Sleep and Alertness in a Duty-Hour Flexibility Trial in Internal Medicine.

Actigraphy Humans Internal Medicine / education Internship and Residency / organization & administration Personnel Staffing and Scheduling / standards Sleep Sleep Deprivation Sleepiness United States Wakefulness Work Schedule Tolerance

Journal

The New England journal of medicine
ISSN: 1533-4406
Titre abrégé: N Engl J Med
Pays: United States
ID NLM: 0255562

Informations de publication

Date de publication:
07 03 2019
Historique:
entrez: 12 3 2019
pubmed: 12 3 2019
medline: 2 4 2019
Statut: ppublish

Résumé

A purpose of duty-hour regulations is to reduce sleep deprivation in medical trainees, but their effects on sleep, sleepiness, and alertness are largely unknown. We randomly assigned 63 internal-medicine residency programs in the United States to follow either standard 2011 duty-hour policies or flexible policies that maintained an 80-hour workweek without limits on shift length or mandatory time off between shifts. Sleep duration and morning sleepiness and alertness were compared between the two groups by means of a noninferiority design, with outcome measures including sleep duration measured with actigraphy, the Karolinska Sleepiness Scale (with scores ranging from 1 [extremely alert] to 9 [extremely sleepy, fighting sleep]), and a brief computerized Psychomotor Vigilance Test (PVT-B), with long response times (lapses) indicating reduced alertness. Data were obtained over a period of 14 days for 205 interns at six flexible programs and 193 interns at six standard programs. The average sleep time per 24 hours was 6.85 hours (95% confidence interval [CI], 6.61 to 7.10) among those in flexible programs and 7.03 hours (95% CI, 6.78 to 7.27) among those in standard programs. Sleep duration in flexible programs was noninferior to that in standard programs (between-group difference, -0.17 hours per 24 hours; one-sided lower limit of the 95% confidence interval, -0.45 hours; noninferiority margin, -0.5 hours; P = 0.02 for noninferiority), as was the score on the Karolinska Sleepiness Scale (between-group difference, 0.12 points; one-sided upper limit of the 95% confidence interval, 0.31 points; noninferiority margin, 1 point; P<0.001). Noninferiority was not established for alertness according to the PVT-B (between-group difference, -0.3 lapses; one-sided upper limit of the 95% confidence interval, 1.6 lapses; noninferiority margin, 1 lapse; P = 0.10). This noninferiority trial showed no more chronic sleep loss or sleepiness across trial days among interns in flexible programs than among those in standard programs. Noninferiority of the flexible group for alertness was not established. (Funded by the National Heart, Lung, and Blood Institute and American Council for Graduate Medical Education; ClinicalTrials.gov number, NCT02274818.).

Sections du résumé

BACKGROUND
A purpose of duty-hour regulations is to reduce sleep deprivation in medical trainees, but their effects on sleep, sleepiness, and alertness are largely unknown.
METHODS
We randomly assigned 63 internal-medicine residency programs in the United States to follow either standard 2011 duty-hour policies or flexible policies that maintained an 80-hour workweek without limits on shift length or mandatory time off between shifts. Sleep duration and morning sleepiness and alertness were compared between the two groups by means of a noninferiority design, with outcome measures including sleep duration measured with actigraphy, the Karolinska Sleepiness Scale (with scores ranging from 1 [extremely alert] to 9 [extremely sleepy, fighting sleep]), and a brief computerized Psychomotor Vigilance Test (PVT-B), with long response times (lapses) indicating reduced alertness.
RESULTS
Data were obtained over a period of 14 days for 205 interns at six flexible programs and 193 interns at six standard programs. The average sleep time per 24 hours was 6.85 hours (95% confidence interval [CI], 6.61 to 7.10) among those in flexible programs and 7.03 hours (95% CI, 6.78 to 7.27) among those in standard programs. Sleep duration in flexible programs was noninferior to that in standard programs (between-group difference, -0.17 hours per 24 hours; one-sided lower limit of the 95% confidence interval, -0.45 hours; noninferiority margin, -0.5 hours; P = 0.02 for noninferiority), as was the score on the Karolinska Sleepiness Scale (between-group difference, 0.12 points; one-sided upper limit of the 95% confidence interval, 0.31 points; noninferiority margin, 1 point; P<0.001). Noninferiority was not established for alertness according to the PVT-B (between-group difference, -0.3 lapses; one-sided upper limit of the 95% confidence interval, 1.6 lapses; noninferiority margin, 1 lapse; P = 0.10).
CONCLUSIONS
This noninferiority trial showed no more chronic sleep loss or sleepiness across trial days among interns in flexible programs than among those in standard programs. Noninferiority of the flexible group for alertness was not established. (Funded by the National Heart, Lung, and Blood Institute and American Council for Graduate Medical Education; ClinicalTrials.gov number, NCT02274818.).

Identifiants

DOI: 10.1056/NEJMoa1810641 PMID: 30855741 PMC: PMC6457111
pubmed: 30855741
doi: 10.1056/NEJMoa1810641
pmc: PMC6457111
mid: NIHMS1523726
doi:

Banques de données

ClinicalTrials.gov
['NCT02274818']

Types de publication

Comparative Study Equivalence Trial Journal Article Multicenter Study Randomized Controlled Trial Research Support, N.I.H., Extramural

Langues

eng

Sous-ensembles de citation

IM

Pagination

915-923

Subventions

Organisme : NINR NIH HHS
ID : K99 NR017416
Pays : United States
Organisme : NHLBI NIH HHS
ID : U01HL125388
Pays : United States
Organisme : NINR NIH HHS
ID : P20 NR018075
Pays : United States
Organisme : NHLBI NIH HHS
ID : U01 HL125388
Pays : United States
Organisme : NHLBI NIH HHS
ID : U01 HL126088
Pays : United States
Organisme : NHLBI NIH HHS
ID : U01HL126088
Pays : United States
Organisme : NINR NIH HHS
ID : F31 NR014603
Pays : United States

Investigateurs

Margot Boigon (M)
Jill Patton (J)
Donna Astiz (D)
Cheryl O'Malley (C)
Richard J Hamill (RJ)
Michael Rosenblum (M)
Charles Smith (C)
Joel Katz (J)
Maria Yialamas (M)
Dominick Tammaro (D)
Jennifer Bolyard (J)
Claudia A Kroker-Bode (CA)
Michael J McFarlane (MJ)
Keith Armitage (K)
Amanda Ewing (A)
Abby L Spencer (AL)
Tammy Wichman (T)
Richard Paluzzi (R)
Aimee Zaas (A)
Suzanne Kraemer (S)
Benjamin Goodman (B)
Lorenzo Di Francesco (L)
Mary Harris (M)
Jillian Catalanotti (J)
Sal Pindiprolu (S)
Paul Foster (P)
Sean M Drake (SM)
Sanjay Desai (S)
Erica N Johnson (EN)
Elizabeth Nilson (E)
William D Surkis (WD)
Jonathon Doroshow (J)
Jatin M Vyas (JM)
Michael Frank (M)
Eric H Green (EH)
Cinnamon Bradley (C)
Soma Wali (S)
Sapna Kuehl (S)
Harvey Friedman (H)
Ronald Witteles (R)
Marissa A Blum (MA)
Curtis Mirkes (C)
Michael Phy (M)
Emily Stewart (E)
Richard Kopelman (R)
Kari Roberts (K)
Jodi Friedman (J)
Brian Gable (B)
Eric Warm (E)
Suzanne Brandenburg (S)
Steven V Angus (SV)
Leigh M Eck (LM)
Susan D Wolfsthal (SD)
Richard M Forster (RM)
James O'Dell (J)
Debra L Bynum (DL)
Lisa Bellini (L)
Mark Pasanen (M)
Kenneth P Steinberg (KP)
Stephanie Ann Call (SA)
Hal H Atkinson (HH)
Melvin Blanchard (M)
Thomas Ciesielski (T)
Nathan Lerfald (N)
Mark D Siegel (MD)

Informations de copyright

Copyright © 2019 Massachusetts Medical Society.

Références

Sleep. 2001 Nov 1;24(7):813-9
pubmed: 11683484
Sleep Med Rev. 2000 Aug;4(4):341-353
pubmed: 12531174
J Sleep Res. 2003 Mar;12(1):1-12
pubmed: 12603781
Sleep. 2003 Mar 15;26(2):117-26
pubmed: 12683469
Sleep. 2003 May 1;26(3):342-92
pubmed: 12749557
N Engl J Med. 2005 Jan 13;352(2):125-34
pubmed: 15647575
Clin Orthop Relat Res. 2006 Aug;449:116-27
pubmed: 16770285
JAMA. 2006 Sep 6;296(9):1055-62
pubmed: 16954484
PLoS Med. 2006 Dec;3(12):e487
pubmed: 17194188
JAMA. 2007 Sep 5;298(9):984-92
pubmed: 17785643
J Clin Sleep Med. 2007 Aug 15;3(5):519-28
pubmed: 17803017
Curr Neurol Neurosci Rep. 2009 Mar;9(2):155-64
pubmed: 19268039
N Engl J Med. 2010 Jul 8;363(2):e3
pubmed: 20573917
BMC Health Serv Res. 2010 Aug 15;10:239
pubmed: 20712854
Sleep. 2010 Aug;33(8):1043-53
pubmed: 20815185
Ann Intern Med. 2010 Dec 21;153(12):829-42
pubmed: 21173417
Sleep. 2011 May 01;34(5):581-91
pubmed: 21532951
Acta Astronaut. 2011 Dec 1;69(11-12):949-959
pubmed: 22025811
Int J Neurosci. 1990 May;52(1-2):29-37
pubmed: 2265922
JAMA. 2012 Dec 5;308(21):2208-17
pubmed: 23212498
Curr Opin Neurobiol. 2013 Oct;23(5):854-63
pubmed: 23523374
JAMA Intern Med. 2013 Apr 22;173(8):707-9; discussion 663
pubmed: 23529748
JAMA Intern Med. 2013 Apr 22;173(8):649-55
pubmed: 23529771
Acad Med. 2014 Mar;89(3):452-9
pubmed: 24448046
Sleep. 2014 Dec 01;37(12):1889-906
pubmed: 25325472
JAMA. 2014 Dec 10;312(22):2364-73
pubmed: 25490327
JAMA. 2014 Dec 10;312(22):2374-84
pubmed: 25490328
Sleep. 2015 Jun 01;38(6):843-4
pubmed: 26039963
Sleep. 2015 Aug 01;38(8):1161-83
pubmed: 26194576
JAMA Surg. 2016 Mar;151(3):273-81
pubmed: 26720622
N Engl J Med. 2016 Feb 25;374(8):713-27
pubmed: 26836220
Sleep. 2017 Apr 1;40(4):
pubmed: 28329124
J Sleep Res. 2017 Oct;26(5):559-566
pubmed: 28370590
Aerosp Med Hum Perform. 2017 Oct 1;88(10):937-946
pubmed: 28923143
N Engl J Med. 2018 Apr 19;378(16):1494-1508
pubmed: 29557719
BMJ Open. 2018 Sep 21;8(9):e021711
pubmed: 30244209
N Engl J Med. 2019 Mar 7;380(10):905-914
pubmed: 30855740

Auteurs

Mathias Basner (M)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).
ORCID: 0000-0002-8453-0812

David A Asch (DA)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

Judy A Shea (JA)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

Lisa M Bellini (LM)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

Michele Carlin (M)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

Adrian J Ecker (AJ)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

Susan K Malone (SK)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

Sanjay V Desai (SV)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

Alice L Sternberg (AL)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

James Tonascia (J)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

David M Shade (DM)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

Joel T Katz (JT)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

David W Bates (DW)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

Orit Even-Shoshan (O)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

Jeffrey H Silber (JH)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

Dylan S Small (DS)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

Kevin G Volpp (KG)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

Christopher G Mott (CG)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

Sara Coats (S)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

Daniel J Mollicone (DJ)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

David F Dinges (DF)

From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.).

Articles similaires

[Redispensing of expensive oral anticancer medicines: a practical application].

Lisanne N van Merendonk, Kübra Akgöl, Bastiaan Nuijen
1.00
Humans Antineoplastic Agents Administration, Oral Drug Costs Counterfeit Drugs

Smoking Cessation and Incident Cardiovascular Disease.

Jun Hwan Cho, Seung Yong Shin, Hoseob Kim et al.
1.00
Humans Male Smoking Cessation Cardiovascular Diseases Female

Evaluation of Low-Value Services Across Major Medicare Advantage Insurers and Traditional Medicare.

Ciara Duggan, Adam L Beckman, Ishani Ganguli et al.
1.00
Humans United States Aged Cross-Sectional Studies Medicare Part C

Effectiveness of Virtual Yoga for Chronic Low Back Pain: A Randomized Clinical Trial.

Hallie Tankha, Devyn Gaskins, Amanda Shallcross et al.
1.00
Humans Yoga Low Back Pain Female Male

Classifications MeSH

questionsmedicales.fr › Techniques d'investigation › Accélérométrie › Actigraphie › Sleep and Alertness in a Duty-Hour Flexibility...
questionsmedicales.fr › Eucaryotes › Animaux › Chordés › Vertébrés › Mammifères › Eutheria › Primates › Haplorhini › Catarrhini › Hominidae › Humains › Sleep and Alertness in a Duty-Hour Flexibility...
questionsmedicales.fr › Professions de santé › Médecine › Médecine interne › Sleep and Alertness in a Duty-Hour Flexibility...
questionsmedicales.fr › Éducation › Enseignement professionnel › Enseignement médical › Enseignement spécialisé en médecine › Internat et résidence › Sleep and Alertness in a Duty-Hour Flexibility...
questionsmedicales.fr › Administration des services de santé › Organisation et administration › Gestion du personnel › Affectation du personnel et organisation du temps de travail › Sleep and Alertness in a Duty-Hour Flexibility...
questionsmedicales.fr › Phénomènes physiologiques de l'appareil locomoteur et du système nerveux › Phénomènes physiologiques du système nerveux › Sommeil › Sleep and Alertness in a Duty-Hour Flexibility...
questionsmedicales.fr › Troubles mentaux › Troubles de la veille et du sommeil › Dyssomnies › Privation de sommeil › Sleep and Alertness in a Duty-Hour Flexibility...
questionsmedicales.fr › Phénomènes physiologiques de l'appareil locomoteur et du système nerveux › Phénomènes physiologiques du système nerveux › Sommeil › Phases du sommeil › Envie de dormir › Sleep and Alertness in a Duty-Hour Flexibility...
questionsmedicales.fr › Régions géographiques › Amériques › Amérique du Nord › États-Unis › Sleep and Alertness in a Duty-Hour Flexibility...
questionsmedicales.fr › Phénomènes physiologiques de l'appareil locomoteur et du système nerveux › Phénomènes physiologiques du système nerveux › Éveil › Vigilance › Sleep and Alertness in a Duty-Hour Flexibility...
questionsmedicales.fr › Administration des services de santé › Organisation et administration › Gestion du personnel › Affectation du personnel et organisation du temps de travail › Tolérance à l'horaire de travail › Sleep and Alertness in a Duty-Hour Flexibility...