Cohort turnover

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Cohort turnover is a term used in the social sciences to describe the simultaneous exit of a large number of experienced employees and a similarly sized entry of new workers. In medicine, most countries introduce their new annual medical school output into medical practice in hospitals at a fixed time of the year and this cohort turnover is likely to lead to the assumption that there is an unsafe period to be admitted to hospital. The results of smaller studies tend to be inconclusive and larger ones only show a small effect. What the studies compare with can also be an issue as disruption of service can happen from many causes and any disruption of service is likely to impact on patient safety in one way or another. There is always the proviso that even if the effect exists, it is easier to organise formal induction and systems design around a known problem than around a diffuse problem that could happen at any time of the year. Also, it might be no coincidence that such change-overs tend to be timed at the time of minimal population morbidity in summer and early autumn[1].

However, as there is also a known holiday effect, such as at Christmas, on hospital mortality and doctor change-over tends to match summer holidays of senior staff the issue is certainly not simple[2].

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Termed July phenomenon or the July effect

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Termed Killing season

  • No effect[14]
  • Decreased quality eg increased mortality[15]

References

  1. Falagas ME, Karageorgopoulos DE, Moraitis LI, Vouloumanou EK, Roussos N, Peppas G, Rafailidis PI. Seasonality of mortality: the September phenomenon in Mediterranean countries. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2009 Sep 21.(Epub ahead of print) (Link to article – subscription may be required.)
  2. a b Englesbe MJ, Pelletier SJ, Magee JC, Gauger P, Schifftner T, Henderson WG, Khuri SF, Campbell DA. Seasonal variation in surgical outcomes as measured by the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP). Annals of surgery. 2007 Sep; 246(3):456-62; discussion 463-5.(Link to article – subscription may be required.)
  3. Buchwald D, Komaroff AL, Cook EF, Epstein AM. Indirect costs for medical education. Is there a July phenomenon? Archives of internal medicine. 1989 Apr; 149(4):765-8.
  4. Barry WA, Rosenthal GE. Is there a July phenomenon? The effect of July admission on intensive care mortality and length of stay in teaching hospitals. Journal of general internal medicine. 2003 Aug; 18(8):639-45.
  5. Schroeppel TJ, Fischer PE, Magnotti LJ, Croce MA, Fabian TC. The "July phenomenon": is trauma the exception? Journal of the American College of Surgeons. 2009 Sep; 209(3):378-84.(Link to article – subscription may be required.)
  6. Garcia S, Canoniero M, Young L. The Effect of July Admission in the Process of Care of Patients with Acute Cardiovascular Conditions. Southern medical journal. 2009 May 7.(Epub ahead of print) (Link to article – subscription may be required.)
  7. Alshekhlee A, Walbert T, DeGeorgia M, Preston DC, Furlan AJ. The impact of Accreditation Council for Graduate Medical Education duty hours, the July phenomenon, and hospital teaching status on stroke outcomes. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2009 May-Jun; 18(3):232-8.(Link to article – subscription may be required.)
  8. Dhaliwal AS, Chu D, Deswal A, Bozkurt B, Coselli JS, Lemaire SA, Huh J, Bakaeen FG. The July effect and cardiac surgery: the effect of the beginning of the academic cycle on outcomes. American journal of surgery. 2008 Nov; 196(5):720-5.(Link to article – subscription may be required.)
  9. Huckman RS, Barro JR (2005) Cohort Turnover and Productivity: The July Phenomenon in Teaching Hospitals. 2005
  10. Rich EC, Gifford G, Luxenberg M, Dowd B. The relationship of house staff experience to the cost and quality of inpatient care. JAMA : the journal of the American Medical Association. 1990 Feb 16; 263(7):953-7.
  11. Bakaeen FG, Huh J, Lemaire SA, Coselli JS, Sansgiry S, Atluri PV, Chu D. The July effect: impact of the beginning of the academic cycle on cardiac surgical outcomes in a cohort of 70,616 patients. The Annals of thoracic surgery. 2009 Jul; 88(1):70-5.(Link to article – subscription may be required.)
  12. Huckman RS, Barro JR (2005) Cohort Turnover and Productivity: The July Phenomenon in Teaching Hospitals. 2005
  13. Shuhaiber JH, Goldsmith K, Nashef SA. Impact of cardiothoracic resident turnover on mortality after cardiac surgery: a dynamic human factor. The Annals of thoracic surgery. 2008 Jul; 86(1):123-30; discussion 130-1.(Link to article – subscription may be required.)
  14. Aylin P, Majeed FA. The killing season--fact or fiction? BMJ (Clinical research ed.). 1994 Dec 24-31; 309(6970):1690.
  15. Jen HM, Bottle A, Majeed A, Bell D, Aylin P. Early In-Hospital Mortality following Trainee Doctors' First Day at Work PLoS ONE 2009 4(9): e7103. doi:10.1371/journal.pone.0007103
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