- Email: [email protected]
Evaluating the July Effect in Oral and Maxillofacial Surgery: Part I—Mandibular Fractures
CRANIOMAXILLOFACIAL TRAUMA
Evaluating the July Effect in Oral and Maxillofacial Surgery: Part I—Mandibular Fractures Hossein E. Jazayeri, BS,* Thomas Xu, MD,y Nima Khavanin, MD,z Amir H. Dorafshar, MBChB,x and Zachary S. Peacock, DMD, MDk Purpose:
The purpose of this study was to determine whether the timing of mandibular fracture repair within the academic year affects the complication rate using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.
Materials and Methods:
The ACS-NSQIP database was accessed and queried from 2008 to 2017 for all Current Procedural Terminology codes pertaining to open treatment of mandibular fractures. The cases were stratified into 2 groups based on academic quarter: the quarter 1 (Q1) group (July-September) and the remaining-quarters group. The inclusion criteria encompassed all Current Procedural Terminology codes in the ACS-NSQIP registry that defined mandibular fractures and age greater than 18 years. Demographic characteristics, as well as medical and surgical complications, were compared between the 2 cohorts. Descriptive statistics were calculated to characterize and compare patient cohorts, and Fisher exact test and c2 analyses were performed to compare complication rates between groups.
Results:
The Q1 group included 614 cases, and the remaining-quarters group included 1,454. The most common individual complications included wound dehiscence (1.6% overall; 2.1% in Q1 group vs 1.4% in remaining-quarters group, P = .22), combined superficial and deep-space infection (4.9% overall; 4.4% in Q1 group vs 3.3% in remaining-quarters group; P = .91 and P = .21, respectively), and reoperation (3.9% overall; 4.6% in Q1 group vs 3.6% in remaining-quarters group, P = .29). Medical complications including acute kidney injury, venous thromboembolism, urinary tract infection, and sepsis or septic shock were rare (<1%). Complication rates did not significantly differ between the third quarter and the remainder of the year on bivariate analysis.
Conclusions: Our results do not support the idea of a ‘‘July effect’’ regarding postoperative outcomes after mandibular fracture repair. Further studies are needed to elucidate this phenomenon within all procedures under the wide umbrella of the specialty. Ó 2019 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1.e1-1.e6, 2019
*DMD Candidate, University of Pennsylvania, Philadelphia, PA.
the statistical validity of the data analysis or the conclusions derived
yResident, Department of Surgery, Rush University Medical
by the authors.
Center, Chicago, IL.
Conflict of Interest Disclosures: None of the authors have any
zResident, Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD.
relevant financial relationship(s) with a commercial interest. Address correspondence and reprint requests to Dr Peacock:
xProfessor and Chief, Division of Plastic and Reconstructive
Department of Oral and Maxillofacial Surgery, Massachusetts Gen-
Surgery, Rush University Medical Center, Chicago, IL.
eral Hospital, 55 Fruit St, Warren 1201, Boston, MA 02114; e-mail:
kAssistant Professor, Department of Oral and Maxillofacial
[email protected]
Surgery, Massachusetts General Hospital and Harvard School of
Received June 5 2019
Dental Medicine, Boston, MA.
Accepted July 30 2019 Ó 2019 American Association of Oral and Maxillofacial Surgeons
The American College of Surgeons National Surgical Quality Improvement Program and the participating hospital are the source of the data herein; they have not verified and are not responsible for
0278-2391/19/30944-9 https://doi.org/10.1016/j.joms.2019.07.019
1.e1
1.e2 The decision of the American College of Surgeons (ACS) to implement the National Surgical Quality Improvement Program (NSQIP) came to fruition after public scrutiny of high rates of morbidity and mortality in Veterans Affairs hospitals nationwide.1 Quality of care was examined across multiple specialties in the Veterans Affairs hospitals by the systematic documentation of risk factors and risk-adjusted outcomes on preoperative and 30-day postoperative evaluations. In 2001, private-sector hospitals similarly took part in the NSQIP to track efficiency of care and surgical outcomes. To date, over 700 medical centers have participated in the program across 49 states.2 With the advent and subsequent evolution of the ACSNSQIP, a surge in publications reporting outcomes of the program has been seen across most surgical specialties.2-10 The NSQIP database is stratified by quarter of the calendar year, which has allowed academic surgeons to specifically examine the first academic quarter (Q1), which denotes the changeover in surgical trainees.11 Consequently, the association between a mass turnover of the physician workforce in teaching hospitals, including the arrival of new trainees nationwide, and an increased rate of patient morbidity and decline in hospital efficiency has been dubbed the ‘‘July phenomenon,’’ or ‘‘July effect.’’12 The underlying hypothesis of the nationally recognized issue that resident turnover in Q1 leads to increased error has been tested extensively. The influx of inexperienced interns was seen to be associated with a somewhat higher degree of patient complications in both domestic and foreign teaching hospitals.13 Not only was this brought to the attention of hospitals but it was also published by notable media outlets, so the public became increasingly cautious of visiting the hospital during the transition period.14 This negative public perception may be harmful to the learning experience and confidence of doctors in training, especially in Q1. To our knowledge, there has been no study in the oral and maxillofacial surgery (OMS) literature that has investigated the presence of a July effect. As such, the purpose of this study was to determine whether perioperative and postoperative complications increase during Q1 of the academic year in open treatment of patients with mandibular fractures. We hypothesized that there would be no significant association between Q1 and the complication rate. The specific aims of the study were 1) to query the ACS-NSQIP database using Current Procedural Terminology (CPT) codes pertaining to mandibular fractures and 2) to compare medical and surgical complications between the Q1 and remainingquarters groups.
JULY EFFECT: MANDIBULAR FRACTURES
Materials and Methods STUDY DESIGN
A retrospective cohort study was designed and implemented. The ACS-NSQIP database was accessed, and cases from 2008 to 2017 under all CPT codes pertaining to mandibular fractures, as classified by the American Association of Professional Coders (AAPC), were identified. The inclusion criteria were defined as any CPT code pertaining to open mandibular fracture repair and age greater than 18 years. STUDY VARIABLES
The primary predictor variable was the academic quarter, stratified into 2 cohorts: the Q1 cohort and the remaining-quarters cohort. The Q1 period was from July to September. The remaining-quarters cohort included the time in the academic year from October to June. The outcome variables were the following 18 clinically relevant medical and surgical outcomes categorized into 2 groups: 1) adverse events included wound dehiscence, superficial surgical-site infection, organ/space infection, and deep incisional infection and 2) serious adverse events were unplanned intubation, prolonged mechanical ventilation greater than 48 hours postoperatively, progressive renal insufficiency, deep vein thrombosis, acute renal failure, urinary tract infection, cardiovascular accident or stroke, myocardial infarction, bleeding requiring transfusions, sepsis, septic shock, reoperation, cardiac arrest, and death within 30 days. STATISTICAL ANALYSIS
Demographic data (age, gender, obesity status, and so on) were obtained and descriptive statistics were calculated for all patients undergoing operations that met the inclusion criteria. The Fisher exact test was performed to compare profiles between patients in the Q1 cohort and the remaining-quarters cohort. In addition, c2 analysis was conducted to compare complication rates between the groups. P < .05 was determined to be statistically significant.
Results In the ACS-NSQIP database between the years 2008 and 2017, a total of 614 mandibular fractures were reported that underwent open treatment in Q1 and 1,454 mandibular fractures were treated in the remaining quarters. Demographic data of patients treated for mandibular fractures are summarized in Table 1. On c2 testing, no statistically significant difference was found between the Q1 and remaining-quarters groups in terms of age (35.6 13.7 years vs 36.8 17.2 years, P = .29), gender (female, 15% vs 18%; P = .15), tobacco
1.e3
JAZAYERI ET AL
Table 1. PATIENT DEMOGRAPHIC CHARACTERISTICS
n (%) Characteristic Age Gender Male Female Diabetes Smoker Obese
Q1 (July-September) (n = 614)
Remaining Quarters (October-June) (n = 1,454)
P Value
576 (93.8)
1,354 (92.5)
.29 .15
519 (85) 94 (15) 37 (6.0) 314 (51) 93 (16.4)
1,193 (82) 261 (18) 58 (4.0) 717 (49) 205 (15.0)
.04 .45 .43
Abbreviation: Q1, first academic quarter. Jazayeri et al. July Effect: Mandibular Fractures. J Oral Maxillofac Surg 2019.
use (51% vs 49%, P = .45), or obesity (16.4% vs 15.0%, P = .43). Q1 patients had a significantly higher prevalence of diabetes (6.0% vs 4.0%, P = .04). The rate of any adverse event (10.42% vs 9.35%, P = .45) or serious adverse events (5.70% vs 4.68%, P = .33) was not statistically significantly different between Q1 and the other quarters (Table 2). Comparison of complication rates within operations between the Q1 and remaining-quarters groups did not show a statistically significant difference in the following adverse events: wound dehiscence (2.12% vs 1.38%, P = .22), superficial surgical-site infection (2.28% vs 2.20%, P = .91), organ/space infection (1.79% vs 1.10%, P = .21), deep incisional infection (2.12% vs 1.10%, P = .07), and pneumonia (1.14% vs 0.55%, P = .15). No difference was found in the following serious adverse events: unplanned intubation (0% vs 0.12%, P = .26), ventilator use greater than 48 hours (0.81% vs 0.48%, P = .36), progressive renal insufficiency (0% vs 0%, P = null), deep vein thrombosis or thrombophlebitis (0% vs 0.07%, P = .52), acute renal failure (0% vs 0%, P = null), urinary tract infection (0.16% vs 0.55%, P = .22), stroke (0.16% vs 0%, P = .12), myocardial infarction (0.33% vs 0.07%, P = .16), bleeding requiring transfusions (1.79% vs 1.65%, P = .82), sepsis (0% vs 0%, P = null), septic shock (0.33% vs 0.21%, P = .61), return to the operating room (4.56% vs 3.58%, P = .29), cardiac arrest (0.16% vs 0%, P = .12), and death (0.16% vs 0.07%, P = .53) (Table 2). Multivariate analysis showed that increasing age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.03 to 1.04; P < .0001) was an independent risk factor for the development of any adverse event (Table 3). It also showed that increasing age (OR, 1.05; 95% CI, 1.04 to 1.06; P < .0001) and obesity (OR, 1.77; 95% CI, 1.05 to 2.98; P = .033) were independent risk factors for the development of a serious adverse event (Table 4). After controlling for baseline covariates,
Q1 was not significantly associated with an adverse event (OR, 1.09; 95% CI, 0.78 to 1.53; P = .63) or serious adverse event (OR, 1.23; 95% CI, 0.78 to 1.93; P = .38) (Tables 3,4).
Discussion The idea of a July effect is particularly germane to the management of craniomaxillofacial trauma, as this period of transition coincides with increased rates of traumatic injury during the summer months.15-17 Mandibular trauma specifically reaches its peak incidence between July and September, with up to 40 to 50% of annual fractures presenting during Q1.18,19 To that end, we endeavored to use a national patient registry to compare patient outcomes after mandibular fracture repair during Q1 versus the remainder of the year. We hypothesized that the transition in personnel would not result in a significant difference in perioperative outcomes during the third quarter of the year—as considerable systemic measures are taken to ameliorate any potential for a July effect in clinical practice. This is the first study of its kind using the ACS-NSQIP database to explore the potential for a July effect in the management of mandibular trauma. Overall, we found that 30-day postoperative complications reported in the database were rare, without any noticeable increase during Q1. The most common individual complications included wound dehiscence (1.1%), infection (1.1% combined superficial and deep space), and 30-day reoperation (2.2%). Although these rates are lower than those in longitudinal studies presented within the literature,20-22 they are in line with those in other analyses focusing on immediate postoperative complication rates.23 Medical complications including acute kidney injury, venous thromboembolism, urinary tract infection, and sepsis or septic shock were exceedingly rare (<1%) (Table 2). Complication rates did not significantly differ between Q1 and the
1.e4
JULY EFFECT: MANDIBULAR FRACTURES
Table 2. COMPLICATION RATES
Complication Rate, %
Event Wound dehiscence Superficial surgical-site infection Organ/space infection Deep incisional infection Pneumonia Unplanned intubation Pulmonary embolism Ventilator > 48 h Progressive renal insufficiency DVT or thrombophlebitis Acute renal failure Urinary tract infection Stroke Myocardial infarction Bleeding requiring transfusions Sepsis Septic shock Return to OR Cardiac arrest Death Serious adverse event Any adverse event
Q1 (July-September) (n = 614)
Remaining Quarters (October-June)(n = 1,454)
P Value
2.12 2.28
1.38 2.20
.22 .91
1.79 2.12 1.14 0 0 0.81 0
1.10 1.10 0.55 0.12 0.23 0.48 0
.21 .07 .15 .26 .26 .36 —
0 0 0.16 0.16 0.33 1.79
0.07 0 0.55 0 0.07 1.65
.52 — .22 .12 .16 .82
0.65 0.33 4.56 0.16 0.16 5.7 10.42
0.28 0.21 3.58 0 0.07 4.68 9.35
.21 .61 .29 .12 .53 .33 .45
Abbreviations: DVT, deep vein thrombosis; OR, operating room; Q1, first academic quarter. Jazayeri et al. July Effect: Mandibular Fractures. J Oral Maxillofac Surg 2019.
remainder of the year on bivariate analysis. Therefore, our results do not support the idea of a July effect regarding 30-day postoperative outcomes after mandibular fracture repair. July marks the beginning of the new academic medical year and brings with it excitement and anticipation as clinicians at all training levels move on to the next postgraduate level. Newly minted interns, fellows, attendings, nurses, and physician assistants must adjust to their new roles and responsibilities. In recent years, a degradation of care has been hypothesized to occur in July.24-26 One wide-cited study reported a 10% increase in fatal medication errors during the month of July.24 Since then, however, several multicenter analyses across a range of medical and surgical subspecialties have brought those findings into question.10,27-32 Most of the popular media coverage on the topic has focused on the theoretical negative effective of resident and intern turnover on clinical decision making during the summer months.33 The reality, however, is that medical education is a balance between trainee
autonomy and learning and patient needs. Treatment planning and critical steps of a procedure are typically not performed by a novice surgeon. Important postoperative decisions regarding treatment protocols and hospital discharge are typically made in a team setting with attending surgeon oversight.34 Although trainee education may in some cases affect efficiency of care, our findings support the notion that at an aggregate level, patient outcomes do not suffer during this period when the learning curve is at its steepest. It is important to note that the structure of the education system for trainees managing craniomaxillofacial trauma also may insulate this cohort from complications resulting from inexperience. Whether it is in an OMS, plastic surgery, or otolaryngology training program, residents in each discipline will have undergone at least 1 year of general surgery training before being tasked with most of the operative responsibility in their postgraduate training. This is not unlike other surgical subspecialties including neurosurgery or cardiac surgery, in which the July effect also has not been observed.13 Several articles have
1.e5
JAZAYERI ET AL
Table 3. MULTIVARIATE REGRESSION FOR OCCURRENCE OF ANY ADVERSE EVENT
Table 4. MULTIVARIATE REGRESSION FOR OCCURRENCE OF SERIOUS ADVERSE EVENT
95% CI
Age Gender Diabetes Smoker Obese Quarter 1
95% CI
OR
Lower
Upper
P Value
1.034 0.981 1.305 1.278 1.050 1.087
1.025 0.655 0.731 0.925 0.684 0.775
1.044 1.468 2.328 1.765 1.612 1.525
<.0001 .925 .368 .137 .823 .628
Age Gender Diabetes Smoker Obese Quarter 1
OR
Lower
Upper
P Value
1.050 0.970 1.015 1.542 1.767 1.225
1.037 0.566 0.486 0.981 1.048 0.777
1.063 1.661 2.123 2.425 2.980 1.931
<.0001 .911 .968 .061 .033 .383
Abbreviations: CI, confidence interval; OR, odds ratio.
Abbreviations: CI, confidence interval; OR, odds ratio.
Jazayeri et al. July Effect: Mandibular Fractures. J Oral Maxillofac Surg 2019.
Jazayeri et al. July Effect: Mandibular Fractures. J Oral Maxillofac Surg 2019.
recently presented data specifically debunking the theory in the fields of otolaryngology9,35 and plastic surgery,10,27,28 with our study doing so in the field of OMS. This study is not without limitations. The ACSNSQIP registry provides high-quality, validated data36 on a multicenter, nationwide sample of patients. Nonetheless, not all centers that participate in the NSQIP are academic hospitals with training programs. Even among academic centers, it is impossible to determine the role of trainees or to account for various systems in place to prevent medical errors, including structured training programs, fail-safes within the electronic medical record, or direct oversight. It is important to emphasize, however, that the theoretical increase in complications during Q1 cannot solely be attributed to trainee education. New attendings and ancillary staff including nurses, technicians, and therapists also must adjust to new roles and responsibilities. As such, this study focused not specifically on resident involvement but rather on the time of the year and its effect on complication rates. In addition, patients with more multi–organ system trauma may be expected to have more serious adverse effects. Although we did compare pre-existing medical comorbidities between groups, we did not perform secondary analyses regarding systemic injuries. The use of the NSQIP database also precludes us from evaluating potential differences in outcomes after closed treatment, nonsurgical care, or postoperative complications that occur outside of the registry’s 30-day window. Longer-term complications pertinent to fracture management including nonunion, malunion, osteomyelitis, late reoperations, and removal of hardware are not included in the database. Other specific adverse outcomes unique to treatment of mandibular fractures, such as malocclusion, inferior alveolar nerve injury, or facial nerve injury, are too esoteric to be included in a national registry such as
the NSQIP registry. Moreover, the postgraduate-year variable for trainees was not included in the database after 2014, so there is no certainty that a trainee was present in the operating room during the operation; however, it is rare for a trainee to not be involved with a patient’s surgical care at an academic medical center. Finally, the NSQIP database does not specify the month of the operation but rather the quarter. Additional research addressing these limitations can build on our findings to ensure that high-quality patient care is preserved year-round. Perioperative complication rates after mandibular fracture repair were not significantly increased at the beginning of the academic year. This article adds to the growing body of literature against the idea of a July effect. Despite the turnover associated with new attendings, residents, and other medical personal, team dynamics and safety measures ensure that a high level of patient care is maintained through this transition period.
References 1. Bailey EA, Collier K, Kelz RR: Debunking the July phenomenon: Are we asking the right questions? JAMA Surg 151:224, 2016 2. Barry WA, Rosenthal GE: Is there a July phenomenon? The effect of July admission on intensive care mortality and length of stay in teaching hospitals. J Gen Intern Med 18:639, 2003 3. Wei EK, Sarff L, Spellberg B: Debunking the July effect myth [published online ahead of print September 8, 2016]. J Patient Saf. https://doi.org/10.1097/PTS.0000000000000308 4. Watkins AA, Bliss LA, Cameron DB, et al: Deconstructing the ‘ July effect’’ in operative outcomes: A national study. J Gastrointest Surg 20:1012, 2016 5. Riguzzi C, Hern HG, Vahidnia F, et al: The July effect: Is emergency department length of stay greater at the beginning of the hospital academic year? West J Emerg Med 15:88, 2014 6. Rao AJ, Bohl DD, Frank RM, et al: The ‘ July effect’’ in total shoulder arthroplasty. J Shoulder Elbow Surg 26:e59, 2017 7. Pierson NS, Kramer DR, Wen T, et al: Preventable complications in epilepsy admissions: The ‘ July effect’’ Epilepsy Res 137:101, 2017 8. Lin Y, Mayer RR, Verla T, et al: Is there a ‘ July effect’’ in pediatric neurosurgery? Childs Nerv Syst 33:1367, 2017
1.e6 9. Hennessey PT, Francis HW, Gourin CG: Is there a ‘ July effect’’ for head and neck cancer surgery? Laryngoscope 123:1889, 2013 10. Blough JT, Jordan SW, De Oliveira GS Jr, et al: Demystifying the ‘ July effect’’ in plastic surgery: A multi-institutional study. Aesthet Surg J 38:212, 2018 11. Bahl A, Hixson CC: July phenomenon impacts efficiency of emergency care. West J Emerg Med 20:157, 2019 12. Thiels CA, Hanson KT, Heller SF, et al: Assessment of patientreported experiences of hospital care and the July phenomenon. JAMA Surg 151:879, 2016 13. Weaver KJ, Neal D, Hoh DJ, et al: The ‘ July phenomenon’’ for neurosurgical mortality and complications in teaching hospitals: An analysis of more than 850,000 neurosurgical patients in the nationwide inpatient sample database, 1998 to 2008. Neurosurgery 71:562, 2012 14. Inaba K, Recinos G, Teixeira PG, et al: Complications and death at the start of the new academic year: Is there a July phenomenon? J Trauma 68:19, 2010 15. Rising WR, O’Daniel JA, Roberts CS: Correlating weather and trauma admissions at a level I trauma center. J Trauma 60: 1096, 2006 16. Friede KA, Osborne MC, Erickson DJ, et al: Predicting trauma admissions: The effect of weather, weekday, and other variables. Minn Med 92:47, 2009 17. Posnick JC, Wells M, Pron GE: Pediatric facial fractures: Evolving patterns of treatment. J Oral Maxillofac Surg 51:836, 1993 18. Atilgan S, Erol B, Yaman F, et al: Mandibular fractures: A comparative analysis between young and adult patients in the southeast region of Turkey. J Appl Oral Sci 18:17, 2010 19. Czerwinski M, Parker WL, Chehade A, Williams HB: Identification of mandibular fracture epidemiology in Canada: Enhancing injury prevention and patient evaluation. Can J Plast Surg 16:36, 2008 20. Stone N, Corneman A, Sandre AR, et al: Treatment delay impact on open reduction internal fixation of mandibular fractures: A systematic review. Plast Reconstr Surg Glob Open 6:e1829, 2018 21. Cohen SM, Rosett BE, Shifrin DA: An analysis of independent variables affecting surgical outcomes in patients undergoing repair of maxillofacial trauma: An American College of Surgeons National Surgical Quality Improvement Program study. J Craniofac Surg 28:596, 2017 22. Lakomkin N, Greenberg SE, Obremskey WT, Sethi MK: The risk of adverse events in orthopaedic trauma varies by anatomic region of surgery: An analysis of fifty thousand four hundred and twenty one patients. Int Orthop 39:2153, 2015
JULY EFFECT: MANDIBULAR FRACTURES 23. Zavlin D, Jubbal KT, Echo A, et al: Multi-institutional analysis of surgical management and outcomes of mandibular fracture repair in adults. Craniomaxillofac Trauma Reconstr 11:41, 2018 24. Phillips DP, Barker GE: A July spike in fatal medication errors: A possible effect of new medical residents. J Gen Intern Med 25: 774, 2010 25. Englesbe MJ, Pelletier SJ, Magee JC, et al: Seasonal variation in surgical outcomes as measured by the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP). Ann Surg 246:456, 2007 26. Ehlert BA, Nelson JT, Goettler CE, et al: Examining the myth of the ‘ July phenomenon’’ in surgical patients. Surgery 150:332, 2011 27. Rangel LK, Gonzalez JA, Kantar RS, et al: Evaluating the July phenomenon in plastic surgery: A National Surgical Quality Improvement Program analysis. Plast Reconstr Surg 141:759e, 2018 28. Wu WW, Medin C, Bucknor A, et al: Evaluating the impact of resident participation and the July effect on outcomes in autologous breast reconstruction. Ann Plast Surg 81:156, 2018 29. Ravi P, Trinh VQ, Sun M, et al: Is there any evidence of a ‘ July effect’’ in patients undergoing major cancer surgery? Can J Surg 57:82, 2014 30. Young JQ, Ranji SR, Wachter RM, et al: ‘ July effect’’: Impact of the academic year-end changeover on patient outcomes: A systematic review. Ann Intern Med 155:309, 2011 31. Pang JH, Karipineni F, Panchal H, et al: Seasonal variations in outcomes after kidney transplantation: UNOS review of 336,330 transplants. J Surg Educ 70:357, 2013 32. Highstead RG, Johnson LS, Street JH III, et al: July—As good a time as any to be injured. J Trauma 67:1087, 2009 33. Crane K: Headed to the hospital? Beware the ‘July effect’. U.S. News & World Report. July 21, 2014. Available at: http:// health.usnews.com/health-news/patient-advice/articles/2014/ 07/21/headed-to-the-hospital-beware-the-julyeffect. Accessed March 16, 2109 34. Perry RP: It’s ok to get sick in July. JAMA 263:994, 1990 35. Bashjawish B, Patel S, Kilic S, et al: Examining the ‘ July effect’’ on patients undergoing pituitary surgery. Int Forum Allergy Rhinol 8:1157, 2018 36. Khavanin N, Gutowski KA, Hume KM, et al: The use of patient registries in breast surgery: A comparison of the tracking operations and outcomes for plastic surgeons and national surgical quality improvement program data sets. Ann Plast Surg 74: 157, 2015
Evaluating the July Effect in Oral and Maxillofacial Surgery: Part I—Mandibular Fractures Hossein E. Jazayeri, BS,* Thomas Xu, MD,y Nima Khavanin, MD,z Amir H. Dorafshar, MBChB,x and Zachary S. Peacock, DMD, MDk Purpose:
The purpose of this study was to determine whether the timing of mandibular fracture repair within the academic year affects the complication rate using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.
Materials and Methods:
The ACS-NSQIP database was accessed and queried from 2008 to 2017 for all Current Procedural Terminology codes pertaining to open treatment of mandibular fractures. The cases were stratified into 2 groups based on academic quarter: the quarter 1 (Q1) group (July-September) and the remaining-quarters group. The inclusion criteria encompassed all Current Procedural Terminology codes in the ACS-NSQIP registry that defined mandibular fractures and age greater than 18 years. Demographic characteristics, as well as medical and surgical complications, were compared between the 2 cohorts. Descriptive statistics were calculated to characterize and compare patient cohorts, and Fisher exact test and c2 analyses were performed to compare complication rates between groups.
Results:
The Q1 group included 614 cases, and the remaining-quarters group included 1,454. The most common individual complications included wound dehiscence (1.6% overall; 2.1% in Q1 group vs 1.4% in remaining-quarters group, P = .22), combined superficial and deep-space infection (4.9% overall; 4.4% in Q1 group vs 3.3% in remaining-quarters group; P = .91 and P = .21, respectively), and reoperation (3.9% overall; 4.6% in Q1 group vs 3.6% in remaining-quarters group, P = .29). Medical complications including acute kidney injury, venous thromboembolism, urinary tract infection, and sepsis or septic shock were rare (<1%). Complication rates did not significantly differ between the third quarter and the remainder of the year on bivariate analysis.
Conclusions: Our results do not support the idea of a ‘‘July effect’’ regarding postoperative outcomes after mandibular fracture repair. Further studies are needed to elucidate this phenomenon within all procedures under the wide umbrella of the specialty. Ó 2019 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1.e1-1.e6, 2019
*DMD Candidate, University of Pennsylvania, Philadelphia, PA.
the statistical validity of the data analysis or the conclusions derived
yResident, Department of Surgery, Rush University Medical
by the authors.
Center, Chicago, IL.
Conflict of Interest Disclosures: None of the authors have any
zResident, Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD.
relevant financial relationship(s) with a commercial interest. Address correspondence and reprint requests to Dr Peacock:
xProfessor and Chief, Division of Plastic and Reconstructive
Department of Oral and Maxillofacial Surgery, Massachusetts Gen-
Surgery, Rush University Medical Center, Chicago, IL.
eral Hospital, 55 Fruit St, Warren 1201, Boston, MA 02114; e-mail:
kAssistant Professor, Department of Oral and Maxillofacial
[email protected]
Surgery, Massachusetts General Hospital and Harvard School of
Received June 5 2019
Dental Medicine, Boston, MA.
Accepted July 30 2019 Ó 2019 American Association of Oral and Maxillofacial Surgeons
The American College of Surgeons National Surgical Quality Improvement Program and the participating hospital are the source of the data herein; they have not verified and are not responsible for
0278-2391/19/30944-9 https://doi.org/10.1016/j.joms.2019.07.019
1.e1
1.e2 The decision of the American College of Surgeons (ACS) to implement the National Surgical Quality Improvement Program (NSQIP) came to fruition after public scrutiny of high rates of morbidity and mortality in Veterans Affairs hospitals nationwide.1 Quality of care was examined across multiple specialties in the Veterans Affairs hospitals by the systematic documentation of risk factors and risk-adjusted outcomes on preoperative and 30-day postoperative evaluations. In 2001, private-sector hospitals similarly took part in the NSQIP to track efficiency of care and surgical outcomes. To date, over 700 medical centers have participated in the program across 49 states.2 With the advent and subsequent evolution of the ACSNSQIP, a surge in publications reporting outcomes of the program has been seen across most surgical specialties.2-10 The NSQIP database is stratified by quarter of the calendar year, which has allowed academic surgeons to specifically examine the first academic quarter (Q1), which denotes the changeover in surgical trainees.11 Consequently, the association between a mass turnover of the physician workforce in teaching hospitals, including the arrival of new trainees nationwide, and an increased rate of patient morbidity and decline in hospital efficiency has been dubbed the ‘‘July phenomenon,’’ or ‘‘July effect.’’12 The underlying hypothesis of the nationally recognized issue that resident turnover in Q1 leads to increased error has been tested extensively. The influx of inexperienced interns was seen to be associated with a somewhat higher degree of patient complications in both domestic and foreign teaching hospitals.13 Not only was this brought to the attention of hospitals but it was also published by notable media outlets, so the public became increasingly cautious of visiting the hospital during the transition period.14 This negative public perception may be harmful to the learning experience and confidence of doctors in training, especially in Q1. To our knowledge, there has been no study in the oral and maxillofacial surgery (OMS) literature that has investigated the presence of a July effect. As such, the purpose of this study was to determine whether perioperative and postoperative complications increase during Q1 of the academic year in open treatment of patients with mandibular fractures. We hypothesized that there would be no significant association between Q1 and the complication rate. The specific aims of the study were 1) to query the ACS-NSQIP database using Current Procedural Terminology (CPT) codes pertaining to mandibular fractures and 2) to compare medical and surgical complications between the Q1 and remainingquarters groups.
JULY EFFECT: MANDIBULAR FRACTURES
Materials and Methods STUDY DESIGN
A retrospective cohort study was designed and implemented. The ACS-NSQIP database was accessed, and cases from 2008 to 2017 under all CPT codes pertaining to mandibular fractures, as classified by the American Association of Professional Coders (AAPC), were identified. The inclusion criteria were defined as any CPT code pertaining to open mandibular fracture repair and age greater than 18 years. STUDY VARIABLES
The primary predictor variable was the academic quarter, stratified into 2 cohorts: the Q1 cohort and the remaining-quarters cohort. The Q1 period was from July to September. The remaining-quarters cohort included the time in the academic year from October to June. The outcome variables were the following 18 clinically relevant medical and surgical outcomes categorized into 2 groups: 1) adverse events included wound dehiscence, superficial surgical-site infection, organ/space infection, and deep incisional infection and 2) serious adverse events were unplanned intubation, prolonged mechanical ventilation greater than 48 hours postoperatively, progressive renal insufficiency, deep vein thrombosis, acute renal failure, urinary tract infection, cardiovascular accident or stroke, myocardial infarction, bleeding requiring transfusions, sepsis, septic shock, reoperation, cardiac arrest, and death within 30 days. STATISTICAL ANALYSIS
Demographic data (age, gender, obesity status, and so on) were obtained and descriptive statistics were calculated for all patients undergoing operations that met the inclusion criteria. The Fisher exact test was performed to compare profiles between patients in the Q1 cohort and the remaining-quarters cohort. In addition, c2 analysis was conducted to compare complication rates between the groups. P < .05 was determined to be statistically significant.
Results In the ACS-NSQIP database between the years 2008 and 2017, a total of 614 mandibular fractures were reported that underwent open treatment in Q1 and 1,454 mandibular fractures were treated in the remaining quarters. Demographic data of patients treated for mandibular fractures are summarized in Table 1. On c2 testing, no statistically significant difference was found between the Q1 and remaining-quarters groups in terms of age (35.6 13.7 years vs 36.8 17.2 years, P = .29), gender (female, 15% vs 18%; P = .15), tobacco
1.e3
JAZAYERI ET AL
Table 1. PATIENT DEMOGRAPHIC CHARACTERISTICS
n (%) Characteristic Age Gender Male Female Diabetes Smoker Obese
Q1 (July-September) (n = 614)
Remaining Quarters (October-June) (n = 1,454)
P Value
576 (93.8)
1,354 (92.5)
.29 .15
519 (85) 94 (15) 37 (6.0) 314 (51) 93 (16.4)
1,193 (82) 261 (18) 58 (4.0) 717 (49) 205 (15.0)
.04 .45 .43
Abbreviation: Q1, first academic quarter. Jazayeri et al. July Effect: Mandibular Fractures. J Oral Maxillofac Surg 2019.
use (51% vs 49%, P = .45), or obesity (16.4% vs 15.0%, P = .43). Q1 patients had a significantly higher prevalence of diabetes (6.0% vs 4.0%, P = .04). The rate of any adverse event (10.42% vs 9.35%, P = .45) or serious adverse events (5.70% vs 4.68%, P = .33) was not statistically significantly different between Q1 and the other quarters (Table 2). Comparison of complication rates within operations between the Q1 and remaining-quarters groups did not show a statistically significant difference in the following adverse events: wound dehiscence (2.12% vs 1.38%, P = .22), superficial surgical-site infection (2.28% vs 2.20%, P = .91), organ/space infection (1.79% vs 1.10%, P = .21), deep incisional infection (2.12% vs 1.10%, P = .07), and pneumonia (1.14% vs 0.55%, P = .15). No difference was found in the following serious adverse events: unplanned intubation (0% vs 0.12%, P = .26), ventilator use greater than 48 hours (0.81% vs 0.48%, P = .36), progressive renal insufficiency (0% vs 0%, P = null), deep vein thrombosis or thrombophlebitis (0% vs 0.07%, P = .52), acute renal failure (0% vs 0%, P = null), urinary tract infection (0.16% vs 0.55%, P = .22), stroke (0.16% vs 0%, P = .12), myocardial infarction (0.33% vs 0.07%, P = .16), bleeding requiring transfusions (1.79% vs 1.65%, P = .82), sepsis (0% vs 0%, P = null), septic shock (0.33% vs 0.21%, P = .61), return to the operating room (4.56% vs 3.58%, P = .29), cardiac arrest (0.16% vs 0%, P = .12), and death (0.16% vs 0.07%, P = .53) (Table 2). Multivariate analysis showed that increasing age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.03 to 1.04; P < .0001) was an independent risk factor for the development of any adverse event (Table 3). It also showed that increasing age (OR, 1.05; 95% CI, 1.04 to 1.06; P < .0001) and obesity (OR, 1.77; 95% CI, 1.05 to 2.98; P = .033) were independent risk factors for the development of a serious adverse event (Table 4). After controlling for baseline covariates,
Q1 was not significantly associated with an adverse event (OR, 1.09; 95% CI, 0.78 to 1.53; P = .63) or serious adverse event (OR, 1.23; 95% CI, 0.78 to 1.93; P = .38) (Tables 3,4).
Discussion The idea of a July effect is particularly germane to the management of craniomaxillofacial trauma, as this period of transition coincides with increased rates of traumatic injury during the summer months.15-17 Mandibular trauma specifically reaches its peak incidence between July and September, with up to 40 to 50% of annual fractures presenting during Q1.18,19 To that end, we endeavored to use a national patient registry to compare patient outcomes after mandibular fracture repair during Q1 versus the remainder of the year. We hypothesized that the transition in personnel would not result in a significant difference in perioperative outcomes during the third quarter of the year—as considerable systemic measures are taken to ameliorate any potential for a July effect in clinical practice. This is the first study of its kind using the ACS-NSQIP database to explore the potential for a July effect in the management of mandibular trauma. Overall, we found that 30-day postoperative complications reported in the database were rare, without any noticeable increase during Q1. The most common individual complications included wound dehiscence (1.1%), infection (1.1% combined superficial and deep space), and 30-day reoperation (2.2%). Although these rates are lower than those in longitudinal studies presented within the literature,20-22 they are in line with those in other analyses focusing on immediate postoperative complication rates.23 Medical complications including acute kidney injury, venous thromboembolism, urinary tract infection, and sepsis or septic shock were exceedingly rare (<1%) (Table 2). Complication rates did not significantly differ between Q1 and the
1.e4
JULY EFFECT: MANDIBULAR FRACTURES
Table 2. COMPLICATION RATES
Complication Rate, %
Event Wound dehiscence Superficial surgical-site infection Organ/space infection Deep incisional infection Pneumonia Unplanned intubation Pulmonary embolism Ventilator > 48 h Progressive renal insufficiency DVT or thrombophlebitis Acute renal failure Urinary tract infection Stroke Myocardial infarction Bleeding requiring transfusions Sepsis Septic shock Return to OR Cardiac arrest Death Serious adverse event Any adverse event
Q1 (July-September) (n = 614)
Remaining Quarters (October-June)(n = 1,454)
P Value
2.12 2.28
1.38 2.20
.22 .91
1.79 2.12 1.14 0 0 0.81 0
1.10 1.10 0.55 0.12 0.23 0.48 0
.21 .07 .15 .26 .26 .36 —
0 0 0.16 0.16 0.33 1.79
0.07 0 0.55 0 0.07 1.65
.52 — .22 .12 .16 .82
0.65 0.33 4.56 0.16 0.16 5.7 10.42
0.28 0.21 3.58 0 0.07 4.68 9.35
.21 .61 .29 .12 .53 .33 .45
Abbreviations: DVT, deep vein thrombosis; OR, operating room; Q1, first academic quarter. Jazayeri et al. July Effect: Mandibular Fractures. J Oral Maxillofac Surg 2019.
remainder of the year on bivariate analysis. Therefore, our results do not support the idea of a July effect regarding 30-day postoperative outcomes after mandibular fracture repair. July marks the beginning of the new academic medical year and brings with it excitement and anticipation as clinicians at all training levels move on to the next postgraduate level. Newly minted interns, fellows, attendings, nurses, and physician assistants must adjust to their new roles and responsibilities. In recent years, a degradation of care has been hypothesized to occur in July.24-26 One wide-cited study reported a 10% increase in fatal medication errors during the month of July.24 Since then, however, several multicenter analyses across a range of medical and surgical subspecialties have brought those findings into question.10,27-32 Most of the popular media coverage on the topic has focused on the theoretical negative effective of resident and intern turnover on clinical decision making during the summer months.33 The reality, however, is that medical education is a balance between trainee
autonomy and learning and patient needs. Treatment planning and critical steps of a procedure are typically not performed by a novice surgeon. Important postoperative decisions regarding treatment protocols and hospital discharge are typically made in a team setting with attending surgeon oversight.34 Although trainee education may in some cases affect efficiency of care, our findings support the notion that at an aggregate level, patient outcomes do not suffer during this period when the learning curve is at its steepest. It is important to note that the structure of the education system for trainees managing craniomaxillofacial trauma also may insulate this cohort from complications resulting from inexperience. Whether it is in an OMS, plastic surgery, or otolaryngology training program, residents in each discipline will have undergone at least 1 year of general surgery training before being tasked with most of the operative responsibility in their postgraduate training. This is not unlike other surgical subspecialties including neurosurgery or cardiac surgery, in which the July effect also has not been observed.13 Several articles have
1.e5
JAZAYERI ET AL
Table 3. MULTIVARIATE REGRESSION FOR OCCURRENCE OF ANY ADVERSE EVENT
Table 4. MULTIVARIATE REGRESSION FOR OCCURRENCE OF SERIOUS ADVERSE EVENT
95% CI
Age Gender Diabetes Smoker Obese Quarter 1
95% CI
OR
Lower
Upper
P Value
1.034 0.981 1.305 1.278 1.050 1.087
1.025 0.655 0.731 0.925 0.684 0.775
1.044 1.468 2.328 1.765 1.612 1.525
<.0001 .925 .368 .137 .823 .628
Age Gender Diabetes Smoker Obese Quarter 1
OR
Lower
Upper
P Value
1.050 0.970 1.015 1.542 1.767 1.225
1.037 0.566 0.486 0.981 1.048 0.777
1.063 1.661 2.123 2.425 2.980 1.931
<.0001 .911 .968 .061 .033 .383
Abbreviations: CI, confidence interval; OR, odds ratio.
Abbreviations: CI, confidence interval; OR, odds ratio.
Jazayeri et al. July Effect: Mandibular Fractures. J Oral Maxillofac Surg 2019.
Jazayeri et al. July Effect: Mandibular Fractures. J Oral Maxillofac Surg 2019.
recently presented data specifically debunking the theory in the fields of otolaryngology9,35 and plastic surgery,10,27,28 with our study doing so in the field of OMS. This study is not without limitations. The ACSNSQIP registry provides high-quality, validated data36 on a multicenter, nationwide sample of patients. Nonetheless, not all centers that participate in the NSQIP are academic hospitals with training programs. Even among academic centers, it is impossible to determine the role of trainees or to account for various systems in place to prevent medical errors, including structured training programs, fail-safes within the electronic medical record, or direct oversight. It is important to emphasize, however, that the theoretical increase in complications during Q1 cannot solely be attributed to trainee education. New attendings and ancillary staff including nurses, technicians, and therapists also must adjust to new roles and responsibilities. As such, this study focused not specifically on resident involvement but rather on the time of the year and its effect on complication rates. In addition, patients with more multi–organ system trauma may be expected to have more serious adverse effects. Although we did compare pre-existing medical comorbidities between groups, we did not perform secondary analyses regarding systemic injuries. The use of the NSQIP database also precludes us from evaluating potential differences in outcomes after closed treatment, nonsurgical care, or postoperative complications that occur outside of the registry’s 30-day window. Longer-term complications pertinent to fracture management including nonunion, malunion, osteomyelitis, late reoperations, and removal of hardware are not included in the database. Other specific adverse outcomes unique to treatment of mandibular fractures, such as malocclusion, inferior alveolar nerve injury, or facial nerve injury, are too esoteric to be included in a national registry such as
the NSQIP registry. Moreover, the postgraduate-year variable for trainees was not included in the database after 2014, so there is no certainty that a trainee was present in the operating room during the operation; however, it is rare for a trainee to not be involved with a patient’s surgical care at an academic medical center. Finally, the NSQIP database does not specify the month of the operation but rather the quarter. Additional research addressing these limitations can build on our findings to ensure that high-quality patient care is preserved year-round. Perioperative complication rates after mandibular fracture repair were not significantly increased at the beginning of the academic year. This article adds to the growing body of literature against the idea of a July effect. Despite the turnover associated with new attendings, residents, and other medical personal, team dynamics and safety measures ensure that a high level of patient care is maintained through this transition period.
References 1. Bailey EA, Collier K, Kelz RR: Debunking the July phenomenon: Are we asking the right questions? JAMA Surg 151:224, 2016 2. Barry WA, Rosenthal GE: Is there a July phenomenon? The effect of July admission on intensive care mortality and length of stay in teaching hospitals. J Gen Intern Med 18:639, 2003 3. Wei EK, Sarff L, Spellberg B: Debunking the July effect myth [published online ahead of print September 8, 2016]. J Patient Saf. https://doi.org/10.1097/PTS.0000000000000308 4. Watkins AA, Bliss LA, Cameron DB, et al: Deconstructing the ‘ July effect’’ in operative outcomes: A national study. J Gastrointest Surg 20:1012, 2016 5. Riguzzi C, Hern HG, Vahidnia F, et al: The July effect: Is emergency department length of stay greater at the beginning of the hospital academic year? West J Emerg Med 15:88, 2014 6. Rao AJ, Bohl DD, Frank RM, et al: The ‘ July effect’’ in total shoulder arthroplasty. J Shoulder Elbow Surg 26:e59, 2017 7. Pierson NS, Kramer DR, Wen T, et al: Preventable complications in epilepsy admissions: The ‘ July effect’’ Epilepsy Res 137:101, 2017 8. Lin Y, Mayer RR, Verla T, et al: Is there a ‘ July effect’’ in pediatric neurosurgery? Childs Nerv Syst 33:1367, 2017
1.e6 9. Hennessey PT, Francis HW, Gourin CG: Is there a ‘ July effect’’ for head and neck cancer surgery? Laryngoscope 123:1889, 2013 10. Blough JT, Jordan SW, De Oliveira GS Jr, et al: Demystifying the ‘ July effect’’ in plastic surgery: A multi-institutional study. Aesthet Surg J 38:212, 2018 11. Bahl A, Hixson CC: July phenomenon impacts efficiency of emergency care. West J Emerg Med 20:157, 2019 12. Thiels CA, Hanson KT, Heller SF, et al: Assessment of patientreported experiences of hospital care and the July phenomenon. JAMA Surg 151:879, 2016 13. Weaver KJ, Neal D, Hoh DJ, et al: The ‘ July phenomenon’’ for neurosurgical mortality and complications in teaching hospitals: An analysis of more than 850,000 neurosurgical patients in the nationwide inpatient sample database, 1998 to 2008. Neurosurgery 71:562, 2012 14. Inaba K, Recinos G, Teixeira PG, et al: Complications and death at the start of the new academic year: Is there a July phenomenon? J Trauma 68:19, 2010 15. Rising WR, O’Daniel JA, Roberts CS: Correlating weather and trauma admissions at a level I trauma center. J Trauma 60: 1096, 2006 16. Friede KA, Osborne MC, Erickson DJ, et al: Predicting trauma admissions: The effect of weather, weekday, and other variables. Minn Med 92:47, 2009 17. Posnick JC, Wells M, Pron GE: Pediatric facial fractures: Evolving patterns of treatment. J Oral Maxillofac Surg 51:836, 1993 18. Atilgan S, Erol B, Yaman F, et al: Mandibular fractures: A comparative analysis between young and adult patients in the southeast region of Turkey. J Appl Oral Sci 18:17, 2010 19. Czerwinski M, Parker WL, Chehade A, Williams HB: Identification of mandibular fracture epidemiology in Canada: Enhancing injury prevention and patient evaluation. Can J Plast Surg 16:36, 2008 20. Stone N, Corneman A, Sandre AR, et al: Treatment delay impact on open reduction internal fixation of mandibular fractures: A systematic review. Plast Reconstr Surg Glob Open 6:e1829, 2018 21. Cohen SM, Rosett BE, Shifrin DA: An analysis of independent variables affecting surgical outcomes in patients undergoing repair of maxillofacial trauma: An American College of Surgeons National Surgical Quality Improvement Program study. J Craniofac Surg 28:596, 2017 22. Lakomkin N, Greenberg SE, Obremskey WT, Sethi MK: The risk of adverse events in orthopaedic trauma varies by anatomic region of surgery: An analysis of fifty thousand four hundred and twenty one patients. Int Orthop 39:2153, 2015
JULY EFFECT: MANDIBULAR FRACTURES 23. Zavlin D, Jubbal KT, Echo A, et al: Multi-institutional analysis of surgical management and outcomes of mandibular fracture repair in adults. Craniomaxillofac Trauma Reconstr 11:41, 2018 24. Phillips DP, Barker GE: A July spike in fatal medication errors: A possible effect of new medical residents. J Gen Intern Med 25: 774, 2010 25. Englesbe MJ, Pelletier SJ, Magee JC, et al: Seasonal variation in surgical outcomes as measured by the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP). Ann Surg 246:456, 2007 26. Ehlert BA, Nelson JT, Goettler CE, et al: Examining the myth of the ‘ July phenomenon’’ in surgical patients. Surgery 150:332, 2011 27. Rangel LK, Gonzalez JA, Kantar RS, et al: Evaluating the July phenomenon in plastic surgery: A National Surgical Quality Improvement Program analysis. Plast Reconstr Surg 141:759e, 2018 28. Wu WW, Medin C, Bucknor A, et al: Evaluating the impact of resident participation and the July effect on outcomes in autologous breast reconstruction. Ann Plast Surg 81:156, 2018 29. Ravi P, Trinh VQ, Sun M, et al: Is there any evidence of a ‘ July effect’’ in patients undergoing major cancer surgery? Can J Surg 57:82, 2014 30. Young JQ, Ranji SR, Wachter RM, et al: ‘ July effect’’: Impact of the academic year-end changeover on patient outcomes: A systematic review. Ann Intern Med 155:309, 2011 31. Pang JH, Karipineni F, Panchal H, et al: Seasonal variations in outcomes after kidney transplantation: UNOS review of 336,330 transplants. J Surg Educ 70:357, 2013 32. Highstead RG, Johnson LS, Street JH III, et al: July—As good a time as any to be injured. J Trauma 67:1087, 2009 33. Crane K: Headed to the hospital? Beware the ‘July effect’. U.S. News & World Report. July 21, 2014. Available at: http:// health.usnews.com/health-news/patient-advice/articles/2014/ 07/21/headed-to-the-hospital-beware-the-julyeffect. Accessed March 16, 2109 34. Perry RP: It’s ok to get sick in July. JAMA 263:994, 1990 35. Bashjawish B, Patel S, Kilic S, et al: Examining the ‘ July effect’’ on patients undergoing pituitary surgery. Int Forum Allergy Rhinol 8:1157, 2018 36. Khavanin N, Gutowski KA, Hume KM, et al: The use of patient registries in breast surgery: A comparison of the tracking operations and outcomes for plastic surgeons and national surgical quality improvement program data sets. Ann Plast Surg 74: 157, 2015