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  • I would like to thank AHRQ for the opportunity to present our findings this morning. This study was presented at the American Association of Endocrine Surgeons and was published in the journal Surgery in 2007.
  • I know that this is not an audience of clinicians, and therefore I will start with a brief primer on the lexicon of GLANDS. The glands that produce hormones in your body that in endocrine surgery we operate on are the thyroid and the parathyroids in your neck; the adrenal glands on top of your kidneys…and the pancreas, in your abdomen.
  • Diseases of these glands are important public health issues, because they are common, and becoming more so. Thyroid disease affects nearly 7% of the US population. Thyroid cancer represents 1.5% of all new cancers, and it is the fastest increasing cancer in women, up 240% in 3 decades. Parathyroid disease afflicts nearly 24/100,000 Americans, but it typically afflicts elderly women. Indeed, 1.5% of the elderly have primary hyperparathyroidism. Adrenal nodules incidentally found on CT scans and autopsies are seen in 5 to 12% of Americans.
  • Many endocrine diseases are treated surgically; this is a picture of a goiter during thyroidectomy.
  • Parathyroidectomy can be performed using minimally invasive techniques under local anesthesia in the outpatient setting.
  • Laparoscopic adrenalectomy has improved patient outcomes, with improved safety, shorter length of hospital stay and lower costs.
  • Using HCUP-NIS data, our research group shown in a relentless fashion that surgeons who do a high volume of thyroidectomy, parathyroidectomy, and adrenalectomy have fewer complications, shorter length of hospital stay, and lower hospital costs.
  • For example, costs of thyroidectomy and parathyroidectomy among children are significantly lower when these operations are performed by high-volume surgeons compared to low-volume surgeons.
  • Length of stay for thyroidectomy in adults is significantly shorter when surgery is performed by high volume compared to low volume surgeons.
  • Complication rates following thyroidectomy in the elderly are significantly lower when surgery is performed by high- compared to low-volume surgeons.
  • Unfortunately, our research group has shown that there appear to be disparities in patient outcomes following endocrine surgery at least in part because of inequity in access to high volume surgeons, based on race, age, socioeconomic status, geographic region of the country, and patient insurance status. Our research group has demonstrated these findings using HCUP-NIS.
  • For example, white patients have significantly greater access to high-volume surgeons compared to minority patients, who more often have their thyroid surgery performed by the lowest volume surgeons.
  • When we mapped out the US population by County and examined where high volume endocrine surgeons are, we found that endocrine surgeons are concentrated in areas with academic medical centers of excellence. These are not necessarily correlated with population density For example, there are 2 high volume surgeons in Los Angeles (population 3.8 million), 7 in Chicago (population 2.8 million), and 7 in Rochester, Minnesota (population 93,000). These data suggest that there continues to be a discrepancy between population density and availability of high-volume endocrine surgeons, and therefore a geographic barrier to access to high volume surgeons.
  • While we are training more specialists in endocrine surgery, the increasing incidence of endocrine disorders raises the questions of whether there will continue to be compromised access to these high-volume surgeons.
  • Therefore, we decided to project endocrine surgeon supply and demand over the next several decades in the U.S.
  • We calculated the anticipated supply by: Combining recent graduates of endocrine surgery fellowships with . Recent graduating chief residents of 5-year general surgery programs. This new supply was added to the existing supply based on HCUP-NIS data on endocrine surgical procedures and the surgeons who performed them between 1999 and 2004.
  • We found important differences in the new supply of surgeons performing endocrine surgery. Among finishing trainees, we found that, on average, general surgery residents perform fewer than 30 endocrine procedures in 5 years of training, as compared to endocrine surgery fellows, who completed an average of 253 procedures during a single year of training.
  • We then looked beyond training and examined what is happening in actual clinical practice. Here we found that the majority of surgeons performing endocrine procedures in the US do fewer than 4 such cases per year. As a result, we found that 75% of surgeons are low volume, and they do just 26% of the cases. In contrast, the highest volume surgeons, who perform more than endocrine cases per year, account for only 1% of surgeons doing these cases, but they perform 24% of the cases.
  • Anticipated demand was calculated by… Population projections from the U.S. Census Bureau Extracting procedures and incidence rates from HCUP-NIS and SEER databases
  • We formulated base, medium, and high estimates for the supply of and demand for endocrine surgeons over the next 25 years. To do this, we factored in a constant annual retirement rate of 2.3% based on current retirement trends in general surgery, performed sensitivity analyses based on several of the critical assumptions on the supply and demand side.
  • We then looked at projections for the number of endocrine surgeons and the total number of cases… In order to encompass the potential growth of endocrine disease, and therefore the need for specialized endocrine surgeons over the next several decades, we used 3 models for our analyses. SUPPLY: The base supply estimate factors in a constant entrance of new members to the profession and a modest increase in the number of endocrine surgery fellowship programs. The medium estimate is based on an increase in the threshold definition of high-volume endocrine surgeons to 88 cases, the mean number of cases performed by high-volume surgeons. The high estimate assumes an annual increase in the number of high-volume surgeons of 14.7%, based on the annual increase in number of high-volume surgeons between 1999 and 2004. Based on our supply modeling, we anticipate between 509-9240 endocrine surgeons by 2030…
  • Based on the US Census Bureau population projections, with no increased incidence in disease, we expect a minimum increase in total endocrine procedures from ~65,000 in 2000 to ~107,000 in 2030 (age adjusted).
  • Projections for endocrine procedures performed between 2004-2030 were calculated using anticipated increases in the incidence of endocrine disease. These were obtained from incidence rates reported by HCUP-NIS state and national discharge information and the Surveillance, Epidemiology, and End Results (SEER) database for thyroid cancer.14,15 Base projections were age-adjusted, but assume no change after 2004 in incidence of endocrine disease and number of endocrine procedures performed. Sensitivity analyses were based on different assumptions about increasing incidence of endocrine disease and procedures, keeping stable estimates of U.S. population change. A demand model that was based on anticipated increases in the incidence of endocrine disease. The base model assumes no change in incidence, but was age-adjusted. The medium and high increases were based on previously published increases in state HCUP-NIS data, using high and low changes in incidence from various states. We felt that encompassing these projections would accommodate the real possibilities of actual trend in the future. We favor the lower base estimate of surgeon supply (about 500) and the medium estimate of demand, approximately 125,000 cases. But there is still a huge gap between supply and demand…
  • PowerPoint® File

    1. 1. The Maturation of a Specialty: Workforce Projections for Endocrine Surgery Julie Ann Sosa, MA, MD, FACS Associate Professor of Surgery Sections of Oncologic and Endocrine Surgery Yale University School of Medicine New Haven, CT
    2. 2. <ul><li>Endocrine glands </li></ul><ul><ul><li>Thyroid </li></ul></ul><ul><ul><li>Parathyroid </li></ul></ul><ul><ul><li>Adrenal glands </li></ul></ul><ul><ul><li>Pancreas </li></ul></ul>Background
    3. 3. Background <ul><li>Rising incidence of endocrine disease </li></ul><ul><ul><li> Thyroid </li></ul></ul><ul><ul><ul><li>6.6% of US population </li></ul></ul></ul><ul><ul><ul><li>Thyroid cancer: 1.5% of all new cancers </li></ul></ul></ul><ul><ul><ul><li>240% increase over 30 yrs </li></ul></ul></ul><ul><ul><ul><li>Fastest growing cancer in women </li></ul></ul></ul><ul><ul><ul><li>Parathyroid </li></ul></ul></ul><ul><ul><ul><li>Incidence: 23.7/100,000 </li></ul></ul></ul><ul><ul><ul><li>1.5% Americans ≥65 yrs (3.9 million) </li></ul></ul></ul><ul><ul><ul><li>Adrenal </li></ul></ul></ul><ul><ul><ul><li>Adrenal incidentalomas: 5-12% of CTs, autopsies </li></ul></ul></ul>
    4. 4. Many endocrine diseases are treated surgically. <ul><li>Thyroidectomy </li></ul>
    5. 5. <ul><li>Minimally invasive surgery under local anesthesia in the outpatient setting. </li></ul>Parathyroidectomy
    6. 6. <ul><li>Laparoscopy has improved outcomes. </li></ul>Adrenalectomy
    7. 7. Volume : Outcome Association <ul><li>High-volume surgeons have better outcomes. </li></ul><ul><ul><li>Fewer complications </li></ul></ul><ul><ul><li>Shorter length of hospital stay </li></ul></ul><ul><ul><li>Lower hospital costs </li></ul></ul><ul><li>Better outcomes for: </li></ul><ul><ul><li>Thyroidectomy </li></ul></ul><ul><ul><li>Parathyroidectomy </li></ul></ul><ul><ul><li>Adrenalectomy </li></ul></ul><ul><ul><li>(Sosa et al, 2007, 2008 using HCUP) </li></ul></ul>
    8. 8. Volume: Cost Association
    9. 9. Volume: Length of Stay Association
    10. 10. Volume: Complication Rate Association
    11. 11. Disparities in Outcomes <ul><li>Inequity in access to high-volume surgeons </li></ul><ul><ul><li>Minorities </li></ul></ul><ul><ul><li>Elderly and super-elderly </li></ul></ul><ul><ul><li>Lower socioeconomic status </li></ul></ul><ul><ul><li>Southern U.S., rural areas </li></ul></ul><ul><ul><li>Government insurance (Medicare, Medicaid) </li></ul></ul>- Sosa et al 2007, 2008 using HCUP
    12. 12. Access to High-Volume Surgeons, By Race
    13. 13. Access to High-Volume Surgeons, By Geographic Region
    14. 14. Problem <ul><li>Despite more specialty-trained endocrine surgeons, the increasing incidence of endocrine disorders raises the question: </li></ul><ul><li>Will there continue to be compromised </li></ul><ul><li>access to high-volume endocrine surgeons? </li></ul>
    15. 15. Objective <ul><li>To project endocrine surgeon supply and demand over the next several decades in the U.S. </li></ul>
    16. 16. Methods - Supply <ul><li>Survey of endocrine surgery fellows </li></ul><ul><ul><li>Demographics </li></ul></ul><ul><ul><li>Clinical experience during residency, fellowship, practice </li></ul></ul><ul><li>General surgery residency – ACGME </li></ul><ul><ul><li>Endocrine surgery experience </li></ul></ul><ul><li>HCUP-NIS, 2004 </li></ul><ul><ul><li>Surgeon volume of endocrine procedures in the U.S. </li></ul></ul>
    17. 17. Comparison of Endocrine Surgery Experience
    18. 18. Volume distribution of surgeons performing endocrine procedures, 2004 * 75 18 6 1 24 25 25 26 *Using HCUP dataset
    19. 19. Methods - Demand <ul><li>U.S. Census Bureau population projections </li></ul><ul><li>HCUP-NIS / SEER (Surveillance, Epidemiology, and End Results) </li></ul><ul><ul><li>Procedures abstracted using ICD-9 procedure,diagnosis codes </li></ul></ul><ul><ul><li>Incidence rates for benign and malignant disease </li></ul></ul>
    20. 20. Sensitivity Analyses <ul><li>Supply </li></ul><ul><li>Annual retirement rate of 2.3% </li></ul><ul><li>Projected number of specialty-trained endocrine surgeons </li></ul><ul><li>Demand </li></ul><ul><li>U.S. Census bureau population projections </li></ul><ul><li>Changes in disease incidence </li></ul><ul><ul><li>HCUP </li></ul></ul><ul><ul><li>SEER </li></ul></ul>
    21. 21. Projected numbers of high-volume endocrine surgeons in the U.S., 2004-2030
    22. 22. Age-adjusted estimates of endocrine procedures in the U.S., 2000-2030
    23. 23. Projections of total endocrine procedures performed in the U.S., 2004-2030
    24. 24. Conclusions <ul><li>Incidence of endocrine disease will continue to increase. </li></ul><ul><li>Specialty-trained endocrine surgeons will increase in number, but </li></ul><ul><li>The majority of endocrine procedures will continue to be performed by lower-volume surgeons. </li></ul>
    25. 25. Implications: Graduate Medical Education <ul><li>Standardization of training across endocrine surgery fellowships </li></ul><ul><ul><li>Case distribution </li></ul></ul><ul><ul><li>Overall volume </li></ul></ul><ul><ul><li>Certification </li></ul></ul>
    26. 26. Implications: Practice <ul><li>Patient, provider education </li></ul><ul><ul><ul><li>NY State cardiac reporting system: publicly available data on mortality following CABG by hospital, surgeon </li></ul></ul></ul><ul><ul><li>Centers of excellence </li></ul></ul><ul><ul><ul><li>Association with endocrine surgery fellowships </li></ul></ul></ul><ul><ul><ul><li>Leapfrog: hospital volume to guide referrals </li></ul></ul></ul>
    27. 27. Implications: Policy <ul><li>Improve access to high-volume surgeons </li></ul><ul><ul><ul><li>Geographic distribution </li></ul></ul></ul><ul><ul><ul><ul><li>Incentives for MDs </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Patient indirect costs </li></ul></ul></ul></ul><ul><ul><ul><li>Lower SES status </li></ul></ul></ul><ul><ul><ul><li>Government insurance (Medicare/Medicaid) </li></ul></ul></ul>