Association Between End-of-Rotation Resident Transition in Care and Mortality Among Hospitalized Patients

IMPORTANCE: Shift-to-shift transitions in care among house staff are associated with adverse events. However, the association between end-of-rotation transition (in which care of the patient is transferred) and adverse events is uncertain. OBJECTIVE: To examine the association of end-of-rotation house staff transitions with mortality among hospitalized patients. DESIGN, SETTING, AND PARTICIPANTS: Retrospective multicenter cohort study of patients admitted to internal medicine services (N = 230 701) at 10 university-affiliated US Veterans Health Administration hospitals (2008-2014). EXPOSURES: Transition patients (defined as those admitted prior to an end-of-rotation transition who died or were discharged within 7 days following transition) were stratified by type of transition (intern only, resident only, or intern + resident) and compared with all other discharges (control). An alternative analysis comparing admissions within 2 days before transition with admissions on the same 2 days 2 weeks later was also conducted. MAIN OUTCOMES AND MEASURES: The primary outcome was in-hospital mortality. Secondary outcomes included 30-day and 90-day mortality and readmission rates. A difference-in-difference analysis assessed whether outcomes changed after the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations. Adjustments included age, sex, race/ethnicity, month, year, length of stay, comorbidities, and hospital. RESULTS: Among 230 701 patient discharges (mean age, 65.6 years; men, 95.8%; median length of stay, 3.0 days), 25 938 intern-only, 26 456 resident-only, and 11 517 intern + resident end-of-rotation transitions occurred. Overall mortality was 2.18% in-hospital, 9.45% at 30 days, and 14.43% at 90 days. Adjusted hospital mortality was significantly greater in transition vs control patients for the intern-only group (3.5% vs 2.0%; odds ratio OR, 1.12 95% CI, 1.03-1.21) and the intern + resident group (4.0% vs 2.1%; OR, 1.18 95% CI, 1.06-1.33), but not for the resident-only group (3.3% vs 2.0%; OR, 1.07 95% CI, 0.99-1.16). Adjusted 30-day and 90-day mortality rates were greater in all transition vs control comparisons (30-day mortality: intern-only group, 14.5% vs 8.8%, OR, 1.17 95% CI, 1.13-1.22; resident-only group, 13.8% vs 8.9%, OR, 1.11 95% CI, 1.04-1.18; intern + resident group, 15.5% vs 9.1%, OR, 1.21 95% CI, 1.12-1.31; 90-day mortality: intern-only group, 21.5% vs 13.5%, OR, 1.14 95% CI, 1.10-1.19; resident-only group, 20.9% vs 13.6%, OR, 1.10 95% CI, 1.05-1.16; intern + resident group, 22.8% vs 14.0%, OR, 1.17 95% CI, 1.11-1.23). Duty hour changes were associated with greater adjusted hospital mortality for transition patients in the intern-only group and intern + resident group than for controls (intern-only: OR, 1.11 95% CI, 1.02-1.21; intern + resident: OR, 1.17 95% CI, 1.02-1.34). The alternative analyses did not demonstrate any significant differences in mortality between transition and control groups. CONCLUSIONS AND RELEVANCE: Among patients admitted to internal medicine services in 10 Veterans Affairs hospitals, end-of-rotation transition in care was associated with significantly higher in-hospital mortality in an unrestricted analysis that included most patients, but not in an alternative restricted analysis. The association was stronger following institution of ACGME duty hour regulations.