John Q. Young, MD, MPP; Sumant R. Ranji, MD; Robert M. Wachter, MD; Connie M. Lee, MD; Brian Niehaus, MD; Andrew D. Auerbach, MD, MPH
Young JQ, Ranji SR, Wachter RM, Lee CM, Niehaus B, Auerbach AD. “July Effect”: Impact of the Academic Year-End Changeover on Patient Outcomes: A Systematic Review. Ann Intern Med. 2011;155:309-315. doi: 10.7326/0003-4819-155-5-201109060-00354
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Published: Ann Intern Med. 2011;155(5):309-315.
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.
Does mass housestaff turnover, which typically occurs during summer, adversely affect outcomes of patients admitted to teaching hospitals?
This systematic review describes 39 studies conducted in inpatient settings that examined the effect of the academic year–end trainee changeover on patient outcomes. Larger and higher-quality studies showed increased mortality and decreased efficiency of care associated with year-end changeover.
Many studies did not account for time trends and clinical characteristics of patients. Few examined medical errors or morbidity outcomes.
Changeover that occurs when experienced housestaff are replaced with new trainees can adversely affect patient care and outcomes.
Appendix Table 1.
Databases were searched on 1 July 2010. ERIC = Educational Research Information Center.
Appendix Table 2.
Appendix Table 3.
Appendix Table 4.
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