Yearly trainee turnover associated with poor patient outcomes

Young JQ. Ann Intern Med. 2011; [E-pub ahead of print.]

At the end of each academic year, teaching hospitals experience trainee changeover that adversely affects patient outcomes. According to data from a systematic review, this yearly turnover, commonly known as the “July effect,” is associated with increased mortality and decreased efficiency.

However, based on the available literature, conclusions about the degree of risk posed, how changeover affects morbidity and safety, or whether particular models are more or less problematic are not clear, researchers said.

“Changeovers in care teams, particularly those that result from trainee switches, raise critical questions for patients, health care systems and training programs,” the researchers wrote.

The review included 39 studies that examined the effects of trainee changeover. All were published between 1989 and July 2010 and reported mortality (n=27) efficiency (n=19), morbidity (n=23) and medical error outcomes (n=6).

More than half of the studies reporting mortality were considered lower-quality studies (59%) and 41% were considered higher-quality studies. Twenty-two percent of studies reporting mortality demonstrated an increase during trainee turnover compared with non-turnover months and nonteaching hospitals. According to the researchers, however, study quality was associated with the number of studies that found statistically significant worsening of mortality; nearly all studies demonstrating an association were considered of higher methodological quality (83%) and 45% reported a statistically significant difference in mortality.

Most studies reporting morbidity outcomes were deemed lower-quality studies (78%). Seventeen percent of studies reported an increase in morbidity; only one was a study of higher quality. All studies reporting medical error outcomes were lower quality and had unclear error detecting methods or no important statistical controls, the researchers said. Turnover was associated with worse safety outcomes, according to half of the studies.

Thirty-seven percent of studies reporting efficiency were of higher quality, and all 37% demonstrated decreased efficiency. Study quality and increasing sample size were associated with the number of studies with a statistically significant reduction in efficiency. For higher-quality studies showing increased lengths of stay, relative worsening of efficiency ranged between 0.3% and 7.2% vs. non-turnover months and/or nonteaching hospitals.

“The existing evidence base is problematic but does frame many reasonable approaches to reducing potential harms,” the researchers wrote in the study. “Increasing emphasis on graded responsibility — in which autonomy increases with competency — may help ensure that individual residents are entrusted with a level of responsibility appropriate for their skill level.”

Disclosure: The researchers report no relevant financial disclosures.

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