"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: 17.81). 07/2011; 155(5):309-15. DOI: 10.1059/0003-4819-155-5-201109060-00354
Source: PubMed


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.

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Available from: John Q Young, Feb 05, 2015
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    • "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. "
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    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.
    Full-text · Article · Aug 2014 · Radiotherapy and Oncology
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    • "A number of studies have investigated the effect of changeover on broad clinical endpoints with varying results. A recent systematic review of such studies suggested that mortality rates for patients admitted just after changeover were higher than for the remainder of the year, though most of the papers in this review were reported to be of low quality.4 The experience in our local Trust is consistent with this: data from the independent body Dr Foster suggest that there are around six more in-hospital deaths in Nottingham in August than would be expected for the volume and case-mix of admissions. "
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    ABSTRACT: To investigate whether measurements of junior doctor on-call workload and performance can clarify the mechanisms underlying the increase in morbidity and mortality seen after junior doctor changeover: the 'August effect'. Quantitative retrospective observational study of routinely collected data on junior doctor workload. Two large teaching hospitals in England. Task level data from a wireless out of hours system (n = 29,885 requests) used by medical staff, nurses, and allied health professionals. Number and type of tasks requested by nurses, time to completion of tasks by junior doctors. There was no overall change in the number of tasks requested by nurses out of hours around the August changeover (median requests per hour 15 before and 14 after, p = 0.46). However, the number of tasks classified as urgent was greater (p = 0.016) equating to five more urgent tasks per day. After changeover, doctors took less time to complete tasks overall due to a reduction in time taken for routine tasks (median 74 vs. 66 min; p = 3.9 × 10(-9)). This study suggests that the 'August effect' is not due to new junior doctors completing tasks more slowly or having a greater workload. Further studies are required to investigate the causes of the increased number of urgent tasks seen, but likely factors are errors, omissions, and poor prioritization. Thus, improved training and quality control has the potential to address this increased duration of unresolved patient risk. The study also highlights the potential of newer technologies to facilitate quantitative study of clinical activity.
    Full-text · Article · Jul 2013
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    • "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. "
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    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.
    Full-text · Article · Jul 2013 · Advances in Health Sciences Education
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