"July effect": Impact of the academic year-end changeover on patient outcomes

University of California, San Francisco, School of Medicine, 94143, USA.
Annals of internal medicine (Impact Factor: 16.1). 07/2011; 155(5):309-15. DOI: 10.1059/0003-4819-155-5-201109060-00354
Source: PubMed

ABSTRACT It is commonly believed that the quality of health care decreases during trainee changeovers at the end of the academic year.
To systematically review studies describing the effects of trainee changeover on patient outcomes.
Electronic literature search of PubMed, Educational Research Information Center (ERIC), EMBASE, and the Cochrane Library for English-language studies published between 1989 and July 2010.
Title and abstract review followed by full-text review to identify studies that assessed the effect of the changeover on patient outcomes and that used a control group or period as a comparator.
Using a standardized form, 2 authors independently abstracted data on outcomes, study setting and design, and statistical methods. Differences between reviewers were reconciled by consensus. Studies were then categorized according to methodological quality, sample size, and outcomes reported.
Of the 39 included studies, 27 (69%) reported mortality, 19 (49%) reported efficiency (length of stay, duration of procedure, hospital charges), 23 (59%) reported morbidity, and 6 (15%) reported medical error outcomes; all studies focused on inpatient settings. Most studies were conducted in the United States. Thirteen (33%) were of higher quality. Studies with higher-quality designs and larger sample sizes more often showed increased mortality and decreased efficiency at time of changeover. Studies examining morbidity and medical error outcomes were of lower quality and produced inconsistent results.
The review was limited to English-language reports. No study focused on the effect of changeovers in ambulatory care settings. The definition of changeover, resident role in patient care, and supervision structure varied considerably among studies. Most studies did not control for time trends or level of supervision or use methods appropriate for hierarchical data.
Mortality increases and efficiency decreases in hospitals because of year-end changeovers, although heterogeneity in the existing literature does not permit firm conclusions about the degree of risk posed, how changeover affects morbidity and rates of medical errors, or whether particular models are more or less problematic.
National Heart, Lung, and Blood Institute.

Download full-text


Available from: John Q Young, Feb 05, 2015
  • Source
    • "Outside radiation oncology, concerns have been raised that new trainees may be associated with higher risk of medical errors. A systematic review of 39 studies conducted in the inpatient setting has previously demonstrated an increased mortality and decreased efficiency of care during the academic year-end changeover period [25]. In a radiotherapy department, the proportion of new radiation therapy graduates will be less than that of a typical surgical or medical department, ensuring better supervision. "
    [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND AND PURPOSE: To ascertain the rate, type, significance, trends and the potential risk factors associated with radiotherapy incidents in a large academic department. MATERIALS AND METHODS: Data for all radiotherapy activities from July 2001 to January 2011 were reviewed from radiotherapy incident reporting forms. Patient and treatment data were obtained from the radiotherapy record and verification database (MOSAIQ) and the patient database (HOSPRO). Logistic regression analyses were performed to determine variables associated with radiotherapy incidents. RESULTS: In that time, 65,376 courses of radiotherapy were delivered with a reported incident rate of 2.64 per 100 courses. The rate of incidents per course increased (1.96 per 100 courses to 3.52 per 100 courses, p<0.001) whereas the proportion of reported incidents resulting in >5% deviation in dose (10.50 to 2.75%, p<0.001) had decreased after the introduction of an online electronic reporting system. The following variables were associated with an increased rate of incidents: afternoon treatment time, paediatric patients, males, inpatients, palliative plans, head-and-neck, skin, sarcoma and haematological malignancies. In general, complex plans were associated with higher incidence rates. CONCLUSION: Radiotherapy incidents were infrequent and most did not result in significant dose deviation. A number of risk factors were identified and these could be used to highlight high-risk cases in the future. Introduction of an online electronic reporting system resulted in a significant increase in the number of incidents being reported.
    Radiotherapy and Oncology 08/2014; 112(2). DOI:10.1016/j.radonc.2014.07.011 · 4.86 Impact Factor
  • Source
    • "Yet, trainees must adapt quickly to frequent transitions in today's clinical environment (Bernabeo et al. 2011). A major transition occurs each July when United States medical trainees simultaneously advance to higher levels of responsibility, and a recent review shows how patient outcomes and care efficiency can suffer (Young et al. 2011). Supervisors expect that more supervision will be required because trainees have not yet been assessed and evaluated for entrustment. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Clinical supervision requires that supervisors make decisions about how much independence to allow their trainees for patient care tasks. The simultaneous goals of ensuring quality patient care and affording trainees appropriate and progressively greater responsibility require that the supervising physician trusts the trainee. Trust allows the trainee to experience increasing levels of participation and responsibility in the workplace in a way that builds competence for future practice. The factors influencing a supervisor's trust in a trainee are related to the supervisor, trainee, the supervisor-trainee relationship, task, and context. This literature-based overview of these five factors informs design principles for clinical education that support the granting of entrustment. Entrustable professional activities offer promise as an example of a novel supervision and assessment strategy based on trust. Informed by the design principles offered here, entrustment can support supervisors' accountability for the outcomes of training by maintaining focus on future patient care outcomes.
    Advances in Health Sciences Education 07/2013; 19(3). DOI:10.1007/s10459-013-9474-4 · 2.71 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: In the beginning of the academic year, medical errors are often attributed to inexperienced medical staff. This potential seasonal influence on health care outcomes is termed the "July effect." No study has demonstrated the July effect in liver transplantation. We reviewed retrospectively collected data from the United Network for Organ Sharing for patients who underwent liver transplantation from October 1987 to June 2011 to determine if surgical outcomes were worse in July compared with rest of the year. We found no clinical difference in early graft survival (91.11% vs 90.72%, p = 0.045) and no difference in early patient survival (94.71% vs 94.42%, p = 0.057). Survival at 1 year, 3 years, and 5 years was also compared and no notable differences were detected. Because the Model for End-stage Liver Disease (MELD) score implementation in 2002 affected the acuity of liver transplant recipients, we further stratified our data to compare pre- and post-MELD survival to remove subjectivity as a confounding factor. MELD stratification revealed no seasonal difference in outcomes. There was no difference in rate of graft failure and acute and chronic rejection between groups. Our findings show no evidence of the July effect in liver transplantation. Each July, thousands of medical residents take on new responsibilities in patient care. It has been suggested that these new practitioners may produce errors that contribute to worse patient outcomes in the beginning of the academic year-a phenomenon called the "July effect." Currently, there are few research studies with controversial evidence of poorer outcomes in July, and no articles address the effect of new medical staff in the setting of liver transplantation. Our study compares short-, medium-, and long-term graft and patient survival between July and August and the remaining months using national data. We also examine survival before and after the implementation of the MELD scoring system to determine its effect on outcomes in the beginning of the academic year.
    Journal of Surgical Education 09/2013; 70(5):669-79. DOI:10.1016/j.jsurg.2013.04.012 · 1.39 Impact Factor
Show more