July effect: Not in a month of Sundays with EP

The “July phenomenon” may be a myth when it comes to cardiac electrophysiology (EP) outcomes, according to a study published in the September issue of Heart Rhythm. The study found no association between years of experience and in-hospital complications.

It did, however, find that the most inexperienced new physicians took longer to perform cardiac device implantations and fluoroscopy with cardiac resynchronization therapy (CRT).

“The ‘July Phenomonenon’ describes poor patient outcomes in teaching hospitals at the beginning of a new academic year when trainees begin. It is unclear if this phenomenon truly exists,” wrote the authors, led by Ata Soleimani Rahbar, MD, of the University of California, San Francisco (UCSF) School of Medicine.

To determine the link between physician inexperience and poor EP outcomes, the researchers examined electronic records of 488 patients who underwent first-time dual-chamber pacemaker or CRT device implantation at UCSF between 2004 and 2011. They calculated the experience of EP fellows using procedure date and job start date.

Inexperience was not associated with a higher rate of complications in either pacemaker or CRT procedures. The researchers did not, however, assess the rate of post-discharge complications.

Experience did seem to matter when it came to the time it takes to complete these procedures.

Every year of experience was associated with a decreased procedure time—19 percent in the pacemaker group and 15 percent in the CRT group. With fluoroscopy, every additional year of experience was associated with a 19 percent decrease in CRT procedure time.

Fellows in their second year completed pacemaker implantations 19.2 minutes quicker than fellows in their first year. They performed CRT implantations 37.7 minutes quicker than their first-year counterparts.

The average time for fluoroscopy was 14.9 minutes for second-year fellows compared with 37.4 minutes for first-year fellows.

Their study findings, the authors noted, were at odds with previous research that found a link between inexperienced pulmonary fellows and higher bronchoscopy complication rates during the initial months of training.

However, “[u]nlike pulmonary fellows who start training in bronchoscopy after internal medicine residency, EP fellows typically begin training in device implantation after internal medicine residency and cardiovascular medicine fellowship. Therefore, EP fellows already have considerable procedure experience and often some device implant experience by the time they start EP fellowship,” they wrote.

“Furthermore,” they continued, “all EP procedures are typically performed directly under the direct supervision of experienced attending physicians and complications are rare.”