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.

Proceedings From the Advances in Surgery Channel Diversity, Equity, and Inclusion Series: Lessons Learned From Asian Academic Surgeons.

In this series of talks and the accompanying panel session, leaders from the Society of Asian Academic Surgeons discuss issues faced by Asian Americans and the importance of the role of mentors and allyship in professional development in the advancement of Asian Americans in leadership roles. Barriers, including the model minority myth, are addressed. The heterogeneity of the Asian American population and disparities in healthcare and in research, specifically as relates to Asian Americans, also are examined.

Perspectives on virtual interviews-A follow-up study of the Comprehensive Endocrine Surgery Fellowship interview process.

BACKGROUND: The American Association of Endocrine Surgeons Comprehensive Endocrine Surgery Fellowship interview stakeholders previously favored in-person interviews, despite time and expense. This study assessed perception changes given mandated virtual interviews because of coronavirus disease 2019. METHODS: Immediately after the 2020 Match, anonymous surveys were distributed to applicants (n = 37) and program directors (n = 22). Mixed-methods analyses were used to evaluate responses. Results were compared to data from a prior study of the 2013 to 2018 in-person interview process. RESULTS: Response rates were 82% (program directors) and 60% (applicants). Compared with prior applicants, 2020 applicants attended similar numbers of interviews (1-10, 32% vs 37%; P = .61), used fewer vacation days (23% vs 56%; P = .01), and most reported 0 expenses. Burdens included lack of protected time for interviews. The virtual format did not compromise applicant ability to meet faculty (mean rank = 6.8/10) or make favorable impressions (mean rank = 6.8/10). Program directors reported equivalent or improved assessments of applicants. Program directors (72%) and applicants (77%) indicated that future interviews should be partially or completely virtual. CONCLUSION: In contrast to prior survey data, applicants and program directors now express interest in virtual or hybrid interview processes. Virtual interviews were less costly, less time-consuming, and met goals effectively. Integrating virtual interview components will require innovative strategies to reduce redundancies and promote equitable access.

Optimizing the fellowship interview process: Perspectives from applicants and program directors of the comprehensive endocrine surgery fellowship program.

BACKGROUND: Approximately 80% of general surgery residents undertake some form of fellowship training. Our objective was to characterize goals and burdens of the interview process among applicants to Comprehensive Endocrine Surgery Fellowship programs. METHODS: Participants included trainees from 2013 to 2019. Results for ranking questions are presented as a mean rank reported out of the total number of selections. RESULTS: Response rate was 54% (n = 75). The most important goal for interviews was meeting the faculty (mean rank 2.4/9), followed by "behind the scenes information" and "make a good impression" (mean rank 3.6 and 3.7, respectively). The most substantial burden for the applicant was expense (mean rank 2.1/7), followed by time away from residency (mean rank 3.1/7). The economic burden of 51% of the applicants was $2,500 to $7,500. Geographic location and expense were the top 2 reasons applicants declined offers of interviews. Despite the process, 76% of respondents indicated that no improvements to the interview process are necessary. Alternative strategies such as videoconferencing or centralized interviews received little support (<10%). CONCLUSION: Despite identifying several burdens, survey respondents believed that in-person interviews are an integral component of the fellowship application process. Indeed, 70% of applicants do not have a first-choice program before interviews, and meeting the faculty is ranked as the greatest priority goal. Our data illustrate the importance of individual specialties evaluating and optimizing their own processes for fellowship interviews.

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.

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.

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.

A cost-effectiveness analysis of adrenalectomy for nonfunctional adrenal incidentalomas: is there a size threshold for resection?

BACKGROUND: Adrenocortical carcinoma (ACC) is a rare, but aggressive, malignancy. Current American Association of Clinical Endocrinologists (AACE)/American Association of Endocrine Surgeons (AAES) guidelines recommend resection of nonfunctional adrenal neoplasms ≥ 4 cm. This study evaluates the cost-effectiveness of this approach. METHODS: A decision tree was constructed for patients with a nonfunctional, 4-cm adrenal incidentaloma with no radiographic suspicion for ACC. Patients were randomized to adrenalectomy, surveillance per AACE/AAES guidelines, or no follow-up ("sign-off"). Incremental cost-effectiveness ratio (ICER) includes health care costs, including missed ACC. ICER (dollar/life-year-saved [LYS]) was determined from the societal perspective. Sensitivity analyses were performed. RESULTS: In the base-case analysis, assuming a 2.0% probability of ACC for a 4-cm tumor, surgery was more cost-effective than surveillance (ICER $25,843/LYS). Both surgery and surveillance were incrementally more cost-effective than sign-off ($35/LYS and $8/LYS, respectively). Sensitivity analysis demonstrated that the model was sensitive to patient age, tumor size, probability of ACC, mortality of ACC, and cost of hospitalization. The results of the model were stable across different cost and complications related to adrenalectomy, regardless of operative approach. CONCLUSION: In our model, adrenalectomy was cost-effective for neoplasms >4 cm and in patients <65 years, primarily owing to the aggressiveness of ACC. Current AACE/AAES guideline recommendations for the resection of adrenal incidentalomas ≥ 4 cm seem to be cost-effective.

Would scan, but which scan? A cost-utility analysis to optimize preoperative imaging for primary hyperparathyroidism.

BACKGROUND: Minimally invasive parathyroidectomy for primary hyperparathyroidism depends on accurate preoperative localization. This study examines the cost-utility of sestamibi in combination with single photon emission computed tomography (sestamibi-SPECT); ultrasound; and 4-dimensional computed tomography (4D-CT). METHODS: A decision tree was constructed for patients undergoing initial parathyroidectomy. Patients were randomized to 1 of 5 preoperative localization protocols: (1) ultrasound; (2) sestamibi-SPECT; (3) 4D-CT; (4) sestamibi-SPECT and ultrasound; and (5) sestamibi-SPECT and ultrasound and 4D-CT, if discordant (sestamibi-SPECT and ultrasound ± 4D-CT). From a societal perspective, all relevant costs were included. Input data were obtained from literature and Medicare. The incremental cost-utility ratio was determined in dollars per quality-adjusted life years ($/QALY). Sensitivity analyses were performed. RESULTS: In the base-case, ultrasound was least expensive, with a cost of $6666, compared to $6773 (4-D CT); $7214 (sestamibi-SPECT and ultrasound ± 4D-CT); $7330 (sestamibi-SPECT); and $7371(sestamibi-SPECT and ultrasound). Sestamibi-SPECT and ultrasound ± 4D-CT were most cost-effective because improved localization resulted in fewer bilateral explorations. QALY were comparable across modalities. Compared to sestamibi-SPECT, ultrasound, 4D- CT, and sestamibi-SPECT and ultrasound ± 4D-CT resulted a win-win situation-costing less and accruing more utility. Sensitivity analyses demonstrated that the model was sensitive to surgery cost and diagnostic accuracy of imaging. CONCLUSION: In our model, sestamibi-SPECT and ultrasound ± 4D-CT were the most cost-effective methods, followed by 4D-CT and ultrasound. Sestamibi-SPECT alone was least cost-effective. Cost-utilities were dependent on the sensitivities of ultrasound and 4D-CT and may vary by institution.

Endocrine surgery.

The increasing complexity in the management of surgical disorders of the thyroid, parathyroid, adrenal glands, and neuroendocrine pancreas tumors have led to the emergence of endocrine surgery as a surgical subspecialty. Studies showing the relationship between hospital/surgeon volume and patient outcomes highlight the importance of advanced postgraduate training in this field.

To supplement or not to supplement: a cost-utility analysis of calcium and vitamin D repletion in patients after thyroidectomy.

BACKGROUND: Postoperative hypocalcemia is the most common complication after thyroidectomy; prevention and treatment remain areas of ongoing debate. The purpose of this study was to determine the incremental cost utility of routine versus selective calcium and vitamin D supplementation after total or completion thyroidectomy. METHODS: A cost-utility analysis using a Markov decision model was performed for a hypothetical cohort of adult patients after thyroidectomy. Routine or selective supplementation of oral calcium carbonate, vitamin D (calcitriol), and intravenous calcium gluconate, when required, was used. Selective supplementation was determined by serum intact parathyroid hormone levels. The incremental cost utility, measured in U.S. dollars per quality-adjusted life-year (QALY), was calculated. RESULTS: In the base-case analysis, the cost of routine supplementation was $102 versus $164 for selective supplementation. Patients in the routine arm gained 0.002 QALYs compared to patients in the selective arm (0.95936 QALYs vs. 0.95725 QALYs). At the population level, this translates into a savings of $29,365/QALY (95% confidence interval, -$66,650 to -$1,772) for routine supplementation. Sensitivity analyses demonstrated that the model was most sensitive to the utility of the hypocalcemic state, postoperative rates of hypocalcemia, and cost of serum parathyroid hormone testing. CONCLUSIONS: Routine oral calcium and calcitriol supplementation in patients after thyroidectomy seems to be less expensive and results in higher patient utility than selective supplementation. Surgeons who have very low rates of hypocalcemia in their patients may benefit less from routine supplementation.

To stimulate or withdraw? A cost-utility analysis of recombinant human thyrotropin versus thyroxine withdrawal for radioiodine ablation in patients with low-risk differentiated thyroid cancer in the United States.

CONTEXT: Use of recombinant human TSH (rhTSH) prior to radioactive iodine remnant ablation for patients with differentiated thyroid cancer avoids the hypothyroid state and improves quality of life. European studies have shown that use of rhTSH vs. thyroid hormone withdrawal is a cost-effective method for preparing patients for ablation. OBJECTIVE: The objective of the study was to determine the cost-utility of rhTSH prior to ablation in the United States. DESIGN/SETTING/SUBJECTS: A Markov decision model was developed for a hypothetical group of adult patients with low-risk differentiated thyroid cancer who were prepared for ablation by either rhTSH or thyroid hormone withdrawal. Patients entered the model after initial thyroidectomy; follow-up was in accordance with current American Thyroid Association guidelines. Input data were obtained from the literature, Medicare reimbursement schedule, and U.S. Bureau of Labor Statistics. Sensitivity analyses were performed for all clinically relevant inputs. MAIN OUTCOME MEASURES: Cost-utility, measured in U.S. dollars per quality-adjusted life-year ($/QALY), was measured. RESULTS: Use of rhTSH yielded an incremental cost-utility of $52,554/QALY (95% confidence interval $52,058-53,050/QALY) (incremental societal cost of $1,365/patient; incremental benefit of 0.026 QALY/patient). The majority of cost and benefit occurs during the preablation, ablation, and postablation period; differences in cost are due to cost of rhTSH and differences in productivity loss (days off work). The model was most sensitive to changes in time off work, cost of rhTSH, and differences in utilities of health states. CONCLUSIONS: In the United States, the cost-effectiveness of rhTSH for ablation in patients with low-risk differentiated thyroid cancer is highly dependent on potential variations in cost of rhTSH, rates of remnant ablation, time off work, and quality of life.

Evolution of the surgeon-volume, patient-outcome relationship.

OBJECTIVE: Higher surgeon volume is associated with improved patient outcomes. This finding has prompted recommendations for increasing specialization and referrals to high-volume surgeons, yet their implementation in clinical practice has not been measured. METHODS: We performed cross-sectional analyses using 1999 and 2005 discharge information from the Health Care Utilization Project National Inpatient Sample to measure whether the number of procedures performed by high-volume surgeons increased over time. Procedures included those demonstrated to have strong surgeon volume-outcome associations in the literature. International Classification of Diseases, Ninth Revision codes were employed for colorectal procedures, esophagectomy, gastrectomy, pancreatectomy, thyroidectomy, coronary artery bypass graft surgery, and carotid endarterectomy. Bivariate analyses and hierarchical generalized linear models were employed to measure association between surgeon volume and length of stay (LOS) and mortality or complications. RESULTS: There was a significant increase in the proportion of procedures performed by high-volume surgeons over time, with the most dramatic increases seen for gastrectomy (54%), pancreatectomy (31%), and thyroidectomy (23%). Having a procedure performed by a high-volume surgeon was associated with patient race and insurance status. Overall, unadjusted mortality and LOS were significantly lower for high-volume surgeons compared with low-volume surgeons in 1999 and 2005. In multivariable hierarchical generalized linear models, only differences in LOS by surgeon volume remained significant in both years. CONCLUSIONS: The proportion of procedures performed by high-volume surgeons increased over a 6-year period, as evidence mounted in support of a surgeon volume-outcome association. Efforts are still needed to improve access among underserved subsets of the population and eliminate apparent disparities based on patient race and insurance status.

Pediatric endocrine surgery: who is operating on our children?

BACKGROUND: High surgeon volume is associated with improved outcomes in adult endocrine surgery. This is the first population-based outcomes study for thyroidectomy/parathyroidectomy in children. METHODS: Cross-sectional analyses were performed using 1999 to 2005 Healthcare Cost and Utilization Project Nationwide Inpatient Sample data. Outcomes included complications, length of stay (LOS), and costs. High-volume surgeons performed >30 cervical endocrine procedures per year in adults and children; pediatric surgeons restricted >90% of their practices to patients

Clinical and economic outcomes of thyroid and parathyroid surgery in children.

CONTEXT: Clinical and economic outcomes after thyroidectomy/parathyroidectomy in adults have demonstrated disparities based on patient age and race/ethnicity; there is a paucity of literature on pediatric endocrine outcomes. OBJECTIVE: The objective was to examine the clinical and demographic predictors of outcomes after pediatric thyroidectomy/parathyroidectomy. DESIGN: This study is a cross-sectional analysis of Healthcare Cost and Utilization Project-National Inpatient Sample hospital discharge information from 1999-2005. All patients who underwent thyroidectomy/parathyroidectomy were included. Bivariate and multivariate analyses were performed to identify independent predictors of patient outcomes. SUBJECTS: Subjects included 1199 patients 17 yr old or younger undergoing thyroidectomy/parathyroidectomy. MAIN OUTCOME MEASURES: Outcome measures included in-hospital patient complications, length of stay (LOS), and inpatient hospital costs. RESULTS: The majority of patients were female (76%), aged 13-17 yr (71%), and White (69%). Whites were more often in the highest income group (80% vs. 8% for Hispanic and 6% for Black; P < 0.01) and had private/HMO insurance (76% vs. 10% for Hispanic and 5% for Black; P < 0.001) rather than Medicaid (13% vs. 32% for Hispanic and 41% for Black; P < 0.001). Ninety-one percent of procedures were thyroidectomies and 9% parathyroidectomies. Children aged 0-6 yr had higher complication rates (22% vs. 15% for 7-12 yr and 11% for 13-17 yr; P < 0.01), LOS (3.3 d vs. 2.3 for 7-12 yr and 1.8 for 13-17 yr; P < 0.01), and higher costs. Compared with children from higher-income families, those from lower-income families had higher complication rates (11.5 vs. 7.7%; P < 0.05), longer LOS (2.7 vs. 1.7 d; P < 0.01), and higher costs. Children had higher endocrine-specific complication rates than adults after parathyroidectomy (15.2 vs. 6.2%; P < 0.01) and thyroidectomy (9.1 vs. 6.3%; P < 0.01). CONCLUSIONS: Children undergoing thyroidectomy/parathyroidectomy have higher complication rates than adult patients. Outcomes were optimized when surgeries were performed by high-volume surgeons. There appears to be disparity in access to high-volume surgeons for children from low-income families, Blacks, and Hispanics.

A population-based study of outcomes from thyroidectomy in aging Americans: at what cost?

BACKGROUND: We wanted to evaluate clinical and economic outcomes after thyroidectomy in patients 65 years of age and older, with special analyses of those aged 80 years and older, in the US. STUDY DESIGN: This was a population-based study using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, 2003-2004, a national administrative database of all patients undergoing thyroidectomy and their surgeon providers. Independent variables included patient demographic and clinical characteristics and surgeon descriptors, including case volume. Clinical and economic outcomes included mean total costs and length of stay (LOS), in-hospital mortality, discharge status, and complications. RESULTS: There were 22,848 patients who underwent thyroidectomies, including 4,092 (18%) aged 65 to 79 years and 744 (3%) 80 years of age or older. On a population level, patient age is an independent predictor of clinical and economic outcomes. Average LOS for patients 80 years and older is 60% longer than for similar patients 65 to 79 years of age (2.9 versus 2.2 days; p < 0.001), complication rates are 34% higher (5.6% versus 2.1%; p < 0.001), and total costs are 28% greater ($7,084 versus $5,917; p < 0.001). High-volume surgeons have shorter LOS and fewer complications but perform fewer thyroidectomies for aging Americans; although they do nearly 29% of these procedures in patients younger than 65 years, they do just 15% of thyroidectomies in patients 80 years and older and 23% in patients 65 to 79 years. CONCLUSIONS: On a population level, clinical and economic outcomes for patients 65 years and older undergoing thyroidectomies are considerably worse than for similar, younger patients. The majority of thyroidectomies in aging Americans is performed by low-volume surgeons. More data are needed about longterm outcomes, but increased referrals to high-volume surgeons for aging Americans are necessary.

Calcitonin measurement in the evaluation of thyroid nodules in the United States: a cost-effectiveness and decision analysis.

CONTEXT: European studies have shown that the use of routine calcitonin screening for detection of medullary thyroid cancer (MTC) in patients with thyroid nodules increases the detection of occult MTC and may improve patient outcomes. Calcitonin screening for MTC has not been recommended in recent U.S. practice guidelines. OBJECTIVE: Our objective was to determine the cost-effectiveness (C/E) of routine calcitonin screening in adult patients with thyroid nodules in the United States. SETTINGS/SUBJECTS: A decision model was developed for a hypothetical group of adult patients presenting for evaluation of thyroid nodules in the United States. Patients were screened using current American Thyroid Association guidelines only, or American Thyroid Association guidelines with routine serum calcitonin screening. Input data were obtained from the literature, the Surveillance Epidemiology and End Results and Healthcare Cost and Utilization Project's Nationwide Inpatient Sample databases, and the Medicare Reimbursement Schedule. Sensitivity analyses were performed for a number of input variables. MAIN OUTCOME MEASURES: C/E, measured in dollars per life years saved (LYS), was calculated. RESULTS: Addition of calcitonin screening to current American Thyroid Association guidelines for the evaluation of thyroid nodules would cost $11,793 per LYS ($10,941-$12,646). When extrapolated to the national level, calcitonin screening for MTC in the United States would yield an additional 113,000 life years at a cost increase of 5.3%. Calcitonin screening C/E is sensitive to patient age and gender, and to changes in disease prevalence, specificity of fine needle aspiration and calcitonin testing, calcitonin screening level, costs of testing, and length of follow-up. CONCLUSION: Routine serum calcitonin screening in patients undergoing evaluation for thyroid nodules appears to be cost effective in the United States, with C/E comparable to the measurement of thyroid stimulating hormone, colonoscopy, and mammography screening.

The maturation of a specialty: Workforce projections for endocrine surgery.

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 age-adjusted 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.

Racial disparities in clinical and economic outcomes from thyroidectomy.

CONTEXT: Thyroid disease is common, and thyroidectomy is a mainstay of treatment for many benign and malignant thyroid conditions. Overall, thyroidectomy is associated with favorable outcomes, particularly if experienced surgeons perform it. OBJECTIVE: To examine racial differences in clinical and economic outcomes of patients undergoing thyroidectomy in the United States. DESIGN, SETTING, PATIENTS: The nationwide inpatient sample was used to identify thyroidectomy admissions from 1999 to 2004, using ICD-9 procedure codes. Race and other clinical and demographic characteristics of patients were collected along with surgeon volume and hospital characteristics to predict outcomes. MAIN OUTCOME MEASURES: Inpatient mortality, complication rates, length of stay (LOS), discharge status, and mean total costs by racial group. RESULTS: In 2003-2004, 16,878 patients underwent thyroid procedures; 71% were white, 14% black, 9% Hispanic, and 6% other. Mean LOS was longer for blacks (2.5 days) than for whites (1.8 days, P < 0.001); Hispanics had an intermediate LOS (2.2 days). Although rare, in-hospital mortality was higher for blacks (0.4%) compared with that for other races (0.1%, P < 0.001). Blacks trended toward higher overall complication rates (4.9%) compared with whites (3.8%) and Hispanics (3.6%, P = 0.056). Mean total costs were significantly lower for whites ($5447/patient) compared with those for blacks ($6587) and Hispanics ($6294). The majority of Hispanics (55%) and blacks (52%) had surgery by the lowest-volume surgeons (1-9 cases per year), compared with only 44% of whites. Highest-volume surgeons (>100 cases per year) performed 5% of thyroidectomies, but 90% of their patients were white (P < 0.001). Racial disparities in outcomes persist after adjustment for surgeon volume group. CONCLUSIONS: These findings suggest that, although thyroidectomy is considered safe, significant racial disparities exist in clinical and economic outcomes. In part, inequalities result from racial differences in access to experienced surgeons; more data are needed with regard to racial differences in thyroid biology and surveillance to explain the balance of observed disparities.