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Original Investigation |

Evaluation of the Perceived Association Between Resident Turnover and the Outcomes of Patients Who Undergo Emergency General Surgery Questioning the July Phenomenon

Adil A. Shah, MD1,2; Cheryl K. Zogg, MSPH, MHS1; Stephanie L. Nitzschke, MD1; Navin R. Changoor, MD1; Joaquim M. Havens, MD1; Ali Salim, MD1; Zara Cooper, MD, MSc1; Adil H. Haider, MD, MPH1
[+] Author Affiliations
1Center for Surgery and Public Health, Harvard Medical School and Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
2Division of General Surgery, Mayo Clinic, Phoenix, Arizona
JAMA Surg. 2016;151(3):217-224. doi:10.1001/jamasurg.2015.3940.
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Importance  The influx of new surgical residents and interns at the beginning of the academic year is assumed to be associated with poor outcomes. Referred to as the July phenomenon, this occurrence has been anecdotally associated with increases in the frequency of medical errors due to intern inexperience. Studies in various surgical specialties provide conflicting results.

Objective  To determine whether an association between the July phenomenon and outcomes exists among a nationally representative sample of patients who underwent emergency general surgery (EGS).

Design, Setting, and Participants  Retrospective analysis of data from the 2007-2011 Nationwide Inpatient Sample. Data on adult patients (≥16 years of age) presenting to teaching hospitals with a principal diagnosis of an EGS condition, as defined by the American Association for the Surgery of Trauma, were retrospectively analyzed. The patients who were included in our study were dichotomized into early (July-August) vs late (September-June) management. The original analyses were conducted in March 2015.

Main Outcomes and Measures  Risk-adjusted multivariable regression based on calculated propensity scores was assessed for associations with differences in in-hospital mortality, complications, length of stay, and total hospital cost.

Results  A total of 1 433 528 patients who underwent EGS were included, weighted to represent 7 095 045 patients from 581 teaching hospitals nationwide; 17.6% were managed early. Relative to patients managed later, early patients had marginally lower risk-adjusted odds of mortality (odds ratio [OR], 0.96 [95% CI, 0.92-0.99]), complications (OR, 0.98 [95% CI, 0.96-0.99]), and developing a secondary EGS condition (OR, 0.97 [95% CI, 0.97-0.98]). Length of stay and total hospital cost were comparable between the 2 groups (P > .05).

Conclusions and Relevance  Contrary to expectations, the EGS patients who were managed early fared equally well, if not better, than the EGS patients who were managed later. Potentially attributable to increased manpower and/or hypervigilance on the part of supervising senior residents or attending physicians, the results suggest that concerns among EGS patients related to the July phenomenon are unfounded.

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Figure 1.
Flow Diagram of the Study’s Patient Selection Process

EGS indicates emergency general surgery; ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification; and NIS, Nationwide Inpatient Sample.

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Figure 2.
Risk-Adjusted Rates of Mortality (A) and Complications (B) for Each Month of the Year

Risk adjusted for propensity score quintile, hospital location, geographical region, hospital bed size, surgical procedure, and emergency general surgery category. Subset analysis on nonteaching hospitals was performed on 1 963 442 patient records from 2557 nonteaching hospitals. Error bars indicate 95% CIs.

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