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Impact of the 'July Effect' on Pancreaticoduodenectomy
*John W Kunstman, *James M Healy, *Timothy D Murtha, Ronald R Salem
Yale University, New Haven, CT
Objective: Concerns, including those of the lay public, regarding quality of care during the month of July at academic medical institutions is increasing. Newly-promoted trainees at all levels with increased responsibilities are thought to be causative. This study seeks to examine patients undergoing pancreaticoduodenectomy (PD) and determine correlation between operative outcomes and date of surgery. PD seems an ideal metric to assess such outcomes, as care of these patients at an academic center involves trainees across multiple departments and post-graduate levels.
Design: Retrospective review of prospective database
Setting: Academic tertiary center
Patients: 460 consecutive patients underwent PD by a single surgeon from 7/2003 to 12/2015. 76.9% of cases were performed for malignancy.
Intervention: Not applicable
Outcome Measures: The primary outcome measure was overall operative morbidity as determined by the Clavien-Dindo scoring system. Secondary outcomes included individual adverse events of interest, length of stay, and operative blood loss.
Results: The results are summarized in the table below. No significant difference was observed in the quarterly incidence or severity of Clavien-Dindo complications and other measured events, such as delayed gastric emptying or postoperative pancreatic fistula. Similarly, the incidence of adverse events in the month of July did not exceed other months of the year.
Table.
Conclusions: Despite concerns regarding care at major teaching hospitals early during the academic year, operative outcomes were not demonstrably altered in patients undergoing PD. As such, we conclude that such concerns amongst patient undergoing major abdominal surgery may be unfounded.
| July-September | October-December | January-March | April-June | July Alone | | Patients (N) | 126 | 115 | 116 | 115 | 49 | | Operative Blood Loss (median, in mL) | 400 | 400 | 350 | 340 | 400 | | Delayed gastric empyting (frequency) | 14.4% | 13.9% | 13.9% | 14.8% | 10.4% | | Postoperative pancreatic fistula, any grade (frequency) | 8% | 8.7% | 8.7% | 12.0% | 6.25% | | Clavien-Dindo Score (median, on discharge) | 1 | 1 | 1 | 1.5 | 2 | | Clavien-Dindo Score (median, 30 day) | 1 | 2 | 2 | 2 | 2 | | Length of Stay (median) | 6 | 7 | 7 | 6 | 6 | | Reoperation (frequency) | 3.2% | 6.9% | 6.9% | 5.5% | 2.1% | | Readmission (frequency) | 20.8% | 20% | 20% | 25% | 25% | | Mortality (frequency) | 1.6% | 0.9% | 0.9% | 0.9% | 0% |
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