The July Phenomenon in Obstetrics (Text Version)

Slide Presentation from the AHRQ 2008 Annual Conference

On September 10, 2008, Rini Rantan, M.D., made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (3.4 MB).

Slide 1

The "July Phenomenon" in Obstetrics

Rini Banerjee Ratan, M.D.
Assistant Clinical Professor

September 10, 2008

Department of Obstetrics and Gynecology
Columbia University Medical Center
In Affiliation with New York-Presbyterian Hospital

Slide includes images of doctors conversing and standing in hallway near nurse's station.

Slide 2

What is the July Phenomenon?

Slide includes New Yorker magazine image of American Flag by Arthur Getz, dated July 2, 1966.

Slide 3

The July Phenomenon in Medicine

Slide includes a photo of several cast members of "Gray's Anatomy."

• New academic year.
• New interns begin training.
• Inferior health care is provided by novice physicians.

Slide 4

New Docs on the Block

Slide includes an image of the Newsweek Web article by Jesse Ellison, dated July 1, 2008. The article is titled: "New Docs on the Block." The first paragraph states: "According to medical lore, July is the worst time to be hospitalized because that's when inexperienced med students start clinical training. But is summer really riskier for patients?"

Slide 5

The New York Times "Science" and "Health"

Slide includes images of two articles from The New York Times Web site Science and Health sections, dated Wednesday, August 6, 2008. The articles are: 1) "Essay: It's July, the Greenest Month in Hospitals. No Need to Panic" from the Science Section; and 2) "CASES; Their Coats Are White but Their Hands are Green." from the Health Section.

Slide 6

The Boston Globe

Slide includes image from The Boston Globe Web site Boston.com's White Coat Notes' Short White Coat blog section on July 18, 2008. It shows the top of an article titled: "The July phenomenon" by Joshua U. Klein.

Slide 7

Is There a July Phenomenon in Obstetrics?

Slide includes cartoon image of a doctor emerging from a delivery room to talk to the father. The caption reads: "It's a baby. Federal regulations prohibit our mentioning its race, age, or gender."

Slide 8

Motivating Factors

Educational

Slide includes photo of students in white lab coats clapping as a young woman walks towards the front of the auditorium.

Slide 9

Slide includes an aerial photo of a hospital campus in New York City.

Slide 10

Medical Education: Obstetrics & Gynecology

• Columbia University College of Physicians & Surgeons.
• New York Presbyterian Hospital.
• Medical Student Clerkship.
• Residency Program.
• Fellowship Programs.

Slide 11

Motivating Factors (continued)

Mission:

Education is an integral part of the tripartite mission of the Department of Obstetrics and Gynecology, along with patient care and research. As a world leader in women's health care, our mission is to provide the finest comprehensive training for future practitioners in our specialty by using the latest knowledge and innovative research and to provide to the community at large the highest quality of patient care.

Slide 12

The I.V. League

Slide includes an image of cartoon strip The I.V. League. In the first frame, a doctor is talking to a new doctor. The caption reads: ..".and don't think I don't know incompetence when I see it!" In the second frame, the doctor is talking to another doctor who witnessed the exchange. The caption reads: "I like to greet all new doctors warmly!"

Slide 13

Motivating Factors (continued)

• Educational.
• Personal.
• Professional.

Images on slide include: Doctors going over charts, a baby foot being foot-printed, a sonogram being conducted, and a medical professional in scrubs and mask holding a newborn.

Slide 14

Journal Article

Slide includes journal article on the July Phenomenon written by Dr. Ratan in the Journal of Perinatology. It also includes two photos: One of a boy, dated August 8, 2006, and one of a girl, dated July 28, 2004.

Slide 15

Study Objective

To determine whether operator-dependent obstetric complications occur at higher in July at teaching hospitals using a large nationwide sample of deliveries.

Slide 16

Study Design

• Data obtained from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) from 1998-2002.
• Largest all-payer inpatient care database in the United States.
• Representative sample of discharges from non-Federal, acute care hospitals in the United States.
• Database includes patient information coded at time of discharge, including age, race, primary expected payer and up to 15 diagnosis codes and procedure ICD-9 codes.

Slide 17

Study Design (continued)

• Singleton deliveries and singleton livebirth admissions among Medicaid patients at teaching hospitals with obstetrician/gynecologist (OB/GYN) residents working on Labor & Delivery were identified.
• Medicaid patient group most likely to be cared for by residents.
• Outcomes for various complications for these patients in July were compared to those occurring in the months from August to June.

Slide 18

Study Results

• 217 hospitals variably sampled each year.
• Majority were urban hospitals with >500 beds.

Table 1: Baseline Hospital Characteristics

^aThis group of 217 hospitals was variably sampled each year, such that the number of hospitals contributing cases to our cohort in a given year ranged from 68-86.
^bThe criteria for bed size vary according to location. For urban hospitals the criteria are small = 1-299 beds, medium = 300-499 beds, and large = 500 + beds. For rural hospitals, the criteria are small = 1-49 beds, medium = 50-99 beds, and large = 100 + beds.

Note: When a hospital was assigned different bed sizes in different years, the larger size was reported here.

Slide 19

Study Results (continued)

No differences in baseline maternal demographics.

Table 2. Patient Demographics

^aRace is not coded for 76075 (25.4%) of patients.
^bMedian income is not coded for 3017 (1.0%) patients.

Slide 20

Study Results (continued)

• 26,546 patients delivered in the month of July.
• 272,584 patients delivered from August to June:
  • (Average of 24,780 deliveries per month).
• No significant difference in the rates of any complications:
  • Caesarean delivery.
  • Vacuum or forceps-associated vaginal delivery.
  • Urethral or bladder injury.
  • Third and fourth degree lacerations.
  • Wound complications.
  • Postpartum hemorrhage and transfusion.
  • Shoulder dystocia.
  • Chorioamnionitis.
  • Anesthesia related events.

Slide 21

Study Results (continued)

No change in rates of birth asphyxia or brachial plexus injury during summer months.

Table 3: Complications

Slide 22

Conclusions ...It's safe to deliver in July!

• No difference in obstetric complications between women delivered at teaching hospitals in the month of July as compared to women delivered during other months of the year.
• Given sampling technique of NIS and large sample size, our cohort is likely an accurate representation of current state of practice of obstetrics at teaching hospitals in the U.S.
• Post-hoc power calculation showed that the study was well powered to detect even subtle differences in clinical outcomes.

Slide 23

Why?

• Increased supervision at the start of the academic year.
• Previous study investigating teaching hospitals found those with highest attending-to-resident ratios had less of a July phenomenon with regard to length of stay and risk-adjusted mortality.

Slide 24

Slide depicts cartoon from www.cartoonstock.com, with blood-covered doctors in operating room reading medical manuals while a patient lies on the table with a gaping hole in their midsection.

Slide 25

Thank You

Questions?

Slide depicts cartoon from cartoonbank.com with doctor telling patient on examining table "Whoa—way too much information!"

Slide 26

References

Slide includes image of list of references.