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Is there a "July phenomenon" in pediatric neurosurgery at teaching hospitals?
Edward R Smith1, William E Butler, Fred G Barker
1Neurosurgical Service, Massachusetts General Hospital, Boston 02114, USA.
Insights
The July intern and resident transition does not increase adverse patient outcomes or inefficient care in pediatric neurosurgery. Studies show no significant rise in mortality, complications, or length of stay during this period.
Area of Science:
- Neurosurgery
- Patient Safety
- Healthcare Policy
Background:
- Recent policy changes in US resident work hours raise concerns about patient safety.
- Speculation exists that the July transition of new medical interns and residents may lead to increased adverse patient outcomes and inefficient care.
Purpose of the Study:
- To investigate whether the July transition of medical residents impacts patient safety and care efficiency in pediatric neurosurgery.
Main Methods:
- Analysis of 4323 pediatric craniotomies for tumor resection and 22,072 shunt operations from 1988-2000.
- Comparison of in-hospital mortality, discharge outcomes, complications, length of stay, and hospital charges between July/August and other months.
Main Results:
- No significant increases in mortality, adverse discharge disposition, neurological complications, or transfusion rates were observed for tumor or shunt surgeries in July/August.
- Length of stay was shorter by 3% for both surgery types, while hospital charges showed minimal changes (0.5% lower for tumor, 0.2% higher for shunt).
Conclusions:
- Pediatric neurosurgery outcomes and efficiency in US teaching hospitals are not negatively impacted by the July resident transition.
- While moderate increases in some adverse events cannot be entirely ruled out, the data do not support a significant association with the July/August period.
Object:
Concern for patient safety, among other reasons, recently prompted sweeping changes in resident work policies in the US. Some have speculated that the arrival of new interns and residents at teaching hospitals each July might cause an annual transient increase in poor patient outcomes and inefficient care.
Methods:
Data were analyzed for 4323 craniotomies for tumor resection and 22,072 shunt operations performed in pediatric patients between 1988 and 2000 in US nonfederal hospitals (Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, Rockville, MD). In-hospital mortality rates, discharge outcome, complications, and efficiency measures (length of stay [LOS] and hospital charges) for patients treated in July and August were compared with similar data for patients in other months. There were no significant increases in any adverse end point for either tumor or shunt operations in July and August. Odds ratios (95% confidence interval [CI]) for outcome of tumor craniotomies performed in July and August compared with outcome for tumor craniotomies performed in other months were as follows: for mortality rate, 0.43 (0.14-1.32); for adverse discharge disposition, 1.03 (0.71-1.51); for neurological complications, 1.00 (0.63-1.59); for transfusion, 0.70 (0.41-1.19). Hospital charges were 0.5% lower (range -6 to 5%) in July and August, and LOS was 3% shorter (range -8 to 3%). Odds ratios (95% CI) for July or August shunt surgery compared with shunt surgery performed in other months were as follows: for mortality rate, 0.96 (0.58-1.60); for adverse discharge disposition, 0.85 (0.66-1.11); for neurological complications, 1.27 (0.75-2.16); for transfusion, 0.81 (0.48-1.37). Hospital charges were 0.2% higher in July and August (range -3 to 3%), and LOS was 3% shorter (range -5 to 0.5%).
Conclusions:
Although moderate increases in some adverse end points could not be excluded, there was no evidence that brain tumor or shunt surgery performed in pediatric patients at US teaching hospitals during July and August is associated with more frequent adverse patient outcome or inefficient care than similar surgery performed during other months.