title: The "July effect" does not have clinical relevance in liver transplantation.
abstract: In the beginning of the academic year, medical errors are often attributed to inexperienced medical staff. This potential seasonal influence on health care outcomes is termed the "July effect." No study has demonstrated the July effect in liver transplantation. We reviewed retrospectively collected data from the United Network for Organ Sharing for patients who underwent liver transplantation from October 1987 to June 2011 to determine if surgical outcomes were worse in July compared with rest of the year. We found no clinical difference in early graft survival (91.11% vs. 90.72%, p = 0.045) and no difference in early patient survival (94.71% vs. 94.42%, p = 0.057). Survival at 1 year, 3 years, and 5 years was also compared and no notable differences were detected. Because the Model for End-stage Liver Disease (MELD) score implementation in 2002 affected the acuity of liver transplant recipients, we further stratified our data to compare pre- and post-MELD survival to remove subjectivity as a confounding factor. MELD stratification revealed no seasonal difference in outcomes. There was no difference in rate of graft failure and acute and chronic rejection between groups. Our findings show no evidence of the July effect in liver transplantation. Each July, thousands of medical residents take on new responsibilities in patient care. It has been suggested that these new practitioners may produce errors that contribute to worse patient outcomes in the beginning of the academic year-a phenomenon called the "July effect." Currently, there are few research studies with controversial evidence of poorer outcomes in July, and no articles address the effect of new medical staff in the setting of liver transplantation. Our study compares short-, medium-, and long-term graft and patient survival between July and August and the remaining months using national data. We also examine survival before and after the implementation of the MELD scoring system to determine its effect on outcomes in the beginning of the academic year.
authors.affiliation: Department of Surgery, Albert Einstein Hospital, Philadelphia, Pennsylvania. Electronic address: karipinf@einstein.edu.
authors.forename: Farah
authors.initials: F
authors.lastname: Karipineni
authors.forename: Hinaben
authors.initials: H
authors.lastname: Panchal
authors.forename: Kamran
authors.initials: K
authors.lastname: Khanmoradi
authors.forename: Afshin
authors.initials: A
authors.lastname: Parsikhia
authors.forename: Jorge
authors.initials: J
authors.lastname: Ortiz
mesh_terms: D000328:Adult; D002983:Clinical Competence; D058625:End Stage Liver Disease / Q000401:mortality* / Q000601:surgery; D005260:Female; D013502:General Surgery / Q000193:education*; D006085:Graft Survival; D006801:Humans; D007396:Internship and Residency / Q000458:organization & administration* / Q000706:statistics & numerical data; D053208:Kaplan-Meier Estimate; D016031:Liver Transplantation / Q000401:mortality*; D019300:Medical Errors / Q000706:statistics & numerical data*; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012720:Severity of Illness Index
keywords: July; Medical Knowledge; Practice-Based Learning and Improvement; Systems-Based Practice; errors; house staff; survival; transplant