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July Effect in Elective Spine Surgery: Analysis of the American College of Surgeons National Surgical Quality Improvement Program Database

Bohl, Daniel D. MPH; Fu, Michael C. BS; Gruskay, Jordan A. BA; Basques, Bryce A. BS; Golinvaux, Nicholas S. BA; Grauer, Jonathan N. MD

doi: 10.1097/BRS.0000000000000196
Health Services Research

Study Design. Retrospective cohort.

Objective. To evaluate for the presence and magnitude of the “July effect” within elective spine surgery.

Summary of Background Data. The July effect is the hypothetical increase in morbidity and mortality thought to be associated with the influx of new (or newly promoted) trainees during the first portion of the academic year. Studies evaluating for the presence and magnitude of the July effect have demonstrated conflicting results.

Methods. We accessed the American College of Surgeons National Surgical Quality Improvement Program database from 2005–2010. Statistical analyses were conducted using bivariate and multivariate logistic regression.

Results. A total of 14,986 cases met inclusion criteria and constitute the study population. Of these, 26.5% occurred in the first academic quarter and 25.3% had resident involvement. The rate of serious adverse events was 1.9 times higher and the rate of any adverse events was 1.6 times higher among cases with resident involvement than among those without (P < 0.001 for both). Among cases without resident involvement, the rates of serious adverse events and any adverse events did not differ by academic quarter. Similarly, among cases with resident involvement, the rates of serious adverse events and any adverse events did not differ by academic quarter.

Conclusion. We could not demonstrate that the training of new (or newly promoted) residents is associated with an increase in the adverse events of spine surgery. Safeguards that have been put in place to ensure patient safety during this training period seem to be effective. Although adverse events were more common among cases with resident involvement than among cases without resident involvement, our data suggest that this association is more likely a product of the riskier population of cases in which residents participate than of the resident involvement itself.

Level of Evidence: 3

Using the American College of Surgeons National Surgical Quality Improvement Database, we found that rate of adverse events after elective spine surgery does not differ by academic quarter; that is, in elective spine surgery, the July effect does not occur.

From the Yale School of Medicine, New Haven, CT.

Address correspondence and reprint requests to Jonathan N. Grauer, MD, Yale School of Medicine, 800 Howard Ave., New Haven, CT 06510; E-mail: jonathan.grauer@yale.edu

Acknowledgment date: September 17, 2013. Revision date: December 15, 2013. Acceptance date: December 16, 2013.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: consultancy, expert testimony, grants.

© 2014 by Lippincott Williams & Wilkins