The july effect: An analysis of never events in the nationwide inpatient sample

Abstract

BACKGROUND Prior studies examining the impact of the “July effect” on in‐hospital mortality rates have generated variable results. In 2008, the Centers for Medicare & Medicaid Services published a series of high‐cost, high‐volume, nonreimbursable hospital‐acquired complications (HACs). These events were believed to be preventable and indicate deficiencies in healthcare delivery. OBJECTIVE The present study aims to investigate the impact of July admissions on patient safety in a national sample using the HACs as a metric. DESIGN/SETTING/PATIENTS Discharge data were collected from all admissions recorded in the Nationwide Inpatient Sample database from 2008 to 2011. HAC incidence was evaluated as a function of admission month, adjusting for demographic and hospital factors in multivariable analysis. MEASURES The outcome measures were HAC occurrence, prolonged length of stay (LOS), and higher inpatient costs. RESULTS A total of 143,019,381 inpatient admissions were recorded, with an overall HAC occurrence of 4.7%. July admissions accounted for 7.6% of the total number of inpatient admissions. July admissions experienced a 6% increase in likelihood of HAC occurrence (odds ratio = 1.06, 95% confidence interval: 1.06–1.07, P < 0.001) when compared to those admitted during all other months. Patients with HAC occurrence had almost 2 times increased likelihood of prolonged LOS (P < 0.001) and higher inpatient costs (P < 0.001). CONCLUSIONS July admissions are associated with increased likelihood of HAC occurrence. This trend may represent breakdowns in organization structure distinct from traditional quality measures, requiring novel transition protocols dedicated to improving HACs. Journal of Hospital Medicine 2015;10:432–438. © 2015 Society of Hospital Medicine

July Syndrome

“…Subsequent studies have been mixed. Several studies that focused on surgical procedures (eg, anterior cervical fusion, elective spine, head and neck cancer surgery) showed no effect, although another study showed an increase in hospital‐acquired complications for patients cared for in July . One of the best studies found that undesirable events were committed as frequently by fifth‐year trainees who were new to the hospital as by interns …”

Impact of the 2003 ACGME Resident Duty Hour Reform on Hospital-Acquired Conditions: A National Retrospective Analysis

“…Our results are consistent with the findings of other aggregate NIS studies. 10,16 The association of reforms with increased HAC frequency may be due to multiple reasons. Increased number of informational exchanges during handoffs has been cited as a source of medical errors in multiple studies.…”

“…15 HACs have been utilized as hospital quality outcome measures in studies. 10,11,16,17 No prior study has evaluated the national incidence of HACs before and after the institution of the 2003 ACGME duty hour limits. Each discharge was treated as an independent event due to the lack of unique patient identifiers.…”

“…The Elixhauser comorbidity index is a set of comprehensive comorbidity measures associated with in-hospital mortality, all-cause mortality, and health care expenditures, designed for the use of large administrative databases and utilized in many prior NIS studies. 10,16,19,20 HACs were defined using CMS-provided criteria by means of International Classification of Disease, ninth revision, Clinical Modification. 8 Outcomes of interest included occurrence of HACs, prolonged length of stay (pLOS), and elevated inpatient costs.…”

Why July Matters

“…In another study, which used Medicare data, rates of hospital-acquired complications were significantly higher for patients admitted in July compared with other months. 7 These worrisome trends are not confined to any single nation. In an international study, rates of fatal medication errors increased by 10% during the month of July in countries with teaching hospitals.…”