PONE-D-24-30541July effect in hospitalized cirrhosis patients: a US nationwide study using difference-in-differences analysisPLOS ONE

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Overall a good study given appears to be novel in looking at the impact of the July effect. It is slightly surprising that there was not significant differences in mortality at all and especially major complications in the teaching hospitals with the new trainees. It would be interesting to see if there would be a difference in terms of types of trainees as not all teaching hospitals have GI fellowships. So if the teaching hospitals include programs without GI fellowships, would the outcomes be different as many patients get admitted to community teaching hospitals that have residency programs but no GI fellowships.

Reviewer #2: Summary: This study investigates the "July effect" by examining the impact of trainee physician turnover on clinical outcomes in cirrhosis patients admitted to US teaching hospitals. Conflicting evidence exists around the July effect, however, this study utilizes a difference-in-differences analysis, comparing outcomes in May and July for teaching versus non-teaching hospitals. The key outcomes measured are mortality and length of stay (LOS), with the results showing no significant difference in mortality but a modest increase in LOS in teaching hospitals, particularly for patients with severe complications. The study emphasizes the need for better supervision of new trainees to mitigate operational disruptions.

Overall Impression: The manuscript is well-written and easy to follow, with clear articulation of the research question, methods, and results. It is methodologically strong and addresses an important research question, contributing valuable insights into the ongoing debate on the July effect. The use of a large, representative dataset (NIS) and a rigorous statistical approach (difference-in-differences) strengthens the validity of the findings. However, there are several areas where further clarification are required, as discussed below.

1. Potential confounding factors: July effect might interact with factors not captured in the dataset, such as differences in hospital staffing structures or the availability of specialized care for cirrhosis patients

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Reviewer #1: No

Reviewer #2: No

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July effect in hospitalized cirrhosis patients: A US nationwide study using difference-in-differences analysis

PONE-D-24-30541R1

Dear Dr. Celdir,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Usama Waqar, M.B.B.S

Academic Editor

PLOS ONE