Is there evidence of a July effect among patients undergoing hysterectomy surgery?


      It is hypothesized that the quality of health care decreases during trainee turnovers at the beginning of the academic year. The influx of new gynecology and surgery residents into hospitals in this setting may be associated with poorer surgical outcomes, known as the July effect.


      We sought to systematically study hysterectomy outcomes in the state of Maryland during the 3-month period July through September as compared to all other months of the academic year, in order to assess for the presence of a July effect in hysterectomy surgery.

      Study Design

      This is a retrospective study of the Maryland Health Services Cost Review Commission Database from July 2012 through September 2015 focused on women undergoing hysterectomies for benign or malignant disease, either by obstetricians and gynecologists or gynecologic oncologists, during July through September vs October through June. Multivariable logistic regressions accounted for clustering by hospitals and adjusted for several cofactors. The primary outcome includes at least 1 of 11 major perioperative in-hospital complications; the secondary outcomes were extended postoperative length of stay (defined as >2 days) and 30-day inpatient readmission rates.


      We identified 6311 hysterectomies (78.2% benign) performed by 424 surgeons at 20 academic hospitals. Patients were primarily white (42.8%), 45–64 years old (54.4%), and had private insurance (66.3%). The unadjusted rate of in-hospital complications was 16.8%, extended length of stay was 30.3%, and 30-day readmissions was 6.6%. After adjustment, patients undergoing hysterectomies during July through September did not have more adverse outcomes relative to those undergoing surgery at other times of the year: complications (adjusted odds ratio, 0.87; 95% confidence interval, 0.75–1.01), length of stay >2 days (adjusted odds ratio, 1.03; 95% confidence interval, 0.90–1.19), and 30-day readmissions (adjusted odds ratio, 0.99; 95% confidence interval, 0.80–1.23). Sensitivity analyses assessing individual complications, hysterectomy outcomes at nonacademic hospitals, and benign vs malignant indications for hysterectomies yielded similar findings.


      Women in Maryland undergoing hysterectomy surgery at academic hospitals during July through September of the academic year did not experience worse outcomes relative to women having surgery in other months. Additional studies are necessary to further assess the possibility of a July effect in hysterectomy on a national basis. Institutions should continue to provide effective surgical training environments for new interns and residents transitioning to more senior roles, while maintaining optimal patient safety.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Cohen S.L.
        • Vitonis A.F.
        • Einarsson J.I.
        Updated hysterectomy surveillance and factors associated with minimally invasive hysterectomy.
        JSLS. 2014; 18
      1. CfDCaP. Key statistics from the national survey of family growth.

        • Barry W.A.
        • Rosenthal G.E.
        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: 639-645
        • Bohl D.D.
        • Fu M.C.
        • Golinvaux N.S.
        • Basques B.A.
        • Gruskay J.A.
        • Grauer J.N.
        The “July effect” in primary total hip and knee arthroplasty: analysis of 21,434 cases from the ACS-NSQIP database.
        J Arthroplast. 2014; 29: 1332-1338
        • Moaddab A.
        • Clark S.L.
        • Dildy G.A.
        • Sangi-Haghpeykar H.
        The July phenomenon in current obstetric practice.
        Am J Obstet Gynecol. 2017; 217: 487-488
        • Shah A.A.
        • Zogg C.K.
        • Nitzschke S.L.
        • et al.
        Evaluation of the perceived association between resident turnover and the outcomes of patients who undergo emergency general surgery: questioning the July phenomenon.
        JAMA Surg. 2016; 151: 217-224
        • Young J.Q.
        • Ranji S.R.
        • Wachter R.M.
        • Lee C.M.
        • Niehaus B.
        • Auerbach A.D.
        “July effect”: impact of the academic year-end changeover on patient outcomes: a systematic review.
        Ann Intern Med. 2011; 155: 309-315
        • Ehlert B.A.
        • Nelson J.T.
        • Goettler C.E.
        • et al.
        Examining the myth of the “July phenomenon” in surgical patients.
        Surgery. 2011; 150: 332-338
        • Ford A.A.
        • Bateman B.T.
        • Simpson L.L.
        • Ratan R.B.
        Nationwide data confirms absence of ‘July phenomenon’ in obstetrics: it’s safe to deliver in July.
        J Perinatol. 2007; 27: 73-76
        • Myles T.D.
        Is there an obstetric July phenomenon?.
        Obstet Gynecol. 2003; 102: 1080-1084
        • Caughey A.B.
        The July phenomenon: why don’t we see it in obstetrics?.
        J Perinatol. 2007; 27: 71-72
        • Fader A.N.
        • Weise R.M.
        • Sinno A.K.
        • et al.
        Utilization of minimally invasive surgery in endometrial cancer care: a quality and cost disparity.
        Obstet Gynecol. 2016; 127: 91-100
        • Mehta A.
        • Xu T.
        • Hutfless S.
        • et al.
        Patient, surgeon, and hospital disparities associated with benign hysterectomy approach and perioperative complications.
        Am J Obstet Gynecol. 2017; 216: 497.e1-497.e10
        • Elixhauser A.
        • Steiner C.
        • Harris D.R.
        • Coffey R.M.
        Comorbidity measures for use with administrative data.
        Med Care. 1998; 36: 8-27
        • Mehta A.
        • Efron D.T.
        • Canner J.K.
        • et al.
        Effect of surgeon and hospital volume on emergency general surgery outcomes.
        J Am Coll Surg. 2017; 225: 666-675.e2
        • Jayatillake R.V.S.
        • MR
        • Senarathna D.L.P.
        Adjusting for a cluster effect in the logistic regression model: an illustration of theory and its application.
        J Natl Sci Found Sri Lanka. 2011; 39: 201-218
        • Richardson L.C.
        • Tian L.
        • Voti L.
        • et al.
        The roles of teaching hospitals, insurance status, and race/ethnicity in receipt of adjuvant therapy for regional-stage breast cancer in Florida.
        Am J Public Health. 2006; 96: 160-166
        • Englesbe M.J.
        • Pelletier S.J.
        • Magee J.C.
        • et al.
        Seasonal variation in surgical outcomes as measured by the American College of Surgeons–National Surgical Quality Improvement Program (ACS–NSQIP).
        Ann Surg. 2007; 246: 456-465
        • Mehra S.
        • Gavard J.A.
        • Gross G.
        • Myles T.
        • Nguyen T.
        • Amon E.
        Door to disposition times for obstetric triage visits: is there a July phenomenon?.
        J Obstet Gynaecol. 2016; 36: 187-191
        • Fallon Jr., W.F.
        • Wears R.L.
        • Tepas III, J.J.
        Resident supervision in the operating room: does this impact on outcome?.
        J Trauma. 1993; 35: 556-561
        • Ahmed N.
        • Devitt K.S.
        • Keshet I.
        • et al.
        A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes.
        Ann Surg. 2014; 259: 1041-1053
        • Ferguson C.M.
        • Kellogg K.C.
        • Hutter M.M.
        • Warshaw A.L.
        Effect of work-hour reforms on operative case volume of surgical residents.
        Curr Surg. 2005; 62: 535-538
        • Shelton J.
        • Kummerow K.
        • Phillips S.
        • et al.
        Patient safety in the era of the 80-hour workweek.
        J Surg Educ. 2014; 71: 551-559
        • Laack T.A.
        • Newman J.S.
        • Goyal D.G.
        • Torsher L.C.
        A 1-week stimulated internship course helps prepare medical students for transition to residency.
        Simul Healthc. 2010; 5: 127-132
        • Chu L.F.
        • Ngai L.K.
        • Young C.A.
        • Pearl R.G.
        • Macario A.
        • Harrison T.K.
        Preparing interns for anesthesiology residency training: development and assessment of the successful transition to anesthesia residency training (START) E-learning curriculum.
        J Grad Med Educ. 2013; 5: 125-129
      2. Rivera-Cruz G, Vargas D, Medina Y. ObGyn residents as teachers: intern boot camp. Available at: Accessed Jan 10, 2018.

        • Haver M.R.V.
        • Borahay M.
        • Jain S.
        • Bastien S.
        • Wen T.
        Ob Gyn intern boot camp: educational outcomes-Council for Residency Education in Obstetrics and Gynecology examinations and preparedness for clinical care.
        Obstet Gynecol. 2016;