The “July Effect” in Primary Total Hip and Knee Arthroplasty: Analysis of 21,434 Cases From the ACS-NSQIP Database

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Abstract

The “July effect” is the hypothetical increase in morbidity thought to be associated with the training of new residents during the first portion of the academic year. We evaluated for the presence of the July effect in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database among 21,434 patients who underwent primary total hip or knee arthroplasty. There was no association of an interaction term for academic quarter and resident involvement with “serious adverse events” (P = 0.656) or “any adverse events” (P = 0.578). As a result, this study could not demonstrate a July effect. Patients can be reassured that undergoing total joint arthroplasty during the first part of the academic year is without increased risk of adverse events related to the training of residents.

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Materials and Methods

We conducted a retrospective cohort study. To do so, we accessed the ACS-NSQIP database, which is available to our institution as a data-contributing member. The ACS-NSQIP is a prospective, multi-institutional outcomes program, the details of which are available elsewhere 13., 14.. Briefly, the ACS-NSQIP collects data on 135 variables, including preoperative comorbidities, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes for patients undergoing surgical

Results

A total of 21,434 cases met inclusion criteria and constitute the study population. Of these, 32.3% were total hip arthroplasty procedures, 67.7% were total knee arthroplasty procedures, 27.5% occurred during the first academic quarter, and 19.9% had resident involvement.

Rates of resident involvement in cases varied by procedure type, modified CCI, and academic quarter, but not by ASA score (Table 1). Specifically, cases of total knee arthroplasty were less likely to have residents involved

Discussion

The “July effect” is the hypothetical increase in morbidity thought to be associated with the influx of new (or newly promoted) residents during the first portion of the academic year. Studies evaluating for the presence and magnitude of the July effect within both medicine and surgery have been conflicted in their results 4., 5., 6., 7., 8., 9., 10., 11., 12.. This study evaluated for the presence and magnitude of the July effect within total hip and knee arthroplasty using the ACS-NSQIP, a

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    Citation Excerpt :

    The July effect is the theorized disruption of the health-care system with an associated increase in medical errors, adverse events, or complications due to an influx of clinically inexperienced residents, fellows, nurses, and physician assistants during the summer months [22]. The July effect on TJA outcomes is questionable, as prior database studies reported no evidence of its existence [7,9]. A similar “August effect” has been hypothesized, related to when adult reconstruction fellows begin their fellowship training; however, although one study demonstrated an August effect on clinical and pain outcomes but not TKA survivorship or complications, most studies have found little evidence of an August effect in arthroplasty [23,24].

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The Conflict of Interest statement associated with this article can be found at http://dx.doi.org/10.1016/j.arth.2014.02.008.

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