical centers. Sleep was objectively estimated with wrist-worn actigraphs. Work hours and subjective sleep data were collected via daily electronic diary. Results: Resident physicians worked fewer total hours per week during the RCWR compared with the EDWR (61.9 ± 4.8 versus 68.4 ± 7.4, respectively; p < 0.0001). During the RCWR, 73% of work hours occurred within shifts of ≤16 consecutive hours. In contrast, during the EDWR, 38% of work hours occurred on shifts of ≤16 consecutive hours. Resident physicians obtained significantly more sleep per week on the RCWR (52.9 ± 6.0 hr) compared with the EDWR (49.1 ± 5.8 hr, p < 0.0001). The percentage of 24 hr intervals with less than 4 hr of actigraphically measured sleep was 9% on the RCWR and 25% on the EDWR (p < 0.0001). Conclusions: RCWRs were effective in reducing weekly work hours and the occurrence of >16 consecutive hour shifts, and improving sleep duration of resident physicians. Although inclusion of the six operational healthcare sites increases the generalizability of these findings, there was heterogeneity in schedule implementation. Additional research is needed to optimize scheduling practices allowing for sufficient sleep prior to all work shifts. Clinical Trial: Multicenter Clinical Trial of Limiting Resident Work Hours on ICU Patient Safety (ROSTERS), https://clinicaltrials.gov/ct2/show/NCT02134847
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The results of one study were reported in two papers (Barger 2019a).
“The results of one study were reported in two papers (Barger 2019a).”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
The Methods (page unavailable) identify this paper as a report from the ROSTERS trial. Our copy cites a separate study-design paper and conference abstracts, but it does not establish that the trial’s results were reported in exactly two papers. (LLM, conf=0.78)
Experimental — accuracy not yet measuredBarger 2019a and Basner 2019 reported sleep duration off-shift.
“Barger 2019a and Basner 2019 reported sleep duration off‐shift.”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
The Methods and Results report resident physicians’ sleep duration using continuous actigraphy and daily diaries, including weekly sleep totals. They do not report a separate measure of sleep duration specifically off-shift; the Results describe total sleep across 24-hour intervals. This verdict concerns Barger 2019a only, not the separately named Basner 2019 paper. (LLM, conf=0.83)
Experimental — accuracy not yet measuredParticipants in Barger 2019a who worked overnight shifts of no more than 16 hours had fewer working hours per week than the control group (MD −6.50 hours, 95% CI −7.73 to −5.27), though this evidence is of very low certainty.
“Participants in Barger 2019a who worked overnight shifts of no more than 16 hours had fewer working hours per week than the control group (MD −6.50 hours, 95% CI −7.73 to −5.27; Analysis 3.3), though this evidence is of very low certainty.”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
The Results (Work hours; page not available) report 68.4 weekly hours under the extended-duration roster versus 61.9 under the roster limiting scheduled shifts to 16 hours, a difference of 6.50 hours. The paper does not report the claimed 95% CI or assess the evidence as being of very low certainty; those parts of the citing sentence are not supported by this source. (LLM, conf=0.86)
Experimental — accuracy not yet measuredIn Barger 2019a, allocation concealment was at unclear risk of bias because there was no clear description of the randomisation procedure.
“Allocation concealment (selection bias) Unclear risk No clear description of the randomisation procedure.”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
The Methods (page unavailable) call ROSTERS a clustered-randomized crossover trial but say that full study-design details are available elsewhere; the passage does not describe how allocation was concealed. This supports the citing authors’ observation that this paper lacks a clear procedural description, but the paper does not itself assess allocation concealment as an unclear risk of bias. (LLM, conf=0.76)
Experimental — accuracy not yet measuredIn Barger 2019a, blinding of outcome assessment for subjective measures was at high risk of bias because the outcome assessment was not blinded.
“Blinding of outcome assessment (detection bias) Subjective measures High risk The outcome assessment was not blinded.”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
The Methods (page unavailable) say residents rated their experience on each schedule in end-of-rotation surveys, supporting concern about blinding for those subjective measures. The paper does not state that outcome assessment was unblinded or assign a high-risk-of-bias rating; that rating is the citing authors’ assessment. (LLM, conf=0.76)
Experimental — accuracy not yet measured
In Barger 2019a, blinding of participants and personnel for subjective measures was at high risk of bias because blinding to group allocation was not possible.
“Blinding of participants and personnel (performance bias) Subjective measures High risk Blinding of participants and personnel to the group allocation was not possible.”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
The Methods describe visibly different resident-physician schedules and self-reported work-experience measures (page unavailable). This supports the study context for the citing authors’ bias assessment, but our copy does not state that blinding participants or personnel was impossible or classify the subjective measures as high risk of bias. (LLM, conf=0.78)
Experimental — accuracy not yet measuredIn Barger 2019a, incomplete outcome data for sleepiness during shifts was at unclear risk of bias because no clear reason for dropouts was provided.
“Incomplete outcome data (attrition bias) Sleepiness during shifts Unclear risk No clear reason for dropouts provided.”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
The Results (page unavailable) report that some rotations lacked sufficient actigraphy or eDiary data, without giving reasons for those missing data. Our copy does not report incomplete data specifically for sleepiness during shifts. The ‘unclear risk’ rating is the citing authors’ assessment, not a finding stated by Barger et al. (LLM, conf=0.78)
Experimental — accuracy not yet measuredParticipants who worked overnight shifts lasting no longer than 16 hours slept more hours per week (Barger 2019a) or during overnight shifts (Basner 2019) than those who worked 24 to 28 hour shifts.
“Participants who worked overnight shifts lasting no longer than 16 hours slept more hours per week (in Barger 2019a) or during (over)night shifts (in Basner 2019) than those who worked overnight shifts of 24 to 28 hours.”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
Barger 2019a and Basner 2019 reported sleepiness during shifts.
“Barger 2019a and Basner 2019 reported sleepiness during shifts.”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
The review found only two high-quality RCTs with sufficient data to include in meta-analysis (Barger 2019a; Basner 2019).
“We found only two high‐quality RCTs with sufficient data to include in our meta‐analysis (Barger 2019a; Basner 2019).”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
Only the two RCTs investigating 80-hour workweeks included a substantial number of women and were conducted in the healthcare sector (Barger 2019a; Basner 2019).
“Only the two RCTs investigating the 80‐hour workweeks included a substantial number of women and were conducted in the healthcare sector (Barger 2019a; Basner 2019).”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
In Barger 2019a, blinding of participants and personnel for objective measures was at low risk of bias because objective measurements using actigraphy were used.
“Blinding of participants and personnel (performance bias) Objective measures Low risk Objective measurements using actigraphy.”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
In Barger 2019a, random sequence generation was at unclear risk of bias because there was no clear description of the randomisation procedure.
“Random sequence generation (selection bias) Unclear risk No clear description of the randomisation procedure.”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
In Barger 2019a, reliability or objectivity of measurement for sleep length and quality was at low risk because an objective measure of sleep length was used.
“Reliable or objective measurement of outcomes Sleep length and quality Low risk Objective measure of sleep length.”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
In Barger 2019a, appropriateness of statistical analysis for cluster allocation was at low risk because the study adjusted for cluster effect.
“Appropriateness of statistical analysis (cluster allocation) Low risk The study adjusted for cluster effect.”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
In Barger 2019a, incomplete outcome data for sleep length off-shift was at unclear risk of bias because no clear reason for dropouts was provided.
“Incomplete outcome data (attrition bias) Sleep length off‐shift Unclear risk No clear reason for dropouts provided.”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
In Barger 2019a, blinding of outcome assessment for objective measures was at low risk of bias because blinding was ensured and unlikely to have been broken.
“Blinding of outcome assessment (detection bias) Objective measures Low risk Blinding of outcome assessment was ensured, and it was unlikely that the blinding could have been broken.”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
The Methods (page not provided) describe actigraphy, electronic diaries, and analysis of the outcomes, but do not say whether outcome assessors were blinded. Searches for blinding, masking, and blinded scoring found no passage establishing that blinding was ensured or unlikely to have been broken. (LLM, conf=0.73)
Experimental — accuracy not yet measuredIn Barger 2019a, reliability or objectivity of measurement for sleepiness was at low risk because the KSS was used to measure sleepiness.
“Reliable or objective measurement of outcomes Sleepiness Low risk KSS used to measure sleepiness.”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
The Methods (page unavailable) describe actigraphy and electronic diaries for measuring sleep duration, but do not say that sleepiness was measured with the KSS. Searches for “KSS,” “Karolinska Sleepiness Scale,” and sleepiness measurement found no passage supporting the stated low-risk assessment. (LLM, conf=0.74)
Experimental — accuracy not yet measuredIn Barger 2019a, recruitment bias was at low risk because the trial reported minimal recruitment after randomisation.
“Recruitment bias Low risk Trial reported minimal recruitment after randomisation.”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
The Methods (Recruitment; page unavailable) say that all eligible residents working in the PICUs during the study interval were invited to participate. The Methods also describe random assignment of the units’ initial schedules, but do not state how many residents were recruited after randomisation or assess recruitment bias. Searched for recruitment timing, enrolment and randomisation. (LLM, conf=0.72)
Experimental — accuracy not yet measuredIn Barger 2019a, selective reporting was at low risk of bias because all outcomes mentioned in the protocol were reported either in Barger 2019a or Rahman 2021.
“Selective reporting (reporting bias) Low risk All outcomes mentioned in the protocol were reported either in Barger 2019a or Rahman 2021 .”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
The Methods describe the ROSTERS trial and refer readers elsewhere for full study-design details; the Results report work-hour and sleep outcomes. Our copy does not compare reported outcomes with those in the protocol or assess selective-reporting bias, and it cannot establish what Rahman 2021 reported. Searched for protocol outcomes, selective reporting, and Rahman 2021. (LLM, conf=0.72)
Experimental — accuracy not yet measuredIn Barger 2019a, other bias was at low risk because no other potential sources of bias were identified.
“Other bias Low risk We identified no other potential sources of bias.”
From Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers (2023) · cites this paper as Barger 2019a
The Methods describe the trial design and analysis, and the Acknowledgments state that funders were not involved in the study. Neither section assesses the study as having low risk of other bias or says that no other potential sources of bias were identified. The quoted judgment appears to be the citing authors’ assessment, not a statement in our copy of Barger 2019a. (LLM, conf=0.72)
Experimental — accuracy not yet measured
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Effect on patient safety of a resident physician schedule without 24-hour shifts
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Self-citationAdapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers
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- Authors
- Barger, L. K., Sullivan, J. P., Blackwell, T., O’Brien, C. S., St. Hilaire, M. A., Rahman, S. A., Phillips, A. J. K., Qadri, S., Wright, K. P., Segar, J. L., McGuire, J. K., Vitiello, M. V., de la Iglesia, H. O., Poynter, S. E., Yu, P. L., Zee, P., Sanderson, A. L., Halbower, A. C., Lockley, S. W., Landrigan, C. P., Stone, K. L., Czeisler, C. A., ROSTERS Study Group, Barger, L. K., Czeisler, C. A., St Hilaire, M. A., Klerman, E. B., Landrigan, C. P., Lockley, S. W., O’Brien, C. S., Phillips, A. J. K., Qadri, S., Rahman, S. A., Sullivan, J. P., Viyaran, N. C., Blackwell, T., Kriesel, D. R., Stone, K. L., Czaja, A. S., Halbower, A. C., Rosenberg, A., Wright, K. P., Cress, G., Erkonen, G. E., Segar, J. L., Armstrong, L. B., Albert, B. D., Bressler, E. A., Daniel, D., Landrigan, C. P., Podd, B. S., Sanderson, A. L., Sectish, T. C., Upchurch, P. A., Wolbrink, T. A., Poynter, S. E., Carver, J., Yu, P. L., Batra, M., Farris, R. W. D., la Iglesia, H. O. D., McGuire, J. K., Vitiello, M. V., & Zee, P. C.
- Affiliations
- Department of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA
- University of Washington, Seattle, WA
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
- Brigham and Women's Hospital (US)
- California Pacific Medical Center (US)
- Children's Hospital Colorado (US)
- University of Colorado Boulder (US)
- University of Iowa Stead Family Children’s Hospital (US)
- Cincinnati Children's Hospital Medical Center (US)
- University of Washington (US)
- Seattle Children's Hospital (US)
- ORCID
- Venue
- Sleep
- Publisher
- Oxford University Press (OUP)
- Published
- 2019-05-20
- Volume
- 42
- Issue
- 8
- ISSN
- 0161-8105 (ISSN-L)
- 1550-9109
- PMC
- PMC6685326
- OpenAlex
- W2946046951
- Cited by
- 43
- References
- 4
- Citations by year
- 2026: 5 · 2025: 4 · 2024: 9 · 2023: 7 · 2022: 4 · 2021: 10 · 2020: 4
- FWCI
- 5.23
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Licence
- academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model (vor)
- Locations
- SLEEP (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Surrey Research Insight Open Access (The University of Surrey) (submittedVersion)
- Funders
- National Heart, Lung, and Blood Institute (U01-HL-111478, U01-HL-111691, NIH K24-HL-105664, R01-HL-128538, R01-HL-114088, R01-GM-105018, R21-HD-086392, P01-AG-009975, NSBRI HFP-02802, HFP-0006, HFP-04201)
- National Institute of Occupational Safety and Health (R01-OH-010300)
- Topics
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and Work-Related Fatigue
- Health Sciences › Health Professions › General Health Professions › Healthcare professionals’ stress and burnout
- Keywords
- sleep duration, shift length, pediatric intensive care unit, actigraphy, work experience, resident fatigue
- MeSH terms
- Shift Work Schedule, Adult, Female, Humans, Internship and Residency, Male, Records, Sleep, Work Schedule Tolerance, Cross-Over Studies, Patient Safety
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