Workforce Projections for Hepato-Pancreato-Biliary Surgery

Supply and demand of hepatopancreatobiliary surgeons in the United States

BACKGROUND

Hepatopancreatobiliary (HPB) surgery requires specialized training and adequate case volumes to maintain procedural proficiency and optimal outcomes. Studies of individual HPB surgeon supply related to annual HPB case demand are sparse. This study assesses the supply and demand of the HPB surgical workforce in the United States (US).

METHODS

The National Inpatient Sample (NIS) was queried from 1998-2019 to estimate the number of HPB procedures performed. To approximate the number of HPB surgeons, models based on previous HPB workforce publications were employed. We then calculated the number of HPB surgeons needed to maintain volume-outcome thresholds at current reported levels of centralization.

RESULTS

In 2019, approximately 37,335 patients underwent inpatient HPB procedures in the US, while an estimated 905-1191 HPB surgeons were practicing. Assuming 50% centralization and an optimal volume-outcome threshold of 24 HPB cases-per-year, only 778 HPB surgeons were needed. Without adjustment in centralization, by 2030 there will be a demand of fewer than 12 annual cases per HPB surgeon.

CONCLUSION

The current supply of HPB surgeons may exceed demand in the United States. Without alteration in training pathways or improved care centralization, by 2030, there will be insufficient HPB case volume per surgeon to maintain published volume-outcome standards.

The Impact of Establishing a Dedicated Liver Surgery Program at a University-affiliated Hospital on Workforce, Workload, Surgical Outcomes, and Trainee Surgical Autonomy and Academic Output

Objective

To detail the implementation of a dedicated liver surgery program at a university-affiliated hospital and to analyze its impact on the community, workforce, workload, complexity of cases, the short-term outcomes, and residents and young faculties progression toward technical autonomy and academic production.

Background

Due to the increased burden of liver tumors worldwide, there is an increased need for liver centers to better serve the community and facilitate the education of trainees in this field.

Methods

The implementation of the program is described. The 3 domains of workload, research, and teaching were compared between 2-year periods before and after the implementation of the new program. The severity of disease, complexity of procedures, and subsequent morbidity and mortality were compared.

Results

Compared with the 2-year period before the implementation of the new program, the number of liver resections increased by 36% within 2 years. The number of highly complex resections, the number of liver resections performed by residents and young faculties, and the number of publications increased 5.5-, 40-, and 6-fold, respectively. This was achieved by operating on more severe patients and performing more complex procedures, at the cost of a significant increase in morbidity but not mortality. Nevertheless, operations during the second period did not emerge as an independent predictor of severe morbidity.

Conclusions

A new liver surgery program can fill the gap between the demand for and supply of liver surgeries, benefiting the community and the development of the next generation of liver surgeons.

Training in Hepatopancreatobiliary Surgery: Assessment of the Hepatopancreatobiliary Surgery Workforce in North America

OBJECTIVE

Evaluate the current status of Hepatopancreatobiliary (HPB) Surgery workforce in North America.

BACKGROUND

HPB fellowships have proliferated, with HPB surgeons entering the field through 3 pathways: transplant surgery, surgical oncology, or HPB surgery training. Impact of this growth is unknown.

METHODS

An anonymous survey was distributed to 654 is used as HPB surgeons from October 2012 to January 2013. Questions evaluated satisfaction with job availability after training and description of current practice. Nationwide Inpatient Sample (NIS) data from 2003 to 2010 was queried to describe the growth of HPB cases in the United States; these data were compared to prior HPB workforce projections performed using 2003 NIS data.

RESULTS

A total of 416 HPB surgeons responded (66%). HPB surgeons are concentrated in a small number of states/provinces with a lack of HPB surgeon workforce in central United States. HPB graduates from 2008 to 2012 report increased difficulty in identifying an HPB-focused practice versus prior to 2008. Mature HPB surgery practices report a composition of 25% to 50% non-HPB operative cases. Fifty-one percent of respondents reported an opinion that current HPB Surgeon production was excessive; however, 2010 NIS data demonstrate that major HPB surgery cases have grown significantly more than was previously projected using 2003 NIS data.

CONCLUSIONS AND RELEVANCE

A cohesive strategy for responsibly responding to the HPB surgical workforce requirements of North America is needed. Elevation of training standards, standardization of requirements for certification, and careful modeling that accounts for regionalization of care should be pursued to prevent overtraining and decentralization of HPB surgical care in the future.

Training and practice of the next generation HPB surgeon: analysis of the 2014 AHPBA residents' and fellows' symposium survey

BACKGROUND

Hepato-pancreato-biliary (HPB) surgery is a complex subspecialty drawing from varied training pools, and the need for competency is rapidly growing. However, no board certification process or standardized training metrics in HPB surgery exist in the Americas. This study aims to assess the attitudes of current trainees and HPB surgeons regarding the state of training, surgical practice and the HPB surgical job market in the Americas.

STUDY DESIGN

A 20-question survey was distributed to members of Americas Hepato-Pancreato-Biliary Association (AHPBA) with a valid e-mail address who attended the 2014 AHPBA. Descriptive statistics were generated for both the aggregate survey responses and by training category.

RESULTS

There were 176 responses with evenly distributed training tracks; surgical oncology (44, 28%), transplant (39, 24.8%) and HPB (38, 24.2%). The remaining tracks were HPB/Complex gastrointestinal (GI) and HPB/minimally invasive surgery (MIS) (29, 16% and 7, 4%). 51.2% of respondents thought a dedicated HPB surgery fellowship would be the best way to train HPB surgeons, and 68.1% felt the optimal training period would be a 2-year clinical fellowship with research opportunities. This corresponded to the 67.5% of the practicing HPB surgeons who said they would prefer to attend an HPB fellowship for 2 years as well. Overall, most respondents indicated their ideal job description was clinical practice with the ability to engage in clinical and/or outcomes research (52.3%).

CONCLUSIONS

This survey has demonstrated that HPB surgery has many training routes and practice patterns in the Americas. It highlights the need for specialized HPB surgical training and career education. This survey shows that there are many ways to train in HPB. A 2-year HPB fellowship was felt to be the best way to train to prepare for a clinically active HPB practice with clinical and outcomes research focus.

What to expect when you're expecting a hepatopancreatobiliary surgeon: self-reported experiences of HPB surgeons from different training pathways

BACKGROUND

Hepatopancreatobiliary (HPB) surgery fellowship training has multiple paths. Prospective trainees and employers must understand the differences between training pathways. This study examines self-reported fellowship experiences and current scope of practice across three pathways.

METHODS

An online survey was disseminated to 654 surgeons. These included active Americas Hepato-Pancreato-Biliary Association (AHPBA) members and recent graduates of HPB, transplant-HPB and HPB-heavy surgical oncology fellowships.

RESULTS

A total of 416 (64%) surgeons responded. Most respondents were male (89%) and most were practising in an academic setting (83%). 290 (70%) respondents underwent formal fellowship training. Although fellowship experiences varied, current practice was largely similar. Minimally invasive surgery (MIS) and ultrasound were the most commonly identified areas of training deficiencies and were, respectively, cited as such by 47% and 34% of HPB-, 49% and 50% of transplant-, and 52% and 25% of surgical oncology-trained respondents. Non-HPB cases performed in current practice included gastrointestinal (GI) and general surgery cases (56% and 49%, respectively) for HPB-trained respondents, transplant and general surgery cases (87% and 21%, respectively) for transplant-trained respondents, and GI surgery and non-HPB surgical oncology cases (70% and 28%, respectively) for surgical oncology-trained respondents.

CONCLUSIONS

Fellowship training in HPB surgery varies by training pathway. Training in MIS and ultrasound is deficient in each pathway. The ultimate scope of non-transplant HPB practice appears similar across training pathways. Thus, training pathway choice is best guided by the training experience desired and non-HPB components of anticipated practice.

Estimating the need for hepato-pancreatico-biliary surgeons in the USA

BACKGROUND

Hepato-pancreatico-biliary (HPB) fellowship training has risen in popularity in recent years and hence large numbers of graduating fellows enter the workforce each year. Studies have proposed that the increase in HPB-trained surgeons will outgrow demand in the USA. This study shows that the need for HPB-trained surgeons refers not to the meeting of demand in terms of case volume, but to improving patient access to care.

METHODS

The National Inpatient Sample (NIS) database for the years 2005-2011 was queried for CPT codes relating to pancreatic, liver and biliary surgical cases. These numbered 6627 in 2005 and increased to 8515 in 2011. Cases were then mapped to corresponding states. The number of procedures in an individual state was divided by the total number of procedures to give a ratio for each state. A similar ratio was calculated for the population of each state to the national population. These ratios were combined to give a ratio by state of observed to expected HPB surgical cases.

RESULTS

Of the 46 states that participate in the NIS, only 18 achieved ratios of observed to expected cases of >1. In the remaining 28 states, the number of procedures was lower than that expected according to each state's population.

CONCLUSIONS

The majority of the USA is underserved in terms of HPB surgery. Given the growing number of HPB-trained physicians entering the job market, this sector should focus on bringing understanding and management of complex disease to areas of the country that are currently in need.

Variation in hospital treatment patterns for metastatic colorectal cancer

BACKGROUND

There are many treatment options for metastatic colorectal cancer (CRC). However, to the authors' knowledge, national treatment patterns for metastatic CRC, and the stability of hospital treatment patterns over time, have not been well described.

METHODS

Data from the 2006 through 2011 National Cancer Data Base were used to study adults with newly diagnosed metastatic CRC (84,161 patients from 1051 hospitals). Using hierarchical models, the authors characterized hospital volume in the use of different treatment modalities (primary site resection, metastatic site resection, chemotherapy, and palliative care). The authors then assessed variation in the receipt of treatment according to the hospitals' relative volume of services used. Finally, the extent to which hospital treatment patterns changed over the past decade was examined.

RESULTS

Overall use of volume of services varied widely (5.0% in the hospitals with low volumes of service to 22.3% in the hospitals with high volumes of service). As hospitals' volumes of services increased, adjusted rates of metastatic site surgery (6.6% to 30.8%; P<.001) and multiagent chemotherapy (37.8% to 57.4%; P<.001) use increased, but primary site resection demonstrated little variation (56.8% vs 59.5%; P = .024). It is interesting to note that use of palliative care also increased (8.1% to 11.3%; P = .002). Hospital treatment patterns did not change over time, with hospitals with high volumes of service consistently using more metastatic site resection and multiagent chemotherapy than hospitals with low volumes of service.

CONCLUSIONS

There is wide variation in hospital treatment patterns for patients with metastatic CRC, and these patterns have been stable over time. It appears that much of the approach for metastatic CRC treatment depends on the hospital in which the patient presents.

A survey-based assessment of the Canadian pediatric surgery workforce

BACKGROUND

There is significant lack of information regarding the Canadian pediatric surgery workforce.

METHODS

An IRB-approved survey aimed at assessing workforce issues was administered to pediatric surgeons and pediatric surgery chiefs in Canada in 2012.

RESULTS

The survey was completed by 98% of practicing surgeons and 13 of the 18 division chiefs. Only 6% of surgeons are older than 60 years, and only a fifth anticipate retirement over the next decade. The workforce is stable, with 82% of surgeons unlikely to change current positions. Surgical volume showed essentially no growth during the 5-year period 2006-2010. The majority of surgeons felt they were performing the right number or too few cases and anticipated minimal or no future growth in their individual practices or that of their group. Based on anticipated vacancies, the best estimate is a need for 20 new pediatric surgeons over the next decade. This need is significantly surpassed by the current output from the Canadian training programs.

CONCLUSIONS

The Canadian pediatric surgery workforce is currently saturated. The mismatch between the number of graduating trainees and the available positions over the next decade has significant repercussions for current surgery and pediatric surgery residents wishing to practice in Canada.

Strategies to reduce variation in the use of surgery

Provision rates for surgery vary widely in relation to identifiable need, suggesting that reduction of this variation might be appropriate. The definition of unwarranted variation is difficult because the boundaries of acceptable practice are wide, and information about patient preference is lacking. Very little direct research evidence exists on the modification of variations in surgery rates, so inferences must be drawn from research on the alteration of overall rates. The available evidence has large gaps, which suggests that some proposed strategies produce only marginal change. Micro-level interventions target decision making that affects individuals, whereas macro-level interventions target health-care systems with the use of financial, regulatory, or incentivisation strategies. Financial and regulatory changes can have major effects on provision rates, but these effects are often complex and can include unintended adverse effects. The net effects of micro-level strategies (such as improvement of evidence and dissemination of evidence, and support for shared decision making) can be smaller, but better directed. Further research is needed to identify what level of variation in surgery rates is appropriate in a specific context, and how variation can be reduced where desirable.

Incorporating an HPB fellowship does not diminish surgical residents' HPB experience in a high-volume training centre

BACKGROUND

Surgical residency training is evolving, and trainees who wish to practice hepato-pancreato-biliary (HPB) surgery in the future will be required to obtain advanced training. As this paradigm evolves, it is crucial that HPB fellowship incorporation into an established surgical residency programme does not diminish surgical residents' exposure to complex HPB procedures. We hypothesized that incorporation of a HPB fellowship in a high-volume clinical training programme would not detract from residents' HPB experience.

METHODS

Resident operative case logs and HPB fellow case logs were reviewed. Resident exposure to complex HPB procedures for 3 years prior to and 3 years after fellowship incorporation were compared.

RESULTS

No significant changes in surgical resident exposure to liver and pancreatic resection were seen between the two time periods. Surgical resident exposure to complex biliary procedures decreased in the 3 years after HPB fellowship incorporation (P= 0.003); however, exceeded the national average in each year except 2006. Graduating residents' overall HPB experience was unchanged in the 3 years prior to and after incorporating an HPB fellow. Expansion of HPB volume was a critical part of successful HPB fellowship implementation.

DISCUSSION

An HPB fellowship programme can be incorporated into a high-volume clinical training programme without detracting from resident HPB experience. Individual training programmes should carefully assess their capability to provide an adequate clinical experience for fellows without diminishing resident exposure to complex HPB procedures.

Hepato-pancreato-biliary training in general surgery residency: is it enough for the real world?

BACKGROUND

Advanced training in hepato-pancreato-biliary (HPB) surgery is available at select centers. No approved fellowships have yet been established.

OBJECTIVE

To determine the level of training in HPB surgery during general surgery residency and to assess the need for additional training.

METHOD

All general surgical residency programs in the United States were surveyed. Resident Review Committee (RRC) and International Hepato-Pancreato-Biliary Association (IHPBA) requirements were compared to Accreditation Council of Graduate Medical Education (ACGME) data.

RESULTS

Eighty of 250 general surgical residency programs (32%) responded to the survey. Eighty percent felt their graduating residents had sufficient HPB training. The average number of pancreatic cases per graduating resident was 10.2 +/- 7.3. The average number of hepatic resections was 8.6 +/- 5.1, and for complex biliary cases, 5.3 +/- 1.3.

CONCLUSIONS

A significant portion of HPB surgery is performed at transplant centers or by HPB surgeons. Guidelines must be established to assure adequate training. When HPB surgery is the main focus of the future practice, residents should seek additional training.