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Table.  Odds That Surgical Patients Reported High Satisfaction With Various HCAHPS Measures With Admission in July or August Compared With Admission From September Through June
Odds That Surgical Patients Reported High Satisfaction With Various HCAHPS Measures With Admission in July or August Compared With Admission From September Through June
1.
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.PubMedGoogle ScholarCrossref
2.
Anderson  KL, Koval  KJ, Spratt  KF.  Hip fracture outcome: is there a “July effect”?  Am J Orthop (Belle Mead NJ). 2009;38(12):606-611.PubMedGoogle Scholar
3.
Smith  ER, Butler  WE, Barker  FG  II.  Is there a “July phenomenon” in pediatric neurosurgery at teaching hospitals?  J Neurosurg. 2006;105(3)(suppl):169-176.PubMedGoogle Scholar
4.
Yaghoubian  A, de Virgilio  C, Chiu  V, Lee  SL.  “July effect” and appendicitis.  J Surg Educ. 2010;67(3):157-160.PubMedGoogle ScholarCrossref
5.
Hospital Consumer Assessment of Healthcare Providers and Systems. Technical notes for HCAHPS Star Ratings. http://www.hcahpsonline.org/files/HCAHPS_Stars_Tech_Notes_Apr2015.pdf. Accessed November 5, 2015.
Research Letter
September 2016

Assessment of Patient-Reported Experiences of Hospital Care and the July Phenomenon

Author Affiliations
  • 1Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
  • 2Department of Surgery, Mayo Clinic, Rochester, Minnesota
JAMA Surg. 2016;151(9):879-880. doi:10.1001/jamasurg.2016.0402

A recent article1 suggested that the influx of new surgical residents at the beginning of the academic year is not associated with worse outcomes among patients undergoing emergency general surgery, contrary to the widely believed July phenomenon. In the modern era of surgical education, other studies have also supported the authors’ findings across other specialties including orthopedics,2 neurosurgery,3 and acute care surgery.4 We hypothesized that patient-centered outcomes are also not associated with the known influx of new surgical residents in July and August.

Methods

After obtaining approval from the Mayo Clinic Institutional Review Board as a minimal-risk study not requiring informed consent, all adult inpatient surgical patients who met criteria for the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey sampling in 2013 or 2014 at a single academic medical center were identified retrospectively in 2015, and those with returned surveys were included. The HCAHPS outcomes measures were constructed in accordance with the published Centers for Medicare and Medicaid Services Star Rating method and dichotomized for analysis (high vs low).5 Multivariable logistic regression was used to replicate Centers for Medicare and Medicaid Services case-mix adjustment (education, overall health status, language, and age), with additional adjustment by patient complexity (by diagnosis related group code), emergent admission, cancer diagnosis, patient sex, and surgical specialty.

Results

We identified 10 822 surgical patients who returned HCAHPS surveys during a 2-year period across all surgical specialties. Of these, 1674 (15.5%) were admitted in July or August and 9148 (84.5%) were admitted in September through June. Patients treated in July or August were more likely to rate the hospital highly on adjusted analysis compared with patients treated during the remainder of the year (global rating: odds ratio = 1.13; 95% CI, 1.00-1.27; P = .045). Scores rating communication with physicians, pain management, communication about medicines, care transition, discharge information, and the overall summary Star Rating were similar between patients admitted in July or August compared with those admitted in any other month (all P > .05) (Table). Seasonal variations were noted, with September/October (odds ratio = 0.83; 95% CI, 0.72-0.97; P = .02) and January/February (odds ratio = 0.82; 95% CI, 0.71-0.95; P = .007) having lower summary Star Ratings than July/August.

Discussion

Surgical patients had equal, and by some measures improved, perceptions of their care during the influx of new surgical residents at our institution. However, seasonal variations in patient-centered outcomes do exist. Although our data cannot elucidate the reasons, we suspect that rigorous oversight and hypervigilance by staff and senior residents as well as an established surgical boot camp and orientation program contributed to these findings. Our study was limited to a single center, but we suspect that there is broad generalizability to other institutions with similar practices. These data, in combination with the findings of Shah et al,1 suggest that the July phenomenon can largely be debunked in the modern era of surgical education.

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Article Information

Corresponding Author: Cornelius A. Thiels, DO, Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (thiels.cornelius@mayo.edu).

Published Online: June 1, 2016. doi:10.1001/jamasurg.2016.0402.

Author Contributions: Drs Thiels and Habermann had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Thiels, Heller, Zielinski, Habermann.

Acquisition, analysis, or interpretation of data: Thiels, Hanson, Habermann.

Drafting of the manuscript: Thiels.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Thiels, Hanson.

Administrative, technical, or material support: Heller, Zielinski.

Study supervision: Thiels, Heller, Zielinski, Habermann.

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery at the Mayo Clinic for their support of this research.

References
1.
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.PubMedGoogle ScholarCrossref
2.
Anderson  KL, Koval  KJ, Spratt  KF.  Hip fracture outcome: is there a “July effect”?  Am J Orthop (Belle Mead NJ). 2009;38(12):606-611.PubMedGoogle Scholar
3.
Smith  ER, Butler  WE, Barker  FG  II.  Is there a “July phenomenon” in pediatric neurosurgery at teaching hospitals?  J Neurosurg. 2006;105(3)(suppl):169-176.PubMedGoogle Scholar
4.
Yaghoubian  A, de Virgilio  C, Chiu  V, Lee  SL.  “July effect” and appendicitis.  J Surg Educ. 2010;67(3):157-160.PubMedGoogle ScholarCrossref
5.
Hospital Consumer Assessment of Healthcare Providers and Systems. Technical notes for HCAHPS Star Ratings. http://www.hcahpsonline.org/files/HCAHPS_Stars_Tech_Notes_Apr2015.pdf. Accessed November 5, 2015.
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