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Cue the Fireworks: Cardiac Surgery in July Might Not Be a Killer

SAN DIEGO — Summertime, and the surviving is easy — at least in thoracic surgery, as a study found no evidence of the infamous “July effect” of newly minted medical trainees on hospital outcomes.

No variations were seen in the National Inpatient Sample for in-hospital mortality between the months or academic quarters when procedures were performed, even after adjusting for various patient-level and hospital-level factors, Rohan Shah, MPH, a medical student at Baylor College of Medicine, and colleagues reported here at the Society of Thoracic Surgeons meeting.

However, the researchers did find that teaching hospitals had lower mortality than non-teaching hospitals in surgical aortic valve replacements, and mitral valve repair or replacements in both the first academic quarter and the fourth academic quarter.

“We found that the July effect does not exist for major cardiac surgery procedures, namely coronary artery bypass grafting, aortic and mitral valve surgery, and ascending aortic replacement,” said Shah in an interview. “Differences in mortality, in-hospital complications, costs, and length of stay were not clinically meaningful between patients admitted in the first academic quartile [including July] and those admitted in the fourth academic quartile.”

The “July effect” of poor inpatient outcomes at teaching hospitals in early summer when fresh medical trainees arrive on the job was supported by a 2013 report in Circulation, which noted that “most large and high-quality studies find a relatively small but statistically significant increase in mortality at the start of the residency year.”

That report found U.S. outcomes for acute heart attack patients were worse only among high-risk patients. They had a higher adjusted mortality in teaching hospitals in July compared to May.

For the new retrospective study, researchers used the National Inpatient Sample to track the various cardiac outcomes from 2012-2014 at both teaching and non-teaching hospitals. There were 301,105 coronary artery bypass grafting procedures, 111,260 surgical aortic valve replacements, 54,985 mitral valve repair or replacement procedures, and 2,655 thoracic aortic aneurysm procedures.

The study findings are positive and should spur discussion about more trainee autonomy, said study co-author Sameer Hirji, MD, a surgery resident at Brigham and Women’s Hospital. “There’s a perception that the July effect is detrimental, so it limits resident opportunities in certain institutions,” he told MedPage Today. “Patients also tend to be concerned about their outcomes in July, and this emphasizes the fact that it doesn’t matter.”

Anupam B. Jena, MD, PhD, of Harvard Medical School and lead author of the 2013 Circulation study called the new findings unsurprising.

“My sense would be that cardiac surgery is highly supervised and that performance in the operating room is driven by attending physicians and cardio-thoracic fellows,” he said. “The latter group would be relatively inexperienced but the OR is a highly controlled setting where supervision may be expected to be greatest.”

By contrast, Jena said, “patients who are admitted with heart attacks to a teaching hospital may routinely be first seen by junior residents with little to moderate supervision.”

In the big picture, Jena said, “the findings should be reassuring to thoracic surgeons who provide care in teaching hospitals at the start of the academic year.”

No study funding was reported.

The authors reported no relevant disclosures.

Hirji, Shah, and Jena reported no relevant disclosures.