There is heightened public awareness and ongoing debate about the effects of sleep deprivation and fatigue on physician performance.1–6 Some studies have demonstrated that medical resident fatigue is associated with a higher rate of errors including percutaneous needle sticks and laceration injuries, as well as postcall motor vehicle crashes.2,7,8 Others have not replicated these findings among surgical residents.9,10 However, legislative reform and comprehensive regulatory efforts have transformed graduate medical education and have imposed strict work hour restrictions on trainees.11 Recent randomized trials demonstrated that loose adherence to these restrictions was not associated with increased complications, fueling further debate on this issue.12 Unlike residents, there is no restriction on the work hours of attending physicians in the United States.4,13
Prior studies on the effect of sleep deprivation of attending surgeons on outcomes have had conflicting results. Single-center studies14 have demonstrated an association with inferior outcomes, whereas multicenter Canadian investigations15,16 have identified no difference. The generalization of the latter studies in the United States is limited given the differences in the practice of medicine between the 2 countries. Additionally, these prior investigations have focused on general surgeons, who frequently subspecialize to only provide emergency care. However, neurosurgeons are very commonly called upon to treat trauma or other neurological pathology emergently, while maintaining a busy elective surgical schedule. No prior study has attempted to answer this question in a comprehensive cohort of neurosurgeons.
We used the New York Statewide Planning and Research Cooperative System (SPARCS)17 to study the association of performing emergency procedures the night before an elective case with mortality, discharge to a facility, and length of stay for patients being treated for unruptured cerebral aneurysms. We used an instrumental variable analysis to simulate the effect of randomization.
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