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

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 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

Volume: Length of Stay Association

Volume: Complication Rate Association

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

Volume distribution of surgeons performing endocrine procedures, 2004* *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.,

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

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

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)