Clin Endosc.  2019 Sep;52(5):486-496. 10.5946/ce.2018.190.

A Nationwide Assessment of the “July Effect” and Predictors of Post-Endoscopic Retrograde Cholangiopancreatography Sepsis at Urban Teaching Hospitals in the United States

  • 1Atlanta VA Medical Center, Decatur, GA, USA.
  • 2Department of Internal Medicine, Nassau University Medical Center, East Meadow, NY, USA.
  • 3Department of Internal Medicine, College of Medicine/Hospital Corporation of America Graduate Medicine Education Consortium, University of Central Florida, Gainesville, FL, USA.
  • 4Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA, USA.
  • 5Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
  • 6Department of Internal Medicine, Jersey Shore University Medical Center, Neptune, NJ, USA.
  • 7Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA.
  • 8Division of Gastroenterology, Department of Internal Medicine, University of Florida, Gainesville, FL, USA.
  • 9Department of Internal Medicine, Mercer University School of Medicine, Macon, GA, USA.
  • 10Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, MO, USA.
  • 11Division of Gastroenterology, Department of Internal Medicine, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA.


To analyze the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) sepsis in the early (July to September) and later (October to June) academic months to assess the "July effect".
The National Inpatient Sample (2010-2014) was used to identify ERCP-related adult hospitalizations at urban teaching hospitals by applying relevant procedure codes from the International Classification of Diseases, 9th revision, Clinical Modification. Post-ERCP outcomes were compared between the early and later academic months. A multivariate analysis was performed to evaluate the odds of post-ERCP sepsis and its predictors.
Of 481,193 ERCP procedures carried out at urban teaching hospitals, 124,934 were performed during the early academic months. The demographics were comparable for ERCP procedures performed during the early and later academic months. A higher incidence (9.4% vs. 8.8%, p<0.001) and odds (odds ratio [OR], 1.07) of post-ERCP sepsis were observed in ERCP performed during the early academic months. The in-hospital mortality rate (7% vs. 7.5%, p=0.072), length of stay, and total hospital charges in patients with post-ERCP sepsis were also equivalent between the 2 time points. Pre-ERCP cholangitis (OR, 3.20) and post-ERCP complications such as cholangitis (OR, 6.27), perforation (OR, 3.93), and hemorrhage (OR, 1.42) were significant predictors of higher post-ERCP sepsis in procedures performed during the early academic months.
The July effect was present in the incidence of post-ERCP sepsis, and academic programs should take into consideration the predictors of post-ERCP sepsis to lower health-care burden.


Pancreatitis; Endoscopic retrograde cholangiopancreatography; Sepsis; Length of stay; Mortality

MeSH Terms

Cholangiopancreatography, Endoscopic Retrograde
Hospital Charges
Hospital Mortality
Hospitals, Teaching*
International Classification of Diseases
Length of Stay
Multivariate Analysis
United States*

Cited by  1 articles

Is the July Effect Real in Patients Undergoing Endoscopic Retrograde Cholangiopancreatography?
Tae Yoon Lee, Yousuke Nakai
Clin Endosc. 2019;52(5):399-400.    doi: 10.5946/ce.2019.132.


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