The Maturation of a Specialty: Workforce Projections for Endocrine Surgery

Slide Presentation from the AHRQ 2008 Annual Conference

On September 10, 2008, Julie Sosa, M.A., M.D., made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (3.2 MB; Plugin Software Help).

Slide 1

The Maturation of a Specialty: Workforce Projections for Endocrine Surgery

Julie Ann Sosa, M.A., M.D., FACS

Associate Professor of Surgery
Sections of Oncologic and Endocrine Surgery
Yale University School of Medicine
New Haven, CT

Slide 2

Background

• Endocrine glands:
  • Thyroid.
  • Parathyroid.
  • Adrenal glands.
  • Pancreas.

Slide contains drawing image of human body, with glands displayed.

Slide 3

Background

Rising incidence of endocrine disease.

• Thyroid:
  • 6.6% of US population.
  • Thyroid cancer: 1.5% of all new cancers.
  • 240% increase over 30 yrs.
  • Fastest growing cancer in women.
• Parathyroid:
  • Incidence: 23.7/100,000.
  • 1.5% Americans ≥65 yrs (3.9 million).
• Adrenal:
  • Adrenal incidentalomas: 5-12% of computer tomography scans (CTs) , autopsies.

Slide 4

Many endocrine diseases are treated surgically.

Thyroidectomy

Slide shows photo of a goiter during thyroidectomy.

Slide 5

Parathyroidectomy

Minimally invasive surgery under local anesthesia in the outpatient setting.

Slide shows photo of parathyroidectomy.

Slide 6

Adrenalectomy

Laparoscopy has improved outcomes.

Slide shows photo of laparoscopy.

Slide 7

Volume: Outcome Association

• High-volume surgeons have better outcomes:
  • Fewer complications.
  • Shorter length of hospital stay.
  • Lower hospital costs.
• Better outcomes for:
  • Thyroidectomy.
  • Parathyroidectomy.
  • Adrenalectomy.

(Sosa et al., 2007, 2008, using Healthcare Cost and Utilization Project [HCUP] data)

Slide 8

Volume: Cost Association

Slide includes bar graph of "Costs for pediatric thyroidectomy and parathyroidectomy, by surgeon volume in HCUP (1999-2005)."

• High volume surgeon—$12,743.
• Low volume surgeon—$15,661.

Slide 9

Volume: Length of Stay Association

Slide includes bar graph of "Length of hospital stay for thyroidectomy in adults, by surgeon volume in HCUP (1999-2005)."

• High volume surgeon—1.6 days.
• Low volume surgeon—2.4 days.

Slide 10

Volume: Complication Rate Association

Slide includes bar graph of "Complication rates following thyroidectomy in the elderly, by surgeon volume in HCUP (1999-2005)."

• High volume surgeon—8.6%.
• Low volume surgeon—12.6%.

Slide 11

Disparities in Outcomes

• Inequity in access to high-volume surgeons:
  • Minorities.
  • Elderly and super-elderly.
  • Lower socioeconomic status.
  • Southern U.S., rural areas.
  • Government insurance (Medicare, Medicaid).

Sosa et al. 2007, 2008 using HCUP

Slide 12

Access to High-Volume Surgeons, By Race

Slide shows bar graph with following legend: Black, White, Hispanic, and Other; the percentage range from 0% to 60%; and Surgeon volume ranges from 1-9 cases, 10-29 cases, 30-100 cases, and > 100 cases.

• 1-9 cases:
  • White—45%.
  • Black—53%.
  • Hispanic—55%.
  • Other—54%.

• 10-29 cases:
  • White—26%.
  • Black—23%.
  • Hispanic—24%.
  • Other—23%.

• 30-100 cases:
  • White—24%.
  • Black—25%.
  • Hispanic—18%.
  • Other—22%.

• >100 cases:
  • White—8%.
  • Black—3%.
  • Hispanic—2%.
  • Other—4%.

Slide 13

Access to High-Volume Surgeons, By Geographic Region

Slide shows map of United States, with endocrine surgeons concentrated in areas with academic medical centers of excellence.

Slide 14

Problem

Despite more specialty-trained endocrine surgeons, the increasing incidence of endocrine disorders raises the question:

Will there continue to be compromised access to high-volume endocrine surgeons?

Slide 15

Objective

To project endocrine surgeon supply and demand over the next several decades in the U.S.

Slide 16

Methods—Supply

• Survey of endocrine surgery fellows:
  • Demographics.
  • Clinical experience during residency, fellowship, practice.
• General surgery residency—Accreditation Council for Graduate Medical Education (ACGME) :
  • Endocrine surgery experience.
• HCUP Nationwide Inpatient Sample (NIS), 2004:
  • Surgeon volume of endocrine procedures in the U.S.

Slide 17

Comparison of Endocrine Surgery Experience

Slide shows bar graph with following legend: Green-Thyroidectomy, Dark Red-Parathyroidectomy, Orange-Adrenalectomy, Bright Red-Endocrine Pancreas, and Yellow-Neck Dissection. Scale is the mean number of cases per program, ranging from 0 to 300. Programs are General Surgery Residency and Endocrine Surgery Fellowship.

Slide 18

Volume distribution of surgeons performing endocrine procedures, 2004*

Slide shows bar graph with following legend: Gray-1 to 4 Cases/Surgeon, Dark Red-5 to 12 Cases/Surgeon, Yellow-13 to 53 Cases/Surgeon, Green->53 Cases/Surgeon. The scale is 0-120%.

* Using HCUP dataset.

Slide 19

Methods—Demand

• U.S. Census Bureau population projections.
• HCUP-NIS/SEER (Surveillance, Epidemiology, and End Results):
  • Procedures abstracted using ICD-9 procedure, diagnosis codes.
  • Incidence rates for benign and malignant disease.

Slide 20

Sensitivity Analyses

Supply

• Annual retirement rate of 2.3%.
• Projected number of specialty-trained endocrine surgeons.

Demand

• U.S. Census Bureau population projections.
• Changes in disease incidence:
  • HCUP.
  • SEER.

Slide 21

Projected numbers of high-volume endocrine surgeons in the U.S., 2004-2030

Slide shows graph with following legend: Red-Base, Yellow-Medium, Green-High volume surgeons. The number of high-volume surgeons are measured from 0 to 10,000.

Slide shows the projected number of high-volume surgeons during the years 2004 through 2030 increasing from 509 to 9,240 endocrine surgeons by 2030.

Slide 22

Age-adjusted estimates of endocrine procedures in the U.S., 2000-2030

Slide shows graph with following legend: Red-Thyroidectomy, Yellow-parathyroidectony, Green-Adrenalectomy, Blue-Endocrine pancreas procedures, Orange-Total endocrine procedures. The number of cases ranges from 0 to 120,000.

Slide shows a minimum increase in total endocrine procedures from ~65,000 in 2000 to ~107,000 in 2030 (age adjusted).

Slide 23

Projections of total endocrine procedures performed in the U.S., 2004-2030

Slide shows graph with following legend: Red-Base, Yellow-Medium, Green-High. The number of cases ranges from 0 to 400,000 Cases.

Slide shows a minimal increase in base and medium surgeon supply, but a projected increase from 75,000 in 2004 to 35,000 cases by 2030.

Slide 24

Conclusions

• Incidence of endocrine disease will continue to increase.
• Specialty-trained endocrine surgeons will increase in number, but.
• The majority of endocrine procedures will continue to be performed by lower-volume surgeons.

Slide 25

Implications: Graduate Medical Education

• Standardization of training across endocrine surgery fellowships:
  • Case distribution.
  • Overall volume.
  • Certification.

Slide 26

Implications: Practice

• Patient, provider education:
  • NY State cardiac reporting system: publicly available data on mortality following coronary artery bypass grafting (CABG) by hospital, surgeon.

• Centers of excellence:
  • Association with endocrine surgery fellowships.
  • Leapfrog: hospital volume to guide referrals.

Slide 27

Implications: Policy

Improve access to high-volume surgeons

• Geographic distribution:
  • Incentives for MDs.
  • Patient indirect costs.
• Lower SES status.
• Government insurance (Medicare/Medicaid).