Impact of July resident turnover on inpatient outcomes in patients with congestive heart failure and concomitant sepsis: Analysis of the national inpatient sample

Abstract

The notion of a “July effect,” suggesting that the influx of new residents in teaching hospitals every July (JU) may adversely affect patient care and outcomes, remains debatable. This study evaluated the impact of resident turnover in JU on patients admitted for congestive heart failure (CHF) and concomitant sepsis. This retrospective cohort study utilized data from the 2016 to 2020 National Inpatient Sample. Patients with CHF and concomitant sepsis hospitalized at teaching hospitals, as determined by International Classification of Diseases, 10^th Revision (ICD-10) codes, were included. Univariate and multivariate logistic regression analyses were performed to estimate in-hospital mortality and secondary outcomes after adjustment for confounders, including cardiac arrest (CA), cardiogenic shock, non-ST segment elevation myocardial infarction, respiratory failure (RF), use of cardiac and respiratory devices, and healthcare resource utilization metrics such as length of stay (LOS) and total hospitalization charges (TOTCHG). Patients were classified according to the month of admission as JU or other months (OM) to investigate the potential impact of the “July effect” on patient outcomes. The study included 281,874 patients, of which 8% were in the JU group and 92% in the OM group. The mean age was 71 ± 13 years, with a slight male predominance (52% vs 48%), and most patients were White (70%). A total of 34,974 in-hospital deaths occurred, with no significant difference between the JU and OM groups (odds ratio [OR] = 0.95; 95% confidence interval [CI] = 0.85-1.06; p=0.329). Similarly, no significant differences were observed in CA (OR = 0.88; 95% CI = 0.70-1.11; p=0.282), RF (OR = 0.98; 95% CI = 0.90-1.06; p=0.597), ventilator use (OR = 0.99; 95% CI = 0.77-1.25; p=0.879), LOS (11.3 vs. 11.3), and TOTCHG (USD 136,377 vs. USD 136,181). However, lower rates of acute kidney injury were observed in the JU group compared with the OM group (OR 0.90; 95% CI, 0.84-0.98, p=0.011). This study demonstrates that the “July effect” does not significantly influence in-hospital outcomes in patients with CHF and concomitant sepsis. While mortality and major clinical outcomes were comparable across groups, lower rates of acute kidney injury were observed in patients admitted in JU. Further research is needed to understand the complex interplay between healthcare resident turnover and patient outcomes.

Keywords

Congestive heart failure / Concomitant sepsis / July effect / July phenomenon / Inpatient outcomes / National inpatient sample / International classification of diseases 10^th revision codes

Acknowledgments

None.

Funding

None.

Conflict of interest

The authors declare that they have no competing interests.

Author contributions

Conceptualization: Oghenetejiri Gbegbaje

Data curation: Oghenetejiri Gbegbaje, Haris Muhammad, Chidubem Ezenna, Gabriel Alugba

Formal analysis: Oghenetejiri Gbegbaje

Investigation: Oghenetejiri Gbegbaje

Methodology: Haris Muhammad

Writing-original draft: Oghenetejiri Gbegbaje, Gabriel Alugba, Favour Nelson, Vicky Kumar, Aparna Iyer, Sidni Fullerton

Writing-review & editing: Oghenetejiri Gbegbaje, Vicky Kumar, Dipal R. Patel, Haris Muhammad

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of data

Not applicable.

References

[1] Barzansky B, Etzel SI.Medical schools in the United States, 2008-2009. JAMA. 2009; 302(12):1349-1355. doi: 10.1001/jama.2009.1324

[2] Haller G, Myles PS, Taffé P, Perneger TV, Wu CL. Rate of undesirable events at beginning of academic year: Retrospective cohort study. BMJ. 2009;339:b3974. doi: 10.1136/bmj.b3974

[3] Young JQ, Ranji SR, Wachter RM, Lee CM, Niehaus B, Auerbach AD. “July effect”: Impact of the academic year-end changeover on patient outcomes: A systematic review. Ann Intern Med. 2011; 155(5):309-315. doi: 10.7326/0003-4819-155-5-201109060-00354

[4] Aylin P, Majeed FA. The killing season--fact or fiction? BMJ. 1994; 309(6970):1690. doi: 10.1136/bmj.309.6970.1690

[5] Blumberg MS. It’s not ok to get sick in July. JAMA. 1990; 264(5):573.

[6] Jena AB, Sun EC, Romley JA.Mortality among high-risk patients with acute myocardial infarction admitted to U.S. Teaching-intensive hospitals in July: A retrospective observational study. Circulation. 2013; 128(25):2754-2763. doi: 10.1161/circulationaha.113.004074

[7] Phillips DP, Barker GE. A July spike in fatal medication errors: A possible effect of new medical residents. J Gen Intern Med. 2010; 25(8):774-779. doi: 10.1007/s11606-010-1356-3

[8] 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. 2003; 18(8):639-645. doi: 10.1046/j.1525-1497.2003.20605.x

[9] 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. 2010; 68(1):19-22. doi: 10.1097/TA.0b013e3181b88dfe

[10] Shah AA, Zogg CK, Nitzschke SL, et al. Evaluation of the perceived association between resident turnover and the outcomes of patients who undergo emergency general surgery: Questioning the July phenomenon. JAMA Surg. 2016; 151(3):217-224. doi: 10.1001/jamasurg.2015.3940

[11] Myers L, Mikhael B, Currier P, et al. The association between physician turnover (the “July effect”) and survival after in-hospital cardiac arrest. Resuscitation. 2017; 114:133-140. doi: 10.1016/j.resuscitation.2017.03.004

[12] Ghumman SS, Ibrahim S, Taylor AM, Fauber N, Ragosta M. The “July effect” in the cardiac catheterization laboratory. Am J Cardiol. 2022; 170:160-165. doi: 10.1016/j.amjcard.2022.01.032

[13] Zogg CK, Metcalfe D, Sokas CM, et al. Reassessing the July effect: 30 Years of evidence show no difference in outcomes. Ann Surg. 2023; 277(1):e204-e211. doi: 10.1097/sla.0000000000004805

[14] Patlolla SH, Truesdell AG, Basir MB, et al. No “July effect” in the management and outcomes of acute myocardial infarction: An 18-year United States national study. Catheter Cardiovasc Interv. 2023; 101:264-273. doi: 10.1002/ccd.30553

[15] Bohl DD, Fu MC, Golinvaux NS, Basques BA, Gruskay JA, Grauer JN. The “July effect” in primary total hip and knee arthroplasty: Analysis of 21,434 cases from the ACS-NSQIP database. J Arthroplasty. 2014; 29(7):1332-1338. doi: 10.1016/j.arth.2014.02.008

[16] Shah RM, Hirji SA, Kiehm S, et al. Debunking the July Effect in cardiac surgery: A national analysis of more than 470,000 procedures. Ann Thorac Surg. 2019; 108(3):929-934. doi: 10.1016/j.athoracsur.2019.06.015

[17] Schumacher DJ, Bria C, Frohna JG. The quest toward unsupervised practice: Promoting autonomy, not independence. JAMA. 2013; 310(24):2613-2614. doi: 10.1001/jama.2013.282324

[18] Kennedy TJ, Lingard L, Baker GR, Kitchen L, Regehr G. Clinical oversight: Conceptualizing the relationship between supervision and safety. J Gen Intern Med. 2007; 22(8): 1080-1085. doi: 10.1007/s11606-007-0179-3

[19] Sterkenburg A, Barach P, Kalkman C, Gielen M, Ten Cate O. When do supervising physicians decide to entrust residents with unsupervised tasks? Acad Med. 2010; 85(9):1408-1417. doi: 10.1097/ACM.0b013e3181eab0ec

[20] Ten Cate O, Snell L, Carraccio C. Medical competence: The interplay between individual ability and the health care environment. Med Teach. 2010; 32(8):669-675. doi: 10.3109/0142159x.2010.500897

[21] Green ML, Aagaard EM, Caverzagie KJ, et al. Charting the road to competence: Developmental milestones for internal medicine residency training. J Grad Med Educ. 2009; 1(1): 5-20. doi: 10.4300/01.01.0003

[22] Claridge JA, Schulman AM, Sawyer RG, Ghezel-Ayagh A, Young JS. The “July phenomenon” and the care of the severely injured patient: Fact or fiction? Surgery. 2001; 130(2): 346-353. doi: 10.1067/msy.2001.116670

[23] Highstead RG, Johnson LS, Street JH 3rd, Trankiem CT, Kennedy SO, Sava JA. July--as good a time as any to be injured. J Trauma. 2009; 67(5):1087-1090. doi: 10.1097/TA.0b013e3181b8441d