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Am J Perinatol 2017; 34(08): 818-825
DOI: 10.1055/s-0037-1598244
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The July Effect on Maternal Peripartum Complications before and after Resident Duty Hour Reform: A Population-Based Retrospective Cohort Study

Ithan D. Peltan
1   Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington Medical Center, Seattle, Washington
2   Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center and University of Utah, Salt Lake City, Utah
3   Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington
,
Crystal E. Brown
1   Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington Medical Center, Seattle, Washington
3   Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington
,
Alson K. Burke
4   Department of Obstetrics and Gynecology, University of Washington Medical Center, Seattle, Washington
,
Eric J. Chow
5   Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
6   Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
,
Ali Rowhani-Rahbar
3   Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington
,
Matthew R. Crull
1   Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington Medical Center, Seattle, Washington
3   Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington
› Author Affiliations
Further Information

Publication History

25 October 2016

03 January 2017

Publication Date:
17 February 2017 (online)

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Abstract

Objective To compare maternal birth complications early versus late in the academic year and to evaluate the impact of resident work hour limitation on the “July effect.”

Study Design We conducted a retrospective, population-based cohort study of 628,414 singleton births in Washington State from 1987 to 2012 measuring the adjusted risk of maternal peripartum complications early (July/August) versus late (April/May) in the academic year. To control for seasonal outcome variation unrelated to trainees' involvement in care as well as long-term trends in maternal complications unrelated to variation in trainees' effect on outcomes across the academic year, we employed difference-in-differences methods contrasting outcomes at teaching to nonteaching hospitals for deliveries before and after restriction of resident work hours in July 2003.

Results Prior to resident work hour limitation in July 2003, women delivering early in the academic year at teaching hospitals suffered more complications (relative risk [RR] 1.05; 95% confidence interval [CI]: 1.00–1.09; p = 0.03). After July 2003, complication risk did not vary significantly across the academic year except at teaching-intensive hospitals, where July/August deliveries experienced fewer complications (RR: 0.95; 95% CI: 0.92–0.98; p = 0.001).

Conclusion Women delivering at teaching hospitals early in the academic year suffered a modest but significant increase in complications before but not after resident work hour reform.

Keywords

July effect - peripartum complications - maternal morbidity - resident work hours - postgraduate medical education - difference-in-differences analysis

Supplementary Material

 

  • References

  • 1 Young JQ, Ranji SR, Wachter RM, Lee CM, Niehaus B, Auerbach AD. “July effect”: impact of the academic year-end changeover on patient outcomes: a systematic review. Ann Intern Med 2011; 155 (05) 309-315
    CrossrefPubMedGoogle Scholar
  • 2 Vaughan L, McAlister G, Bell D. ‘August is always a nightmare’: results of the Royal College of Physicians of Edinburgh and Society of Acute Medicine August transition survey. Clin Med (Lond) 2011; 11 (04) 322-326
    CrossrefPubMedGoogle Scholar
  • 3 Bakalar N. . Focus on Hospitals' ‘July Effect’. New York Times, February 5, 2013:D4
    PubMed
  • 4 Huckman RS, Barro JR. Cohort Turnover and Productivity: The July Phenomenon in Teaching Hospitals. Cambridge, MA: National Bureau of Economic Research; 2005: 1-45
    Google Scholar
  • 5 Jen MH, Bottle A, Majeed A, Bell D, Aylin P. Early in-hospital mortality following trainee doctors' first day at work. PLoS One 2009; 4 (09) e7103 . Doi: 10.1371/journal.pone.0007103
    CrossrefPubMedGoogle Scholar
  • 6 Phillips DP, Barker GEC. A July spike in fatal medication errors: a possible effect of new medical residents. J Gen Intern Med 2010; 25 (08) 774-779
    CrossrefPubMedGoogle Scholar
  • 7 Myles TD. Is there an obstetric July phenomenon?. Obstet Gynecol 2003; 102 (5 Pt 1): 1080-1084
    PubMedGoogle Scholar
  • 8 Ford AA, Bateman BT, Simpson LL, Ratan RB. Nationwide data confirms absence of ‘July phenomenon’ in obstetrics: it's safe to deliver in July. J Perinatol 2007; 27 (02) 73-76
    CrossrefPubMedGoogle Scholar
  • 9 Philibert I, Friedmann P, Williams WT. ; ACGME Work Group on Resident Duty Hours. Accreditation Council for Graduate Medical Education. New requirements for resident duty hours. JAMA 2002; 288 (09) 1112-1114
    CrossrefPubMedGoogle Scholar
  • 10 Hohner V. BERD to CHARS Linkage Rate. Olympia, WA: Washington State Department of Health, Office of Hospital and Patient Data Systems; 1999
    Google Scholar
  • 11 Lydon-Rochelle MT, Holt VL, Nelson JC. , et al. Accuracy of reporting maternal in-hospital diagnoses and intrapartum procedures in Washington State linked birth records. Paediatr Perinat Epidemiol 2005; 19 (06) 460-471
    CrossrefPubMedGoogle Scholar
  • 12 International Classification of Diseases. 9th Revision, Clinical Modification. Atlanta, GA: Centers for Disease Control and Prevention; 2011
    Google Scholar
  • 13 Say L, Souza JP, Pattinson RC. ; WHO working group on Maternal Mortality and Morbidity classifications. Maternal near miss--towards a standard tool for monitoring quality of maternal health care. Best Pract Res Clin Obstet Gynaecol 2009; 23 (03) 287-296
    CrossrefPubMedGoogle Scholar
  • 14 Callaghan WM, Mackay AP, Berg CJ. Identification of severe maternal morbidity during delivery hospitalizations, United States, 1991-2003. Am J Obstet Gynecol 2008; 199 (02) 133.e1-133.e8
    CrossrefPubMedGoogle Scholar
  • 15 Gray KE, Wallace ER, Nelson KR, Reed SD, Schiff MA. Population-based study of risk factors for severe maternal morbidity. Paediatr Perinat Epidemiol 2012; 26 (06) 506-514
    CrossrefPubMedGoogle Scholar
  • 16 Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ. Evaluating obstetrical residency programs using patient outcomes. JAMA 2009; 302 (12) 1277-1283
    CrossrefPubMedGoogle Scholar
  • 17 American Medical Association. Graduate Medical Education Directory. Chicago, IL: American Medical Association; 1986-2013
    Google Scholar
  • 18 Jena AB, Sun EC, Romley JA. Mortality among high-risk patients with acute myocardial infarction admitted to U.S. teaching-intensive hospitals in July: a retrospective observational study. Circulation 2013; 128 (25) 2754-2763
    CrossrefPubMedGoogle Scholar
  • 19 Centers for Disease Control and Prevention. Pediatric and Pregnancy Nutrition Surveillance System Health Indicators. Atlanta, GA: Centers for Disease Control and Prevention; 2011
    Google Scholar
  • 20 World Health Organization. Born Too Soon: The Global Action Report on Preterm Birth. 2012 . Available at http://www.who.int/pmnch/media/news/2012/201204_borntoosoon-report.pdf
    PubMedGoogle Scholar
  • 21 Torvie AJ, Callegari LS, Schiff MA, Debiec KE. Labor and delivery outcomes among young adolescents. Am J Obstet Gynecol 2015; 213 (01) 95.e1-95.e8
    CrossrefPubMedGoogle Scholar
  • 22 Simonsen SME, Lyon JL, Alder SC, Varner MW. Effect of grand multiparity on intrapartum and newborn complications in young women. Obstet Gynecol 2005; 106 (03) 454-460
    CrossrefPubMedGoogle Scholar
  • 23 Darrow LA, Strickland MJ, Klein M. , et al. Seasonality of birth and implications for temporal studies of preterm birth. Epidemiology 2009; 20 (05) 699-706
    CrossrefPubMedGoogle Scholar
  • 24 Lydon-Rochelle MT, Holt VL, Cárdenas V. , et al. The reporting of pre-existing maternal medical conditions and complications of pregnancy on birth certificates and in hospital discharge data. Am J Obstet Gynecol 2005; 193 (01) 125-134
    CrossrefPubMedGoogle Scholar
  • 25 Zou GY, Donner A. Extension of the modified Poisson regression model to prospective studies with correlated binary data. Stat Methods Med Res 2013; 22 (06) 661-670
    CrossrefPubMedGoogle Scholar
  • 26 Dimick JB, Ryan AM. Methods for evaluating changes in health care policy: the difference-in-differences approach. JAMA 2014; 312 (22) 2401-2402
    CrossrefPubMedGoogle Scholar
  • 27 Barry WA, Rosenthal GE. Is there a July phenomenon? The effect of July admission on intensive care mortality and length of stay in teaching hospitals. J Gen Intern Med 2003; 18 (08) 639-645
    CrossrefPubMedGoogle Scholar
  • 28 Nasca TJ, Day SH, Amis Jr ES. ; ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med 2010; 363 (02) e3 . Doi: 10.1056/NEJMsb1005800
    CrossrefPubMedGoogle Scholar
  • 29 Bailit JL, Blanchard MH. The effect of house staff working hours on the quality of obstetric and gynecologic care. Obstet Gynecol 2004; 103 (04) 613-616
    CrossrefPubMedGoogle Scholar
  • 30 Volpp KG, Rosen AK, Rosenbaum PR. , et al. Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. JAMA 2007; 298 (09) 975-983
    CrossrefPubMedGoogle Scholar
  • 31 Volpp KG, Rosen AK, Rosenbaum PR. , et al. Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. JAMA 2007; 298 (09) 984-992
    CrossrefPubMedGoogle Scholar
  • 32 Nuthalapaty FS, Carver AR, Nuthalapaty ES, Ramsey PS. The perceived impact of duty hour restrictions on the residency environment: a survey of residency program directors. Am J Obstet Gynecol 2006; 194 (06) 1556-1562
    CrossrefPubMedGoogle Scholar
  • 33 Blanchard MH, Amini SB, Frank TM. Impact of work hour restrictions on resident case experience in an obstetrics and gynecology residency program. Am J Obstet Gynecol 2004; 191 (05) 1746-1751
    CrossrefPubMedGoogle Scholar
  • 34 Short AC, Rogers SJ, Magann EF, Rieg TS, Shapiro A, Morrison JC. The 80-hour workweek restriction: How are OB/GYN resident procedure numbers affected?. J Matern Fetal Neonatal Med 2006; 19 (12) 801-806
    PubMedGoogle Scholar
  • 35 Basso O, Olsen J, Bisanti L, Juul S, Boldsen J. Are seasonal preferences in pregnancy planning a source of bias in studies of seasonal variation in reproductive outcomes? The European Study Group on Infertility and Subfecundity. Epidemiology 1995; 6 (05) 520-524
    CrossrefPubMedGoogle Scholar