Is there a "July effect" in pediatric neurosurgery?

Exploring the 'January effect' at a university hospital in Pakistan: a retrospective cohort study investigating the impact of trainee turnover on patient care quality outcomes

OBJECTIVE

There are reports of a potential rise in a teaching hospital's morbidity and mortality rates during the trainee turnover period, i.e., with the induction of new residents and house staffs, and the changeover of clinical teams. The published literature displays mixed reports on this topic with lack of reproducible observations. The current study was conducted to explore existence of any such phenomenon (January effect) in Pakistan.

METHODS

This retrospective cohort study was conducted at Aga Khan University Hospital, Karachi, Pakistan. Five-year (2013-2018) record of all the patients in all age groups related to these outcomes was retrieved and recorded in specifically designed questionnaire. Different outcome measures were used as indicators of patient care and change in these outcomes at the time of new induction was related to possible January effect.

RESULTS

During the five-year study period, more than 1100 new trainees were inducted into the post graduate medical education program (average of 237 per year) with more than 22,000 inpatient admissions (average of 45,469 per year). Some patterns were observed in frequencies of surgical site infections, medication errors, sentinel events, patient complaints, and adverse drug reactions. However, these were not consistently reproducible and could not be directly attributed to the trainee turnover. All other indicators did not show any pattern and were considered inconclusive. No effect of overlap was observed.

CONCLUSIONS

Inconsistency in the patient care quality indicators do not favor existence of January effect in our study. Further research is recommended to establish our results.

"July Effect" in Spinal Fusions: A Coarsened Exact-Matched Analysis

BACKGROUND

Few neurosurgical studies examine the July Effect within elective spinal procedures, and none uses an exact-matched protocol to rigorously account for confounders.

OBJECTIVE

To evaluate the July Effect in single-level spinal fusions, after coarsened exact matching of the patient cohort on key patient characteristics (including race and comorbid status) known to independently affect neurosurgical outcomes.

METHODS

Two thousand three hundred thirty-eight adult patients who underwent single-level, posterior-only lumbar fusion at a single, multicenter university hospital system were retrospectively enrolled. Primary outcomes included readmissions, emergency department visits, reoperation, surgical complications, and mortality within 30 days of surgery. Logistic regression was used to analyze month as an ordinal variable. Subsequently, outcomes were compared between patients with surgery at the beginning vs end of the academic year (ie, July vs April-June), before and after coarsened exact matching on key characteristics. After exact matching, 99 exactly matched pairs of patients (total n = 198) were included for analysis.

RESULTS

Among all patients, operative month was not associated with adverse postoperative events within 30 days of the index operation. Furthermore, patients with surgeries in July had no significant difference in adverse outcomes. Similarly, between exact-matched cohorts, patients in July were observed to have noninferior adverse postoperative events.

CONCLUSION

There was no evidence suggestive of a July Effect after single-level, posterior approach spinal fusions in our cohort. These findings align with the previous literature to imply that teaching hospitals provide adequate patient care throughout the academic year, regardless of how long individual resident physician assistants have been in their particular role.

Reassessing the July Effect: 30 Years of Evidence Show No Difference in Outcomes

OBJECTIVE

The aim of this study was to critically evaluate whether admission at the beginning versus end of the academic year is associated with increased risk of major adverse outcomes.

SUMMARY BACKGROUND DATA

The hypothesis that the arrival of new residents and fellows is associated with increases in adverse patient outcomes has been the subject of numerous research studies since 1989. Methods: We conducted a systematic review and random-effects meta-analysis of July Effect studies published before December 20, 2019, looking for differences in mortality, major morbidity, and readmission. Given a paucity of studies reporting readmission, we further analyzed 7 years of data from the Nationwide Readmissions Database to assess for differences in 30-day readmission for US patients admitted to urban teaching versus nonteach-ing hospitals with 3 common medical (acute myocardial infarction, acute ischemic stroke, and pneumonia) and 4 surgical (elective coronary artery bypass graft surgery, elective colectomy, craniotomy, and hip fracture) conditions using risk-adjusted logistic difference-in-difference regression.

RESULTS

A total of 113 studies met inclusion criteria; 92 (81.4%) reported no evidence of a July Effect. Among the remaining studies, results were mixed and commonly pointed toward system-level discrepancies in efficiency. Metaanalyses of mortality [odds ratio (95% confidence interval): 1.01 (0.98-1.05)] and major morbidity [1.01 (0.99-1.04)] demonstrated no evidence of a July Effect, no differences between specialties or countries, and no change in the effect over time. A total of 5.98 million patient encounters were assessed for readmission. No evidence of a July Effect on readmission was found for any of the 7 conditions.

CONCLUSION

The preponderance of negative results over the past 30 years suggests that it might be time to reconsider the need for similarly-themed studies and instead focus on system-level factors to improve hospital efficiency and optimize patient outcomes.

Postoperative complications after gastrointestinal pediatric surgical procedures: outcomes and socio-demographic risk factors

BACKGROUND

Several socio-demographic characteristics are associated with complications following certain pediatric surgical procedures. In this comprehensive study, we sought to determine socio-demographic risk factors and resource utilization of children with complications after common pediatric surgical procedures.

METHODS

We performed a population-based cohort study utilizing the 2016 Healthcare Cost and Use Project Kids' Inpatient Database (KID) to identify and characterize pediatric patients (age 0-21 years) in the United States with common inpatient pediatric gastrointestinal surgical procedures: appendectomy, cholecystectomy, colonic resection, pyloromyotomy and small bowel resection. Multivariable logistic regression modeling was used to identify socio-demographic predictors of postoperative complications. Length of stay and hospitalization costs for patients with and without postoperative complications were compared.

RESULTS

A total of 66,157 pediatric surgical hospitalizations were identified. Of these patients, 2,009 had postoperative complications. Male sex, young age, African American and Native American race and treatment in a rural hospital were associated with significantly greater odds of postoperative complications. Mean length of stay was 4.58 days greater and mean total costs were $11,151 (US dollars) higher in the complication cohort compared with patients without complications.

CONCLUSIONS

Postoperative complications following inpatient pediatric gastrointestinal surgery were linked to elevated healthcare-related expenditure. The identified socio-demographic risk factors should be considered in the risk stratification before pediatric surgical procedures. Targeted interventions are required to reduce preventable complications and surgical disparities.

The "July Effect" in the Cardiac Catheterization Laboratory

In Interventional Cardiology, the academic year and a new training cycle begin in July. It is unclear if patient outcomes are impacted by the time of year in the training cycle. The National Cardiovascular Data Registry collects outcomes related to percutaneous coronary interventions (PCIs). We used the database for our institution to review the relation between the time of year and patient outcomes. We performed a retrospective review of National Cardiovascular Data Registry data from 2011 to 2017. Outcomes were compared between the end (quarter 2 [Q2]) and the start of the academic year (quarter 3 [Q3]). Chi-square and Fisher's exact test was used: 1,041 (Q2) and 980 (Q3) patients underwent PCI. Patient characteristics were similar between the 2 quarters except for a higher rate of heart failure for patients in Q3 (250 [24%] vs 275 [29%], p = 0.03). There was no difference in overall nonfatal adverse events between Q2 and Q3 (53 [5.1%] vs 58 [5.9%], p = 0.41). Patients in Q3 experienced a higher incidence of stroke (1 [0.1%] vs 7 [0.7%], p = 0.03) and PCI risk-adjusted mortality (8.29 [0.8%] vs 18.13 [1.9%], p = 0.03). In conclusion, there does not appear to be a significant "July Effect" in an academic cardiac catheterization laboratory in terms of most complications with an observed higher incidence of stroke and PCI risk-adjusted mortality early in the year that may be related to a difference in the characteristics of the patient population.

The July Phenomenon and Pediatric Trauma

BACKGROUND

The July Phenomenon describes concerns that patients presenting early in the academic year experience worse outcomes. Given the standardized approach to pediatric trauma patients, we hypothesized that the July Phenomenon would not impact morbidity or mortality.

METHODS

A retrospective review of patients ≤16 Y presenting to a level I pediatric trauma center between March 2009 and March2019 was performed. Pediatric patients admitted during the study period were compared for differences in outcome by month of presentation. The primary outcome was mortality. Secondary outcomes were complications, and length of emergency department, hospital and Intensive Care Unit stay. Multivariable regression was used to evaluate the effect of month of admission on outcomes.

RESULTS

A total of 6,135 patients were evaluated, with 605 patients presenting in July. Univariate analysis failed to demonstrate consistently increased mortality, complications, or length of emergency department, hospital or Intensive Care Unit stay in July compared to months later in the academic year. On multivariate analysis, admission in July was not an independent predictor of worse outcomes.

CONCLUSIONS

In this level I pediatric trauma center, pediatric trauma patients presenting earlier in the academic year have similar outcomes to those presenting later, and there is no evidence of a July Phenomenon in this population.

"July Effect" Revisited: July Surgeries at Residency Training Programs are Associated with Equivalent Long-term Clinical Outcomes Following Lumbar Spondylolisthesis Surgery

STUDY DESIGN

Retrospective analysis of a prospective registry.

OBJECTIVE

We utilized the Quality Outcomes Database (QOD) registry to investigate the "July Effect" at QOD spondylolisthesis module sites with residency trainees.

SUMMARY OF BACKGROUND DATA

There is a paucity of investigation on the long-term outcomes following surgeries involving new trainees utilizing high-quality, prospectively collected data.

METHODS

This was an analysis of 608 patients who underwent single-segment surgery for grade 1 degenerative lumbar spondylolisthesis at 12 high-enrolling sites. Surgeries were classified as occurring in July or not in July (non-July). Outcomes collected included estimated blood loss, length of stay, operative time, discharge disposition, complications, reoperation and readmission rates, and patient-reported outcomes (Oswestry Disability Index [ODI], Numeric Rating Scale [NRS] Back Pain, NRS Leg Pain, EuroQol-5D [EQ-5D] and the North American Spine Society [NASS] Satisfaction Questionnaire). Propensity score-matched analyses were utilized to compare postoperative outcomes and complication rates between the July and non-July groups.

RESULTS

Three hundred seventy-one surgeries occurred at centers with a residency training program with 21 (5.7%) taking place in July. In propensity score-matched analyses, July surgeries were associated with longer operative times ( average treatment effect = 22.4 minutes longer, 95% confidence interval 0.9-449.0, P = 0.041). Otherwise, July surgeries were not associated with significantly different outcomes for the remaining perioperative parameters (estimated blood loss, length of stay, discharge disposition, postoperative complications), overall reoperation rates, 3-month readmission rates, and 24-month ODI, NRS back pain, NRS leg pain, EQ-5D, and NASS satisfaction score (P > 0.05, all comparisons).

CONCLUSION

Although July surgeries were associated with longer operative times, there were no associations with other clinical outcomes compared to non-July surgeries following lumbar spondylolisthesis surgery. These findings may be due to the increased attending supervision and intraoperative education during the beginning of the academic year. There is no evidence that the influx of new trainees in July significantly affects long-term patient-centered outcomes.Level of Evidence: 3.

The New Trainee Effect in Tracheal Intubation Procedural Safety Across PICUs in North America: A Report From National Emergency Airway Registry for Children

OBJECTIVES

Tracheal intubation carries a high risk of adverse events. The current literature is unclear regarding the "New Trainee Effect" on tracheal intubation safety in the PICU. We evaluated the effect of the timing of the PICU fellow academic cycle on tracheal intubation associated events. We hypothesize 1) PICUs with pediatric critical care medicine fellowship programs have more adverse tracheal intubation associated events during the first quarter (July-September) of the academic year compared with the rest of the year and 2) tracheal intubation associated event rates and first attempt success performed by pediatric critical care medicine fellows improve through the 3-year clinical fellowship.

DESIGN

Retrospective cohort study.

SETTING

Thirty-seven North American PICUs participating in National Emergency Airway Registry for Children.

PATIENTS

All patients who underwent tracheal intubations in the PICU from July 2013 to June 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The occurrence of any tracheal intubation associated events during the first quarter of the academic year (July-September) was compared with the rest in four different types of PICUs: PICUs with fellows and residents, PICUs with fellows only, PICUs with residents only, and PICUs without trainees. For the second hypothesis, tracheal intubations by critical care medicine fellows were categorized by training level and quarter for 3 years of fellowship (i.e., July-September of 1st yr pediatric critical care medicine fellowship = first quarter, October-December of 1st yr pediatric critical care medicine fellowship = second quarter, and April-June during 3rd year = 12th quarter). A total of 9,774 tracheal intubations were reported. Seven-thousand forty-seven tracheal intubations (72%) were from PICUs with fellows and residents, 525 (5%) with fellows only, 1,201 (12%) with residents only, and 1,001 (10%) with no trainees. There was no difference in the occurrence of tracheal intubation associated events in the first quarter versus the rest of the year (all PICUs: July-September 14.9% vs October-June 15.2%; p = 0.76). There was no difference between these two periods in each type of PICUs (all p ≥ 0.19). For tracheal intubations by critical care medicine fellows (n = 3,836), tracheal intubation associated events significantly decreased over the fellowship: second quarter odds ratio 0.64 (95% CI, 0.45-0.91), third quarter odds ratio 0.58 (95% CI, 0.42-0.82), and 12th quarter odds ratio 0.40 (95% CI, 0.24-0.67) using the first quarter as reference after adjusting for patient and device characteristics. First attempt success significantly improved during fellowship: second quarter odds ratio 1.39 (95% CI, 1.04-1.85), third quarter odds ratio 1.59 (95% CI, 1.20-2.09), and 12th quarter odds ratio 2.11 (95% CI, 1.42-3.14).

CONCLUSIONS

The New Trainee Effect in tracheal intubation safety outcomes was not observed in various types of PICUs. There was a significant improvement in pediatric critical care medicine fellows' first attempt success and a significant decline in tracheal intubation associated event rates, indicating substantial skills acquisition throughout pediatric critical care medicine fellowship.

The July Effect and its Impact on External Ventricular Drain Placement by Neurosurgical Trainees-Analysis of the National Inpatient Sample

OBJECTIVE

External ventricular drain (EVD) placement is a life-saving procedure performed frequently by neurosurgical residents. The July effect is a theoretic decline in quality of health care sometimes perceived in teaching hospitals at the start of an academic year. We sought to quantify the learning curve of ventriculostomy drain placement in teaching hospitals and determine its impact on patient outcomes, health care utilization, and cost.

METHODS

The National Inpatient Sample was queried for patients admitted nonelectively between 2012 and 2015 requiring EVD placement at a teaching hospital determined by using International Classification of Diseases, Ninth Revision codes. Rates of multiple EVD placements per admission, infection and hemorrhage, mortality, length and cost of hospital stay, and discharge disposition were compared between admissions in the first quarter (Q1) of an academic year (July-September) versus those in Q4 (April-June).

RESULTS

A total of 7783 admissions met inclusion criteria (3901 in Q1 and 3882 in Q4). The odds ratios (OR) for all combined complications, mortality, and long-term care disposition were similar between Q1 and Q4 groups. There was a significant reduction in the OR of wound and infectious complications in Q1 versus Q4 (1.60% vs. 2.31%; OR, 0.66; P = 0.01). The impact of Q1 EVD placement on total hospital charge and number of EVD codes was not statistically significant. However, there was a statistically significant reduction in length of stay in Q1 compared with Q4 (β = -0.04 days; P < 0.0001).

CONCLUSIONS

There was no evidence of a July effect on EVD complication rates in outcomes for patients admitted in the beginning of an academic year versus the end.

Evaluating the July Effect in Oral and Maxillofacial Surgery: Part I-Mandibular Fractures

PURPOSE

The purpose of this study was to determine whether the timing of mandibular fracture repair within the academic year affects the complication rate using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

MATERIALS AND METHODS

The ACS-NSQIP database was accessed and queried from 2008 to 2017 for all Current Procedural Terminology codes pertaining to open treatment of mandibular fractures. The cases were stratified into 2 groups based on academic quarter: the quarter 1 (Q1) group (July-September) and the remaining-quarters group. The inclusion criteria encompassed all Current Procedural Terminology codes in the ACS-NSQIP registry that defined mandibular fractures and age greater than 18 years. Demographic characteristics, as well as medical and surgical complications, were compared between the 2 cohorts. Descriptive statistics were calculated to characterize and compare patient cohorts, and Fisher exact test and χ² analyses were performed to compare complication rates between groups.

RESULTS

The Q1 group included 614 cases, and the remaining-quarters group included 1,454. The most common individual complications included wound dehiscence (1.6% overall; 2.1% in Q1 group vs 1.4% in remaining-quarters group, P = .22), combined superficial and deep-space infection (4.9% overall; 4.4% in Q1 group vs 3.3% in remaining-quarters group; P = .91 and P = .21, respectively), and reoperation (3.9% overall; 4.6% in Q1 group vs 3.6% in remaining-quarters group, P = .29). Medical complications including acute kidney injury, venous thromboembolism, urinary tract infection, and sepsis or septic shock were rare (<1%). Complication rates did not significantly differ between the third quarter and the remainder of the year on bivariate analysis.

CONCLUSIONS

Our results do not support the idea of a "July effect" regarding postoperative outcomes after mandibular fracture repair. Further studies are needed to elucidate this phenomenon within all procedures under the wide umbrella of the specialty.

Preoperative laboratory testing before pediatric neurosurgery: an NSQIP-Pediatrics analysis

OBJECTIVES

The goal of this study was to evaluate clinical predictors of abnormal preoperative laboratory values in pediatric neurosurgical patients.

METHODS

Data obtained in children who underwent a neurosurgical operation were extracted from the prospective National Surgical Quality Improvement Program-Pediatrics (NSQIP-P, 2012-2013) registry. Multivariable logistic regression evaluated predictors of preoperative laboratory values that might require further evaluation (white blood cell count < 2000/μl, hematocrit < 24%, platelet count < 100,000/μl, international normalized ratio > 1.4, or partial thromboplastin time > 45 seconds) or a preoperative transfusion (within 48 hours prior to surgery). Variables screened included patient demographics; American Society of Anesthesiologists (ASA) physical designation classification; comorbidities; recent steroid use, chemotherapy, or radiation therapy; and admission type. Predictive score validation was performed using the NSQIP-P 2014 data.

RESULTS

Of the 6556 patients aged greater than 2 years, 68.9% (n = 5089) underwent laboratory testing, but only 1.9% (n = 125) had a critical laboratory value. Predictors of a laboratory abnormality were ASA class III-V; diabetes mellitus; hematological, hypothrombotic, or oncological comorbidities; nutritional support; recent chemotherapy; systemic inflammatory response syndrome; and a nonelective hospital admission. These 9 variables were used to create a predictive score, with a single point assigned for each predictor. The prevalence of critical values in the validation population (NSQIP-P 2014) of patients greater than 2 years of age was 0.3% with a score of 0, 1.0% in those with a score of 1, 1.6% in those with a score of 2, and 6.2% in those with a score ≥ 3. Higher score was predictive of a critical value (OR 2.33, 95% CI 1.91-2.83, p < 0.001, C-statistic 0.76) and with the requirement of a perioperative transfusion (intraoperatively or within 72 hours postoperatively; OR 1.42, 95% CI 1.22-1.67, p < 0.001) in the validation population. Moreover, when the same score was applied to children aged 2 years or younger, a greater score was predictive of a critical value (OR 2.47, 95% CI 2.15-2.84, p < 0.001, C-statistic 0.76).

CONCLUSIONS

Critical laboratory values in pediatric neurosurgical patients are largely predicted by clinical characteristics, and abnormal preoperative laboratory results are rare in patients older than 2 years of age without comorbidities who are undergoing elective surgery. The NSQIP-P critical preoperative laboratory value scale is proposed to indicate patients with the highest odds of an abnormal value. The scale can assist with triaging preoperative testing based on the surgical risk, as determined by the treating surgeon and anesthesiologist.

Physician turnover and its association with mortality after non-cardiac surgery: a retrospective cohort analysis of patients in South Korea

PURPOSE

To assess the association between physician turnover, mortality, and length of hospital stay after non-cardiac surgery in South Korea.

METHODS

This retrospective cohort study is based on analysis of the medical records of patients who underwent non-cardiac surgery between January, 2010 and December, 2016. The primary outcomes were the differences in 30-day, 90-day, and overall mortality between non-cardiac surgery performed during the turnover period and that performed during the non-turnover period.

RESULTS

The subjects of the analysis were 106,832 patients who underwent non-cardiac surgery. Among them, 17,788 patients underwent surgery during the turnover period and 89,044 underwent surgery during the non-turnover period. Multivariable Cox regression analysis revealed no significant differences in postoperative 30-day mortality (P = 0.427), 90-day mortality (P = 0.854), or overall mortality (P = 0.928) between surgery conducted during the turnover period and that conducted during the non-turnover period. Surgery performed during the physician turnover period was associated with a 0.21-day increase compared with surgery performed during the non-turnover period (coefficient: 0.21, 95% confidence interval: 0.00-0.42, P = 0.038).

CONCLUSIONS

Physician turnover was not associated with postoperative 30-day, 90-day, or overall mortality after non-cardiac surgery. However, the length of hospital stay was slightly longer for patients who underwent non-cardiac surgery in the turnover period.

Trainee physician turnover and 30-day mortality in Korean intensive care units

PURPOSE

Previous studies have found an increase in in-hospital mortality when trainee physicians rotate. Our retrospective cohort study investigated whether trainee physicians' turnover influenced 30-day mortality in Korean intensive care units (ICUs), which have high-intensity daytime intensivist coverage only on weekdays.

MATERIALS AND METHODS

Participants were adults over 19years old admitted to ICUs in a Korean tertiary care academic hospital between 2012 and 2016. Demographic and clinical data were collected on admission, and dates of death recorded. The primary outcome was the association between ICU admission in the turnover periods (March and May) and 30-day mortality after admission to ICUs with high-intensity daytime intensivist coverage.

RESULTS

Overall, there was no significant correlation between ICU admission during turnover periods and 30-day mortality [hazard ratio (HR), 1.06; 95% confidence interval (CI), 0.83-1.35, P=0.647]; the same trend was found for ICU admissions when there was no intensivist coverage (HR: 1.24, 95% CI: 0.91-1.69, P=0.177).

CONCLUSIONS

We found no overall association between physician turnover and 30-day mortality of patients admitted to ICUs with high-intensity daytime intensivist coverage or with no intensivist coverage.