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Worse outcomes after spinal metastases surgery at academic medical centers in July

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Patients undergoing surgery for spinal metastases at teaching hospitals in July have higher mortality and complication rates than similar patients treated in other months, according to a report in the August 25th online issue of Cancer.

“The ‘July effect’ has long been anecdotal in nature,” Dr. Ali Bydon from Johns Hopkins University, School of Medicine, Baltimore, Maryland told Reuters Health in an email. “Although this study may be the best evidence yet, it is important to remember that it is retrospective, based on a national administrative database, and restricted to patients with metastatic spinal disease. While we may extrapolate from this study that this is a widespread issue in academic centers, we are cautious in our interpretations.”

“July 1st is a key date in the field of Medicine,” Dr. Bydon explained. “It’s when students become interns, interns become residents, residents become fellows, and fellows become unsupervised attending physicians. Moreover, accompanying each of these professional transitions are potentially new hospital environments and teams. It’s also the time that seasoned physicians may be on vacation with their families, taking advantage of the end of the school year. The convergence of these factors may add complexity and inefficiency to routine cases seen at academic centers during this time.”

Most studies, however, have not found inferior outcomes at the beginning of the academic medical year for medical, obstetric, trauma, critical care, or surgical patients, although some have found that admission to teaching hospitals in July is associated with increased rates of errors or complications.

Dr. Bydon and colleagues examined the perioperative outcomes of patients with metastatic disease who underwent spinal surgery at teaching hospitals in July compared with those admitted between August and June using data retrospectively extracted from the Nationwide Inpatient Sample from 2005 to 2008.

The adjusted odds of in-hospital death were 81% higher for patients admitted to teaching hospitals in July (7.5% crude mortality) compared with the rest of the year (4.1% crude mortality). It was also higher for patients admitted in July or August compared with the rest of the year.

In contrast, in-hospital mortality at nonteaching hospitals was lower in July (1.3%) than in the rest of the year (5.0%).

Similarly, the adjusted odds of developing an intraoperative or implant complication were twice as high in July as during the rest of the year at teaching hospitals, whereas the odds of developing such a complication did not differ between patients admitted in July and those admitted at other times of the year at nonteaching hospitals.

The risk of postoperative complication, the median length of hospital stay, the total hospital charges, and the odds of a nonroutine discharge did not differ by time of year for either teaching or nonteaching hospitals.

“Though we don’t profess a solution to this complicated problem, our study aims to spark the conversation, highlighting the importance of validating our data in a prospective fashion and considering solutions as a field to standardize the care rendered to patients throughout the year,” Dr. Bydon concluded. “Do we need to have everybody promoted during a single month or could we consider staggering transitions among medical professionals? For example, can fellows be promoted to attending physicians in January? Is that feasible and what effect would that have on outcomes?”

Dr. Bydon added, “ The solution cannot rest on the shoulder of individual academic centers. This problem, if validated, requires a national solution with extensive feedback from healthcare providers, healthcare administrators, legislators, and public advocates.”

The impact of July hospital admission on outcome after surgery for spinal metastases at academic medical centers in the United States, 2005 to 2008
Cancer 25 August 2011.