The “July Effect”: A Look at July Medical Admissions in Teaching Hospitals

Background: Acute stroke care provided by comprehensive stroke centers usually follows prespecified protocols. However, there are concerns about lower quality of care and poorer stroke outcomes early after new trainnees (e.g.) residents start in July in academic/teaching hospitals. This has been called ‘the July effect’. Objective: To evaluate access to specialized care and outcomes among patients admitted with an acute ischemic stroke (AIS) in July and other months. Hypothesis: We hypothesized that there were no significant differences in access to stroke care and outcomes for patients admitted in July when new trainees start at academic centers. Methods: Patients presenting with an AIS at 11 stroke centers in Ontario, Canada, between 2003 and 2009 were identified from the Registry of the Canadian Stroke Network. We compared performance measures and functional outcomes (death at 30 days, modified Rankin Scale 3 to 5 at discharge) between AIS patients admitted in July of each studied year and those who admitted during other months. Results: Of 10,319 eligible patients with an AIS, 882 (8.5%) were admitted in July. There was not difference in age, sex, or baseline stroke severity between patients admitted in July or other months. Among the performance measures analyzed, AIS admitted in July were less likely to receive thrombolysis (12.1% vs. 16.0%, p=0.002), swallowing test (64.4% vs. 67.9%, p=0.033), and admission to stroke unit (61.9% vs. 67.6%, <0.001). There was no difference in death at 30-days (16.4% vs. 16.1%, p=0.823) or poor functional outcome (61.0% vs. 63.5%, p=0.14) between two groups (Table). Conclusion: AIS patients admitted in July were less likely to receive thrombolysis and be admitted to stroke units compared to patients admitted on the rest of the year. However, there was no negative effect of “admission on July” on functional outcome or death.

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Does the “July Effect” of new trainees at teaching hospitals impact outcomes for patients hospitalized with heart failure? Real-world analyses of more than half a million US admissions

American Heart Journal Plus: Cardiology Research and Practice ◽

10.1016/j.ahjo.2021.100072 ◽

2021 ◽

pp. 100072

Author(s):

Ahmed A. Kolkailah ◽

Marwan S. Abougergi ◽

Parth V. Desai ◽

Axi Patel ◽

Setri Fugar ◽

...

Keyword(s):

Heart Failure ◽

Real World ◽

Teaching Hospitals ◽

July Effect

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Abstract 61: Seasonal Variation of In-Hospital Mortality in Patients with Acute Ischemic Stroke

Stroke ◽

10.1161/str.46.suppl_1.61 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Nilay Kumar ◽

Neetika Garg ◽

Monica Khunger ◽

Anand Venkatraman

Keyword(s):

Ischemic Stroke ◽

Seasonal Variation ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

Winter Season ◽

Teaching Hospitals ◽

National Database ◽

Hospital Discharges ◽

Incidence And Mortality ◽

July Effect

Background and objectives: Seasonal patterns in incidence and mortality are well known for cardiovascular diseases (CVD) including acute myocardial infarction and arrhythmias. It is unclear whether in-hospital mortality in patients with acute ischemic stroke (AIS) exhibits seasonal variation. Methods: We searched the 2011 Nationwide Inpatient Sample for discharges with a principal diagnosis of AIS using the ICD-9 codes 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91 and 437.1. Seasonal variation in in-hospital mortality was tested using logistic regression with admission season and month as categorical predictors in separate models. In addition to annual variation, we tested for the “July effect” of increase in mortality in teaching hospitals. Results: There was an estimated 467, 849 discharges for AIS of which 21,149 (4.53%) died in the hospital. Compared to summer months, the risk of in-hospital mortality was 12.6% higher in winter and 10.2% higher in the fall (p=0.004 for winter vs. summer, p=0.024 for fall vs. summer). Compared to August, mortality was 18.20% higher in January (p=0.026 for comparison) and 24.3% higher in December (p=0.003 for comparison) (Table shows odds ratio of death compared to reference season/month). We did not find any evidence of a “July effect” of increased mortality, often attributed to new trainees, in teaching hospitals (p=0.830 for June vs. July) Conclusions: In a large national database of hospital discharges related to AIS, mortality was significantly higher in colder months compared to warmer months. Our study adds to the growing body of evidence that links winter season to worse outcomes in CVD.

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The Impact Of “July Effect” On “Failure To Rescue”: Do Patients Who Undergo Coronary Artery Bypass Grafting At Teaching Hospitals Face A Selective Disadvantage?

Journal of Surgical Research ◽

10.1016/j.jss.2010.11.589 ◽

2011 ◽

Vol 165 (2) ◽

pp. 203-204

Author(s):

D.M. Overbey ◽

T.K. Dao ◽

R.R. Gopaldas

Keyword(s):

Coronary Artery ◽

Coronary Artery Bypass Grafting ◽

Coronary Artery Bypass ◽

Artery Bypass ◽

Teaching Hospitals ◽

Bypass Grafting ◽

Failure To Rescue ◽

Artery Bypass Grafting ◽

July Effect ◽

The Impact

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Lack of July effect in the utilization of neuraxial and peripheral nerve block in US teaching hospitals: a retrospective analysis

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2020-101318 ◽

2020 ◽

Vol 45 (5) ◽

pp. 357-361

Author(s):

Sang Jo Kim ◽

Lauren Wilson ◽

Jiabin Liu ◽

David H Kim ◽

Megan Fiasconaro ◽

...

Keyword(s):

Peripheral Nerve ◽

Nerve Block ◽

Peripheral Nerve Block ◽

Neuraxial Anesthesia ◽

House Staff ◽

Teaching Hospitals ◽

Nerve Blocks ◽

Peripheral Nerve Blocks ◽

Opioid Prescribing ◽

July Effect

BackgroundGiven the steep learning curve for neuraxial and peripheral nerve blocks, utilization of general anesthesia may increase as new house staff begin their residency programs. We sought to determine whether “July effect” affects the utilization of neuraxial anesthesia, peripheral nerve blocks, and opioid prescribing for lower extremity total joint arthroplasties (TJA) in July compared with June in teaching and non-teaching hospitals.MethodsNeuraxial anesthesia, peripheral nerve block use, and opioid prescribing trends were assessed using the Premier database (2006–2016). Analyses were conducted separately for teaching and non-teaching hospitals. Differences in proportions were evaluated via χ2 test, while differences in opioid prescribing were analyzed via Wilcoxon rank-sum tests.ResultsA total of 1 723 256 TJA procedures were identified. The overall proportion of neuraxial anesthesia use in teaching hospitals was 14.4% in both June and July (p=0.940). No significant changes in neuraxial use were seen in non-teaching hospitals (24.5% vs 24.9%; p=0.052). Peripheral nerve block utilization rates did not differ in both teaching (15.4% vs 15.3%; p=0.714) and non-teaching hospitals (10.7% vs 10.5%; p=0.323). Overall median opioid prescribing at teaching hospitals changed modestly from 262.5 oral morphine equivalents (OME) in June to 260 in July (p=0.026) while median opioid prescribing remained at a constant value of 255 OME at non-teaching hospitals (p=0.893).ConclusionUtilization of neuraxial and regional anesthesia techniques was not affected during the initial transition period of new house staff in US teaching institutions. It is feasible that enough resources are available in the system to accommodate periods of turnover and maintain levels of regional anesthetic care including additional attending anesthesiologist oversight.

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Mortality among high-risk patients admitted with septic shock to U.S. teaching hospitals in July: Does the ‘July Effect’ exist?

Heart & Lung ◽

10.1016/j.hrtlng.2017.01.010 ◽

2017 ◽

Vol 46 (2) ◽

pp. 110-113 ◽

Cited By ~ 8

Author(s):

Amina Saqib ◽

Uroosa Ibrahim ◽

Parshva Patel ◽

Abhyudaya Joshi ◽

Michel Chalhoub

Keyword(s):

Septic Shock ◽

High Risk ◽

Teaching Hospitals ◽

High Risk Patients ◽

July Effect ◽

Risk Patients

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July Effect on Mortality and Complications in Patients With ARDS in US Teaching Hospitals

American Journal of Critical Care ◽

10.4037/ajcc2021608 ◽

2021 ◽

Vol 30 (4) ◽

pp. e64-e70

Author(s):

Titilope Olanipekun ◽

Abimbola Chris-Olaiya ◽

Shawn Esperti ◽

Vinod Nambudiri ◽

Richard Duff ◽

...

Keyword(s):

Mechanical Ventilation ◽

Bloodstream Infection ◽

The United States ◽

Teaching Hospitals ◽

Complication Rates ◽

Ventilator Associated Pneumonia ◽

Central Catheter ◽

Difference In Differences ◽

July Effect ◽

States Experience

Background Each July, teaching hospitals in the United States experience an influx of new resident and fellow physicians. It has been theorized that this occurrence may be associated with increased patient mortality, complication rates, and health care resource use, a phenomenon known as the “July effect.” Objective To assess the existence of a July effect in clinical outcomes of patients with acute respiratory distress syndrome (ARDS) receiving mechanical ventilation in the intensive care unit in US teaching hospitals. Methods The National Inpatient Sample database was queried for all adult patients with ARDS who received mechanical ventilation from 2012 to 2014. Using a multivariate difference-in-differences (DID) model, differences in mortality, ventilator-associated pneumonia, iatrogenic pneumothorax, central catheter–associated bloodstream infection, and Clostridium difficile infection were compared between teaching and nonteaching hospitals during April-May and July-August. Results There were 70 535 and 43 175 hospitalizations meeting study criteria in teaching and nonteaching hospitals, respectively. Multivariate analyses revealed no differential effect on the rates of all-cause inpatient mortality (DID, 0.66; 95% CI, −0.42 to 1.75), C difficile infection (DID, 0.29; 95% CI, −0.19 to 0.78), central catheter–associated bloodstream infection (DID, 0.14; 95% CI, −0.04 to 0.33), iatrogenic pneumothorax (DID, 0.00; 95% CI, −0.25 to 0.24), ventilator-associated pneumonia (DID, 0.22; 95% CI, −0.05 to 0.49), and any complication (DID, 0.60; 95% CI, −0.01 to 1.20) for July-August versus April-May in teaching hospitals compared with nonteaching hospitals. Conclusion This study did not show a differential July effect on mortality outcomes and complication rates in ARDS patients receiving mechanical ventilation in teaching hospitals compared with nonteaching hospitals.

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Abstract 16269: Does the “July Effect” Impact Heart Failure Outcomes? A Real-World Analysis of More Than Half a Million Nationwide Admissions

Circulation ◽

10.1161/circ.142.suppl_3.16269 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Ahmed A Kolkailah ◽

Marwan Abougergi ◽

Parth V Desai ◽

Axi Patel ◽

Setri Fugar ◽

...

Keyword(s):

Heart Failure ◽

Primary Diagnosis ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Teaching Hospitals ◽

Total Cost ◽

Safe Patient Care ◽

Inpatient Outcomes ◽

July Effect ◽

Mortality Difference

Background: The “July effect” is a well-described phenomenon in academic medicine, relating to the annual influx of new trainees. We examined whether the “July effect” impacts inpatient outcomes of admissions for heart failure (HF). Methods: Between 2012 and 2014, we included adult patients (≥18 years) with a primary diagnosis of HF, defined using ICD-9 codes, from the National Inpatient Sample. We excluded non-teaching hospitals. Primary endpoint was in-hospital mortality. Secondary endpoints included hospital length of stay (LOS) and total cost adjusted for inflation. Logistic regression and adjusted odds ratio (OR) were used to adjust for confounders. Based on academic calendar, we classified admissions into 4 quarters (Q1-4). Q1 and Q4 were designated to assess the effect of novice (July effect) vs. seasoned trainees, respectively. Results: We identified 699,675 HF admissions during Q1 and Q4 over the study period. Mean age was 71 years and 48% were females. There were 20,270 in-hospital deaths (Q1 9,695 vs. Q4 10,575). After adjusting for confounders, there was no mortality difference between Q1 and Q4 admissions; adjusted OR 0.96, p = 0.23 (Figure). Similarly, there was no difference in hospital LOS or total cost; 5.8 vs. 5.8 days, p = 0.66 and $13,755 vs. $13,586, p = 0.46, in Q1 and Q4, respectively. Conclusion: In the largest study to date, there was no evidence of a “July effect” on inpatient HF outcomes. This may be credited to the well-defined guidelines which facilitate safe patient care in these patients.

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The Rookie Goes to Bat: Is there a “July Effect” on Stroke Treatment at Teaching Hospitals?

The Neurohospitalist ◽

10.1177/1941874417740055 ◽

2017 ◽

Vol 8 (1) ◽

pp. 5-6

Author(s):

Tigran Kesayan ◽

Juan Ramos-Canseco ◽

David Z. Rose

Keyword(s):

Teaching Hospitals ◽

Stroke Treatment ◽

July Effect

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Door-to-Needle Time in Acute Stroke Treatment and the “July Effect”

The Neurohospitalist ◽

10.1177/1941874417733108 ◽

2017 ◽

Vol 8 (1) ◽

pp. 24-28 ◽

Cited By ~ 2

Author(s):

Maximiliano A. Hawkes ◽

Federico Carpani ◽

Mauricio F. Farez ◽

Sebastian F. Ameriso

Keyword(s):

Intravenous Thrombolysis ◽

National Institutes Of Health ◽

Teaching Hospitals ◽

Intracranial Hemorrhages ◽

Time Rate ◽

Stroke Outcomes ◽

Stroke Treatment ◽

July Effect ◽

The Impact ◽

Academic Year

Intravenous thrombolysis improves outcomes in acute ischemic stroke in a time-dependent fashion. As in teaching hospitals, clinical outcomes may worsen due to the arrival of new inexperienced house staff early in the academic year (July effect, JE), we evaluated the impact of the “JE” on the door-to-needle time for intravenous thrombolysis and other stroke outcomes. In this retrospective cohort study, we assessed all acute ischemic strokes treated with intravenous thrombolysis between July 2003 and June 2016. Among 101 patients, there was no detrimental July effect on the door-to-needle time, rate of thrombolysis within 60 minutes of arrival, thrombolysis of stroke mimics, post-thrombolysis intracranial hemorrhages, National Institutes of Health Stroke Scale, and modified Rankin Scale outcomes.

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