‘July effect’ results in cost burden after total joint arthroplasty
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The “July effect” appears to exist among total joint arthroplasty procedures and results in a significant cost burden to the health care system, according to a recently published study.
“Despite the typically successful outcomes of total joint arthroplasty (TJA) procedures, complications and readmissions after total knee arthroplasty (TKA) and total hip arthroplasty (THA) can be disastrous for the patient, the provider and the entire health care system,” Zachary A. Rockov, MD, of the University of Arizona College of Medicine, and colleagues wrote. “The ‘July effect’ refers to the assumed increased risk of complications during July, when medical school graduates within the United States transition to residency programs. The actual existence of a July effect is controversial in the literature, both in orthopedics as well as other medical specialties.”
In a nationwide database search, investigators identified 1,193,034 TJA procedures (primary: n= 1,107,657; revision: n= 85,377) and analyzed these for 30-day readmission rates, time to readmission and readmission costs.
Among all procedure types, investigators found a 3.9% 30-day readmission rate after index procedure discharge in July. This resulted in the highest monthly readmission rate of the year (4.9%). The July effect was most pronounced in the primary TKA cohort (3.9% vs. 3.6%), and stratified results showed the highest readmission rate occurred if the index procedure took place at a nonteaching hospital (4.5%). In July alone, the annualized cost variant for readmission after TJA procedure was estimated at $18.6 million.
“This study provides evidence that a July effect appears to exist for TJA procedures ... In addition, a separate but related May effect appears to exist at teaching institutions, a finding that has never been previously reported,” Rockov and colleagues concluded. “Future research is needed to determine the causes of and possible solutions to these costly problems.”
Perspective
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Jonathan R. Dattilo, MD
I’d like to first commend the authors on the study of this important topic. They used a national database to identify temporal discrepancies in readmission rates and analyzed the additional financial strain this placed on the health system. They found the highest readmission rates in May for teaching institutions and in July for non-teaching institutions.
Patient safety is a crucial concern, not only in total joint replacement, but all of health care.
As described by the authors, the “July effect” is an assumed increased risk of complications as trainees matriculate in the month of July. I would caution readers that here it is important to distinguish between increased readmissions in July and the presence of a “July effect.” The July increased readmissions were seen in non-teaching hospitals, which would have presumably not involved trainees.
I’d also emphasize that these studies are not about assigning blame to anyone, but rather are for quality improvement, identifying systematic issues which could improve for the safety of our patients. I agree with Zachary A. Rockov, MD, and his colleagues that it will be important in the future to elucidate the reasons behind both the increased readmissions during these 2 months and the discrepancies between teaching and non-teaching hospitals for the ultimate betterment of our patients.
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