Research confirms "July effect" on patient deaths

An onslaught of new residents and exodus of experienced ones leads to inefficient care, but the extent of the phenomenon remains uncertain, a study says.

By Carolyne Krupa — Posted July 15, 2011

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Research shows that an influx of fledgling physicians to hospitals nationwide each July contributes to a rise in patient deaths and inefficiencies in care. But the extent of those increases and the reasons behind them remain unclear, says an Annals of Internal Medicine study.

Many researchers have studied the so-called July effect, in which patient outcomes decline as a result of hospitals undergoing major work-force changes as new residents come in and older ones complete their training.

"Teaching hospitals experience a massive exodus of highly experienced physician trainees who are also familiar with the working environment of the hospital," said John Q. Young, MD, lead study author and associate program director of the University of California, San Francisco, School of Medicine's psychiatry residency program. "Those that remain assume new, more responsible roles in treating patients. And many newly minted physicians arrive to begin their training."

He likened it to a football team swapping rookies for veterans in the middle of an important game.

For the study, researchers analyzed 39 studies on the July effect published between Jan. 1, 1989, and July 1, 2010. Results varied greatly but linked the changeover to higher patient mortality rates and inefficiencies such as longer hospital stays and surgeries and higher hospital charges in July.

But the question remains whether those increases are due to inexperience, poor supervision or the loss of knowledge of more experienced residents, said the study, published online July 12.

"The overall quality of the studies was poor," Dr. Young said. "Methologic limitations and study heterogeneity ... [do] not permit firm conclusions about the degree of risk posed, how changeover affects morbidity and safety, or whether particular models are more or less problematic."

Future research should provide better quality data on the July effect, including its impact on outpatient settings, and examine possible solutions, he said.

Meanwhile, teaching hospitals should take steps to reduce potential harms, such as better orienting residents for clinical practice, testing residents' competency and assigning responsibilities based on their skill levels, Dr. Young said.

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