New Data Largely Discount 'July Phenomenon'

"Don’t have surgery in July!" This is the folk wisdom regarding the purported "July Phenomenon" – the perception that it is more dangerous to have an operation in July than at any other time of year. July heralds the onslaught of new interns; July also means that current residents are given additional duties and responsibility. "Why risk an operation in a month when trainee inexperience must surely dilute the quality of patient care?" is the intuitive assumption.

A recent study reported in ‘Surgery’, however, showed that this concern is unfounded.

Multivariate analysis indicated that only 1 out of the 10 most common surgical procedures (lower extremity artery bypass grafting) showed a significant increase in mortality concurrent with the so-called July Phenomenon (odds ratio, 1.34; P = .034).

The researchers also found that there was no significant increase in serious adverse events (SAE) for any of the procedures (Surgery 2011;150:332-8).

The previous medical literature shows no consensus on the subject. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) suggested that greater rates of postsurgical problems were related to that time of year (Ann. Surg. 2007;246:456-62).

In contrast, studies in obstetrics and neurology showed that no July Phenomenon existed, as did surgical studies in specialties including trauma, pediatric neurosurgery, and cardiac surgery, according to Dr. Bryan A. Ehlert and colleagues at East Carolina University, Greenville, N.C.

To investigate the issue in a broader surgical context, Dr. Ehlert and his colleagues studied the ACS-NSQIP database records of 89,473 patients who had the 10 most common inpatient operative procedures in 2005-2007.

They compared 26,287 patients who had surgery in the July 1–Sept. 30 quarter (called the "first academic quarter," or FAQ) with a control population of 63,186 patients who had equivalent surgery during the rest of the year (Oct. 1–June 30).

They assessed the following 10 procedures: appendectomy, (lower extremity) artery bypass graft, initial reducible ventral hernia repair, laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic gastric bypass, partial colectomy, rechanneling of artery, repair of bowel opening, and small-bowel resection.

The two populations showed no significant differences in a wide variety of demographic characteristics including age (average, about 54 years); sex (about 45% male); and presence of coronary artery disease, renal disease, peripheral vascular disease (PVD/PAD), and diabetes. Slight but significant differences were found only in the presence of hypertension (50.0% in the FAQ group vs. 48.4% in controls, respectively) and history of smoking (24.0% vs. 23.4%).

Especially important to the study, there was no significant difference in resident participation in patient care (72.7% vs. 73.0%) or the highest resident level in postgraduate year (2.6 years each).

"Although July might seem intuitively to be a precarious time to undergo an operation due to the influx of new interns and increased responsibilities of rising residents, our findings for the most part discount the presence of a ‘July Phenomenon’ in surgical patients," the authors stated.

Discrepancies between the previous ACS-NSQIP report and their findings were attributed to the much larger sample size in the current study (183 centers vs. 18).

They postulated that the lower extremity bypass graft FAQ group showed greater mortality than did the control group because the vascular subsets had a significantly greater modified Charlson comorbidity index, compared with the nonvascular subsets in the FAQ population (CCI, 3.72 vs. 1.56; P less than .001).

"New surgery interns may not be as adept at recognizing the needs of these patients who are often sicker. As a result, these patient populations may benefit from more senior residents and attending physician involvement as new interns learn how to manage patients with complex cardiovascular disease," they suggested.

A weakness of the study reported by the authors is the crude estimate of patient outcomes, which focuses only on morbidity and mortality and does not include data on duration of stay, medication errors, or cost-effectiveness – all of which could possibly be affected by new interns.

For example, they noted that new interns may be more likely to order more unnecessary laboratory tests, or they may fail to remove invasive devices or monitoring devices that are no longer needed, which may in turn lead to increased infections.

In addition, they also stated that interns may have more difficulties when confronted with rarer operations than the 10 most common procedures that were evaluated.

The researchers disclosed no conflicts that the journal deemed relevant to report.

"Don’t have surgery in July!" This is the folk wisdom regarding the purported "July Phenomenon" – the perception that it is more dangerous to have an operation in July than at any other time of year. July heralds the onslaught of new interns; July also means that current residents are given additional duties and responsibility. "Why risk an operation in a month when trainee inexperience must surely dilute the quality of patient care?" is the intuitive assumption.

A recent study reported in ‘Surgery’, however, showed that this concern is unfounded.

Multivariate analysis indicated that only 1 out of the 10 most common surgical procedures (lower extremity artery bypass grafting) showed a significant increase in mortality concurrent with the so-called July Phenomenon (odds ratio, 1.34; P = .034).

The researchers also found that there was no significant increase in serious adverse events (SAE) for any of the procedures (Surgery 2011;150:332-8).

The previous medical literature shows no consensus on the subject. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) suggested that greater rates of postsurgical problems were related to that time of year (Ann. Surg. 2007;246:456-62).

In contrast, studies in obstetrics and neurology showed that no July Phenomenon existed, as did surgical studies in specialties including trauma, pediatric neurosurgery, and cardiac surgery, according to Dr. Bryan A. Ehlert and colleagues at East Carolina University, Greenville, N.C.

To investigate the issue in a broader surgical context, Dr. Ehlert and his colleagues studied the ACS-NSQIP database records of 89,473 patients who had the 10 most common inpatient operative procedures in 2005-2007.

They compared 26,287 patients who had surgery in the July 1–Sept. 30 quarter (called the "first academic quarter," or FAQ) with a control population of 63,186 patients who had equivalent surgery during the rest of the year (Oct. 1–June 30).

They assessed the following 10 procedures: appendectomy, (lower extremity) artery bypass graft, initial reducible ventral hernia repair, laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic gastric bypass, partial colectomy, rechanneling of artery, repair of bowel opening, and small-bowel resection.

The two populations showed no significant differences in a wide variety of demographic characteristics including age (average, about 54 years); sex (about 45% male); and presence of coronary artery disease, renal disease, peripheral vascular disease (PVD/PAD), and diabetes. Slight but significant differences were found only in the presence of hypertension (50.0% in the FAQ group vs. 48.4% in controls, respectively) and history of smoking (24.0% vs. 23.4%).

Especially important to the study, there was no significant difference in resident participation in patient care (72.7% vs. 73.0%) or the highest resident level in postgraduate year (2.6 years each).

"Although July might seem intuitively to be a precarious time to undergo an operation due to the influx of new interns and increased responsibilities of rising residents, our findings for the most part discount the presence of a ‘July Phenomenon’ in surgical patients," the authors stated.

Discrepancies between the previous ACS-NSQIP report and their findings were attributed to the much larger sample size in the current study (183 centers vs. 18).

They postulated that the lower extremity bypass graft FAQ group showed greater mortality than did the control group because the vascular subsets had a significantly greater modified Charlson comorbidity index, compared with the nonvascular subsets in the FAQ population (CCI, 3.72 vs. 1.56; P less than .001).

"New surgery interns may not be as adept at recognizing the needs of these patients who are often sicker. As a result, these patient populations may benefit from more senior residents and attending physician involvement as new interns learn how to manage patients with complex cardiovascular disease," they suggested.

A weakness of the study reported by the authors is the crude estimate of patient outcomes, which focuses only on morbidity and mortality and does not include data on duration of stay, medication errors, or cost-effectiveness – all of which could possibly be affected by new interns.

For example, they noted that new interns may be more likely to order more unnecessary laboratory tests, or they may fail to remove invasive devices or monitoring devices that are no longer needed, which may in turn lead to increased infections.

In addition, they also stated that interns may have more difficulties when confronted with rarer operations than the 10 most common procedures that were evaluated.

The researchers disclosed no conflicts that the journal deemed relevant to report.

"Don’t have surgery in July!" This is the folk wisdom regarding the purported "July Phenomenon" – the perception that it is more dangerous to have an operation in July than at any other time of year. July heralds the onslaught of new interns; July also means that current residents are given additional duties and responsibility. "Why risk an operation in a month when trainee inexperience must surely dilute the quality of patient care?" is the intuitive assumption.

A recent study reported in ‘Surgery’, however, showed that this concern is unfounded.

Multivariate analysis indicated that only 1 out of the 10 most common surgical procedures (lower extremity artery bypass grafting) showed a significant increase in mortality concurrent with the so-called July Phenomenon (odds ratio, 1.34; P = .034).

The researchers also found that there was no significant increase in serious adverse events (SAE) for any of the procedures (Surgery 2011;150:332-8).

The previous medical literature shows no consensus on the subject. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) suggested that greater rates of postsurgical problems were related to that time of year (Ann. Surg. 2007;246:456-62).

In contrast, studies in obstetrics and neurology showed that no July Phenomenon existed, as did surgical studies in specialties including trauma, pediatric neurosurgery, and cardiac surgery, according to Dr. Bryan A. Ehlert and colleagues at East Carolina University, Greenville, N.C.

To investigate the issue in a broader surgical context, Dr. Ehlert and his colleagues studied the ACS-NSQIP database records of 89,473 patients who had the 10 most common inpatient operative procedures in 2005-2007.

They compared 26,287 patients who had surgery in the July 1–Sept. 30 quarter (called the "first academic quarter," or FAQ) with a control population of 63,186 patients who had equivalent surgery during the rest of the year (Oct. 1–June 30).

They assessed the following 10 procedures: appendectomy, (lower extremity) artery bypass graft, initial reducible ventral hernia repair, laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic gastric bypass, partial colectomy, rechanneling of artery, repair of bowel opening, and small-bowel resection.

The two populations showed no significant differences in a wide variety of demographic characteristics including age (average, about 54 years); sex (about 45% male); and presence of coronary artery disease, renal disease, peripheral vascular disease (PVD/PAD), and diabetes. Slight but significant differences were found only in the presence of hypertension (50.0% in the FAQ group vs. 48.4% in controls, respectively) and history of smoking (24.0% vs. 23.4%).

Especially important to the study, there was no significant difference in resident participation in patient care (72.7% vs. 73.0%) or the highest resident level in postgraduate year (2.6 years each).

"Although July might seem intuitively to be a precarious time to undergo an operation due to the influx of new interns and increased responsibilities of rising residents, our findings for the most part discount the presence of a ‘July Phenomenon’ in surgical patients," the authors stated.

Discrepancies between the previous ACS-NSQIP report and their findings were attributed to the much larger sample size in the current study (183 centers vs. 18).

They postulated that the lower extremity bypass graft FAQ group showed greater mortality than did the control group because the vascular subsets had a significantly greater modified Charlson comorbidity index, compared with the nonvascular subsets in the FAQ population (CCI, 3.72 vs. 1.56; P less than .001).

"New surgery interns may not be as adept at recognizing the needs of these patients who are often sicker. As a result, these patient populations may benefit from more senior residents and attending physician involvement as new interns learn how to manage patients with complex cardiovascular disease," they suggested.

A weakness of the study reported by the authors is the crude estimate of patient outcomes, which focuses only on morbidity and mortality and does not include data on duration of stay, medication errors, or cost-effectiveness – all of which could possibly be affected by new interns.

For example, they noted that new interns may be more likely to order more unnecessary laboratory tests, or they may fail to remove invasive devices or monitoring devices that are no longer needed, which may in turn lead to increased infections.

In addition, they also stated that interns may have more difficulties when confronted with rarer operations than the 10 most common procedures that were evaluated.

The researchers disclosed no conflicts that the journal deemed relevant to report.