Health Care Cost Reductions with Machine Learning-Directed Evaluations during Radiation Therapy - An Economic Analysis of a Randomized Controlled Study.

BACKGROUND: Machine learning (ML) may cost-effectively direct health care by identifying patients most likely to benefit from preventative interventions to avoid negative and expensive outcomes. System for High-Intensity Evaluation During Radiation Therapy (SHIELD-RT; NCT04277650) was a single-institution, randomized controlled study in which electronic health record-based ML accurately identified patients at high risk for acute care (emergency visit or hospitalization) during radiotherapy (RT) and targeted them for supplemental clinical evaluations. This ML-directed intervention resulted in decreased acute care utilization. Given the limited prospective data showing the ability of ML to direct interventions cost-efficiently, an economic analysis was performed. METHODS: A post hoc economic analysis was conducted of SHIELD-RT that included RT courses from January 7, 2019, to June 30, 2019. ML-identified high-risk courses (≥10% risk of acute care during RT) were randomized to receive standard of care weekly clinical evaluations with ad hoc supplemental evaluations per clinician discretion versus mandatory twice-weekly evaluations. The primary outcome was difference in mean total medical costs during and 15 days after RT. Acute care costs were obtained via institutional cost accounting. Physician and intervention costs were estimated via Medicare and Medicaid data. Negative binomial regression was used to estimate cost outcomes after adjustment for patient and disease factors. RESULTS: A total of 311 high-risk RT courses among 305 patients were randomized to the standard (n=157) or the intervention (n=154) group. Unadjusted mean intervention group supplemental visit costs were $155 per course (95% confidence interval, $142 to $168). The intervention group had fewer acute care visits per course (standard, 0.47; intervention, 0.31; P=0.04). Total mean adjusted costs were $3110 per course for the standard group and $1494 for the intervention group (difference in means, $1616 [95% confidence interval, $1450 to $1783]; P=0.03). CONCLUSIONS: In this economic analysis of a randomized controlled, health care ML study, mandatory supplemental evaluations for ML-identified high-risk patients were associated with both reduced total medical costs and improved clinical outcomes. Further study is needed to determine whether economic results are generalizable. (Funded in part by The Duke Endowment, The Conquer Cancer Foundation, the Duke Department of Radiation Oncology, and the National Cancer Institute of the National Institutes of Health [R01CA277782]; ClinicalTrials.gov number, NCT04277650.).

At the Intersection of Intersectionality: Race and Gender Diversity Among Surgical Faculty and Trainees.

OBJECTIVE: To compare the representation of intersectional (ie, racial/ethnic and gender) identities among surgical faculty versus medical students. BACKGROUND: Health disparities are pervasive in medicine, but diverse physicians may help the medical profession achieve health equity. METHODS: Data from the Association of American Medical Colleges for 140 programs (2011/2012-2019/2020) were analyzed for students and full-time surgical faculty. Underrepresented in medicine (URiM) was defined as Black/African American, American Indian/Alaskan Native, Hispanic/Latino/Spanish Origin, or Native Hawaiian/Other Pacific Islander. Non-White included URiM plus Asian, multiracial, and non-citizen permanent residents. Linear regression was used to estimate the association of year and proportions of URiM and non-White female and male faculty with proportions of URiM and non-White students. RESULTS: Medical students were comprised of more White (25.2% vs 14.4%), non-White (18.8% vs 6.6%), and URiM (9.6% vs 2.8%) women and concomitantly fewer men across all groups versus faculty (all P < 0.01). Although the proportion of White and non-White female faculty increased over time (both P ≤ 0.001), there was no significant change among non-White URiM female faculty, nor among non-White male faculty, regardless of whether they were URiM or not. Having more URiM male faculty was associated with having more non-White female students (estimate = +14.5% students/100% increase in faculty, 95% CI: 1.0% to 8.1%, P = 0.04), and this association was especially pronounced for URiM female students (estimate = +46.6% students/100% increase in faculty, 95% CI: 36.9% to 56.3%, P < 0.001). CONCLUSIONS: URiM faculty representation has not improved despite a positive association between having more URiM male faculty and having more diverse students.

Australian young people's perspectives about the political determinants of the climate crisis.

ISSUE ADDRESSED: There has been little focus on young people's views about the political determinants of the climate crisis. As young people are likely to be the group most impacted by political decisions relating to the climate crisis, it is essential to understand their views about government decision-making. METHODS: A qualitatively-led online survey of n = 500 young Australians aged 15-24 years. Open text questions sought young people's views about current government climate policies, perceptions about policy effectiveness, and how governments could improve their climate responses. Reflexive thematic analysis was used to interpret and construct themes from the data. RESULTS: Young people perceived that governments were not taking serious action on the climate crisis. They stated that climate policies were largely influenced by economic imperatives, rather than concern for the wellbeing of current and future generations. They perceived that governments had a duty of care to protect them from the climate crisis, and needed to engage young people in climate discussions and decision-making. CONCLUSIONS: Young people's perspectives about the political determinants of the climate crisis provides information about their understanding of government policies and their recommendations for action. There is a need for collaboration between young people and decision-makers to urgently develop effective climate policies. SO WHAT?: Young people understand key issues relating to the political determinants of the climate crisis. The health promotion community has a role in advocating for structural changes in policymaking processes to ensure young people have a seat at the decision-making table.

Breast cancer survivors with pain: an examination of the relationships between body mass index, physical activity, and symptom burden.

PURPOSE: Overweight and obesity are common for breast cancer survivors and associated with high symptom burden (i.e., pain, fatigue, depressive symptoms). Physical activity may protect breast cancer survivors with higher body mass indexes (BMI) from increased symptoms. However, the role of physical activity in buffering the relationship between higher BMI and greater symptoms is unclear. METHODS: Baseline data from a randomized trial investigating Pain Coping Skills Training among breast cancer survivors (N = 327) with pain were used to examine the relationship between self-reported BMI (kg/m2) and physical activity level (Rapid Assessment of Physical Activity; suboptimal vs. optimal) with pain (Brief Pain Inventory; severity and interference), fatigue (PROMIS-Fatigue short form), and depressive symptoms (Center for Epidemiological Studies Depression Scale). Analyses were conducted in SPSS. Hayes PROCESS macro (Model 1) assessed whether physical activity moderated the relationship between BMI and symptoms. RESULTS: Lower BMI (B = .06, p < .01) and optimal physical activity (B = - .69, p < .01) were independently associated with lower pain interference. Lower BMI was also associated with lower pain severity (B = .04, p < .001). Neither BMI nor physical activity was associated with fatigue or depressive symptoms. Physical activity did not moderate the relationship between BMI and symptoms. CONCLUSIONS: Among breast cancer survivors experiencing pain, higher BMI and being less physically active were related to greater pain (i.e., severity and/or interference). Physical activity did not buffer the relationships between BMI and pain, fatigue, and depressive symptoms, suggesting that physical activity alone may not be sufficient to influence the strength of the relationships between BMI and symptoms.

Breast Cancer Risk Assessment and Screening Practices Reported Via an Online Survey.

BACKGROUND: Breast cancer screening guidelines differ between organizations, and significant variations in practice patterns exist. Previous evidence suggests that provider-level factors are the greatest contributors to risk assessment and screening practice variability. This study aimed to characterize provider factors associated with breast cancer risk assessment and screening practice patterns, and to assess perceived barriers to providing risk assessment. METHODS: An online survey was distributed to providers at a single academic institution and to providers publicly via social media (January to August 2022). Respondents in the United States who care for adult women at risk for the development of breast cancer were included. RESULTS: Most of the respondents in the 143 completed surveys were white/Caucasian (79%) females (90%) age 50 years or younger (79%), and whereas 97% discuss breast cancer screening with their patients, only 90% order screening mammograms. Risk factor assessment was common (93%), typically performed at the first visit (51%). Additional training in genetics or risk assessment was uncommon (17%), although the majority were interested but did not have the time or resources (55%). Although most (64%) did not perceive barriers to providing risk assessment or appropriate screening, the most common barriers were time (77%) and education (55%). Barriers were more common among family practice or obstetrics and gynecology (OB/GYN) providers and those who worked in an academic setting (all p < 0.05). CONCLUSIONS: Breast cancer risk assessment and screening practices are highly variable. Although time is the major barrier to providing risk assessment, providers also need education. Primary care organizations could partner with breast cancer-focused societies for additional resources.

The lived experience of financial harm from gambling in Australia.

The financial consequences associated with harmful gambling create significant health and social stressors for individuals, their families, and communities. However, there has been limited research exploring how people impacted by gambling harm conceptualise and experience the financial impacts on their lives. To help fill this gap, this study used in-depth qualitative interviews with gamblers harmed by their own gambling and affected others harmed by someone else's gambling. Reflexive thematic analysis was used to interpret the data. The study had three key findings. First, prior to experiencing harm, gamblers and affected others did not consider the financial risks associated with gambling and only recognised the risks once the financial losses negatively impacted other areas of their lives. Second, gamblers and affected others managed the day-to-day financial impacts of gambling by adjusting their financial priorities, reducing spending in other areas, or accruing debt. Finally, the financial impacts of gambling and the associated financial management strategies led to broader and long-term problems for gamblers and affected others. This study demonstrates that financial harms from gambling are complex and contribute to the stigmatisation of people who experience harm. Current educational messages and tools simplify this complex issue and may legitimise gambling as a leisure activity which can be managed by making 'responsible' financial decisions. Public health and health promotion initiatives must recognise this complexity, developing approaches that are independent from the gambling industry and informed by lived experience.

Australian young people's perceptions of the commercial determinants of the climate crisis.

There is increasing public health focus on how corporate practices impact population health and well-being. While the commercial determinants of the climate crisis pose serious threats to human and planetary health, governments largely seek to balance climate action with economic imperatives. Global stakeholders recognize that young people have important voices in influencing climate responses. However, few studies have investigated young people's perceptions of the commercial determinants of the climate crisis. A qualitatively led online survey of n = 500 young Australians (15-24 years) investigated their understanding of corporate responses to the climate crisis, factors that influenced these responses and strategies to respond. A reflexive approach to thematic analysis was used. Three themes were constructed from the data. First, young people perceived that corporate responses to the climate crisis focussed on soft options and lacked meaningful action. Second, they stated that these responses were largely influenced by economic imperatives rather than planetary health, with policy levers needed to implement environmentally responsible corporate practices. Third, young people perceived that systems needed change to create demand for a cleaner environment, leading to improved practices. Young people have a clear understanding of the commercial determinants of the climate crisis and associated threats to population health. They recognize that corporate practices (and consumer demand) will not change without significant policy and structural change. Public health and health promotion stakeholders should work alongside young people to influence decision-makers to address harmful corporate behaviours.

"It shows we are serious": Young people in Australia discuss climate justice protests as a mechanism for climate change advocacy and action.

OBJECTIVE: This article aims to understand young Australians' perspectives of climate justice protests as a mechanism for climate change advocacy and action. METHOD: A qualitatively led online survey was conducted with n=511 young Australians (15-24 years). Open-text questions prompted for young people's perceptions of the appeal, accessibility, and effectiveness of climate justice protests in climate change action. A reflexive thematic analysis was conducted to construct themes from the data. RESULTS: Participants perceived that protests were an important mechanism for young people to draw attention to the need for climate action. However, they also stated that the clear messages that were sent to governments via protests did not necessarily lead to government action. Young people perceived that there were some structural issues that prevented them from taking part in these types of activities, including living far away from protests, not being accessible for young people with disabilities, and limited support from family members and/or friends to participate. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH: Climate justice activities engage young people and give them hope. The public health community has a role to play in supporting access to these activities and championing young people as genuine political actors in addressing the climate crisis.

Modifiable patient-reported factors associated with cancer-screening knowledge and participation in a community-based health assessment.

BACKGROUND: We sought to identify modifiable factors associated with cancer screening in a community-based health assessment. METHODS: 24 organizations at 47 community events in central North Carolina distributed a 91-item survey from April-December 2017. Responses about (1) interest in disease prevention, (2) lifestyle choices (e.g., diet, tobacco), and (3) perceptions of primary care access/quality were abstracted to examine their association with self-reported screening participation and knowledge about breast, prostate, and colorectal cancer. RESULTS: 2135/2315 participants (92%; 38.5% White, 38% Black, 9.9% Asian) completed screening questions. >70% of screen-eligible respondents reported guideline-concordant screening. Healthy dietary habits were associated with greater knowledge about breast and colorectal cancer screening; reporting negative attitudes about and barriers to healthcare were associated with less breast, prostate, and colorectal cancer screening. Having a place to seek medical care (a proxy for primary care access) was independently associated with being ∼5 times as likely to undergo colorectal screening (OR 4.66, 95% CI 1.58-13.79, all p < 0.05). CONCLUSIONS: In this diverse, community-based sample, modifiable factors were associated with screening engagement, highlighting opportunities for behavioral intervention.

Do health halos and conspicuous consumption influence the appeal and risk perceptions of e-cigarettes among young Cambodian men?

INTRODUCTION: Reduced risk perceptions influence young people's consumption behaviours of e-cigarettes, suggesting that a health halo effect may be associated with these devices. Product, performative, and social factors contribute to the appeal of e-cigarettes, with young people using e-cigarettes with friends as part of social interactions. This study explored the factors that influence the appeal and risk perceptions associated with e-cigarettes among young Cambodian men. METHODS: A mixed-method, interviewer-administered survey with 147 young men in Cambodia, who were aged between 18 and 24 years and identified as cigarette smokers. Participants described their attitudes and consumption behaviours surrounding e-cigarettes, recalled e-cigarette promotions, and described their risk perceptions towards e-cigarettes. Descriptive statistics were calculated for quantitative data, and thematic analysis was conducted for qualitative data. RESULTS: Some participants associated e-cigarettes with affluence and exclusivity, describing these devices as products that rich and/or younger people use. Participants also described product attributes that were appealing about e-cigarettes, such as variety of flavours, vapour, and performing smoke 'styles' with friends, which differentiated the product from combustible cigarettes. Participants also had reduced risk perceptions towards e-cigarettes, with some commenting that e-cigarettes were not harmful or might be health-enhancing. CONCLUSION: Some young people may perceive e-cigarettes as a form of conspicuous consumption, which they associated with social status and identity. A health halo effect appears to be associated with e-cigarettes among some young people. This may influence young people to underestimate the potential health risks associated with these devices.

Association of Smartphone Ownership and Internet Use With Markers of Health Literacy and Access: Cross-sectional Survey Study of Perspectives From Project PLACE (Population Level Approaches to Cancer Elimination).

BACKGROUND: Telehealth is an increasingly important component of health care delivery in response to the COVID-19 pandemic. However, well-documented disparities persist in the use of digital technologies. OBJECTIVE: This study aims to describe smartphone and internet use within a diverse sample, to assess the association of smartphone and internet use with markers of health literacy and health access, and to identify the mediating factors in these relationships. METHODS: Surveys were distributed to a targeted sample designed to oversample historically underserved communities from April 2017 to December 2017. Multivariate logistic regression was used to estimate the association of internet and smartphone use with outcomes describing health care access and markers of health literacy for the total cohort and after stratifying by personal history of cancer. Health care access was captured using multiple variables, including the ability to obtain medical care when needed. Markers of health literacy included self-reported confidence in obtaining health information. RESULTS: Of the 2149 participants, 1319 (61.38%) were women, 655 (30.48%) were non-Hispanic White, and 666 (30.99%) were non-Hispanic Black. The median age was 51 years (IQR 38-65). Most respondents reported using the internet (1921/2149, 89.39%) and owning a smartphone (1800/2149, 83.76%). Compared with the respondents with smartphone or internet access, those without smartphone or internet access were more likely to report that a doctor was their most recent source of health information (344/1800, 19.11% vs 116/349, 33.2% for smartphone and 380/1921, 19.78% vs 80/228, 35.1% for internet, respectively; both P<.001). Internet use was associated with having looked for information on health topics from any source (odds ratio [OR] 3.81, 95% CI 2.53-5.75) and confidence in obtaining health information when needed (OR 1.83, 95% CI 1.00-3.34) compared with noninternet users. Smartphone owners had lower odds of being unable to obtain needed medical care (OR 0.62, 95% CI 0.40-0.95) than nonsmartphone owners. Among participants with a prior history of cancer, smartphone ownership was significantly associated with higher odds of confidence in ability to obtain needed health information (OR 5.63, 95% CI 1.05-30.23) and lower odds of inability to obtain needed medical care (OR 0.17, 95% CI 0.06-0.47), although these associations were not significant among participants without a prior history of cancer. CONCLUSIONS: We describe widespread use of digital technologies in a community-based cohort, although disparities persist. In this cohort, smartphone ownership was significantly associated with ability to obtain needed medical care, suggesting that the use of smartphone technology may play a role in increasing health care access. Similarly, major illnesses such as cancer have the potential to amplify health engagement. Finally, special emphasis must be placed on reaching patient populations with limited digital access, so these patients are not further disadvantaged in the new age of telehealth.

Radiofrequency Identification Track for Tray Optimization: An Instrument Utilization Pilot Study in Surgical Oncology.

BACKGROUND: Surgical instrument tray reduction attempts to minimize intraoperative inefficiency and processing costs. Previous reduction methods relied on trained observers manually recording instrument use (i.e. human ethnography), and surgeon and/or staff recall, which are imprecise and inherently limited. We aimed to determine the feasibility of radiofrequency identification (RFID)-based intraoperative instrument tracking as an effective means of instrument reduction. METHODS: Instrument trays were tagged with unique RFID tags. A RFID reader tracked instruments passing near RFID antennas during 15 breast operations performed by a single surgeon; ethnography was performed concurrently. Instruments without recorded use were eliminated, and 10 additional cases were performed utilizing the reduced tray. Logistic regression was used to estimate odds of instrument use across cases. Cohen's Kappa estimated agreement between RFID and ethnography. RESULTS: Over 15 cases, 37 unique instruments were used (median 23 instruments/case). A mean 0.64 (median = 0, range = 0-3) new instruments were added per case; odds of instrument use did not change between cases (OR = 1.02, 95%CI 1.00-1.05). Over 15 cases, all instruments marked as used by ethnography were recorded by RFID tracking; 7 RFID-tracked instruments were never recorded by ethnography. Tray size was reduced 40%. None of the 25 eliminated instruments were required in 10 subsequent cases. Cohen's Kappa comparing RFID data and ethnography over all cases was 0.82 (95%CI 0.79-0.86), indicating near perfect agreement between methodologies. CONCLUSIONS: Intraoperative RFID instrument tracking is a feasible, data-driven method for surgical tray reduction. Overall, RFID tracking represents a scalable, systematic, and efficient method of optimizing instrument supply across procedures.

You are welcome here: A practical guide to diversity, equity, and inclusion for undergraduates embarking on an ecological research experience.

As we build a more diverse, equitable, and inclusive culture in the ecological research community, we must work to support new ecologists by empowering them with the knowledge, tools, validation, and sense of belonging in ecology to succeed. Undergraduate research experiences (UREs) are critical for a student's professional and interpersonal skill development and key for recruiting and retaining students from diverse groups to ecology. However, few resources exist that speak directly to an undergraduate researcher on the diversity, equity, and inclusion (DEI) dimensions of embarking on a first research experience. Here, we write primarily for undergraduate readers, though a broader audience of readers, especially URE mentors, will also find this useful. We explain many of the ways a URE benefits undergraduate researchers and describe how URE students from different positionalities can contribute to an inclusive research culture. We address three common sources of anxiety for URE students through a DEI lens: imposter syndrome, communicating with mentors, and safety in fieldwork. We discuss the benefits as well as the unique vulnerabilities and risks associated with fieldwork, including the potential for harassment and assault. Imposter syndrome and toxic field experiences are known to drive students, including students from underrepresented minority groups, out of STEM. Our goal is to encourage all students, including those from underrepresented groups, to apply for UREs, build awareness of their contributions to inclusion in ecology research, and provide strategies for overcoming known barriers.

A Case-Control Study Examining Disparities in Clinical Trial Participation Among Breast Surgical Oncology Patients.

BACKGROUND: Clinical trial participation among racial and ethnic minorities remains low despite national efforts. We sought to determine how participation in clinical trials by breast surgical oncology patients has changed over time and what characteristics are associated with participation. METHODS: Women with breast cancer enrolled in National Cancer Institute-sponsored, cooperative-group trials from 2000 to 2012 and who underwent oncologic surgery (n = 17 125) were compared with trial-eligible women in the National Cancer Database diagnosed in 2000-2012 (n = 792 719). Race-specific trial participation was plotted over time by income and reported as a proportion of the combined cohorts. Factors associated with trial participation were estimated using logistic regression; we report odds ratios (ORs) with 95% confidence intervals (CIs). A P value less than .05 was considered statistically significant for all analyses. All tests were two-sided. RESULTS: Participation declined across all groups over time because of a decrease in the scale and number of trials. In 2000-2003, Asian-Pacific Islander (7.17%), Hispanic (3.48%), and white (7.13%) patients from the highest income group had higher participation than their lower-income counterparts (Asian-Pacific Islander: 3.95%; Hispanic: 2.67%; white: 5.96%), but by 2008-2012, only high-income white patients participated more than lower-income whites (0.32% vs 0.25%, all P < .01). Black (OR = 0.80, 95% CI = 0.75 to 0.85) and Hispanic (OR = 0.84, 95% CI = 0.77 to 0.92) patients were less likely to participate than whites, but there were statistically significant interactions between income and race and ethnicity, with high-income black patients being approximately 50% less likely to participate than lower-income blacks (all P < .001). CONCLUSIONS: Multifaceted interventions addressing the intersectionality of race, ethnicity, and other patient characteristics are needed to address persistent disparities in trial participation among breast surgical oncology patients.

Axillary lymph node dissection in node-positive breast cancer: are ten nodes adequate and when is enough, enough?

PURPOSE: National guidelines define adequate axillary lymph node dissections as those yielding ≥ 10 lymph nodes (LNs). We aimed to identify the optimal LN yield among node-positive patients. METHODS: Using the National Cancer Data Base (2010-2015), we categorized node-positive patients as follows: (1) neoadjuvant chemotherapy (NAC, cN1-3 or ypN1mi-3) or (2) upfront surgery (pN1-3). A restricted cubic splines model was used to estimate LN retrieval thresholds associated with change in overall survival (OS). RESULTS: 129,685 patients were identified: 21.2% NAC, 78.8% upfront surgery. Low, moderate, and high retrieval thresholds were estimated to be 1-6, 7-21, and > 21 LNs (upfront surgery), and 1-7, 8-22, and > 22 LNs (NAC). In an adjusted model, high versus low LN yield was associated with greater receipt of adjuvant chemotherapy (upfront surgery OR 1.96, p < 0.001) and greater use of adjuvant radiation (upfront surgery OR 1.08, p = 0.02; NAC OR 1.23, p = 0.002). After adjustment, high versus low LN retrieval was associated with improved OS (upfront surgery HR 0.86, p < 0.001; NAC HR 0.77, p < 0.001). Worse OS was associated with retrieving fewer LNs, likely as a result of an under-staged axilla and missed opportunity for adjuvant therapy, while better OS was independently associated with retrieval of up to approximately 20 LNs, after which survival did not improve. CONCLUSION: In node-positive breast cancer, the number of nodes retrieved is significantly associated with an increased positive nodal count and greater use of adjuvant therapy. Removal of approximately 20 LNs may improve survival by both more accurate nodal staging and increased adjuvant therapy use.

Examining relationships between perceptions and objective assessments of neighborhood environment and sedentary time: Data from the Washington, D.C. Cardiovascular Health and Needs Assessment.

Sedentary time (ST) and neighborhood environment (NE) are predictors of cardiovascular (CV) health. However, little is known about ST's relationship with NE. We examined associations of perceived and objective NE with ST in the predominantly African American faith-based population of the Washington, D.C. CV Health and Needs Assessment. After using community-based research principles, participants reported NE perceptions, including sidewalks, recreational areas, and crime presence. Factor analysis was conducted to explore pertinent constructs; factor sums were created and combined as Total Perception Score (TPS) (higher score = more favorable perception). Objective NE was assessed using Google Maps and the Active Neighborhood Checklist (ANC). ST was self-reported. Linear regression determined relationships between TPS and ST, and ANC scores and ST, for 1) overall population, 2) lower median-income D.C. areas, and 3) higher median-income DC and Maryland areas. For the sample (N = 98.9% African-American, 78% female), lower median-income areas had significantly lower mean TPS and ANC scores than higher median-income areas (p < 0.001). Three factors (neighborhood violence, physical/social environment, and social cohesion) were associated with overall NE perception. Among those in lower median-income areas, there was a negative association between TPS and ST that remained after covariate adjustment; this was not observed in higher median-income areas. There was no association between ANC scores and ST. Poorer NE perception is associated with greater ST for those in lower income areas, while objective environment is not related to ST. Multi-level interventions are needed to improve NE perceptions in lower-median income areas, reduce ST, and improve CV health.

Each procedure matters: threshold for surgeon volume to minimize complications and decrease cost associated with adrenalectomy.

BACKGROUND: An association has been suggested between increasing surgeon volume and improved patient outcomes, but a threshold has not been defined for what constitutes a "high-volume" adrenal surgeon. METHODS: Adult patients who underwent adrenalectomy by an identifiable surgeon between 1998-2009 were selected from the Healthcare Cost and Utilization Project National Inpatient Sample. Logistic regression modeling with restricted cubic splines was utilized to estimate the association between annual surgeon volume and complication rates in order to identify a volume threshold. RESULTS: A total of 3,496 surgeons performed adrenalectomies on 6,712 patients; median annual surgeon volume was 1 case. After adjustment, the likelihood of experiencing a complication decreased with increasing annual surgeon volume up to 5.6 cases (95% confidence interval, 3.27-5.96). After adjustment, patients undergoing resection by low-volume surgeons (<6 cases/year) were more likely to experience complications (odds ratio 1.71, 95% confidence interval, 1.27-2.31, P = .005), have a greater hospital stay (relative risk 1.46, 95% confidence interval, 1.25-1.70, P = .003), and at increased cost (+26.2%, 95% confidence interval, 12.6-39.9, P = .02). CONCLUSION: This study suggests that an annual threshold of surgeon volume (≥6 cases/year) that is associated with improved patient outcomes and decreased hospital cost. This volume threshold has implications for quality improvement, surgical referral and reimbursement, and surgical training.