Original Article
The Effect of July Admission on Inpatient Morbidity, Mortality, and Discharge
Disposition After Endovascular Coiling in Subarachnoid Hemorrhage
Rafael De la Garza Ramos1, Neil Haranhalli1, Andrew J. Kobets1, Jonathan Nakhla1, Allan L. Brook2, Reza Yassari1,
Eugene S. Flamm1, David J. Altschul1
- OBJECTIVE: To investigate effect of July admission on
short-term outcome after endovascular coiling of patients
with subarachnoid hemorrhage (SAH) owing to ruptured
aneurysms.
- METHODS: Data from the National Inpatient Sample
(2012e2014) were gathered. Adult patients with SAH
who underwent endovascular therapy at a teaching
hospital were identified. Admissions during July were
compared with other months as well as based on
admission quarter (AQ): AQ1 (July to September),
AQ2 (October to December), AQ3 (January to March), and
AQ4 (April to June). Outcome measures included
inpatient morbidity (death, iatrogenic stroke, or
myocardial infarction), inpatient mortality, and nonrou-
tine discharges.
- RESULTS: The National Inpatient Sample database
yielded 8515 patients with a diagnosis of SAH who un-
derwent endovascular coiling between 2012 and 2014.
Among these, 665 (7.8%) were admitted in July, and 7850
(92.2%) were admitted in other months. Overall, there
were no differences in any of the examined outcomes,
including morbidity (15.0% vs. 17.3%, P [ 0.513), mor-
tality (10.5% vs. 11.8%, P [ 0.665), or nonroutine
discharge (57.1% vs. 59.7%, P [ 0.567), for patients
admitted in July versus other months. Based on AQ, 24.5%
of patients were admitted in AQ1, 26.0% in AQ2, 23.8% in
AQ3, and 25.7% in AQ4. Similar to July versus other month
admissions, there were no significant differences in
outcomes based on AQ.
Key words
- Aneurysm
- Coil
- Complication
- Endovascular
- July effect
- Subarachnoid hemorrhage
Abbreviations and Acronyms
AQ: Admission quarter
NIS: Nationwide Inpatient Sample
SAH: Subarachnoid hemorrhage
WORLD NEUROSURGERY -: ---, - 2017
- CONCLUSIONS: Based on findings of this national
investigation, patients with SAH owing to ruptured aneu-
rysms who undergo endovascular therapy during the
beginning of the academic year in July may not have worse
short-term outcome compared with patients with admis-
sions during other months.
INTRODUCTION
S
ubarachnoid hemorrhage (SAH) following intracranial
aneurysm rupture accounts for approximately 5% of all
stroke cases.1 It has an estimated incidence of 10.5 per
100,000 persons per year and most commonly affects women
during the sixth decade of life.2,3 More importantly, overall
30-day mortality rate of SAH is 40%, and approximately 50% of
patients remain with disability owing to brain injury.4 At the
present time, treatment of ruptured aneurysms has shifted
toward favoring endovascular management when certain
morphologic criteria are met, owing to the less invasive nature
of the procedure and relatively similar outcome compared with
craniotomy and clipping.5,6 Nonetheless, endovascular coiling
requires adequate hospital infrastructure, effective interaction of
multidisciplinary teams (e.g., neurosurgery, interventional radi-
ology, neurology, critical care medicine), and experienced
providers.
The “July effect” has been a matter of debate for decades. First
described almost 30 years ago,7 this phenomenon refers to the
perceived notion that new hospital staff (e.g., students,
residents, fellows) first starting training in July may contribute
to an increased rate of adverse events during patient care.
From the Departments of 1Neurological Surgery and 2Interventional Neuroradiology,
Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
To whom correspondence should be addressed: David J. Altschul, M.D.
[E-mail: daltschu@montefiore.org]
Citation: World Neurosurg. (2017).
https://doi.org/10.1016/j.wneu.2017.09.126
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org E1
 ORIGINAL ARTICLE
RAFAEL DE LA GARZA RAMOS ET AL. EFFECT OF JULY ADMISSION ON SAH OUTCOMES

Although several studies have found significant differences in myocardial infarction), inpatient mortality, and having a nonrou-
outcomes, such as higher rates of postoperative complications,8 tine discharge (discharge other than home, self-care, or planned
higher rates of fatal medication errors,9 or more frequent acute care hospital inpatient admission). Secondary outcome
occurrences of nonreimbursable hospital-acquired conditions,10 measures included length of stay and total hospital charges.
for patients admitted during July versus other months, multiple
other studies, including in the neurosurgical literature, have
Statistical Analysis
failed to show the existence of such a phenomenon.11-17 Despite
Discharge weights supplied by the NIS were used to calculate
multiple studies examining the impact of July admission on pa-
national estimates. Two cohorts were established for analysis—
tient outcomes, there are limited data on patients with SAH,
July admission versus other months. Patient demographics and
particularly patients undergoing endovascular management.
outcomes were compared between groups via Student t tests or c2
Therefore, the purpose of this study was to determine if patients
tests as appropriate. Additionally, outcomes were compared be-
admitted during the early academic year had higher rates of
tween admission quarters (AQ) based on the academic year as
complications, mortality, or a nonroutine discharge after under-
going endovascular coiling of ruptured aneurysms with SAH.

Table 1. Characteristics of Patients Admitted with Primary

MATERIALS AND METHODS
Diagnosis of Subarachnoid Hemorrhage Who Underwent
Data Source Endovascular Coiling of Ruptured Aneurysm Between 2012 and
This cohort study used the National Inpatient Sample (NIS) 2014
database for the years 2012e2014. It was deemed exempt from All July Other
review by the local institutional review board (2016-6862). The NIS Parameter Patients Admission Months P Value
is currently the largest inpatient database in the United States,
with discharge information from >7 million hospital admissions Number of cases 8515 665 7850
per year. Starting in 2012, the NIS underwent a redesign to Age, years, 55.6
14.4 57.2
14.6 55.5
14.3 0.177
improve national estimates. Rather than capturing all discharges mean
SD
from a 20% sample of hospitals in the United States, it is now a
Male (%) 35.1 30.1 35.5 0.210
sample of discharge records from all participating hospitals. It
contains demographic, diagnostic, and procedural data, with di- Female (%) 64.9 69.9 64.5
agnoses and procedures captured in the form of International Race (%)
Classification of Diseases, Ninth Revision codes. In recent years,
White 59.7 60.3 59.7 0.737
multiple studies have used the NIS to examine neurosurgical
trends and outcomes, given the ability to produce large samples Black 17.4 19.8 17.2
and national estimates.11,18-22 Hispanic 13.6 10.3 13.8
Other 9.3 9.6 9.3
Study Sample
Primary inclusion criteria for our study were patients with a pri- Comorbidities (%)
mary discharge diagnosis of SAH (International Classification of Smoking 29.1 23.3 29.6 0.124
Diseases, Ninth Revision code 430) and treatment with endovas- Hypertension 67.2 71.4 66.8 0.277
cular coiling (International Classification of Diseases, Ninth
Revision code 39.52, 39.72, or 39.79). Exclusion criteria included PVD 10.4 9.8 10.5 0.808
associated diagnoses of intracranial injury, recurrent SAH, arte- CHF 6.2 7.5 6.1 0.520
riovenous malformation, associated craniotomy/aneurysm clip- COPD 13.1 9.8 13.4 0.237
ping, admission to a nonteaching hospital, age <18 years old, and
no data on month of admission. DM uncomplicated 9.9 12.8 9.6 0.240
DM complicated 0.7 0.0 0.8 0.312
Collected Data CKD 3.8 3.8 3.8 0.999
Examined demographic data included patient age, sex, race,
Primary insurance (%)
medical comorbidities, primary insurance, and all patients refined
diagnosis related group mortality risk. All patients refined diag- Medicare 29.0 31.6 28.7 0.886
nosis related group mortality risk ranges from 1 to 4; 1 represents Medicaid 15.4 15.0 15.4
minor likelihood of dying, and 4 represents extreme likelihood of
Private 40.6 40.6 40.6
dying. Other collected data included external ventricular drain
placement, length of stay, and total hospital charges (excluding Other
professional fees). APR-DGR mortality risk 2.8
1.1 2.7
1.2 2.9
1.1 0.157

PVD, peripheral vascular disease; CHF, congestive heart failure; COPD, chronic obstructive
Outcome Measures
pulmonary disease; DM, diabetes mellitus; CKD chronic kidney disease; APR-DGR, all
The 3 outcome measures examined in this study were develop-
patients refined diagnosis related group.
ment of at least 1 complication (mortality, iatrogenic stroke, or

E2 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2017.09.126

 ORIGINAL ARTICLE
RAFAEL DE LA GARZA RAMOS ET AL. EFFECT OF JULY ADMISSION ON SAH OUTCOMES

Table 2. Treatment and Outcomes of Patients Admitted with a Primary Diagnosis of Subarachnoid Hemorrhage Who Underwent
Endovascular Coiling of Ruptured Aneurysm Between 2012 and 2014
Parameter All Patients July Admission Other Months P Value

Number of cases 8515 665 7850

Ventriculostomy (%) 45.6 39.9 46.1 0.168
Complication (%) 17.1 15.0 17.3 0.513
Mortality (%) 11.7 10.5 11.8 0.665
Stroke (%) 3.1 3.0 3.1 0.942
Myocardial infarction (%) 3.3 3.0 3.3 0.850
Mortality (%) 11.7 10.5 11.8 0.665
Nonroutine discharge 59.5 57.1 59.7 0.567
Length of stay, days, mean
SD 17.4
11.9 16.4
10.5 17.5
12.0 0.249
Total hospital charges, mean
SD $329,757
245,179 $341,545
292,030 $328,756
240,865 0.626

follows: AQ1 (July to September), AQ2 (October to December), Treatment of ruptured aneurysms has evolved into minimally
AQ3 (January to March), and AQ4 (April to June). All analyses were invasive techniques such as endovascular coiling or stenting for
conducted in Stata SE 12 (StataCorp LLC, College Station, Texas, select cases, with evidence suggesting that functional outcomes
USA). Statistical significance was set at P < 0.05. are relatively similar or slightly better compared with open sur-
gery and clipping.6 Nonetheless, endovascular management
requires availability of an angiography suite, adequate team
RESULTS
training and coordination, and experienced staff. Given that
Using the NIS database, 8515 patients with a diagnosis of SAH who July represents the beginning of the new academic year and
underwent endovascular coiling between 2012 and 2014 were commencement of training for residents and fellows, the
identified. Among these, 665 (7.8%) were admitted in July, and purpose of this study was to determine whether patients
7850 (92.2%) were admitted in other months. Mean age for the admitted during this month had different short-term outcome
entire group was 55.6 years
14.4 (57.2 years
14.6 for July pa- compared with patients admitted other months when undergo-
tients vs. 55.5 years
14.3 for other months, P ¼ 0.177), and almost ing endovascular management of SAH.
two thirds of patients in both groups were female (69.9% in July After examining >8000 admissions from the NIS of patients
and 64.5% in other months, P ¼ 0.210) (Table 1). Demographic undergoing endovascular treatment of ruptured aneurysms be-
data revealed no differences in race, comorbidities, primary tween 2012 and 2014, we found no evidence of a July effect. Pa-
insurance, or all patients refined diagnosis related group tients had similar rates of mortality, composite morbidity
mortality risk.
When examining treatment and outcomes, which are summa-
rized in Table 2, ventriculostomy was performed in 39.5% of
patients admitted in July and 46.1% of patients admitted during
other months (P ¼ 0.168). Overall, there were no differences in
any of the examined outcomes, including morbidity (15.0% vs.
17.3%), mortality (10.5% vs. 11.8%), or nonroutine discharge
(57.1% vs. 59.7%) for patients admitted in July versus other
months. Lastly, length of stay (16.4 days
10.5 vs. 17.5 days

12.0) and total hospital charges ($341,545
292,030 vs. $328,756

240,865) were also not different between cohorts. Based on
AQ, 24.5% of patients were admitted in AQ1, 26.0% in AQ2,
23.8% in AQ3, and 25.7% in AQ4. Similar to July versus other
month admissions, there were no significant differences in
outcomes based on AQ (Figure 1).

DISCUSSION
Patients with SAH owing to aneurysm rupture are usually criti-
cally ill, particularly when there is associated hydrocephalus,
decreased level of consciousness, or neurologic deficits.
Figure 1. Outcomes based on admission quarter (AQ). There were no
significant differences in complication rates (P ¼ 0.686), mortality (P ¼ 0.147),
or nonroutine discharge rates (P ¼ 0.848) between groups.

WORLD NEUROSURGERY -: ---, - 2017 www.WORLDNEUROSURGERY.org E3

 ORIGINAL ARTICLE
RAFAEL DE LA GARZA RAMOS ET AL. EFFECT OF JULY ADMISSION ON SAH OUTCOMES

(mortality, stroke, or myocardial infarction), and rates of
nonroutine discharges compared with patients admitted any other
month. Likewise, no significant difference was found for patients
admitted in the beginning of the academic year (AQ1) versus pa-
tients admitted during the end of the academic year (AQ4). These
findings suggest that endovascular treatment of patients with SAH
is not hindered by month of admission, reflecting a high quality of
care throughout the academic year.
Commensurate with our findings, McDonald et al.,11 using the
NIS to examine the July effect for all SAH admissions between
2001 and 2008, also found no difference in mortality or
discharge disposition after controlling for differences in
demographic, treatment, and hospital characteristics. However,
these authors did find that complication rates were significantly
lower for patients admitted to teaching versus nonteaching
institutions. Nonetheless, no distinction was made between
treatment modalities (coiling vs. clipping), and patients who did
not undergo any treatment were also included in their
investigation. In another investigation, Lieber et al.17 used the
National Surgical Quality Improvement Program database to
compare outcomes for all neurosurgical operative patients
(cranial, open vascular, and spine) treated in AQ1 versus AQ4.
The authors examined 16,343 open procedures (no endovascular
cases) in academic centers and found a 2.3% versus 2.4% 30-day
mortality rate (P ¼ 0.570), 12.7% versus 11.7% severe complica-
tion rate (P ¼ 0.031), 4.7% versus 5.6% mild complication rate
(P ¼ 0.250), 9.8% versus 8.5% surgical complication rate (P ¼
0.030), and 7.3% versus 8.7% medical complication rate (P ¼
0.200). Although severe complications and surgical complications
were significantly higher, this represents approximately a 1%
difference, which according to the authors is unlikely to be clin-
ically significant. Thus, Lieber et al.17 concluded that there was not
clear evidence for existence of a July effect in adult neurosurgery
and that quality of patient care was most likely maintained
during the educational transition time from July through
September.
As mentioned earlier, neurosurgical patients, particularly pa-
tients with SAH, require a specialized level of care that is unlikely
to be compromised during July. Although incoming interns or
fellows may be directly involved in care for patients with SAH, the
actual coiling or stenting of ruptured aneurysms is almost always
performed by attending physicians, which may explain the
absence of a July effect observed in this study. Vascular neuro-
surgeons, interventional radiologists, and interventional neurolo-
gists undergo extensive postgraduate training before treating
patients with ruptured aneurysms and most of the time are the
leaders of the treating team, which also helps with supervision of
incoming staff.
The findings in the present study are limited by the use of an
administrative database not specific to neurosurgical patients.
Specific data such as Hunt and Hess grade for SAH or presence or
absence of neurologic deficits are not available within the NIS.
Although this may represent an important limitation, it is unlikely
that a specific grade is more likely to manifest in a specific month
versus another. Lastly, although no evidence of a July effect was
observed in the inpatient setting, whether this applies to long-
term outcomes is also unknown and warrants further
investigation.
CONCLUSIONS
The findings of the present study suggest that undergoing
endovascular treatment of ruptured aneurysms in July does not
increase the risk of adverse outcome compared with other
months. This study suggests that, on a national level, critical care
for patients with SAH is preserved regardless of the month of
presentation.

REFERENCES
1. Barry C, Turner RJ, Corrigan F, Vink R. New
therapeutic approaches to subarachnoid hemor-
rhage. Expert Opin Investig Drugs. 2012;21:845-859.
2. Linn FH, Rinkel GJ, Algra A, van Gijn J. Incidence
of subarachnoid hemorrhage: role of region, year,
and rate of computed tomography: a meta-anal-
ysis. Stroke. 1996;27:625-629.
3. Lanzino G, Kassell NF, Germanson TP,
Kongable GL, Truskowski LL, Torner JC, et al.
Age and outcome after aneurysmal subarachnoid
hemorrhage: why do older patients fare worse?
J Neurosurg. 1996;85:410-418.
4. Dority JS, Oldham JS. Subarachnoid hemorrhage:
an update. Anesthesiol Clin. 2016;34:577-600.
5. Spetzler RF, McDougall CG, Albuquerque FC,
Zabramski JM, Hills NK, Partovi S, et al. The
Barrow Ruptured Aneurysm Trial: 3-year results.
J Neurosurg. 2013;119:146-157.
6. Li H, Pan R, Wang H, Rong X, Yin Z,
Milgrom DP, et al. Clipping versus coiling for
ruptured intracranial aneurysms: a systematic re-
view and meta-analysis. Stroke. 2013;44:29-37.
7. Buchwald D, Komaroff AL, Cook EF, Epstein AM.
Indirect costs for medical education. Is there a
July phenomenon? Arch Intern Med. 1989;149:
765-768.
8. Englesbe MJ, Pelletier SJ, Magee JC, Gauger P,
Schifftner T, Henderson WG, 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;246:456-462 [discussion: 463-465].
9. Phillips DP, Barker GE. A July spike in fatal
medication errors: a possible effect of new med-
ical residents. J Gen Intern Med. 2010;25:774-779.
10. Wen T, Attenello FJ, Wu B, Ng A, Cen SY,
Mack WJ. The July effect: an analysis of never
events in the nationwide inpatient sample. J Hosp
Med. 2015;10:432-438.
11. McDonald RJ, Cloft HJ, Kallmes DF. Impact of
admission month and hospital teaching status on
outcomes in subarachnoid hemorrhage: evidence
against the July effect. J Neurosurg. 2012;116:
157-163.
12. Dhaliwal AS, Chu D, Deswal A, Bozkurt B,
Coselli JS, LeMaire SA, et al. The July effect and
cardiac surgery: the effect of the beginning of the
academic cycle on outcomes. Am J Surg. 2008;196:
720-725.
13. Claridge JA, Schulman AM, Sawyer RG, Ghezel-
Ayagh A, Young JS. The “July phenomenon” and
the care of the severely injured patient: fact or
fiction? Surgery. 2001;130:346-353.
14. Barry WA, Rosenthal GE. Is there a July phe-
nomenon? The effect of July admission on inten-
sive care mortality and length of stay in teaching
hospitals. J Gen Intern Med. 2003;18:639-645.
15. De la Garza-Ramos R, Passias PG, Schwab FJ,
Lafage V, Sciubba DM. The effect of July admis-
sion on inpatient morbidity and mortality after

E4 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2017.09.126


RAFAEL DE LA GARZA RAMOS ET AL.
adult spinal deformity surgery. Int J Spine Surg.
2016;10:3.
16. Lin Y, Mayer RR, Verla T, Raskin JS, Lam S. Is
there a “July effect” in pediatric neurosurgery?
Childs Nerv Syst. 2017;33:1367-1371.
17. Lieber BA, Appelboom G, Taylor BE, Malone H,
Agarwal N, Connolly ES Jr. Assessment of the
“July effect”: outcomes after early resident transi-
tion in adult neurosurgery. J Neurosurg. 2016;125:
213-221.
18. De la Garza Ramos R, Goodwin CR, Nakhla J,
Nasser R, Yassari R, Flamm ES, et al. The
nationwide burden of neurological conditions
requiring emergency neurosurgery. Neurosurgery.
2017;81:422-431.
19. De la Garza Ramos R, Goodwin CR, Abu-
Bonsrah N, Bydon A, Witham TF, Wolinsky JP,
WORLD NEUROSURGERY -: ---, - 2017
EFFECT OF JULY ADMISSION ON SAH OUTCOMES
et al. The epidemiology of spinal tuberculosis in
the United States: an analysis of 2002-2011 data.
J Neurosurg Spine. 2017;26:507-512.
20. Sonig A, Shallwani H, Natarajan SK, Shakir HJ,
Hopkins LN, Snyder KV, et al. Better outcomes
and reduced hospitalization cost are associated
with ultra-early treatment of ruptured intracranial
aneurysms: a US nationwide data sample study
[e-pub ahead of print]. Neurosurgery. doi:10.1093/
neuros/nyx241, accessed May 15, 2017.
21. Pandey AS, Wilkinson DA, Gemmete JJ,
Chaudhary N, Thompson BG, Burke JF. Impact of
weekend presentation on short-term outcomes
and choice of clipping vs coiling in subarachnoid
hemorrhage. Neurosurgery. 2017;81:87-91.
22. Thakur JD, Storey C, Kalakoti P, Ahmed O,
Dossani RH, Menger RP, et al. Early intervention
ORIGINAL ARTICLE
in cauda equina syndrome associated with better
outcomes: a myth or reality? Insights from the
Nationwide Inpatient Sample database 2005-2011.
Spine J. 2017;17:1435-1448.
Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 16 August 2017; accepted 19 September 2017
Citation: World Neurosurg. (2017).
https://doi.org/10.1016/j.wneu.2017.09.126
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2017 Elsevier Inc. All
rights reserved.
www.WORLDNEUROSURGERY.org E5