This form of secondary/primary care support did not transfer information effectively, and we suspect similar problems would arise in other similar communities. Different methods of clinician/patient information exchange need to be developed for diabetes in this South Asian group.

There is concern that churning in Medicaid excludes children from the accountability system for managed care because they may not meet the one-year continuous enrollment requirement. This study explores the effect of churning in measuring childhood immunization coverage rates under the current accountability system. Data were collected from administrative databases at the Centers for Medicaid and Medicare Services and 12 states with high Medicaid managed care penetration. On average in the 12 states only 39% of the children enrolled in one specific managed care plan met the continuous enrollment requirement. However, Centers for Medicaid and Medicare Services data showed that 78% of children were enrolled in Medicaid (but not the same plan) continuously for 12 months. Both plan-specific rates and overall Medicaid rates varied greatly across the states. Policies that result in churning mean that many vulnerable children fall outside of the accountability structure intended to assure that they receive necessary services.

Churning in Medicaid has been long recognized as a problem leading to breaks in coverage. Tenure in Medicaid managed care has received less attention. Recent reports indicate that children's tenures in health plans are far shorter than tenures in Medicaid itself, but explanations for the difference are not given. In the research reported here, we conducted case studies in five states to determine difference in tenure and reasons for the difference. Our investigation showed that children were enrolled in Medicaid two to four months longer than in specific Medicaid health plans. The major reasons for the gap were retroactive enrollment in Medicaid and delays in selecting a health plan. Frequent and burdensome Medicaid renewal processes exacerbate the problem, resulting in breaks in enrollment and the need to reenroll. The task of managing the care of Medicaid children is difficult without adequate tenures in health plans.

IntroductionThe European Working Time Directive (EWTD) came into force in August 2009 and dictates that junior doctors should not work >48 h on an average week. Many trusts have had to alter on call rotas to be compliant with the directive. Many trainees, particularly in procedure based specialities, have been concerned about the reduction in procedural training. Previous studies have mainly looked at number of hours worked and not the impact on number of procedures performed or new patients seen in outpatients. Our aim was to examine the effect of the EWTD on important training areas; number of colonoscopies performed, number of ERCPs performed and new outpatients seen by gastroenterology trainees.MethodsWorking hours changed from 56 h per week to 48 h per week in February 2009. In our unit, this was delivered by increasing numbers of days off during a full rota cycle without changing individual timetables. Personal logs and local IT systems were examined for 6 months prior to and for 6 months following the change to determine number of new patients seen in outpatients and number of colonoscopies/ERCPs performed. Only three of the trainees attended colonoscopy lists as the fourth post is a hepatology fellowship post and only two of the trainees performed ERCP. Both periods included the same amount of annual and study leave.ResultsFrom August 2008 to February 2009 the four trainees saw 602 new patients and were present at/performed 196 colonoscopies. The two trainees performing ERCP attended/performed 120 procedures during this period. From February 2009 to August 2009 there was a reduction in the number of colonoscopies attended/performed down to 160 (19.4% reduction, p=0.002). There was also a reduction in the number of new patients seen to 456 (24.3% reduction, p=0.01). There was a reduction in the number of ERCPs performed to 104 (13.3% reduction, p=0.1) but this was not statistically significant. Extrapolating these figures to a 5-year training programme, under the 48 h limit trainees would see 730 less new patients, perform 180 less colonoscopies and 80 less ERCPs. Each reductions of these accounts for around a least a year of training.ConclusionThere has been significant impact of the EWTD on training in gastroenterology particularly in colonoscopy training and new patient assessment. ERCP may be impacted however the current numbers are too small. New models of training will be required to address this problem perhaps focusing on post training fellowships.