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J Stroke Cerebrovasc Dis. 2009 May-Jun;18(3):232-8. doi: 10.1016/j.jstrokecerebrovasdis.2008.10.006.

The impact of Accreditation Council for Graduate Medical Education duty hours, the July phenomenon, and hospital teaching status on stroke outcomes.

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Neurological Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH 44106-5040, USA.



Acute ischemic stroke (AIS) is common cause of hospital admission. The objective of this study was to determine the impact of the new Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations on AIS outcomes including inhospital mortality.


Hospitalized patients with AIS were selected from the National Inpatient Sample database. Patients with AIS with a known mortality and hospital teaching status were included for the years 2000 through 2005. Inhospital mortality and predictors of mortality were stratified by the hospital teaching status. To determine the variability of mortality around the month of July (July phenomenon) the trend of mortality was determined in teaching hospitals stratified by the calendar month of each year.


In all, 377,266 patients were included in this analysis; 43.0% were admitted to teaching hospitals. Overall inhospital mortality was 10.8%, slightly higher in teaching hospitals (11.4% v 10.3%, P < .0001). The trend in AIS mortality showed a decline during the 6 years included in this study in both hospital types (P < .0001). Adjusted analysis showed decline in mortality in both hospital types after July 1, 2003: odds ratio (OR) 0.91 (95% confidence interval [CI] 0.87, 0.94) in teaching hospitals and OR 0.81 (95% CI 0.78, 0.84) in nonteaching hospitals. Predictors of AIS-associated hospital mortality were similar in both hospital types except for sepsis, which was another independent predictor of death in nonteaching hospitals (OR 1.58, 95% CI 1.30, 1.94). There was no significant change in AIS mortality when stratified by each calendar month within the years included in this study (P value = .25-.93).


There was no difference in AIS mortality after the implementation of the new ACGME duty hour standards. In addition, data support the lack of July phenomenon in neurology residency programs in regard to AIS mortality.

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