LAUSR

We would like to comment on the first study investigating the “July effect” in post-endoscopic retrograde cholangiopancreatography (ERCP) sepsis at teaching hospitals in the United States. This study is particularly significant because the July effect has not been previously evaluated in relation to the incidence of post-ERCP sepsis. Hypothetically, post-ERCP complications will be higher in the early academic year, when trainees are relatively inexperienced in the ERCP procedure and in preand post-ERCP patient care. It is logical to assume that the undeveloped skill set of newcomers in the early academic months will lead to worse outcomes as compared with those in the remainder of the academic year, and this phenomenon is referred to as the “July effect”. However, there is no convincing evidence to demonstrate the presence of the July effect in post-ERCP complications. The National Inpatient Sample (NIS) database in the United States provides large and reliable data that can be used to evaluate whether a July effect truly exists. In this study, the authors utilized the NIS database to compare the incidence of post-ERCP sepsis in the early (July to September) and late (October to June) academic months in 481,193 ERCP procedures between 2010 and 2014. A higher incidence (9.4% vs. 8.8%, p<0.001) and higher odds (odds ratio, 1.07) of post-ERCP sepsis were observed in ERCP procedures performed during the early academic months. However, the in-hospital mortality rate (7% vs. 7.5%, p=0.072), length of hospital stay, and total hospital charges in patients with post-ERCP sepsis were equivalent between the 2 time points. Although no data are flawless in these types of analyses, it is impressive to know that, as far as this study can inform, there is marginal but statistically significant evidence suggesting that a July effect exists in the occurrence of post-ERCP sepsis. This study raises the question of why it is important to know the effect of trainees on post-ERCP complications. Although the results have been rather variable among studies, several studies have reported reduced efficiency in health-care delivery at the beginning of the academic year among numerous medical conditions, as demonstrated by increased length of hospital stay and mortality. Contrary to the results of this study, another study using the NIS database reported that a July effect does not exist in the occurrence of post-ERCP complications. It also found that the rates of post-ERCP pancreatitis did not differ in teaching hospitals throughout the academic year, suggesting that the presence of in-training fellows and residents is not a risk factor for the development of post-ERCP pancreatitis. However, Cheng et al. revealed that ERCP procedures that involved trainees had a higher risk for post-ERCP pancreatitis. It is unclear why the results of studies investigating the July Received: July 3, 2019 Accepted: July 10 , 2019 Correspondence: Yousuke Nakai Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo 113-8655, Japan Tel: +81-3-3815-5411, Fax: +81-3-5800-9801, E-mail: [email protected] ORCID: https://orcid.org/0000-0001-7411-1385