Is There a July Phenomenon?

William A. Barry, MD, Gary E. Rosenthal, MD

In This Article

Abstract and Introduction

Background: It has been suggested that inexperience of new housestaff early in an academic year may worsen patient outcomes. Yet, few studies have evaluated the "July Phenomenon," and no studies have investigated its effect in intensive care patients, a group that may be particularly susceptible to deficiencies in management stemming from housestaff inexperience.
Objective: Compare hospital mortality and length of stay (LOS) in intensive care unit (ICU) admissions from July to September to admissions during other months, and compare that relationship in teaching and nonteaching hospitals, and in surgical and nonsurgical patients.
Design, Setting, and Patients: Retrospective cohort analysis of 156,136 consecutive eligible patients admitted to 38 ICUs in 28 hospitals in Northeast Ohio from 1991 to 1997.
Results: Adjusting for admission severity of illness using the APACHE III methodology, the odds of death was similar for admissions from July through September, relative to the mean for all months, in major (odds ratio [OR], 0.96; 95% confidence interval [95% CI], 0.91 to 1.02; P = .18), minor (OR, 1.02; 95% CI, 0.93 to 1.10; P = .66), and nonteaching hospitals (OR, 0.96; 95% CI, 0.91 to 1.01; P = .09). The adjusted difference in ICU LOS was similar for admissions from July through September in major (0.3%; 95% CI, -0.7% to 1.2%; P = .61) and minor (0.2%; 95% CI, -0.9% to 1.4%; P = .69) teaching hospitals, but was somewhat shorter in nonteaching hospitals (-0.8%; 95% CI, -1.4% to -0.1%; P = .03). Results were similar when individual months and academic years were examined separately, and in stratified analyses of surgical and nonsurgical patients.
Conclusions: We found no evidence to support the existence of a July phenomenon in ICU patients. Future studies should examine organizational factors that allow hospitals and residency programs to compensate for inexperience of new housestaff early in the academic year.

A growing body of literature has demonstrated that hospitals or physicians with higher volumes achieve better outcomes for patients undergoing surgical procedures or hospitalized for some medical conditions.[1,2,3,4,5] Further studies have demonstrated that physician experience with such procedures as laparoscopic cholecystectomy, total hip arthroplasty, colonoscopy, and cardiovascular interventions, is an important determinant of outcomes.[6,7,8,9,10,11] Given such findings, it is reasonable to be concerned about the potential impact of the relative inexperience of trainees in teaching hospitals early in the academic year.

Each July, teaching hospitals experience an influx of new physicians recently graduated from medical schools, and they assign new positions of responsibility to senior residents and fellows. Medical education is a fundamental component of the mission of teaching hospitals, and in these centers, interns, residents, and fellows directly provide much of the care delivered to patients. This dynamic of care delivery by less experienced physicians has led to concern about the quality of care delivered early in the academic year, known colloquially as the July Phenomenon.[12]

While some prior studies suggest that the costs of care in teaching hospitals are higher early in the academic year,[13,14,15] a few others have found no differences in quality of care.[14,15,16,17] However, these earlier studies were based on administrative data, which makes it difficult to adjust for potential differences in case-mix and severity of illness. Moreover, no prior studies have evaluated critical care patients. Because of their higher acuity, such patients may be particularly susceptible to initial errors in management that may stem from physician inexperience and may represent an ideal group to detect the presence of a July Phenomenon.

To address these issues further, we studied consecutive admissions to intensive care units of 5 major teaching hospitals in a large metropolitan region. We compared 2 widely used outcome measures-in-hospital mortality and length of stay (LOS) in patients admitted from July through September and during later months of the academic year. Data abstracted from medical records were included in risk adjustment models based on the APACHE III methodology,[18] a validated model used to adjust for differences in severity of illness in critical care patients. We performed similar analyses in 23 minor teaching and nonteaching facilities to determine whether relationships between month of admission and outcomes were similar in hospitals that should not be as susceptible to a July Phenomenon.