Assessment of the “July Effect”: outcomes after early resident transition in adult neurosurgery

Evidence Against a Traumatic Brain Injury "July Effect": An Analysis of 3 160 452 Patients From the National Inpatient Sample

BACKGROUND AND OBJECTIVES

The "July Effect" hypothesizes increased morbidity and mortality after the addition of inexperienced physicians at the beginning of an academic year. However, the impact of newer members on neurosurgical teams managing patients with traumatic brain injury (TBI) has yet to be examined. This study conducted a nationwide analysis to evaluate the existence of the "July Effect" in the setting of patients with TBI.

METHODS

The Healthcare Cost and Utilization Project Central Distributor's National Inpatient Sample data set was queried for patients with TBI using International Classification of Diseases (ICD)-9 and ICD-10 codes. Discharges were included for diagnoses of traumatic epidural, subdural, or subarachnoid hemorrhages. Only patients treated at teaching hospitals were included to ensure resident involvement in care. Patients were grouped into July admission and non-July admission cohorts. A subgroup of patients with neurotrauma undergoing any form of cranial surgery was created. Perioperative variables were recorded. Rates of different complications were assayed. Groups were compared using χ2 tests (qualitative variables) and t-tests or Mann-Whitney U-tests (quantitative variables). Logistic regression was used for binary variables. Gamma log-linked regression was used for continuous variables.

RESULTS

The National Inpatient Sample database yielded a weighted average of 3 160 452 patients, of which 312 863 (9.9%) underwent surgical management. Patients admitted to the hospital in July had a 5% decreased likelihood of death (P = .027), and a 5.83% decreased likelihood of developing a complication (P < .001) compared with other months of the year. July admittance to a hospital showed no significant impact on mean length of stay (P = .392) or routine discharge (P = .147). Among patients with TBI who received surgical intervention, July admittance did not significantly affect the likelihood of death (P = .053), developing a complication (P = .477), routine discharge (P = .986), or mean length of stay (P = .385).

CONCLUSION

The findings suggested that there is no "July Effect" on patients with TBI treated at teaching hospitals in the United States.

"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.

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.

Fellow Involvement in Primary Total Knee Arthroplasty: Is There an "August Effect?"

The purpose of this study is to determine if a fellow's involvement, as well as duration of a fellow's training, impacts complications, outcomes, and survivorship in primary total knee arthroplasty (TKA). A retrospective review identified 2,790 consecutive patients (3,530 knees) who underwent primary TKA between 2003 and 2008. A 2-year minimum follow-up was available on 2,785 knees (2,195 patients). Operative data, clinical outcomes, complications, and survivorship were compared between cases with and without a fellow involved as well as comparing cases in the first quarter (Q1) of the academic year to the last three quarters (Q2-4). Mean follow-up was 9.7 years. Fellows were involved in 1,434 (41%) surgeries. Fellow cases had significantly longer tourniquet times (59.5 vs. 49 minutes, p < 0.001) and operative times (82.4 vs. 70.8 minutes, p < 0.001). Overall, there was no difference in clinical, functional, or pain outcomes between attending and fellow cases. Fellow cases during Q1 had significantly worse pain scores (p = 0.009) and clinical scores (p < 0.001). Revision rate, infection rates, and survivorship were not significantly different between fellow and attendings or during Q1 of fellowship compared with attendings. Primary TKA survivorship and complications were not affected by fellow involvement or academic quarter. An "August Effect" may be suggested for clinical and pain outcomes in the first 3 months of fellowship.

The July Effect in Podiatric Medicine and Surgery Residency

The period when medical students begin residency in teaching hospitals throughout the United States heralds a period known in the medical community as the "July Effect." Though several sentinel studies associated this timeframe with an increase in medical errors, residencies since demystified this phenomenon within their respective specialty. This study aims to evaluate the presence of the July Effect in a podiatric medicine and surgery residency program. A retrospective chart review was conducted, comparing patient demographics and surgical outcomes including length of stay, operative time and readmission rate between the first (July, August, September) and fourth (April, May June) quarters of the academic year from 2014-2019. A total of 206 patients met the inclusion criteria, where 99 received care in the first, resident-naïve, quarter and 107 received care in the fourth, resident-experienced, quarter. No difference in patient demographics including sex, body mass index, or comorbidity index was appreciated between both quarters (p<0.05). Those patients who underwent soft tissue and bone debridements, digital, forefoot, midfoot and rearfoot amputations experienced no statistically significant difference in length of stay, operative time, or readmission rate between both quarters (p<0.05). The results of this study did not support the presence of the July Effect in our foot and ankle surgery residency. Future studies can further explore this phenomenon by examining patients admitted following traumatic injury or elective procedures. Moreover, this study shows the curriculum employed at our program provides sufficient support, guidance, and resources to limit errors attributed to the July Effect.

"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.

Evaluating resident involvement and the 'July effect' in parotidectomy

OBJECTIVE

This study aimed to evaluate the effect of resident involvement and the 'July effect' on peri-operative complications after parotidectomy.

METHOD

The American College of Surgeons National Surgical Quality Improvement Program database was queried for parotidectomy procedures with resident involvement between 2005 and 2014.

RESULTS

There were 11 733 cases were identified, of which 932 involved resident participation (7.9 per cent). Resident involvement resulted in a significantly lower reoperation rate (adjusted odds ratio, 0.18; 95 per cent confidence interval, 0.05-0.73; p = 0.02) and readmission rate (adjusted odds ratios 0.30; 95 per cent confidence interval, 0.11-0.80; p = 0.02). However, resident involvement was associated with a mean 24 minutes longer adjusted operative time and 23.5 per cent longer adjusted total hospital length of stay (respective p < 0.01). No significant difference in surgical or medical complication rates or mortality was found when comparing cases among academic quarters.

CONCLUSION

Resident participation is associated with significantly decreased reoperation and readmission rates as well as longer mean operative times and total length of stay. Resident transitions during July are not associated with increased risk of adverse peri-operative outcomes after parotidectomy.

The Cost of the "July Effect" in Microsurgery

The existence of the "July effect," or the idea that the new academic year intrinsically has an increased complication rate is evaluated in microsurgical free tissue transfer procedures. The National Surgical Quality Improvement Program registry was queried for all free flap procedures performed between 2005 and 2016 (n = 3405). Cases were grouped as having occurred in the first academic quarter (Q1: July 1-September 30) or fourth quarter (Q4: April 1-June 30). Demographical data and complications were compared using univariate χ analysis, multivariate logistic regression was used to control for confounding variables, and inpatient stay and operating cost estimates were created. Of a total of 1722 cases, 905 were performed in the first academic quarter and 817 were performed in the fourth academic quarter. There was no significant difference between Q1 and Q4 in readmission rate (P = 0.378) or reoperation rate (P = 0.730). Patients in Q1 had significantly longer operative times (P = 0.001) and length of stay (P = 0.002) compared with those in Q4. In addition, cost of inpatient stay and operating costs associated with each free flap were significantly increased in Q1 compared with Q4 (P = 0.029; P = 0.001). The total cost per quarter for free flaps was also significantly more expensive in Q1 vs Q4, with the highest average difference in cost of $350,010.64 (P = 0.001). Having surgery early in the academic year does not put patients at any increased risk for major complications but is associated with increased operating time, length of stay, and total cost.

Evaluating the Impact of Resident Participation and the July Effect on Outcomes in Autologous Breast Reconstruction

OBJECTIVE

Although resident involvement in surgical procedures is critical for training, it may be associated with increased morbidity, particularly early in the academic year-a concept dubbed the "July effect." Assessments of such phenomena within the field of plastic surgery have been both limited and inconclusive. We sought to investigate the impact of resident participation and academic quarter on outcomes for autologous breast reconstruction.

METHODS

All autologous breast reconstruction cases after mastectomy were gathered from the 2005-2012 American College of Surgeons National Surgical Quality Improvement Program database. Multivariable logistic regression models were constructed to investigate the association between resident involvement and the first academic quarter (Q1 = July-September) with 30-day morbidity (odds ratios [ORs] with 95% confidence intervals). Medical and surgical complications, median operation time, and length of stay (LOS) were also compared.

RESULTS

Overall, 2527 cases were identified. Cases with residents (n = 1467) were not associated with increased 30-day morbidity (OR, 1.20; 0.95-1.52) when compared with those without (n = 1060), although complications including transfusion (OR, 2.08; 1.39-3.13) and return to the operating room (OR, 1.46; 1.11-1.93) were more frequently observed in resident cases. Operation time and LOS were greater in cases with resident involvement.In cases with residents, there was decreased morbidity in Q1 (n = 343) when compared with later quarters (n = 1124; OR, 0.67; 0.48-0.92). Specifically, transfusion (OR, 0.52; 0.29-0.95), return to operating room (OR, 0.64; 0.41-0.98), and surgical site infection (OR, 0.37; 0.18-0.75) occurred less often during Q1. No differences in median operation time or LOS were observed within this subgroup.

CONCLUSIONS

Our study reveals that resident involvement in autologous breast reconstruction is not associated with increased morbidity and offers no evidence for a July effect. Notably, our results suggest that resident cases performed earlier in the academic year, when surgical attendings may offer more surveillance and oversight, is associated with decreased morbidity.

Revisiting the "July Effect" in Plastic Surgery: New Data to Support Resident Autonomy

BACKGROUND

The "July Effect" represents a topic of considerable interest across residency programs. This study investigated the frequency of postoperative complications following procedures with plastic surgery resident participation (all postgraduate year [PGY] levels) during the first (quarter 3, July-September) and last academic quarters.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to calculate complication rates from 2006 to 2010. Resident involvement was analyzed as a categorical variable consisting of "juniors" (PGY1-PGY3), and "seniors" (PGY4-PGY6). Outcomes from procedures during Q3 were compared with all quarters. Propensity score matching and adjustment enabled logistic regression identifying the effect of resident involvement and admission.

RESULTS

Among all cosmetic and reconstructive procedures (n = 6625), mean operative time was not significantly greater in Q3 compared with all other quarters (P = 0.069); no significant differences in complication rates were observed between Q3 and all other quarters, though superficial surgical site infection (SSI) approached significance (3.3% of procedures in Q3 vs 2.5% in all other quarters, P = 0.063). Among reconstructive procedures only (n = 5677), mean operative time was not significantly greater in Q3 compared with all other quarters (P = 0.119); the same held true for cosmetic procedures only (P = 0.275). Surgical site infection, however, was significantly more likely to occur with reconstructive procedures only, in Q3 compared with all other quarters (3.5% of cases vs 2.3%, P = 0.024). When adjusting for PGY status and matching populations, superficial SSI and return to the operating room were not significantly more common in Q3. When adjusting for quarter of admission, however, superficial SSI was significantly more common among the overall and noncosmetic cases with participation by junior residents (P = 0.013 and 0.020, respectively).

CONCLUSIONS

This may represent the first fully reproducible, transparent National Surgical Quality Improvement Program study in plastic surgery that demonstrates the absence of a clinically significant "July Effect," and suggests that an appropriate degree of resident autonomy may pose minimal risk during both cosmetic and reconstructive procedures in residency training. Additionally, the findings encourage the development a plastic surgery-specific database to remedy inherent difficulties with larger, more comprehensive surgical databases.

Effect of an additional neurosurgical resident on procedure length, operating room time, estimated blood loss, and post-operative length-of-stay

Introduction: Neurosurgical residency training is costly, with expenses largely borne by the academic institutions that train residents. One expense is increased operative duration, which leads to poorer patient outcomes. Although other studies have assessed the effect of one resident assisting, none have investigated two residents; thus, we sought to investigate if two residents versus one scrubbed-in impacted operative time, estimated blood loss (EBL), and length-of-stay (LOS).Methods: In this retrospective review of patients who underwent a neurosurgical procedure involving one or two residents between January 2013 and April 2016, we performed multivariable linear regression to determine if there was an association between resident participation and case length, operating room time, EBL, and LOS. We also included patient demographics, attending surgeon, day of the week, start time, pre-operative LOS, procedure performed, and other variables in our model. Only procedures performed at least 40 times during the study period were analyzed.Results: Of 860 procedures that met study criteria, 492 operations were one of six procedures performed at least 40 times, which were anterior cervical discectomy and fusion, cerebrospinal fluid (CSF) shunt insertion, CSF shunt revision, lumbar laminectomy, intracranial hematoma evacuation, and non-skull base, supratentorial parenchymal brain tumor resection. An additional resident was associated with a 35.1-min decrease (p = .01) in operative duration for lumbar laminectomies. However, for intracranial hematoma evacuations, an extra resident was associated with a 24.1 min increase (p = .03) in procedural length. There were no significant differences observed in the other four surgeries.Conclusion: An additional resident may lengthen duration of intracranial hematoma evacuations. However, two residents scrubbed-in were associated with decreased lumbar laminectomy duration. Overall, an extra resident does not increase procedural duration, total operating room utilization, EBL, or post-operative LOS. Allowing two residents to scrub in may be a safe and cost-effective method of educating neurosurgical residents.

Reporting Methodology of Neurosurgical Studies Utilizing the American College of Surgeons-National Surgical Quality Improvement Program Database: A Systematic Review and Critical Appraisal

BACKGROUND

Use of large databases such as the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) has become increasingly common in neurosurgical research.

OBJECTIVE

To perform a critical appraisal and evaluation of the methodological reporting for studies in neurosurgical literature that utilize the ACS-NSQIP database.

METHODS

We queried Ovid MEDLINE, EMBASE, and PubMed databases for all neurosurgical studies utilizing the ACS-NSQIP. We assessed each study according to number of criteria fulfilled with respect to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement, REporting of studies Conducted using Observational Routinely-collected Health Data (RECORD) Statement, and Journal of American Medical Association–Surgical Section (JAMA-Surgery) Checklist. A separate analysis was conducted among papers published in core and noncore journals in neurosurgery according to Bradford's law.

RESULTS

A total of 117 studies were included. Median (interquartile range [IQR]) scores for number of fulfilled criteria for STROBE Statement, RECORD Statement, and JAMA-Surgery Checklist were 20 (IQR:19-21), 9 (IQR:8-9), and 6 (IQR:5-6), respectively. For STROBE Statement, RECORD Statement, and JAMA-Surgery Checklist, item 9 (potential sources of bias), item 13 (supplemental information), and item 9 (missing data/sensitivity analysis) had the highest number of studies with no fulfillment among all studies (56, 68, 50%), respectively. When comparing core journals vs noncore journals, no significant difference was found (STROBE, P = .94; RECORD, P = .24; JAMA-Surgery checklist, P = .60).

CONCLUSION

While we observed an overall satisfactory reporting of methodology, most studies lacked mention of potential sources of bias, data cleaning methods, supplemental information, and external validity. Given the pervasive role of national databases and registries for research and health care policy, the surgical community needs to ensure the credibility and quality of such studies that ultimately aim to improve the value of surgical care delivery to patients.

Adverse Events After Microvascular Decompression: A National Surgical Quality Improvement Program Analysis

BACKGROUND

Although microvascular decompression (MVD) is a durable treatment for medically refractory trigeminal neuralgia, hemifacial spasm, or glossopharyngeal neuralgia attributable to neurovascular conflict, few national studies have analyzed predictors of postoperative complications.

OBJECTIVE

To determine the incidence and risk factors for adverse events after MVD.

METHODS

Patients who underwent MVD were extracted from the prospectively collected National Surgical Quality Improvement Program registry (2006-2017). Multivariable logistic regression identified predictors of 30-day adverse events and unplanned readmission; multivariable linear regression analyzed predictors of a longer hospital stay.

RESULTS

Among the 1005 patients evaluated, the mortality was 0.3%, major neurologic complication rate 0.4%, and 2.8% had a nonroutine hospital discharge. Patient age was not a predictor of any adverse events. Statistically significant independent predictors both of any adverse event (9.2%) and of a longer hospitalization were American Society of Anesthesiologists (ASA) classification III-IV designation and longer operative duration (P ≤ 0.03) The 30-day readmission rate was 6.8%, and the most common reasons were surgical site infections (22.4%) and cerebrospinal fluid leakage (14.3%). Higher ASA classification, diabetes mellitus, and operative time were predictors of readmission (P < 0.04).

CONCLUSIONS

In this National Surgical Quality Improvement Program analysis, postoperative morbidity and mortality after MVD was low. Patient age was not a predictor of postoperative complications, whereas higher ASA classification, diabetes mellitus, and longer operative duration were predictive of any adverse event and readmission. ASA classification provided superior risk stratification compared with the total number of patient comorbidities or laboratory values. These data can assist with preoperative patient counseling and risk stratification.

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.

Venous thromboembolism and intracranial hemorrhage after craniotomy for primary malignant brain tumors: a National Surgical Quality Improvement Program analysis

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), frequently complicates the postoperative course of primary malignant brain tumor patients. Thromboprophylactic anticoagulation is commonly used to prevent VTE at the risk of intracranial hemorrhage (ICH). We extracted all patients who underwent craniotomy for a primary malignant brain tumor from the National Surgical Quality Improvement Program (NSQIP) registry (2005-2015) to perform a time-to-event analysis and identify relevant predictors of DVT, PE, and ICH within 30 days after surgery. Among the 7376 identified patients, the complication rates were 2.6, 1.5, and 1.3% for DVT, PE, and ICH, respectively. VTE was the second-most common major complication and third-most common reason for readmission. ICH was the most common reason for reoperation. The increased risk of VTE extends beyond the period of hospitalization, especially for PE, whereas ICH occurred predominantly within the first days after surgery. Older age and higher BMI were overall predictors of VTE. Dependent functional status and longer operative times were predictive for VTE during hospitalization, but not for post-discharge events. Admission two or more days before surgery was predictive for DVT, but not for PE. Preoperative steroid usage and male gender were predictive for post-discharge DVT and PE, respectively. ICH was associated with various comorbidities and longer operative times. This multicenter study demonstrates distinct critical time periods for the development of thrombotic and hemorrhagic events after craniotomy. Furthermore, the VTE risk profile depends on the type of VTE (DVT vs. PE) and clinical setting (hospitalized vs. post-discharge patients).

Is there a "July effect" in pediatric neurosurgery?

PURPOSE

The belief that July, when resident physicians' training year begins, may be associated with increased risk of patient morbidity and mortality is known as the "July effect." This study aimed to compare complication rates after pediatric neurosurgical procedures in the first versus last academic quarters in two national datasets.

METHODS

Data were extracted from the National Surgical Quality Improvement Program-Pediatrics (NSQIP-P) database for year 2012 for 30-day complication events and the Kids' Inpatient Database (KID) for year 2012 for in-hospital complication events after pediatric neurosurgical procedures. Descriptive and analytic statistical methods were used to characterize the impact of seasonal variation between the first and last quarters on complications.

RESULTS

Three thousand six hundred twenty-four procedures in the NSQIP-P dataset and 14,855 hospitalizations in KID were included in the study cohort. No significant difference was observed between the first and fourth quarters for these complication events: wound disruption/dehiscence, wound infection, nerve injury, bleeding requiring transfusion, central line-associated BSI, deep venous thrombosis/pulmonary embolism, urinary tract infection, renal failure, re-intubation/pulmonary failure, cardiac arrest, stroke, coma, and death. There was no difference in the average length of stay or average length of surgical time. In the NSQIP-P, the first quarter was associated with a significantly increased incidence of pneumonia and unplanned re-operation; there was a trend towards increased incidence of unplanned re-admission and sepsis. In KID, there was no difference in the rate of pneumonia or sepsis.

CONCLUSION

For the majority of morbidity and mortality events, no significant difference was found in occurrence rates between the first and last quarters.

Readmission and Other Adverse Events after Transsphenoidal Surgery: Prevalence, Timing, and Predictive Factors

BACKGROUND

Transsphenoidal surgery is a common neurosurgical procedure for accessing the pituitary and anterior skull base, yet few multicenter analyses have evaluated outcomes after this procedure.

STUDY DESIGN

Patients undergoing transsphenoidal surgery from 2006 to 2015 were extracted from the American College of Surgeons NSQIP database. Logistic regression was used to identify predictors of 30-day complications.

RESULTS

Of 1,240 patients included in this analysis, 6.9% experienced a major complication, and 9.4% experienced any complication within 30 days. Other adverse events included death in 0.7% and nonroutine hospital discharge in 5.3%. Most adverse events occurred within the first 2 weeks postoperatively; 82.9% of patients experienced their first complication during the initial hospital stay. Multivariable analysis demonstrated that predictors of hospital stay longer than 4 days included American Society of Anesthesiologists classification III to V (p = 0.015), insulin-dependent diabetes mellitus (p < 0.001), and operative time in the third and fourth quartiles (both p < 0.001). American Society of Anesthesiologists classification III to V and operative time in the fourth quartile were also predictors of any adverse event (p = 0.01 and p = 0.005, respectively). Among these patients, 3.7% underwent reoperation, the most common reason for which was postoperative cerebrospinal fluid leak (63.6%). Readmission occurred after 8.5% of cases at a median of 11.0 days post-discharge. The most common cause of readmission was hyponatremia (29.5%), followed by delayed postoperative cerebrospinal fluid leak (16.0%).

CONCLUSIONS

Overall rates of adverse events in patients undergoing transsphenoidal surgery are relatively low, and most occur before discharge from the hospital. Post-discharge complications associated with transsphenoidal surgery include deep vein thrombosis, pulmonary embolism, and urinary tract infection. Delayed postoperative cerebrospinal fluid leak is the major cause of reoperation, and hyponatremia is the major cause of readmission.

The "July effect" in total shoulder arthroplasty

BACKGROUND

New medical doctors enter their residency fields in July, a time in the hospital in which patient morbidity and mortality rates are perceived to be higher. It remains controversial whether a "July effect" exists in different areas of medicine and surgery, including in orthopedic surgery. The purpose of this study is to test for the July effect in patients undergoing primary total shoulder arthroplasty (TSA).

METHODS

Patients who underwent primary TSA from 2005-2012 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Cases were categorized as involving residents or fellows and as occurring during the first academic quarter. Rates of composite and any adverse event outcomes were compared between patient groups using multivariate logistic regression.

RESULTS

A total of 1591 patients met the inclusion criteria. Of these cases, 711 (44.7%) had resident or fellow involvement and 390 (24.5%) were performed in the first academic quarter. There were few demographic and comorbidity differences between cases with and without residents or fellows or between cases performed during the first quarter and during the rest of the year. Overall, the rate of serious adverse events was 1.6% and the rate of any adverse events was 6.5%.

DISCUSSION AND CONCLUSION

Using one of the largest cohorts of primary TSA patients, this study could not provide evidence for a July effect. In the context of the recent growth in the volume of TSA procedures, these findings provide important reassurance to patients that it is safe to schedule their elective procedures at training institutions during the first part of the academic year.

National Database Research in Spine Surgery: Limitations in the Current Literature

Many of the studies in the spine surgical literature using national databases have been directed at examining adverse events, readmission rates, cost, and risk factors for poorer outcomes. Although such studies allow for assessment of large cohorts taken from multiple institutions, they are limited by data collection methods, short-term follow-up, and minimal assessment of functional outcomes. Furthermore, few studies are directed at producing actionable practice changes to improve patient care. Recent work aimed at producing databases with more relevance to spine surgery represent exciting developments to the rapidly growing field of health outcomes research.

Effect of timing of cannulation on outcome for pediatric extracorporeal life support

PURPOSE

Literature reports worse outcomes for operations performed during off-hours. As this has not been studied in pediatric extracorporeal life support (ECLS), we compared complications based on the timing of cannulation..

METHODS

This is a retrospective review of 176 pediatric ECLS patients between 2004 and 2015. Patients cannulated during daytime hours (7:00 A.M. to 7:00 P.M., M-F) were compared to off-hours (nighttime or weekend) using t-test and Chi-square.

RESULTS

The most common indications for ECLS were congenital diaphragmatic hernia (33 %) and persistent pulmonary hypertension (23 %). When comparing regular hours (40 %) to off-hours cannulation (60 %), there were no significant differences in central nervous system complications, hemorrhage (extra-cranial), cannula repositioning, conversion from venovenous to venoarterial, mortality on ECLS, or survival-to-discharge. The overall complication rate was slightly lower in the off-hours group (45.7 % versus 61.9 %, P = 0.034).

CONCLUSION

Outcomes were not significantly worse for patients undergoing ELCS cannulation during off-hours compared to normal weekday working hours.

Examining the July Effect: A National Survey of Academic Leaders in Medicine

BACKGROUND

Whether the "July Effect" affects perspectives or has prompted changes in US Internal Medicine residency programs is unknown.

METHODS

We designed a survey-based study to assess views and efforts aimed at preventing harm in July. A convenience sampling strategy (email listserv and direct messages to program leaders via the Electronic Residency Application Service) was used to disseminate the survey.

RESULTS

The response rate was 16% (65/418 programs); however, a total of 262 respondents from all 50 states where residency programs are located were included. Most respondents (n = 201; 77%) indicated that errors occur more frequently in July compared with other months. The most common identified errors included incorrect or delayed orders (n = 183, 70% and n = 167, 64%, respectively), errors in discharge medications (n = 144, 55%), and inadequate information exchange at handoffs (n = 143, 55%). Limited trainee experience (n = 208, 79%), lack of understanding hospital workflow, and difficulty using electronic medical record systems (n = 194; 74% and n = 188; 72%, respectively) were reported as the most common factors contributing to these errors. Programs reported instituting several efforts to prevent harm in July: for interns, additional electronic medical record training (n = 178; 68%) and education on handoffs and discharge processes (n = 176; 67% and n = 108; 41%, respectively) were introduced. Similarly, for senior residents, teaching sessions on how to lead a team (n = 158; 60%) and preferential placement of certain residents on harder rotations (n = 103; 39%) were also reported. Most respondents (n = 140; 53%) also solicited specific "July attendings" using a volunteer system or highest teaching ratings.

CONCLUSION

Residency programs in Internal Medicine appear to have instituted various changes to mitigate harm in July. Further evaluation to understand the impact of these interventions on trainee education and patient safety is necessary.