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Lack of July effect in the utilization of neuraxial and peripheral nerve block in US teaching hospitals: a retrospective analysis
  1. Sang Jo Kim1,2,
  2. Lauren Wilson1,
  3. Jiabin Liu1,2,
  4. David H Kim1,2,
  5. Megan Fiasconaro1,
  6. Jashvant Poeran3,
  7. Carrie Freeman1,
  8. Jonathan Beathe1,2 and
  9. Stavros Memtsoudis1,2,4,5
  1. 1Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
  2. 2Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
  3. 3Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  4. 4Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
  5. 5Department of Healthy Policy and Research, Weill Cornell Medical College, New York, NY, United States
  1. Correspondence to Dr Stavros Memtsoudis, Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY 10021, USA; memtsoudiss{at}


Background Given the steep learning curve for neuraxial and peripheral nerve blocks, utilization of general anesthesia may increase as new house staff begin their residency programs. We sought to determine whether “July effect” affects the utilization of neuraxial anesthesia, peripheral nerve blocks, and opioid prescribing for lower extremity total joint arthroplasties (TJA) in July compared with June in teaching and non-teaching hospitals.

Methods Neuraxial anesthesia, peripheral nerve block use, and opioid prescribing trends were assessed using the Premier database (2006–2016). Analyses were conducted separately for teaching and non-teaching hospitals. Differences in proportions were evaluated via χ2 test, while differences in opioid prescribing were analyzed via Wilcoxon rank-sum tests.

Results A total of 1 723 256 TJA procedures were identified. The overall proportion of neuraxial anesthesia use in teaching hospitals was 14.4% in both June and July (p=0.940). No significant changes in neuraxial use were seen in non-teaching hospitals (24.5% vs 24.9%; p=0.052). Peripheral nerve block utilization rates did not differ in both teaching (15.4% vs 15.3%; p=0.714) and non-teaching hospitals (10.7% vs 10.5%; p=0.323). Overall median opioid prescribing at teaching hospitals changed modestly from 262.5 oral morphine equivalents (OME) in June to 260 in July (p=0.026) while median opioid prescribing remained at a constant value of 255 OME at non-teaching hospitals (p=0.893).

Conclusion Utilization of neuraxial and regional anesthesia techniques was not affected during the initial transition period of new house staff in US teaching institutions. It is feasible that enough resources are available in the system to accommodate periods of turnover and maintain levels of regional anesthetic care including additional attending anesthesiologist oversight.

  • regional anesthesia
  • lower extremity
  • pain medicine

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  • Twitter @jbLiujb, @jashvant_p, @sgmemtsoudis

  • Contributors SJK, JP, and SM: helped in the study design/planning, interpretation of results, manuscript preparation and review. LW: helped in study design/planning, data analysis, interpretation of results, manuscript preparation and review. JL, DHK, MF, CF, and JB: helped in study design/planning, interpretation of results, and manuscript review.

  • Funding This study was funded internally by the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.

  • Competing interests SM is a director on the boards of the American Society of Regional Anesthesia and Pain Medicine and the Society of Anesthesia and Sleep Medicine. He is a one-time consultant for Sandoz and Teikoku and is currently on the medical advisory board of HATH. He has a pending US Patent application for a Multicatheter Infusion System. US-2017-0361063. He is the owner of SGM Consulting, LLC and co-owner of FC Monmouth, LLC. None of the above relations influenced the conduct of the present study. All other authors declare no conflicts of interest.

  • Patient consent for publication Not required.

  • Ethics approval Approval was obtained from the Institutional Review Board (IRB) of Hospital for Special Surgery which waived the requirement for informed consent (IRB #2012–050).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data may be obtained from a third party and are not publicly available. Data used for this analysis was from the Premier Healthcare database. It can be obtained from Premier Healthcare pending completion of a data use agreement.