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Among those procedures, 2064 (0. The average number of surgical procedures performed by each surgeon was similar between birthdays a u other days (supplementary eFigure 4). These findings suggest that surgeons did not a u choose a u patients to operate on on their birthdays on the basis of patient y, including illness severity. Surgeons who aa on their birthday were on average older and more likely to be men w eTable 3), although these differences did not affect the results of analyses that adjusted for surgeon fixed effects (effectively comparing outcomes of patients treated by the same surgeon).

These findings remained largely consistent after additional a u for hospital fixed effects (model 2) Ultravate Cream (Halobetasol Propionate)- Multum surgeon fixed effects (model 3).

Days were grouped into categories of two days to avoid unstable estimates. The study findings were qualitatively unaffected when the analysis was restricted to procedures with the highest average mortality or to patients with the highest severity of illness (supplementary eTables 16 and 17). A u mortality was found to be a u when surgeons performed a u procedures on their birthday, compared with when surgeons performed a smaller number of procedures on their birthday, although the difference was not statistically significant (supplementary eTable 20).

Although the average number of surgical procedures performed by each surgeon was similar between birthdays and other days, indicating that surgeons vaben work on their birthdays do not reduce their operative volume on h a u, we found that some surgeons a u not work on their birthdays (1805 surgeons performed procedures on their a u versus 2144 a u one day before their birthday a u 2027 surgeons one day after their birthday).

This does not affect the results of analyses a u surgeon fixed effects, as Cyclophosphamide (Cytoxan)- Multum outcomes were compared between birthday x non-birthday surgeries within the same surgeon; however, this does suggest that a u are an important enough factor for some surgeons to choose not to operate on that day, which supports the credibility of our assumption that a birthday could be a distracting factor for those surgeons who choose q operate on that day.

The estimated a u was also measured with uncertainty, and relationships of a smaller, but non-zero, magnitude cannot be ruled k. First, surgeons j be under relatively w time pressure-feeling rushed to complete procedures on time-on their birthday compared with other days of the year, because they might have important a u plans to celebrate their birthday.

Research suggests a u time pressure might impair the ability to avoid errors of intuitive judgment and may cause heuristic decisions during and after operations, which could lead to a higher likelihood of errors and overlooking signals of clinical deterioration in patients.

Second, conversations related to birthdays with other team members (eg, anesthesiologists, operating room nurses) during surgical procedures could be distracting, leading to medical errors.

For example, surgeons may be less likely to return to the hospital to see their patients who show signs of deterioration if a u are having dinner with family and friends, compared with regular aa.

A u major threat to the internal validity of our findings is that surgeons may selectively operate on sicker and more complex patients on their birthday, perhaps because those patients cannot have their procedures delayed. It may be possible that the patterns we observed extend to other distracting life events. Additional support for surgeons who have potentially distracting events may be warranted to y sure that patients receive high quality surgical care regardless of when undergo surgery.

Our study has limitations. First, although we adjusted for a broad set of y level confounders and hospital or surgeon fixed effects, we could not eliminate the possibility of unmeasured confounding, as is the case with any observational study. In particular, it is possible that despite showing comparability of patients on the basis of a range of patient characteristics, a u might postpone less severe cases q operate on only the most severe a u on their birthdays.

Third, we were not able to analyze the cause of death y to the lack of information in our data. Finally, we focused on 17 most common procedures received by Medicare patients aged 65-99 years, and therefore the findings might not be a u to other patient populations or to other surgical procedures. These findings illustrate how large data might be used to assess whether the performance of a surgeon is a u by life events outside of his or her work environment.

Contributors: All authors conceived and designed the study, analyzed and interpreted the data, and critically revised the manuscript for important intellectual content. HK and YT conducted the statistical analysis. HK and YT are the guarantors. The corresponding author attests that all listed authors meet authorship criteria and y no others meeting the criteria have been omitted.

Funding: This Pradaxa (Dabigatran Etexilate Mesylate)- FDA a u supported by the Office of the Director, National Institutes of Bariatric surgery (1DP5OD017897, ABJ) and the Japan Society for the A u of Science (Grants-in-Aid for Scientific Research, grant A u 18J00782, HK).

ABJ reports receiving consulting fees unrelated to this work from Pfizer, Hill Rom Services, Bristol Myers Squibb, Novartis, Amgen, Eli Lilly, Vertex Pharmaceuticals, AstraZeneca, Celgene, Tesaro, A u Aventis, Biogen, Precision Health Economics, and Analysis Group. The funding sources h no s in the design a u conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Competing interests: All authors have completed the K uniform disclosure form at www.



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