Hirji Sameer A, Singh Supreet, Okoh Alexis K, Malarczyk Alexandra, Percy Edward D, Harloff Morgan T, Kolkailah Ahmed A, Zogg Cheryl K, Loccoh Emefah, Yazdchi Farhang, Russo Mark J, O'Gara Patrick, Shah Pinak, Kaneko Tsuyoshi
Division of Cardiac Surgery, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Cardiovascular Research Institute, RWJ Barnabas Health, Newark, New Jersey, USA.
Struct Heart. 2022 Mar 17;6(1):100001. doi: 10.1016/j.shj.2022.100001. eCollection 2022 Apr.
The "July effect", the perception of worse outcomes in the first month of training, has been previously demonstrated in critical care medicine and general surgery. However, the July effect in the context of structural heart interventions (i.e., transcatheter aortic valve replacement [TAVR] and MitraClip) remains unknown.
All adult patients undergoing TAVR or MitraClip in the 2012-2016 National Inpatient Sample were included. Outcomes were compared by procedure month and academic year quartiles (i.e., between the first academic year quartile [Q1] vs. the fourth quartile [Q4]). Outcomes between teaching and nonteaching hospitals were compared using risk-adjusted logistic difference-in-difference regression.
During the study period, 94,170 TAVR (Q1: 25,250; Q4: 23,170) and 8750 MitraClip (Q1: 2220; Q4: 2150) procedures were performed. In-hospital mortality did not vary as per academic year quartiles for either procedure, even after risk adjustment. These findings persisted in sensitivity analysis by procedure month and newer device era (2015-2016; all > 0.05). In the subgroup analysis, the unadjusted and adjusted Q1 vs. Q4 in-hospital mortality between teaching and nonteaching hospitals were similar for either procedure. In-hospital mortality also did not vary by procedure month when stratified by hospital teaching status for both procedures. However, postprocedural complication rates appeared to be improving among the TAVR teaching hospitals for stroke, major bleeding, and vascular complications (all < 0.05).
In this large, nationwide study, the July effect was not evident for structural heart interventions. With increasing interest and growth in transcatheter procedures, early resident and fellow teaching can be achieved with appropriate supervision.
“七月效应”，即在培训的第一个月中出现更差结果的这种认知，先前已在重症医学和普通外科中得到证实。然而，在结构性心脏介入治疗（即经导管主动脉瓣置换术 [TAVR] 和二尖瓣夹合术）背景下的“七月效应”仍然未知。
纳入2012 - 2016年全国住院患者样本中所有接受TAVR或二尖瓣夹合术的成年患者。通过手术月份和学年四分位数（即第一学年四分位数 [Q1] 与第四四分位数 [Q4] 之间）比较结果。使用风险调整后的逻辑差分回归比较教学医院和非教学医院之间的结果。
在研究期间，共进行了94,170例TAVR手术（Q1：25,250例；Q4：23,170例）和8750例二尖瓣夹合术（Q1：2220例；Q4：2150例）。对于这两种手术中的任何一种，即使在风险调整后，住院死亡率也未随学年四分位数而变化。这些发现在按手术月份和更新设备时代（2015 - 2016年；所有P>0.05）进行的敏感性分析中持续存在。在亚组分析中，教学医院和非教学医院之间，两种手术中未调整和调整后的Q1与Q4住院死亡率相似。按医院教学状态对两种手术进行分层时，住院死亡率也未随手术月份而变化。然而，在TAVR教学医院中，术后中风、大出血和血管并发症的并发症发生率似乎在改善（所有P<0.05）。
在这项大规模的全国性研究中，结构性心脏介入治疗未出现“七月效应”。随着经导管手术的兴趣增加和发展，可以在适当监督下实现早期住院医师和进修医师的教学。
