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

Endocrine glands• Thyroid• Parathyroid• Adrenal glands• Pancreas

Background

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: 23.7/100,0001.5% Americans ≥65 yrs (3.9 million)

Adrenal• Adrenal incidentalomas: 5-12% of CTs, autopsies

Many endocrine diseases are treated surgically.

Thyroidectomy

Minimally invasive surgery under local anesthesia in the outpatient setting.

Parathyroidectomy

Laparoscopy has improved outcomes.

Adrenalectomy

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 HCUP)

Volume: Cost Association

Costs for pediatric thyroidectomy and parathyroidectomy, by surgeon volume in HCUP (1999-2005)

12,743

15,661

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

High-Volume Low-VolumeSurgeon Volume

Co

st

($)

Volume: Length of Stay Association

Length of hospital stay for thyroidectomy in adults, by surgeon volume in HCUP (1999-2005)

1.6

2.4

0

0.5

1

1.5

2

2.5

3

High-Volume Low-VolumeSurgeon Volume

Len

gth

of

Sta

y

Volume: Complication Rate Association

Complication rates following thyroidectomy in the elderly, by surgeon volume in HCUP (1999-2005)

8.6

12.6

0

2

4

6

8

10

12

14

High-Volume Low-Volume

Surgeon Volume

Co

mp

lica

tio

n R

ate

(%)

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

Access to High-Volume Surgeons, By Race

Access to High-Volume Surgeons,By Geographic Region

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?

Objective

• To project endocrine surgeon supply and demand over the next several

decades in the U.S.

Methods - Supply

Survey of endocrine surgery fellows Demographics Clinical experience during residency, fellowship, practice

General surgery residency – ACGME Endocrine surgery experience

HCUP-NIS, 2004 Surgeon volume of endocrine procedures in the U.S.

Comparison of Endocrine Surgery Experience

0

50

100

150

200

250

300

General Surgery Residency Endocrine Surgery Fellowship

Training Program

Mea

n N

um

ber

Cas

es/P

rog

ram

Thyroidectomy Parathyroidectomy Adrenalectomy Endocrine Pancreas Neck Dissection

Volume distribution of surgeons performing endocrine procedures, 2004*

0

20

40

60

80

100

120

Percent of surgeons Percent of total cases

Per

cent

1-4 cases/surgeon 5-12 cases/surgeon 13-53 cases/surgeon >53 cases/surgeon

75

18

6

1

24

25

25

26

*Using HCUP dataset

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

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

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

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

2004 2010 2020 2030

Year

Nu

mb

er o

f hig

h-v

olu

me

surg

eon

s

Base Medium High

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

0

20000

40000

60000

80000

100000

120000

2000 2004 2010 2020 2030

Years

Nu

mb

er o

f Cas

es

Thyroidectomy Parathyroidectomy Adrenalectomy

Endocrine pancreas procedures Total endocrine procedures

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

0

50000

100000

150000

200000

250000

300000

350000

400000

2004 2010 2020 2030

Years

Nu

mb

er o

f Cas

es

Base Medium High

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.

Implications: Graduate Medical Education

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

Implications: Practice Patient, provider education

• NY State cardiac reporting system: publicly available data on mortality following CABG by hospital, surgeon

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

Implications: Policy

• Improve access to high-volume surgeons• Geographic distribution

• Incentives for MDs• Patient indirect costs

• Lower SES status • Government insurance (Medicare/Medicaid)