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. Endocrine glands Thyroid Parathyroid Adrenal glands Pancreas Background

3. 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

4. Many endocrine diseases are treated surgically. Thyroidectomy

5. Minimally invasive surgery under local anesthesia in the outpatient setting. Parathyroidectomy

6. Laparoscopy has improved outcomes. Adrenalectomy

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 HCUP)

8. Volume: Cost Association

9. Volume: Length of Stay Association

10. Volume: Complication Rate Association

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

12. Access to High-Volume Surgeons, By Race

13. Access to High-Volume Surgeons, By Geographic Region

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?

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

16. 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.

17. Comparison of Endocrine Surgery Experience

18. Volume distribution of surgeons performing endocrine procedures, 2004* 75 18 6 1 24 25 26 *Using HCUP dataset

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

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

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

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

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

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.

25. Implications: Graduate Medical Education  Standardization of training across endocrine surgery fellowships  Case distribution  Overall volume  Certification

26. 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

27. Implications: Policy Improve access to high-volume surgeons Geographic distribution Incentives for MDs Patient indirect costs Lower SES status Government insurance (Medicare/Medicaid)