The July Effect and its Impact on External Ventricular Drain Placement by Neurosurgical Trainees-Analysis of the National Inpatient Sample

OBJECTIVE: External ventricular drain (EVD) placement is a life-saving procedure performed frequently by neurosurgical residents. The July effect is a theoretic decline in quality of health care sometimes perceived in teaching hospitals at the start of an academic year. We sought to quantify the learning curve of ventriculostomy drain placement in teaching hospitals and determine its impact on patient outcomes, health care utilization, and cost. METHODS: The National Inpatient Sample was queried for patients admitted nonelectively between 2012 and 2015 requiring EVD placement at a teaching hospital determined by using International Classification of Diseases, Ninth Revision codes. Rates of multiple EVD placements per admission, infection and hemorrhage, mortality, length and cost of hospital stay, and discharge disposition were compared between admissions in the first quarter (Q1) of an academic year (July-September) versus those in Q4 (April-June). RESULTS: A total of 7783 admissions met inclusion criteria (3901 in Q1 and 3882 in Q4). The odds ratios (OR) for all combined complications, mortality, and long-term care disposition were similar between Q1 and Q4 groups. There was a significant reduction in the OR of wound and infectious complications in Q1 versus Q4 (1.60% vs. 2.31%; OR, 0.66; P = 0.01). The impact of Q1 EVD placement on total hospital charge and number of EVD codes was not statistically significant. However, there was a statistically significant reduction in length of stay in Q1 compared with Q4 (beta = -0.04 days; P < 0.0001). CONCLUSIONS: There was no evidence of a July effect on EVD complication rates in outcomes for patients admitted in the beginning of an academic year versus the end.