Surgeon compensation in academic medicine.

Academic surgery is the best career one could ever aspire to have; however, given the long duration of training and the anticipated education debt, surgeon compensation has not kept pace with the compensation of other comparable careers. As surgeon compensation has experienced increased downward pressure, it has become of growing importance to those in academic medicine/surgery. Competitive compensation is necessary, even if not sufficient, for successful faculty recruitment and retention. The optimal compensation system should encourage the best possible patient care, inspire teamwork, maximize the department's or physician practice's ability to recruit and retain faculty, support all missions, and be viewed as equitable and transparent. The goal of an optimal compensation system is to have faculty minds focused on things other than compensation-those elements of their job that are most important, such as career development, multidisciplinary clinical programs, research, and education. One way to ensure that compensation stays in the background for academic surgeons is for leadership to keep this front and center. Compensation plans can influence behavior and time management and affect the clinical, academic, and educational contributions of surgeons and physicians of all specialties. As we strive to optimize the productivity and engagement of a health system's most valuable resource-those who deliver surgical care and create new knowledge-compensation is an important variable in need of constant attention.

Going for Broke: The Impact of Cost of Living on Surgery Resident Stipend Value.

OBJECTIVE: The objective of this study was to provide a direct comparison of first-year general surgery resident stipends across states and major cities, using the Cost-of-Living Index (COLI) to determine stipend value. BACKGROUND: Financial challenges are among residents' top sources of stress, and this may be exacerbated in areas with high costs of living. A 2021 survey found that the mean first-year medical resident stipend increased by 0.6%, or $358, from 2020 to 2021, and only 33% of institutions used cost-of-living to determine annual resident stipend adjustments. METHODS: An American Medical Association database was used to identify accredited general surgery residency programs. The 2021-2022 stipend data for first-year general surgery positions were obtained, then data were grouped by state and major city and averaged. Major cities were defined as cities with >4 programs.A direct comparison of stipends was performed using the COLI. RESULTS: Stipend data were available for 337 of 346 general surgery programs. The national average first-year residency stipend was $60,064±$4233. The average COLI-adjusted stipend was $57,090±$5742, with a value loss of -$3493, or 5%.For major cities, the average stipend was $63,383±$4524, and the average COLI-adjusted stipend was $46,929±$8383, with an average value loss of -$16,454, or 26%. CONCLUSIONS: The financial burdens that residents face cannot be overlooked, and the cost of living has a meaningful impact on resident stipend value. The current Graduate Medical Education compensation structure limits federal and institutional capacity to adjust for the cost of living and creates an insulated market in which residents are under-compensated.

Patterns of Unnecessary Insurer Prior Authorization Denials in a Complex Surgical Oncology Practice.

INTRODUCTION: Insurance prior authorization (PA) is a determination of need, required by a health insurer for an ordered test/procedure. If the test/procedure is denied, a peer-to-peer (P2P) discussion between ordering provider and payer is used to appeal the decision. The objective of this study was to measure the number and patterns of unnecessary PA denials. METHODS: This was a retrospective review at a quaternary cancer center from October 2021 to March 2022. Included were all patients with outpatient imaging orders for surgical planning or surveillance of gastrointestinal, endocrine, or skin cancer. Primary outcome was unnecessary initial denial (UID) defined as an order that required preauthorization, was initially denied by the insurer, and subsequently overturned by P2P. RESULTS: Nine hundred fifty seven orders were placed and 419 required PA (44%). Of tests requiring authorization, 55/419 (13.1%) were denied. Variability in the likelihood of initial denial was seen across insurers, ranging from 0% to 57%. Following P2P, 32/55 were overturned (58.2% UID). The insurers most likely to have a UID were Aetna (100%), Anthem (77.8%), and Cigna (50.0%). UID was most common for gastrointestinal (58.9%) and endocrine (58.3%) cancers. Average P2P was 33.5 min (interquartile range 28-40). CONCLUSIONS: The majority of imaging studies initially denied were overturned after P2P. If all UIDs were eliminated, this would represent 108 less P2P discussions with an estimated time-savings of 60.3 h annually within a high-volume surgical oncology practice. Combined personnel costs to the health systems and stress on patients with cancer due to image-associated PAs and P2P appear hard to justify.

Cost-effectiveness analysis of universal germline testing for patients with pancreatic cancer.

BACKGROUND: Historically, germline testing of patients with pancreatic cancer was performed selectively in patients with a strong family history of cancer. Current guidelines recommend universal testing because some patients may have actionable germline pathogenic variants without family history. METHODS: We conducted a cost-effectiveness analysis using a decision-tree model to compare universal versus selective testing strategies for patients with pancreatic cancer. Costs, probabilities, and overall survival were estimated from the published literature and institutional data. One-way and probabilistic sensitivity analyses explored model uncertainty. RESULTS: Universal germline genetic testing had an incremental cost of $310 with an increase of 0.003 life-years. The incremental cost-effectiveness ratio was $121,924/life-years. Parameters which were most impactful (sensitivity analysis) included the median overall survival of patients with advanced disease treated with personalized therapy, cost of personalized therapy for advanced disease, and the probability of receiving personalized therapy in advanced disease. A strategy of selective testing was more cost-effective in 59% of iterations when the willingness-to-pay threshold was set to $100,000/life-years. CONCLUSION: Our model suggested that selective germline testing of patients with newly diagnosed pancreatic cancer is more cost-effective than universal testing. Additional research is needed to explore the impact of cascade testing of relatives on cost-effectiveness.

Disparities in access to care and outcomes in patients with adrenocortical carcinoma.

BACKGROUND: Surgical resection remains the mainstay of treatment for patients with adrenocortical carcinoma (ACC). The aim of the present study is to examine disparities in access to surgical resection and identify factors associated with overall survival following surgical resection. METHODS: The National Cancer Database was queried for patients with ACC (2004-2013). Patient characteristics and disease details were abstracted. Logistic regression analysis was performed to examine the factors associated with surgical resection, and a multivariate Cox proportional hazards model was used to identify predictors of survival in the surgical cohort. RESULTS: Surgical resection was performed in 2007/2946 (68%) ACC patients. On multivariate logistic regression analysis controlling for clinicodemographic factors, surgery was less likely to be performed in patients ≥56 y, males, African-Americans, patients with government insurance, or those treated at community cancer centers (P < 0.05). On a multivariate Cox proportional hazards model adjusting for clinicodemographic and treatment variables, older age (≥56 y) and presence of comorbidities were associated with worse overall survival. CONCLUSIONS: These findings suggest that there are demographic and socioeconomic disparities in access to surgical resection for ACC. However, after adjusting for patient and clinical characteristics, only patient age and presence of comorbidities were predictors of worse survival in patients undergoing surgery for ACC. More data are needed to determine the factors driving these disparities.

Neoadjuvant treatment sequencing adds value to the care of patients with operable pancreatic cancer.

Treatment sequencing for resectable pancreatic cancer remains controversial and there is lack of level one evidence comparing neoadjuvant versus adjuvant strategies. However, a comparison of the cost-effectiveness analysis of the treatment strategies may help to better define the healthcare value of each approach. This review will highlight the rationale for multimodality therapy in the treatment of pancreatic cancer, discuss the advantages and disadvantages of adjuvant therapy, and conceptualize the cost-effectiveness of a neoadjuvant approach with regard to healthcare value. J. Surg. Oncol. 2016;114:291-295. © 2016 Wiley Periodicals, Inc.

Analysis of an institutional protocol for thyroid lobectomy: Utility of routine intraoperative frozen section and expedited (overnight) pathology.

BACKGROUND: Intraoperative frozen section (FS) often is performed in patients who undergo thyroid lobectomy to determine the need for completion thyroidectomy. At our institution, if FS pathology is benign, final pathology is expedited overnight. The aim of this study was to determine the utility of FS and to identify a cost-effective management algorithm for thyroid lobectomy. METHODS: A retrospective review was performed of patients who underwent thyroid lobectomy between January 2009 and May 2013. Preoperative cytology ranged from "benign" to "suspicious for malignancy." Clinically significant cancers were defined as >1 cm in size, or multifocal microcarcinomas. RESULTS: Of the 192 patients who underwent thyroid lobectomy with FS, FS was suspicious for malignancy in 5 (3%) patients; 1 (0.5%) underwent immediate completion thyroidectomy. On final pathology, 9 (5%) patients had clinically significant cancers and underwent completion thyroidectomy. FS had a sensitivity and positive predictive value of 22% and 40%, respectively, in identifying clinically significant thyroid cancer. Cost of thyroid lobectomy at varying rates of same-day discharge favored thyroid lobectomy without FS but with expedited pathology for all scenarios. CONCLUSION: At our institution, there appears to be limited utility of FS at the time of thyroid lobectomy given the low predictive value for diagnosing a clinically significant thyroid cancer. In patients who are admitted overnight, expedited pathology is slightly less costly and may improve patient quality-of-life and decrease costs by avoiding delayed completion thyroidectomy. Overnight pathology for patients who undergo thyroid lobectomy may achieve modest cost-savings depending on institutional FS results and rates of malignancy.

Diagnostic laparoscopy should be performed before definitive resection for pancreatic cancer: a financial argument.

OBJECTIVES: Laparoscopy is recommended to detect radiographically occult metastases in patients with pancreatic cancer before curative resection. This study was conducted to test the hypothesis that diagnostic laparoscopy (DL) is cost-effective in patients undergoing curative resection with or without neoadjuvant therapy (NAT). METHODS: Decision tree modelling compared routine DL with exploratory laparotomy (ExLap) at the time of curative resection in resectable cancer treated with surgery first, (SF) and borderline resectable cancer treated with NAT. Costs (US$) from the payer's perspective, quality-adjusted life months (QALMs) and incremental cost-effectiveness ratios (ICERs) were calculated. Base case estimates and multi-way sensitivity analyses were performed. Willingness to pay (WtP) was US$4166/QALM (or US$50,000/quality-adjusted life year). RESULTS: Base case costs were US$34,921 for ExLap and US$33,442 for DL in SF patients, and US$39,633 for ExLap and US$39,713 for DL in NAT patients. Routine DL is the dominant (preferred) strategy in both treatment types: it allows for cost reductions of US$10,695/QALM in SF and US$4158/QALM in NAT patients. CONCLUSIONS: The present analysis supports the cost-effectiveness of routine DL before curative resection in pancreatic cancer patients treated with either SF or NAT.

Cost analysis of thyroid lobectomy and intraoperative frozen section versus total thyroidectomy in patients with a cytologic diagnosis of "suspicious for papillary thyroid cancer".

BACKGROUND: The optimal operation for a patient with a thyroid nodule "suspicious for papillary thyroid cancer (PTC)" on fine-needle aspiration (FNA) is unclear. This study examines the incremental cost-utility of thyroid lobectomy with intraoperative frozen section (thyroid lobectomy) versus total thyroidectomy. METHODS: Cost-utility analysis was performed for patients with a cytologic diagnosis of "suspicious for PTC" on FNA. Patients underwent either initial total thyroidectomy or thyroid lobectomy and, if needed, completion thyroidectomy. The incremental cost-utility ratio (ICUR; US$/quality-adjusted-life-year [QALY]), was determined from a societal perspective. RESULTS: The base-case ICUR of thyroid lobectomy is $90,776/QALY, strongly favoring total thyroidectomy as a more cost-effective modality. On sensitivity analyses, the model is sensitive to the accuracy of frozen section and to the rate of injury to the recurrent laryngeal nerve (RLN). Thyroid lobectomy is more cost-effective only if both frozen section and final pathology are benign in ≥92% of patients (ICUR $47,959/QALY at 92%). With increasing rates of unilateral (>5%) or bilateral (>2%) RLN injury associated with total thyroidectomy, there is a trend toward thyroid lobectomy being more cost effective ($53,127 and $51,325/QALY, respectively). CONCLUSION: In our model, initial total thyroidectomy is cost-effective for patients with a single thyroid nodule suspicious for PTC on FNA. Our results strongly support total thyroidectomy for initial treatment; thyroid lobectomy is preferred only when complications reach unacceptable levels.

The cost-effectiveness of neoadjuvant chemoradiation is superior to a surgery-first approach in the treatment of pancreatic head adenocarcinoma.

BACKGROUND: In treating pancreatic cancer, there is no clearly defined optimal sequence of chemotherapy, radiation therapy and surgery. Therefore, cost-effectiveness should be considered. The objective of this study was to compare cost and outcomes between a surgery-first approach versus neoadjuvant chemoradiation followed by surgery for resectable pancreatic head cancer. METHODS: A decision analytic model was constructed to compare the 2 approaches. Data from the National Cancer Database, National Surgical Quality Improvement Program, and literature populated the surgery-first arm. Data from our prospectively maintained institutional pancreatic cancer database populated the neoadjuvant arm. Costs were estimated by Medicare payment (2011 U.S. dollars). Survival was reported in quality-adjusted life-months (QALMs). RESULTS: The neoadjuvant chemoradiation arm consisted of 164 patients who completed preoperative therapy. Of these, 36 (22 %) did not proceed to surgery; 12 (7 %) underwent laparotomy but had unresectable disease; and 116 (71 %) underwent definitive resection. The surgery-first approach cost $46,830 and yielded survival of 8.7 QALMs; the neoadjuvant chemoradiation approach cost $36,583 and yielded survival of 18.8 QALMs. In the neoadjuvant arm, costs and survival times for patients not undergoing surgery, those with unresectable disease at laparotomy, and those completing surgery were $12,401 and 7.7 QALMs, $20,380 and 7.1 QALMs, and $45,673 and 23.4 QALMs, respectively. CONCLUSIONS: Neoadjuvant chemoradiation for pancreatic cancer identifies patients with early metastases or poor performance status, who can be spared an ineffective or prohibitively morbid operation, and is associated with improved survival at significantly lower cost than a surgery-first approach. Neoadjuvant chemoradiation followed by surgery is a strategy that provides more cost-effective care than a surgery-first approach.

Outcomes and economic analysis of routine preoperative 4-dimensional CT for surgical intervention in de novo primary hyperparathyroidism: does clinical benefit justify the cost?

BACKGROUND: Preoperative imaging in patients with primary hyperparathyroidism provides important localization information. Although 4-dimensional neck CT (4DCT) can precisely localize hyperfunctioning parathyroid tissue, the contribution of 4DCT to overall cost, operating room time, and hospital stay is unknown. STUDY DESIGN: Records of 535 patients with primary hyperparathyroidism who underwent parathyroidectomy at our institution from 1996 to 2010 were reviewed. All patients had preoperative cervical ultrasonography and sestamibi scanning, and most (78.9%) underwent preoperative 4DCT. A decision tree was constructed to compare extent of procedure, operating room time, length of stay, failure rate, and total cost of each strategy (with and without 4DCT). Costs were determined by 2010 Medicare reimbursement. RESULTS: For patients with and without preoperative 4DCT, respectively, mean operating room time (64.4 vs 61.4 minutes; p = 0.58) and failure rate (1.9% vs 4.4%; p = 0.12) were not significantly different. Length of stay was higher in the no-CT cohort (0.61 vs 0.23 days; p < 0.001). Patients with a preoperative 4DCT were significantly more likely to undergo a limited parathyroidectomy (90.3% vs 80.5%; p = 0.004). Mean cost of care per patient in the CT and no-CT cohorts was $6,572 and $6,306, respectively. CONCLUSIONS: The introduction of routine 4DCT into the preoperative workup for surgical intervention in primary hyperparathyroidism does not appear to shorten operating room time or decrease failure rate significantly. However, preoperative 4DCT is associated with shorter hospital stays and improved rates of minimally invasive parathyroidectomy. This clinical benefit must be weighed against the increased cost associated with routine preoperative 4DCT.