July Mortality Effect in Hospitals Is Real

Jim Kling

July 11, 2011

July 11, 2011 (UPDATED July 12, 2011)  — During year-end changeovers in hospital trainees, mortality increases and efficiency decreases, according to a systematic review of studies published online July 12 in the Annals of Internal Medicine.

There is a common perception that healthcare quality suffers during trainee academic year-end changeovers, when the average healthcare worker experience abruptly declines and established teams are broken up. The researchers conducted a systematic review of studies that investigated the effects of changeover on patient outcomes.

They searched PubMed, the Educational Research Information Center, EMBASE, and the Cochrane Library for English-language studies conducted between 1989 and July 2010 that used a control group or period of comparison.

John Q. Young, MD, MPP, from the Department of Psychiatry, University of California–San Francisco, School of Medicine, and colleagues categorized studies by methodologic quality, sample size, and reported outcomes. Thirty-nine studies were included, most conducted in the United States and all focused on inpatient settings. Measured outcomes included mortality (27 studies, 69%), efficiency (length of stay, duration of procedure, hospital charges,19 studies, 49%), morbidity (23 studies, 59%), and medical errors (6 studies, 15%).

The studies varied widely in quality. For example, 16 studies (41%) did not adjust for risk, and thus were considered to be poor quality. In contrast, 8 (21%) used a concurrent control and adjusted for patient factors and time trends; these studies were considered to be very good quality. Overall, 13 studies (33%) were judged to be of higher quality, and these studies were more likely to report higher mortality and lower efficiency during changeovers.

Studies that focused on morbidity and medical error outcomes were more likely to be judged to be of lower quality, and their findings were inconsistent.

The study was limited by several factors, including a focus on English-language reports and the fact that none of the studies considered the effect of changeovers in ambulatory care settings. There were also inconsistencies in the definition of changeover, resident role in patient care, and supervision structure. In addition, few studies controlled for time trends or level of supervision, and few employed methods appropriate for hierarchical data.

Although the studies point to increased risks during changeovers, because of the heterogeneity among the studies, it is not possible to know the magnitude of the risk.

The researchers suggest that the "July effect" could be addressed by introducing changeover systems that incorporate human factor principles. They could also be designed to avoid cognitive overload and fatigue. Alternatively, system disruption could be reduced by staggering trainee start dates.

The review backs up long-held suspicions that standards of care suffer at the beginning of academic years, according to Paul Barach, MD, MPH, from the University Medical Center Utrecht, the Netherlands, and Ingrid Philibert, PhD, MBA, from the Accreditation Council for Graduate Medical Education, Chicago, Illinois, the authors of an accompanying editorial.

"Reliable-quality and safe patient care throughout the academic year will require a multipronged approach, one that recognizes the need to immerse trainees in a new clinical environment but with seasoned mentorship, close supervision, and graduated clinical responsibilities.... We need to better understand how best to protect patients and providers during cohort turnovers while developing a culture where trainees feel psychologically safe to speak up, admit error, challenge poor practices, and learn to be accountable for their actions," the editorialists write.

The senior author, Andrew D. Auerbach, MD, was supported by a grant from the National Heart, Blood, and Lung Institute. The other authors have disclosed no relevant financial relationships.

Ann Intern Med. Published online July 11, 2011. Article full text Editorial full text