title: Increased Mortality for Elective Surgery during Summer Vacation: A Longitudinal Analysis of Nationwide Data.
abstract: Surgical safety during vacation periods may be influenced by the interplay of several factors, including workers' leave, hospital activity, climate, and the variety of patient cases. This study aimed to highlight an annually recurring peak of surgical mortality during summer in France and explore its main predictors. We selected all elective of open surgical procedures performed in French hospitals between 2007 and 2012. Surgical mortality variation was analyzed over time in relation to workers leaving on vacation, the volume of procedures performed by hospitals, and temperature changes. We ran a multilevel logistic regression for exploring the determinants of surgical mortality, taking into account the clustering of patients within hospitals and adjusting for patient and hospital characteristics. A total of 609 French hospitals had 8,926,120 discharges related to open elective surgery. During 6 years, we found a recurring mortality peak of 1.15% (95% CI 1.09-1.20) in August compared with 0.81% (0.79-0.82, p<.001) in other months. The incidence of worker vacation was 43.0% (38.9-47.2) in August compared with 7.3% (4.6-10.1, p<.001) in other months. Hospital activity decreased substantially in August (78,126 inpatient stays, 75,298-80,954) in relation to other months (128,142, 125,697-130,586, p<.001). After adjusting for all covariates, we found an "August effect" reflecting a higher risk to patients undergoing operations at this time (OR 1.16, 95% CI 1.12-1.19, p<.001). The main study limitation was the absence of data linkage between surgical staffing and mortality at the hospital level. The observed, recurring mortality peak in August raises questions about how to maintain hospital activity and optimal staffing through better regulation of human activities.
authors.affiliation: Hospices Civils de Lyon, Pôle Information Médicale Evaluation Recherche, Lyon, F-69003, France; INSERM Research Unit 1033, Lyon, F-69003, France; Université Claude Bernard Lyon 1, Health Services and Performance Research Lab, Lyon, F-69003, France.
authors.forename: Pascal
authors.initials: P
authors.lastname: Caillet
authors.affiliation: Hospices Civils de Lyon, Pôle Information Médicale Evaluation Recherche, Lyon, F-69003, France; Université Claude Bernard Lyon 1, Health Services and Performance Research Lab, Lyon, F-69003, France.
authors.forename: Cécile
authors.initials: C
authors.lastname: Payet
authors.affiliation: Hospices Civils de Lyon, Pôle Information Médicale Evaluation Recherche, Lyon, F-69003, France; Université Claude Bernard Lyon 1, Health Services and Performance Research Lab, Lyon, F-69003, France.
authors.forename: Stéphanie
authors.initials: S
authors.lastname: Polazzi
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital - Harvard Medical School, Boston, Massachusetts, United States of America.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Carty
authors.affiliation: Université Claude Bernard Lyon 1, Health Services and Performance Research Lab, Lyon, F-69003, France; Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Service de Chirurgie Générale et Endocrinienne, Pierre Bénite, F-69300, France.
authors.forename: Jean-Christophe
authors.initials: JC
authors.lastname: Lifante
authors.affiliation: Hospices Civils de Lyon, Pôle Information Médicale Evaluation Recherche, Lyon, F-69003, France; Université Claude Bernard Lyon 1, Health Services and Performance Research Lab, Lyon, F-69003, France; Center for Surgery and Public Health, Brigham and Women's Hospital - Harvard Medical School, Boston, Massachusetts, United States of America.
authors.forename: Antoine
authors.initials: A
authors.lastname: Duclos
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D017558:Elective Surgical Procedures / Q000401:mortality*; D005260:Female; D005602:France / Q000453:epidemiology; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D012621:Seasons