- Email: [email protected]
The maturation of a specialty: Workforce projections for endocrine surgery
The maturation of a specialty: Workforce projections for endocrine surgery Julie Ann Sosa, MD, Tracy S. Wang, MD, Heather L. Yeo, MD, Pritesh J. Mehta, BA, Leon Boudourakis, BA, Robert Udelsman, MD , and Sanziana A. Roman, MD, New Haven, Conn
Background. There has been an increase in the incidence of endocrine diseases and the number of endocrine procedures in the United States. Higher surgeon volume is associated with improved patient outcomes. Fellowship programs will lead to more specialty-trained endocrine surgeons. We make projections for the supply of endocrine surgeons and demand for endocrine procedures over the next 15 years. Methods. Supply projections are based on data from the Accreditation Council for Graduate Medical Education, a survey of American Association of Endocrine Surgery fellowship program graduates, and Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS). Demand is estimated using HCUP-NIS, U.S. Census Bureau projections, and a literature review. Results. There were 64,275 endocrine procedures performed in 2000 and 80,505 in 2004. Using ageadjusted population projections and increasing incidence of endocrine diseases, 103,704 endocrine procedures are anticipated in 2020. High-volume endocrine surgeons are few in number, but perform 24% of endocrine procedures. Surgeon supply is projected to increase to 938 by 2020; this is based on fellowship graduation rates, retirement trends, and increasing annual endocrine case volume among high-volume surgeons. Alternative projections of supply and demand are generated to test the sensitivity of our analyses to different assumptions. Conclusion. Labor force planning in endocrine surgery is essential if the demand for more high-volume endocrine specialists is to be met. (Surgery 2007;142:876-83.) From the Section of Endocrine Surgery, Department of Surgery, Yale–New Haven Hospital, Yale University School of Medicine, New Haven, Conn
Endocrine disorders are being diagnosed more commonly; this trend is especially true for thyroid and parathyroid disease. Palpable thyroid nodules are present in 4%-7% of American adults.1,2 The incidence of thyroid cancer has risen from 4.8 cases per 100,000 population in 1975 to 9.0 cases per 100,000 in 2003; thyroid cancer accounts for 1.5% of all new cancers in the United States.3,4 There are 100,000 new cases of primary hyperparathyroidism each year; it affects 1 in 500 women and 1 in 2,000 men ⬎40 years.5 Endocrine surgery has become a recognized specialty. In the last 5 years, several endocrine surgery
Accepted for publication September 6, 2007. Reprint requests: Sanziana A. Roman, MD, 333 Cedar Street, P.O. Box 208062, New Haven, CT 06520.E-mail: sanziana. [email protected] 0039-6060/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2007.09.005
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centers have developed advanced postgraduate training programs. Accordingly, in 2004, the Executive Council of the American Association of Endocrine Surgeons (AAES) mandated the development of a fellowship curriculum to formalize advanced training objectives and content. Currently, there are 14 fellowship programs in North America. Graduates of these fellowship programs are expected to bolster the ranks of endocrine surgeons in the next several decades. Recent studies have demonstrated a positive association between higher hospital and/or surgeon volume and improved patient outcomes for carotid endarterectomy, abdominal aortic aneurysm repairs, esophagectomy, pancreaticoduodenectomy, and lung resection.6-10 In particular, high surgeon volume has been associated with improved outcomes for thyroidectomy.11 Despite growth in the number of specialtytrained endocrine surgeons, the increasing incidence of endocrine disorders raises the question of whether there will continue to be disparity in pa-
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tient access to high-volume endocrine surgeons. We formulate projections for the supply of highvolume endocrine surgeons and the demand for thyroid, parathyroid, adrenal, and endocrine pancreas procedures to anticipate the need for specialty-trained, high-volume endocrine surgeons. METHODS Supply projections are based on surgeon data collected from the Accreditation Council for Graduate Medical Education (ACGME), a survey of recent graduates of AAES fellowship programs, the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS), and the medical literature. In 1986, a computerized national database was started by the Residency Review Committee for Surgery to measure the operative experience of all graduating chief residents in categorical general surgery training programs. National program data are available on the ACGME website (www.acgme. org). The category “endocrine surgery” includes thyroidectomy (partial or total), parathyroidectomy, adrenalectomy, and resection for neuroendocrine tumors of the pancreas. Head and neck surgery encompasses resection of lesions of the lips, tongue, mouth, parotid and other salivary glands, radical neck dissections, resection of the mandible and maxilla, and tracheostomy. For the purposes of this study, only neck dissections from the head and neck experience were included. A survey was e-mailed to graduates of endocrine surgery fellowship programs between 2003 and 2006. Demographic (age, gender, year of fellowship completion) and clinical (endocrine procedures completed during residency, fellowship, and current surgical practice) data were collected. This portion of our protocol was approved by the Human Investigations Committee. The balance of the study was exempt. The HCUP-NIS, sponsored by the Agency for Health Research and Quality, is an administrative database of hospital inpatient stays and the largest all-payer inpatient database publicly available in the United States. Data from 5-8 million hospital stays at 1,000 hospitals approximate a 20% stratified sample of U.S. community hospitals. HCUP-NIS data from 1999 and 2004 were used. In 1999, data sources were from 24 states, including 984 hospitals and 7,198,929 discharges (unweighted). Data from 2004 were from 37 states, 1,004 hospitals, and 8,004,571 discharges (unweighted). Surgeons performing endocrine procedures in 2004 were sorted into provider volume categories by quartile; high-volume surgeons were in the up-
Table I. ICD-9 definitions of endocrine procedures Procedure
ICD-9 procedure code
ICD-9 diagnosis code
Thyroidectomy Parathyroidectomy Adrenalectomy Endocrine pancreas
6.3x 6.8x 7.2x, 7.3x 52.5x, 52.6x, 52.7x
* * * 157.4, 211.x, 251.x
*Diagnosis codes were not used to limit numbers of thyroidectomy, parathyroidectomy, and adrenalectomy.
per quartile (⬎53 cases/year); surgeons were included, irrespective of subspecialty or type of practice setting. This estimate was extrapolated to the total population based on a 20% sample. An annual retirement rate of 2.3% was factored into all supply models.12 The base estimate factors in the entrance of new members to the profession (graduates of endocrine surgery fellowship), with allowance made for up to 20 programs by 2017. The medium estimate is based on an increase in the threshold definition of high-volume endocrine surgeons to those who perform 88 cases/year, which is the current mean number of cases performed by high-volume surgeons (range, 53-169 cases/year). 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 highvolume surgeons observed between 1999 and 2004. Demand projections are based on HCUP-NIS, U.S. Census Bureau population projections (www. census.gov), and a medical literature review. Thyroid, parathyroid, adrenal, and endocrine pancreas procedures were identified by procedure and diagnosis criteria using International Classification of Diseases, 9th revision (ICD-9) codes (Table I).13 U.S. Census Bureau age-adjusted population projections were based on the 2000 Census. Projections for endocrine procedures performed between 2004 and 2020 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. Projections of medium-increases in
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Fig 1. Comparison of endocrine surgery experience: General surgery residency vs. endocrine surgery fellowship.
the demand for endocrine procedures performed were: (1) thyroidectomy, 2.9%/year increase in thyroid cancer incidence (thyroid cancer procedures are 15.8% of all thyroid procedures); (2) parathyroidectomy, 3.1%/year; (3) adrenalectomy, 5.0%/ year; and (4) endocrine pancreas procedures, 3.6%/year.14,15 Projections of high increases in the demand for endocrine procedures were: (1) thyroidectomy, 1.1%/year increase; (2) parathyroidectomy, 9.4%/year; (3) adrenalectomy, 12.0%/year; and (4) endocrine pancreas procedures, 6.3%/ year.14,16 A sensitivity analysis of the projected supply and demand balance was performed using different assumptions about the percent share of endocrine surgery procedures performed by high-volume endocrine surgeons. RESULTS Supply. Since 2001, graduating general surgery chief residents on average have performed ⬍30 endocrine procedures during training. These numbers include an average of 18 thyroidectomies, 8.6 parathyroidectomies, 1.8 adrenalectomies, 0.1 operations for neuroendocrine tumors of the pancreas, and an average of 20.8 head/neck procedures, including 1.5 neck dissections. This is in contrast to the graduates of endocrine surgery fellowships (Figure 1). The survey response rate was 50%, including 7 women and 8 men with a mean age of 36.1 (range, 33-41) years. During their residency, fellows performed a mean of 78 endocrine procedures (range, 20-131) and 2.9 neck dissections (range, 0-6). The average number of endocrine procedures during fellowship was 253 (range, 107-445), including 127 thyroidectomies, 90 parathyroidectomies, 15 neck dissections, 15 adrenalectomies, and 3.0 pancreas procedures (Table II). Three respondents performed no minimally invasive parathyroidectomies. In their
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current practice, fellowship graduates perform an average of 162 endocrine procedures per year (range, 37-370). Thirteen of 15 respondents practice at academic medical centers; 12 of 15 take an average of 3.8 general surgery and/or trauma calls per month. There were 45 high-volume endocrine surgeons in the 2004 HCUP-NIS sample who performed a mean of 88 endocrine cases per year (Table III). We extrapolated this for the U.S. population based on the 20% sample; they represented just 1% of surgeons performing endocrine operations, but did 24% of the cases (Figure 2). This share remained stable over 5 years. There were 2,381 surgeons in the lowest quartile (ⱕ4 cases/year), who did an average of just 1.8 cases/year. Between 1999 and 2004, they lost 16% of their share to higher volume colleagues. By 2004, surgeons in the lowest quartile represented 75% of surgeons doing only 26% of all endocrine cases. Our base model for supply accounts only for increases in high-volume surgeons from graduation of fellowship programs (Figure 3). The variation in projections observed in our medium and high models is in large part the result of assumptions made regarding: (1) the definition of the minimum case volume threshold (53-88 cases/year for the medium assumption model); and (2) the projected annual increase in high-volume surgeon share (14.7% based on increasing numbers of highvolume surgeons, 1999-2004) for the high assumption model. Ultimately, they result in a range for high-volume surgeon supply of 414-2,351 surgeons. Demand. Based on U.S. Census Bureau population projections, we expect a minimum increase in total endocrine procedures from 65,275 in 2000 to 97,700 in 2020 (age adjusted; Figure 4). When we factor in continuing increases in incidence of endocrine diseases and thereby in endocrine procedures (Table IV), projections of endocrine operations increase, from 103,704 procedures in 2020 for a medium-level increase in incidence, to 173,509 for a high-level increase (Figure 5). The largest proportion of this increase is driven by rising parathyroidectomy rates observed in some states; they are reported to be as high as 9.4% in the literature.12 DISCUSSION In this study, we project the supply of highvolume endocrine surgeons and the demand for endocrine procedures based on data regarding operative experience of surgical trainees, a national discharge database, the U.S. Census Bureau, and a literature review. The number of endocrine proce-
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Table II. Operative experience (case numbers) during fellowship, 2003-2006 Fellows Procedure
F1
F2
F3
F4
F5
F6
F7
F8
F9
F10
F11
F12
F13
F14
F15
Average
Thyroidectomy Parathyroidectomy Neck dissection Adrenalectomy Endocrine pancreas Total
196 147 16 18 0
105 110 10 15 0
98 52 12 16 5
97 70 28 9 2
100 75 5 30 1
300 100 5 10 2
80 125 18 10 0
90 60 40 25 2
— — — — —
200 200 30 15 0
131 42 2 7 3
75 73 5 17 3
120 120 20 25 20
70 10 15 10 2
110 80 5 7 1
127 90 15 15 3
377
240
183
206
211
420
233
217
325
445
185
173
305
107
203
253
Table III. Comparison of lowest vs. highest volume surgeons performing endocrine procedures, HCUP-NIS 1999-2004 Quartile Lowest volume Case definition Surgeons Cases Mean cases/surgeon Highest volume Case definition Surgeons Cases Mean cases/surgeon
1999 n (%)
2004 n (%)
1-3 2532 (77) 3817 (31) 1.5
1-4 2381 (75) 4184 (26) 1.8
ⱖ33 45 (1) 4861 (24) 75
ⱖ53 45 (1) 3995 (24) 88
% ⌬ 1999-2004
% ⌬ case share 1999-2004 ⫺16
⫺2 ⫺5 0 0 0
Abbreviation: Healthcare Cost and Utilization Project National Inpatient Sample.
Fig 3. Sensitivity analysis of projected numbers of highvolume endocrine surgeons in the U.S., 2004-2020.
Fig 2. Supply: Summary of the volume distribution of surgeons performing endocrine procedures, HCUP-NIS, 2004.
dures has increased by 23% over the last 5 years, with a projected increase of 21%-116% over the next 15 years. Overall, we favor the medium estimates for both supply and demand because data supporting improved outcomes for high-volume
endocrine surgeons will likely translate into referral patterns directed to these surgeons, who may, in turn, increase the share of their practices committed to endocrine surgery. With the development of new and safer surgical technology (i.e. minimally invasive parathyroidectomy), potential new indications for parathyroidectomy (i.e. psychiatric and neurocognitive disability), increasing incidence of thyroid cancer, and the aging of the population, we believe an increase is likely in the demand for parathyroid and thyroid surgery. Despite a projected increase in high-volume surgeons, we expect
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Fig 4. Age-adjusted estimates of endocrine procedures performed in the U.S., 2000-2020.
the majority of these endocrine operations to be performed by lower-volume surgeons. This variation in surgeon experience implies variation in the quality of patient outcomes, because surgeon volume is a strong predictor of outcomes for (at least) thyroidectomy and parathyroidectomy. The U.S. Government Accountability Office noted that “the regular assessment of the future health workforce supply and demand is key to setting policies” that will help to ensure access to quality, cost-effective health care.17 In 2006, the Health Resources and Services Administration published physician supply and demand projections to 2020. There is consensus that by 2020 demand will outstrip supply, particularly within medical subspecialties. Although the number of full-time equivalent primary care physicians will grow by 18%, there is a projected decline in surgical subspecialties.17 In 1975, the Study on Surgical Services for the United States was published. The study evaluated the distribution of surgical services and the interaction between surgery and other fields of medicine and the community.18 Since 1976, workforce projections in pediatric surgery have been updated every 5 years.19 Workload projections for surgical oncology were examined by Etzioni et al,20 who found a growing demand for oncologic procedures driven by the aging of the U.S. population. They conclude that growth in demand, combined with surgeon shortages, will lead to decreased access to care for cancer patients.20 Our analysis suggests that projected increases in endocrine procedures are not driven by population aging. This concept makes sense; thyroidectomy is the most common endocrine procedure, and it affects young and middle-aged women. Factors that explain the increase in endocrine procedures include improved diagnostic imaging (i.e. thyroid ultrasonography and computed tomographic identification of adrenal incidentalomas) and development of new surgical
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techniques, such as laparoscopic adrenalectomy and minimally invasive parathyroidectomy. There are limited data regarding the endocrine surgery labor force. The majority of thyroidectomies in the United States are performed by surgeons doing ⬍12 of these operations per year (Figure 2). This was identified previously by Sosa et al11; nearly two thirds of surgeons in Maryland perform ⬍1 thyroidectomy/year. In a study by Saunders et al,21 the majority of endocrine procedures were performed by surgeons whose practices were ⬍25% endocrine surgery; surgeons with ⬎76% endocrine practices made up only 1% of surgeons performing parathyroidectomy, thyroidectomy, and adrenalectomy.21 Recent studies have documented the association between volume and outcomes.6-11 Using SEER data, Begg et al6 found higher hospital volume linked with decreased mortality for pancreatectomy and esophagectomy. Birkmeyer et al7 found similar differences in mortality by hospital volume for 14 cardiovascular and oncologic procedures. This has been documented in pediatrics; children undergoing tracheostomy at low-volume hospitals had higher rates of complications than those at highvolume hospitals.22 Surgeon volume also is correlated with patient outcomes and is related inversely to operative mortality for at least 8 cardiovascular/ oncologic procedures after adjusting for hospital volume.10 The importance of surgeon experience has been studied for thyroidectomy. Based on Maryland data, surgeons doing ⱖ100 cases had the fewest complications with no association observed between hospital volume and outcomes.11 The majority of endocrine procedures are not performed by high-volume surgeons. One possible explanation is related to training. General surgery chief residents complete their training with minimal exposure to endocrine surgery, performing just 11% of the average experience of endocrine surgery fellows. Endocrine surgery fellowships are few; access to these training programs is limited by the fact that there are few high-volume surgeons to serve as mentors. Furthermore, fellowship case volumes (107-445) and variety of cases differ (parathyroidectomies, 23%-54% of total cases; neck dissections, 1%-14%). The AAES has established criteria for curriculum development; further standardization, and/or certification might be necessary. The need for standardized educational objectives and curricula has been shown in trauma surgery; the Eastern Association for the Surgery of Trauma found that lack of these parameters creates an environment detrimental to recruitment and retention of trauma surgeons.23
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Table IV. Demand: Sensitivity analysis of projections of endocrine procedures in the United States, 2004-2020 Procedure Thyroidectomy Base Medium High Parathyroidectomy Base Medium High Adrenalectomy Base Medium High Endocrine pancreas Base Medium High
Estimates of Increase (%)
2004
2010
2020
—* 2.9† 1.1‡
56,595
61,320 58,169 60,436
67,633 60,612 66,688
—* 3.06§ 9.35储
17,580
19,430 21,065 30,056
22,278 28,475 73,472
—* 5.0# 12.0**
4,755
5,222 6,618 9,386
5,804 11,852 29,150
—* 3.58†† 6.32‡‡
1,575
1,720 1,945 2,275
1,987 2,765 4,199
Abbreviations: AAES, American Association of Endocrine Surgeons; HCUP, Healthcare Cost and Utilization Project. *Age-adjusted estimates based on U.S. Census Bureau Projections and 2004 endocrine procedures. †SEER database 1975-2003, adjusted for incidence of thyroid cancer.15 ‡HCUP national estimate, 1994-2005.14 §HCUP national estimate, 1994-2005.14 储HCUP estimate for Massachusetts, 1997-2005.14 #HCUP national estimate, 1994-2005.14 **Gallagher et al, AAES 2007 meeting (abstract).16 ††HCUP estimate for Florida, 1997-2005.14 ‡‡HCUP estimate for Massachusetts, 1997-2005.14
Fig 5. Sensitivity analysis of projections of total endocrine procedures performed in the U.S., 2004-2020.
Access to high-volume endocrine surgeons is an impediment to their increasing volume share given their current geographic distribution. In 2006, there were 7 AAES members in Chicago (population 2.8 million) and Rochester, Minnesota (population 93,000), providing 1 endocrine surgeon/ 410,000 and 13,000 persons, respectively. There are only 2 AAES members in Los Angeles (population 3.8 million), implying a high-volume endocrine surgeon to population ratio of 1 to 1.9 million. Patients need to be well enough and have the financial resources to travel to these surgeons. Re-
ferral to high-volume surgeons for endocrine procedures is not yet mandated by Leapfrog or other payers, who treat provider volume as an indicator for referral for pancreaticoduodenectomy and esophagectomy. Our study has limitations. HCUP-NIS is a 20% sample of U.S. hospitals. Extrapolation to the entire population might not always be appropriate. The database does not include federal hospitals. Nevertheless, HCUP-NIS is used-widely and well validated in health services research. We relied on ICD-9 procedure and diagnosis codes to extract cases; ICD-9 reporting and coding errors could lead to different results, although this has not been shown to be pervasive. Data from HCUP encompass all surgeons performing endocrine procedures, regardless of specialty; the surgeons include general, endocrine, and head and neck surgeons, as well as otolaryngologists. With regard to training, there are currently 102 otolaryngology programs in the United States graduating 254 residents each year; we anticipate the number of otolaryngology residents to remain stable, in contrast to the increasing number of general surgery residents entering endocrine surgery fellowships.
882 Sosa et al
A minority of endocrine procedures will be performed by high-volume endocrine surgeons unless there is a substantial shift in awareness among patients, payers, and referring physicians that endocrine surgery volume is a predictor of outcome. High-volume surgeons may have limited capacity to increase individual caseloads due to the limitations of an individual surgeon as well as patient preferences, socioeconomic status, and geographic considerations. For example, if our estimate of base supply is paired with our base estimate of demand, high-volume surgeons will perform a mean of 66 and 57 procedures in 2010 and 2020, respectively; however, if our base estimate supply is paired with our high-demand estimate, high-volume surgeons will need to increase annual caseloads to 77 and 101 cases, respectively (assuming no increase in high-volume surgeon share of all cases). In summary, labor force planning in endocrine surgery is necessary. It has important implications for patient outcomes and access to care, as well as graduate medical education, particularly with respect to endocrine surgery fellowships. DISCUSSION Dr Maria Allo (San Jose, California): Your data are very interesting, but I could see where they could also bite you, specifically with respect to endocrine pancreatic surgery. And one of the things that comes to mind is, given the paucity of pancreatic islet cell tumors that fellows get to experience, with the very few exceptions that were shown on your slide, do your data suggest that endocrine fellowships may not be considered qualification for doing pancreatic surgery, except in the rare instances where the fellow is trained at one of these few centers? The second question is, did you look at all in terms of the manpower analysis at the numbers of otolaryngology, head, and neck surgeons, who are being trained to do thyroid–parathyroid surgery, some of whom are now sort of subspecializing? Dr Tracy S. Wang (New Haven, Connecticut): With respect to the pancreatic procedures, obviously the focus of our study was to present the data and not necessarily to make any clear-cut judgments on what as endocrine specialists we are able to perform. Obviously, as you saw, there is a wide variety of training. And this is partly because a lot of neuroendocrine tumors are also performed as surgical oncologists, so we have not incorporated that into our data. With respect to otolaryngology, in terms of the actual numbers of surgeons our data do include otolaryngology just because HCUP data do not dif-
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ferentiate in terms of specialty. We did a small survey of otolaryngology residencies, and we did not present the data because we did not have a large enough sample to be able to compare it with general surgery residents. And it did show that on average they performed more thyroidectomy and parathyroidectomy cases than general surgery residents across the country. But again, our purpose in this paper was also to discuss surgeons performing high-volume endocrine surgeries and not necessarily endocrine surgeries per se. In terms of our projections, we included only AAES members. We looked into the otolaryngology residency data and we found there are 102 programs. They graduate about 250 residents per year. And we did not anticipate that this would change drastically over the next several years, whereas with the increase in endocrine surgery fellowships there would be an increase in general surgery residents entering endocrine surgery. Dr Ronald Merrell (Richmond, Virginia): Thank you very much for doing this. I think that workforce studies are going to be important in everything that we do over the next number of years. I believe the greatest lesson I take away from your report is that endocrine surgery is not going to be able to meet the need by any measure for the population in the upcoming years, so we have to look at how others are getting their care. And I would encourage consideration of the surgical oncology fellowships, which have a much richer representation of endocrine. And in fact, with the otolaryngology residencies in a place like my own, which has a strong endocrine program, the otolaryngology residents do almost no thyroid and parathyroid surgery. So thank you very much. And we have to figure how between that 14% and the 100% it can be done conscionably. REFERENCES 1. Maddox PR, Wheeler MH. Approach to thyroid nodules. In: Clark OH, Duh QY, Kebebew E, editors: Textbook of endocrine surgery. 2nd edition. Philadelphia: Elsevier Saunders; 2005. p. 85-92. 2. Vander JV, Gaston EA, Dawber TR. The significance of nontoxic thyroid nodules: final report of a 15-year study of the incidence of thyroid malignancy. Ann Intern Med 1968;69:537-40. 3. Ries LAG, Harkins D, Krapcho M, Mariotto A, Miller BA, Feuer EJ, et al, editors. SEER Cancer Statistics Review, 19752003. National Cancer Institute. Bethesda, MD. Available at: http://seer.cancer.gov/csr/1975-2003/. Accessed 2006. 4. Hegedüs L. The thyroid nodule. N Engl J Med 2004; 351:1764-71. 5. Lal G, Clark OH. Diagnosis of primary hyperparathyroidism and indications for parathyroidectomy. In: Clark OH, Duh QY, Kebebew E, editors: Textbook of endocrine surgery.
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6.
7.
8.
9.
10.
11.
12. 13.
14.
15.
2nd edition. Philadelphia: Elsevier Saunders; 2005. p. 384-92. Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA 1998;280:1747-51. Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346:1128-37. Peck C, Peck J, Peck A. Comparison of carotid endarterectomy at high- and low-volume hospitals. Am J Surg 2001;181:450-3. van Lanschot JJ, Hulscher JB, Buskens CH, Tilanus HW, Ten Kate FJ, Obertop H. Hospital volume and surgical mortality for esophagectomy. Cancer 2001;91:1574-8. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349: 2117-27. Sosa JA, Bowman HM, Tielsch HM, Powe NR, Gordon TA, Udelsman R. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg 1998;228:320-30. Jonasson O, Kwakwa F. Retirement age and the work force in general surgery. Ann Surg 1996;224:574-582. Department of Health and Human Services. The international classification of diseases, 9th revision, clinical modification: ICD-9-CM. Washington (D.C.): U.S. Government Printing Office; 1998. Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS). Available at: http://www.hcup-us. ahrq.gov/home.jsp. Accessed May 2007. Surveillance, Epidemiology and End Results (SEER) fast stats: thyroid cancer. Available at: http://seer.cancer.
16.
17.
18. 19.
20.
21.
22.
23.
gov/faststats/sites.php?site⫹Thyroid⫹Cancer&stat⫽ Incidence. Accessed May 2007. Gallagher S, Baksh K, Wahi M, Haines K, Lee A, Enriques J, et al. The relationship of hospital volume and provider volume is inversely correlated to adverse outcomes in a statewide analysis of 1,816 adrenalectomies. Available at: www.endocrinesurgery.org/mtgs/AAES07abstracts.pdf. Accessed May 2007. U.S. Department of Health and Human Services, Health Resources and Services Administration. Bureau of Health Professions (2006). Physician Supply and Demand: Projections to 2020. Available at: http://bhpr.hrsa.gov/healthworkforce/ reports/physiciansupplydemand/default.htm. Accessed May 2007. Moore FD. Report on the manpower subcommittee. Ann Surg 1975;182:526-30. O’Neill JA, Gautam S, Geiger JD, Ein SH, Holder TM, Bloss RS, et al. A longitudinal analysis of the pediatric surgeon workforce. Ann Surg 2000;232:442-53. Etzioni DA, Liu JH, Maggard MA, O’Connell JB, Ko CY. Workload projections for surgical oncology: will we need more surgeons? Ann Surg Onc 2003;10: 1112-7. Saunders BD, Wainess RM, Dimick JB, Doherty GM, Upchurch GR, Gauger PG. Who performs endocrine operations in the United States? Surgery 2003;134:92431. Berry JG, Lieu TA, Forbes PW, Goldmann DA. Hospital volumes for common pediatric specialty operations. Arch Pediatr Adolesc Med 2007;161:38-43. Chiu WC, Scalea TM, Rotondo MF. Summary report on current clinical trauma care fellowship training programs. J Trauma 2005;58:605-13.
Background. There has been an increase in the incidence of endocrine diseases and the number of endocrine procedures in the United States. Higher surgeon volume is associated with improved patient outcomes. Fellowship programs will lead to more specialty-trained endocrine surgeons. We make projections for the supply of endocrine surgeons and demand for endocrine procedures over the next 15 years. Methods. Supply projections are based on data from the Accreditation Council for Graduate Medical Education, a survey of American Association of Endocrine Surgery fellowship program graduates, and Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS). Demand is estimated using HCUP-NIS, U.S. Census Bureau projections, and a literature review. Results. There were 64,275 endocrine procedures performed in 2000 and 80,505 in 2004. Using ageadjusted population projections and increasing incidence of endocrine diseases, 103,704 endocrine procedures are anticipated in 2020. High-volume endocrine surgeons are few in number, but perform 24% of endocrine procedures. Surgeon supply is projected to increase to 938 by 2020; this is based on fellowship graduation rates, retirement trends, and increasing annual endocrine case volume among high-volume surgeons. Alternative projections of supply and demand are generated to test the sensitivity of our analyses to different assumptions. Conclusion. Labor force planning in endocrine surgery is essential if the demand for more high-volume endocrine specialists is to be met. (Surgery 2007;142:876-83.) From the Section of Endocrine Surgery, Department of Surgery, Yale–New Haven Hospital, Yale University School of Medicine, New Haven, Conn
Endocrine disorders are being diagnosed more commonly; this trend is especially true for thyroid and parathyroid disease. Palpable thyroid nodules are present in 4%-7% of American adults.1,2 The incidence of thyroid cancer has risen from 4.8 cases per 100,000 population in 1975 to 9.0 cases per 100,000 in 2003; thyroid cancer accounts for 1.5% of all new cancers in the United States.3,4 There are 100,000 new cases of primary hyperparathyroidism each year; it affects 1 in 500 women and 1 in 2,000 men ⬎40 years.5 Endocrine surgery has become a recognized specialty. In the last 5 years, several endocrine surgery
Accepted for publication September 6, 2007. Reprint requests: Sanziana A. Roman, MD, 333 Cedar Street, P.O. Box 208062, New Haven, CT 06520.E-mail: sanziana. [email protected] 0039-6060/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2007.09.005
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centers have developed advanced postgraduate training programs. Accordingly, in 2004, the Executive Council of the American Association of Endocrine Surgeons (AAES) mandated the development of a fellowship curriculum to formalize advanced training objectives and content. Currently, there are 14 fellowship programs in North America. Graduates of these fellowship programs are expected to bolster the ranks of endocrine surgeons in the next several decades. Recent studies have demonstrated a positive association between higher hospital and/or surgeon volume and improved patient outcomes for carotid endarterectomy, abdominal aortic aneurysm repairs, esophagectomy, pancreaticoduodenectomy, and lung resection.6-10 In particular, high surgeon volume has been associated with improved outcomes for thyroidectomy.11 Despite growth in the number of specialtytrained endocrine surgeons, the increasing incidence of endocrine disorders raises the question of whether there will continue to be disparity in pa-
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tient access to high-volume endocrine surgeons. We formulate projections for the supply of highvolume endocrine surgeons and the demand for thyroid, parathyroid, adrenal, and endocrine pancreas procedures to anticipate the need for specialty-trained, high-volume endocrine surgeons. METHODS Supply projections are based on surgeon data collected from the Accreditation Council for Graduate Medical Education (ACGME), a survey of recent graduates of AAES fellowship programs, the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS), and the medical literature. In 1986, a computerized national database was started by the Residency Review Committee for Surgery to measure the operative experience of all graduating chief residents in categorical general surgery training programs. National program data are available on the ACGME website (www.acgme. org). The category “endocrine surgery” includes thyroidectomy (partial or total), parathyroidectomy, adrenalectomy, and resection for neuroendocrine tumors of the pancreas. Head and neck surgery encompasses resection of lesions of the lips, tongue, mouth, parotid and other salivary glands, radical neck dissections, resection of the mandible and maxilla, and tracheostomy. For the purposes of this study, only neck dissections from the head and neck experience were included. A survey was e-mailed to graduates of endocrine surgery fellowship programs between 2003 and 2006. Demographic (age, gender, year of fellowship completion) and clinical (endocrine procedures completed during residency, fellowship, and current surgical practice) data were collected. This portion of our protocol was approved by the Human Investigations Committee. The balance of the study was exempt. The HCUP-NIS, sponsored by the Agency for Health Research and Quality, is an administrative database of hospital inpatient stays and the largest all-payer inpatient database publicly available in the United States. Data from 5-8 million hospital stays at 1,000 hospitals approximate a 20% stratified sample of U.S. community hospitals. HCUP-NIS data from 1999 and 2004 were used. In 1999, data sources were from 24 states, including 984 hospitals and 7,198,929 discharges (unweighted). Data from 2004 were from 37 states, 1,004 hospitals, and 8,004,571 discharges (unweighted). Surgeons performing endocrine procedures in 2004 were sorted into provider volume categories by quartile; high-volume surgeons were in the up-
Table I. ICD-9 definitions of endocrine procedures Procedure
ICD-9 procedure code
ICD-9 diagnosis code
Thyroidectomy Parathyroidectomy Adrenalectomy Endocrine pancreas
6.3x 6.8x 7.2x, 7.3x 52.5x, 52.6x, 52.7x
* * * 157.4, 211.x, 251.x
*Diagnosis codes were not used to limit numbers of thyroidectomy, parathyroidectomy, and adrenalectomy.
per quartile (⬎53 cases/year); surgeons were included, irrespective of subspecialty or type of practice setting. This estimate was extrapolated to the total population based on a 20% sample. An annual retirement rate of 2.3% was factored into all supply models.12 The base estimate factors in the entrance of new members to the profession (graduates of endocrine surgery fellowship), with allowance made for up to 20 programs by 2017. The medium estimate is based on an increase in the threshold definition of high-volume endocrine surgeons to those who perform 88 cases/year, which is the current mean number of cases performed by high-volume surgeons (range, 53-169 cases/year). 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 highvolume surgeons observed between 1999 and 2004. Demand projections are based on HCUP-NIS, U.S. Census Bureau population projections (www. census.gov), and a medical literature review. Thyroid, parathyroid, adrenal, and endocrine pancreas procedures were identified by procedure and diagnosis criteria using International Classification of Diseases, 9th revision (ICD-9) codes (Table I).13 U.S. Census Bureau age-adjusted population projections were based on the 2000 Census. Projections for endocrine procedures performed between 2004 and 2020 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. Projections of medium-increases in
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Fig 1. Comparison of endocrine surgery experience: General surgery residency vs. endocrine surgery fellowship.
the demand for endocrine procedures performed were: (1) thyroidectomy, 2.9%/year increase in thyroid cancer incidence (thyroid cancer procedures are 15.8% of all thyroid procedures); (2) parathyroidectomy, 3.1%/year; (3) adrenalectomy, 5.0%/ year; and (4) endocrine pancreas procedures, 3.6%/year.14,15 Projections of high increases in the demand for endocrine procedures were: (1) thyroidectomy, 1.1%/year increase; (2) parathyroidectomy, 9.4%/year; (3) adrenalectomy, 12.0%/year; and (4) endocrine pancreas procedures, 6.3%/ year.14,16 A sensitivity analysis of the projected supply and demand balance was performed using different assumptions about the percent share of endocrine surgery procedures performed by high-volume endocrine surgeons. RESULTS Supply. Since 2001, graduating general surgery chief residents on average have performed ⬍30 endocrine procedures during training. These numbers include an average of 18 thyroidectomies, 8.6 parathyroidectomies, 1.8 adrenalectomies, 0.1 operations for neuroendocrine tumors of the pancreas, and an average of 20.8 head/neck procedures, including 1.5 neck dissections. This is in contrast to the graduates of endocrine surgery fellowships (Figure 1). The survey response rate was 50%, including 7 women and 8 men with a mean age of 36.1 (range, 33-41) years. During their residency, fellows performed a mean of 78 endocrine procedures (range, 20-131) and 2.9 neck dissections (range, 0-6). The average number of endocrine procedures during fellowship was 253 (range, 107-445), including 127 thyroidectomies, 90 parathyroidectomies, 15 neck dissections, 15 adrenalectomies, and 3.0 pancreas procedures (Table II). Three respondents performed no minimally invasive parathyroidectomies. In their
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current practice, fellowship graduates perform an average of 162 endocrine procedures per year (range, 37-370). Thirteen of 15 respondents practice at academic medical centers; 12 of 15 take an average of 3.8 general surgery and/or trauma calls per month. There were 45 high-volume endocrine surgeons in the 2004 HCUP-NIS sample who performed a mean of 88 endocrine cases per year (Table III). We extrapolated this for the U.S. population based on the 20% sample; they represented just 1% of surgeons performing endocrine operations, but did 24% of the cases (Figure 2). This share remained stable over 5 years. There were 2,381 surgeons in the lowest quartile (ⱕ4 cases/year), who did an average of just 1.8 cases/year. Between 1999 and 2004, they lost 16% of their share to higher volume colleagues. By 2004, surgeons in the lowest quartile represented 75% of surgeons doing only 26% of all endocrine cases. Our base model for supply accounts only for increases in high-volume surgeons from graduation of fellowship programs (Figure 3). The variation in projections observed in our medium and high models is in large part the result of assumptions made regarding: (1) the definition of the minimum case volume threshold (53-88 cases/year for the medium assumption model); and (2) the projected annual increase in high-volume surgeon share (14.7% based on increasing numbers of highvolume surgeons, 1999-2004) for the high assumption model. Ultimately, they result in a range for high-volume surgeon supply of 414-2,351 surgeons. Demand. Based on U.S. Census Bureau population projections, we expect a minimum increase in total endocrine procedures from 65,275 in 2000 to 97,700 in 2020 (age adjusted; Figure 4). When we factor in continuing increases in incidence of endocrine diseases and thereby in endocrine procedures (Table IV), projections of endocrine operations increase, from 103,704 procedures in 2020 for a medium-level increase in incidence, to 173,509 for a high-level increase (Figure 5). The largest proportion of this increase is driven by rising parathyroidectomy rates observed in some states; they are reported to be as high as 9.4% in the literature.12 DISCUSSION In this study, we project the supply of highvolume endocrine surgeons and the demand for endocrine procedures based on data regarding operative experience of surgical trainees, a national discharge database, the U.S. Census Bureau, and a literature review. The number of endocrine proce-
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Table II. Operative experience (case numbers) during fellowship, 2003-2006 Fellows Procedure
F1
F2
F3
F4
F5
F6
F7
F8
F9
F10
F11
F12
F13
F14
F15
Average
Thyroidectomy Parathyroidectomy Neck dissection Adrenalectomy Endocrine pancreas Total
196 147 16 18 0
105 110 10 15 0
98 52 12 16 5
97 70 28 9 2
100 75 5 30 1
300 100 5 10 2
80 125 18 10 0
90 60 40 25 2
— — — — —
200 200 30 15 0
131 42 2 7 3
75 73 5 17 3
120 120 20 25 20
70 10 15 10 2
110 80 5 7 1
127 90 15 15 3
377
240
183
206
211
420
233
217
325
445
185
173
305
107
203
253
Table III. Comparison of lowest vs. highest volume surgeons performing endocrine procedures, HCUP-NIS 1999-2004 Quartile Lowest volume Case definition Surgeons Cases Mean cases/surgeon Highest volume Case definition Surgeons Cases Mean cases/surgeon
1999 n (%)
2004 n (%)
1-3 2532 (77) 3817 (31) 1.5
1-4 2381 (75) 4184 (26) 1.8
ⱖ33 45 (1) 4861 (24) 75
ⱖ53 45 (1) 3995 (24) 88
% ⌬ 1999-2004
% ⌬ case share 1999-2004 ⫺16
⫺2 ⫺5 0 0 0
Abbreviation: Healthcare Cost and Utilization Project National Inpatient Sample.
Fig 3. Sensitivity analysis of projected numbers of highvolume endocrine surgeons in the U.S., 2004-2020.
Fig 2. Supply: Summary of the volume distribution of surgeons performing endocrine procedures, HCUP-NIS, 2004.
dures has increased by 23% over the last 5 years, with a projected increase of 21%-116% over the next 15 years. Overall, we favor the medium estimates for both supply and demand because data supporting improved outcomes for high-volume
endocrine surgeons will likely translate into referral patterns directed to these surgeons, who may, in turn, increase the share of their practices committed to endocrine surgery. With the development of new and safer surgical technology (i.e. minimally invasive parathyroidectomy), potential new indications for parathyroidectomy (i.e. psychiatric and neurocognitive disability), increasing incidence of thyroid cancer, and the aging of the population, we believe an increase is likely in the demand for parathyroid and thyroid surgery. Despite a projected increase in high-volume surgeons, we expect
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Fig 4. Age-adjusted estimates of endocrine procedures performed in the U.S., 2000-2020.
the majority of these endocrine operations to be performed by lower-volume surgeons. This variation in surgeon experience implies variation in the quality of patient outcomes, because surgeon volume is a strong predictor of outcomes for (at least) thyroidectomy and parathyroidectomy. The U.S. Government Accountability Office noted that “the regular assessment of the future health workforce supply and demand is key to setting policies” that will help to ensure access to quality, cost-effective health care.17 In 2006, the Health Resources and Services Administration published physician supply and demand projections to 2020. There is consensus that by 2020 demand will outstrip supply, particularly within medical subspecialties. Although the number of full-time equivalent primary care physicians will grow by 18%, there is a projected decline in surgical subspecialties.17 In 1975, the Study on Surgical Services for the United States was published. The study evaluated the distribution of surgical services and the interaction between surgery and other fields of medicine and the community.18 Since 1976, workforce projections in pediatric surgery have been updated every 5 years.19 Workload projections for surgical oncology were examined by Etzioni et al,20 who found a growing demand for oncologic procedures driven by the aging of the U.S. population. They conclude that growth in demand, combined with surgeon shortages, will lead to decreased access to care for cancer patients.20 Our analysis suggests that projected increases in endocrine procedures are not driven by population aging. This concept makes sense; thyroidectomy is the most common endocrine procedure, and it affects young and middle-aged women. Factors that explain the increase in endocrine procedures include improved diagnostic imaging (i.e. thyroid ultrasonography and computed tomographic identification of adrenal incidentalomas) and development of new surgical
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techniques, such as laparoscopic adrenalectomy and minimally invasive parathyroidectomy. There are limited data regarding the endocrine surgery labor force. The majority of thyroidectomies in the United States are performed by surgeons doing ⬍12 of these operations per year (Figure 2). This was identified previously by Sosa et al11; nearly two thirds of surgeons in Maryland perform ⬍1 thyroidectomy/year. In a study by Saunders et al,21 the majority of endocrine procedures were performed by surgeons whose practices were ⬍25% endocrine surgery; surgeons with ⬎76% endocrine practices made up only 1% of surgeons performing parathyroidectomy, thyroidectomy, and adrenalectomy.21 Recent studies have documented the association between volume and outcomes.6-11 Using SEER data, Begg et al6 found higher hospital volume linked with decreased mortality for pancreatectomy and esophagectomy. Birkmeyer et al7 found similar differences in mortality by hospital volume for 14 cardiovascular and oncologic procedures. This has been documented in pediatrics; children undergoing tracheostomy at low-volume hospitals had higher rates of complications than those at highvolume hospitals.22 Surgeon volume also is correlated with patient outcomes and is related inversely to operative mortality for at least 8 cardiovascular/ oncologic procedures after adjusting for hospital volume.10 The importance of surgeon experience has been studied for thyroidectomy. Based on Maryland data, surgeons doing ⱖ100 cases had the fewest complications with no association observed between hospital volume and outcomes.11 The majority of endocrine procedures are not performed by high-volume surgeons. One possible explanation is related to training. General surgery chief residents complete their training with minimal exposure to endocrine surgery, performing just 11% of the average experience of endocrine surgery fellows. Endocrine surgery fellowships are few; access to these training programs is limited by the fact that there are few high-volume surgeons to serve as mentors. Furthermore, fellowship case volumes (107-445) and variety of cases differ (parathyroidectomies, 23%-54% of total cases; neck dissections, 1%-14%). The AAES has established criteria for curriculum development; further standardization, and/or certification might be necessary. The need for standardized educational objectives and curricula has been shown in trauma surgery; the Eastern Association for the Surgery of Trauma found that lack of these parameters creates an environment detrimental to recruitment and retention of trauma surgeons.23
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Table IV. Demand: Sensitivity analysis of projections of endocrine procedures in the United States, 2004-2020 Procedure Thyroidectomy Base Medium High Parathyroidectomy Base Medium High Adrenalectomy Base Medium High Endocrine pancreas Base Medium High
Estimates of Increase (%)
2004
2010
2020
—* 2.9† 1.1‡
56,595
61,320 58,169 60,436
67,633 60,612 66,688
—* 3.06§ 9.35储
17,580
19,430 21,065 30,056
22,278 28,475 73,472
—* 5.0# 12.0**
4,755
5,222 6,618 9,386
5,804 11,852 29,150
—* 3.58†† 6.32‡‡
1,575
1,720 1,945 2,275
1,987 2,765 4,199
Abbreviations: AAES, American Association of Endocrine Surgeons; HCUP, Healthcare Cost and Utilization Project. *Age-adjusted estimates based on U.S. Census Bureau Projections and 2004 endocrine procedures. †SEER database 1975-2003, adjusted for incidence of thyroid cancer.15 ‡HCUP national estimate, 1994-2005.14 §HCUP national estimate, 1994-2005.14 储HCUP estimate for Massachusetts, 1997-2005.14 #HCUP national estimate, 1994-2005.14 **Gallagher et al, AAES 2007 meeting (abstract).16 ††HCUP estimate for Florida, 1997-2005.14 ‡‡HCUP estimate for Massachusetts, 1997-2005.14
Fig 5. Sensitivity analysis of projections of total endocrine procedures performed in the U.S., 2004-2020.
Access to high-volume endocrine surgeons is an impediment to their increasing volume share given their current geographic distribution. In 2006, there were 7 AAES members in Chicago (population 2.8 million) and Rochester, Minnesota (population 93,000), providing 1 endocrine surgeon/ 410,000 and 13,000 persons, respectively. There are only 2 AAES members in Los Angeles (population 3.8 million), implying a high-volume endocrine surgeon to population ratio of 1 to 1.9 million. Patients need to be well enough and have the financial resources to travel to these surgeons. Re-
ferral to high-volume surgeons for endocrine procedures is not yet mandated by Leapfrog or other payers, who treat provider volume as an indicator for referral for pancreaticoduodenectomy and esophagectomy. Our study has limitations. HCUP-NIS is a 20% sample of U.S. hospitals. Extrapolation to the entire population might not always be appropriate. The database does not include federal hospitals. Nevertheless, HCUP-NIS is used-widely and well validated in health services research. We relied on ICD-9 procedure and diagnosis codes to extract cases; ICD-9 reporting and coding errors could lead to different results, although this has not been shown to be pervasive. Data from HCUP encompass all surgeons performing endocrine procedures, regardless of specialty; the surgeons include general, endocrine, and head and neck surgeons, as well as otolaryngologists. With regard to training, there are currently 102 otolaryngology programs in the United States graduating 254 residents each year; we anticipate the number of otolaryngology residents to remain stable, in contrast to the increasing number of general surgery residents entering endocrine surgery fellowships.
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A minority of endocrine procedures will be performed by high-volume endocrine surgeons unless there is a substantial shift in awareness among patients, payers, and referring physicians that endocrine surgery volume is a predictor of outcome. High-volume surgeons may have limited capacity to increase individual caseloads due to the limitations of an individual surgeon as well as patient preferences, socioeconomic status, and geographic considerations. For example, if our estimate of base supply is paired with our base estimate of demand, high-volume surgeons will perform a mean of 66 and 57 procedures in 2010 and 2020, respectively; however, if our base estimate supply is paired with our high-demand estimate, high-volume surgeons will need to increase annual caseloads to 77 and 101 cases, respectively (assuming no increase in high-volume surgeon share of all cases). In summary, labor force planning in endocrine surgery is necessary. It has important implications for patient outcomes and access to care, as well as graduate medical education, particularly with respect to endocrine surgery fellowships. DISCUSSION Dr Maria Allo (San Jose, California): Your data are very interesting, but I could see where they could also bite you, specifically with respect to endocrine pancreatic surgery. And one of the things that comes to mind is, given the paucity of pancreatic islet cell tumors that fellows get to experience, with the very few exceptions that were shown on your slide, do your data suggest that endocrine fellowships may not be considered qualification for doing pancreatic surgery, except in the rare instances where the fellow is trained at one of these few centers? The second question is, did you look at all in terms of the manpower analysis at the numbers of otolaryngology, head, and neck surgeons, who are being trained to do thyroid–parathyroid surgery, some of whom are now sort of subspecializing? Dr Tracy S. Wang (New Haven, Connecticut): With respect to the pancreatic procedures, obviously the focus of our study was to present the data and not necessarily to make any clear-cut judgments on what as endocrine specialists we are able to perform. Obviously, as you saw, there is a wide variety of training. And this is partly because a lot of neuroendocrine tumors are also performed as surgical oncologists, so we have not incorporated that into our data. With respect to otolaryngology, in terms of the actual numbers of surgeons our data do include otolaryngology just because HCUP data do not dif-
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ferentiate in terms of specialty. We did a small survey of otolaryngology residencies, and we did not present the data because we did not have a large enough sample to be able to compare it with general surgery residents. And it did show that on average they performed more thyroidectomy and parathyroidectomy cases than general surgery residents across the country. But again, our purpose in this paper was also to discuss surgeons performing high-volume endocrine surgeries and not necessarily endocrine surgeries per se. In terms of our projections, we included only AAES members. We looked into the otolaryngology residency data and we found there are 102 programs. They graduate about 250 residents per year. And we did not anticipate that this would change drastically over the next several years, whereas with the increase in endocrine surgery fellowships there would be an increase in general surgery residents entering endocrine surgery. Dr Ronald Merrell (Richmond, Virginia): Thank you very much for doing this. I think that workforce studies are going to be important in everything that we do over the next number of years. I believe the greatest lesson I take away from your report is that endocrine surgery is not going to be able to meet the need by any measure for the population in the upcoming years, so we have to look at how others are getting their care. And I would encourage consideration of the surgical oncology fellowships, which have a much richer representation of endocrine. And in fact, with the otolaryngology residencies in a place like my own, which has a strong endocrine program, the otolaryngology residents do almost no thyroid and parathyroid surgery. So thank you very much. And we have to figure how between that 14% and the 100% it can be done conscionably. REFERENCES 1. Maddox PR, Wheeler MH. Approach to thyroid nodules. In: Clark OH, Duh QY, Kebebew E, editors: Textbook of endocrine surgery. 2nd edition. Philadelphia: Elsevier Saunders; 2005. p. 85-92. 2. Vander JV, Gaston EA, Dawber TR. The significance of nontoxic thyroid nodules: final report of a 15-year study of the incidence of thyroid malignancy. Ann Intern Med 1968;69:537-40. 3. Ries LAG, Harkins D, Krapcho M, Mariotto A, Miller BA, Feuer EJ, et al, editors. SEER Cancer Statistics Review, 19752003. National Cancer Institute. Bethesda, MD. Available at: http://seer.cancer.gov/csr/1975-2003/. Accessed 2006. 4. Hegedüs L. The thyroid nodule. N Engl J Med 2004; 351:1764-71. 5. Lal G, Clark OH. Diagnosis of primary hyperparathyroidism and indications for parathyroidectomy. In: Clark OH, Duh QY, Kebebew E, editors: Textbook of endocrine surgery.
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6.
7.
8.
9.
10.
11.
12. 13.
14.
15.
2nd edition. Philadelphia: Elsevier Saunders; 2005. p. 384-92. Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA 1998;280:1747-51. Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346:1128-37. Peck C, Peck J, Peck A. Comparison of carotid endarterectomy at high- and low-volume hospitals. Am J Surg 2001;181:450-3. van Lanschot JJ, Hulscher JB, Buskens CH, Tilanus HW, Ten Kate FJ, Obertop H. Hospital volume and surgical mortality for esophagectomy. Cancer 2001;91:1574-8. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349: 2117-27. Sosa JA, Bowman HM, Tielsch HM, Powe NR, Gordon TA, Udelsman R. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg 1998;228:320-30. Jonasson O, Kwakwa F. Retirement age and the work force in general surgery. Ann Surg 1996;224:574-582. Department of Health and Human Services. The international classification of diseases, 9th revision, clinical modification: ICD-9-CM. Washington (D.C.): U.S. Government Printing Office; 1998. Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS). Available at: http://www.hcup-us. ahrq.gov/home.jsp. Accessed May 2007. Surveillance, Epidemiology and End Results (SEER) fast stats: thyroid cancer. Available at: http://seer.cancer.
16.
17.
18. 19.
20.
21.
22.
23.
gov/faststats/sites.php?site⫹Thyroid⫹Cancer&stat⫽ Incidence. Accessed May 2007. Gallagher S, Baksh K, Wahi M, Haines K, Lee A, Enriques J, et al. The relationship of hospital volume and provider volume is inversely correlated to adverse outcomes in a statewide analysis of 1,816 adrenalectomies. Available at: www.endocrinesurgery.org/mtgs/AAES07abstracts.pdf. Accessed May 2007. U.S. Department of Health and Human Services, Health Resources and Services Administration. Bureau of Health Professions (2006). Physician Supply and Demand: Projections to 2020. Available at: http://bhpr.hrsa.gov/healthworkforce/ reports/physiciansupplydemand/default.htm. Accessed May 2007. Moore FD. Report on the manpower subcommittee. Ann Surg 1975;182:526-30. O’Neill JA, Gautam S, Geiger JD, Ein SH, Holder TM, Bloss RS, et al. A longitudinal analysis of the pediatric surgeon workforce. Ann Surg 2000;232:442-53. Etzioni DA, Liu JH, Maggard MA, O’Connell JB, Ko CY. Workload projections for surgical oncology: will we need more surgeons? Ann Surg Onc 2003;10: 1112-7. Saunders BD, Wainess RM, Dimick JB, Doherty GM, Upchurch GR, Gauger PG. Who performs endocrine operations in the United States? Surgery 2003;134:92431. Berry JG, Lieu TA, Forbes PW, Goldmann DA. Hospital volumes for common pediatric specialty operations. Arch Pediatr Adolesc Med 2007;161:38-43. Chiu WC, Scalea TM, Rotondo MF. Summary report on current clinical trauma care fellowship training programs. J Trauma 2005;58:605-13.