Looking forward – May 2014

David B. Hoyt, MD, FACS

Thomas C. Ricketts III, PhD, MPH, Managing Director of the American College of Surgeons (ACS) Health Policy Research Institute, Washington, DC, recently brought to my attention a report from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. “Trends in Operating Room Procedures in U.S. Hospitals, 2001–2011,” indicates that although the overall number of procedures remained relatively stable over that time, the volume of some procedures grew while the number of other types of operations declined.* I thought many of you, particularly surgical educators, would be interested in reviewing some highlights from the report and in considering the implications on the surgical workforce and training.

Findings

The report indicates that some operating room (OR) procedures have become more prevalent, whereas other operations are being performed less frequently. Some examples are as follows:*

  • In 2001, musculoskeletal procedures constituted 17.9 percent of all procedures, but in 2011, this number rose to 24.2 percent, representing a 38 percent increase. Knee arthroplasty nearly doubled from 371,600 procedures in 2001 to 718,500 procedures in 2011, and hip replacement procedures increased by 40 percent, from 332,500 operations to 466,500. Spinal fusion increased by 70 percent, from 287,600 in 2001 to 488,300 in 2011.
  • OR procedures involving the digestive system accounted for 18 percent of the operations performed in 2001 versus 18.5 percent of the procedures in 2011, representing a 5 percent increase in volume. The volume of appendectomies decreased by 13 percent, from approximately 376,700 procedures in 2001 to 327,100 in 2011. Colorectal resection and cholecystectomy remained relatively stable during this time.
  • The percentage of OR procedures involving the cardiovascular system decreased from 15.5 percent in 2001 to 13.6 percent in 2011, an 11 percent decrease in volume. Coronary artery bypass graft operations decreased by 46 percent, from approximately 395,100 procedures in 2001 to 213,700 procedures in 2011. Percutaneous coronary angioplasty decreased by 28 percent and pacemaker or cardioverter/defibrillator procedures increased by 42 percent, while heart valve procedures remained fairly stable. Both endarterectomy and peripheral vascular bypass decreased by approximately one-third.
  • OR procedures involving the female and male genital organs each constituted more than 8 percent of all OR procedures in 2011, and both decreased in volume from 2001 (33 percent for female genital organs and 10 percent for male genital organs).
  • Obstetrical operations represented slightly more than 8 percent of all OR procedures in 2011—a 23 percent increase in volume since 2001, with a 28 percent increase in the volume of cesarean sections.

The trends uncovered in the study likely are the result of several factors, including an aging patient population combined with advances in technology and pharmaceuticals. Older individuals are more likely to suffer from musculoskeletal disease, such as osteo- and rheumatoid arthritis and disc deterioration, and to require hip replacements, spinal fusion, knee operations, and so on. Meanwhile, advances in noninvasive procedures, technology, and medication are likely spurring the decline in cardiovascular operations and certain gastrointestinal conditions.

Implications for the future

These trends will likely have profound implications for the surgical workforce of the future. “The reduced demand in community hospitals for selected procedures combined with growth in others can change the structure of the surgical community,” said Dr. Ricketts, professor of health policy and management and social medicine at the University of North Carolina (UNC) Gillings School of Global Public Health and the UNC School of Medicine-Chapel Hill. “The drop in the total number of procedures such as appendectomy, combined with the lack of growth in colorectal resection and cholecystectomy—procedures performed most often by general surgeons—has implications for whom we train, as well as how we train surgeons.”

The conventional wisdom for many years has been that the aging baby boom patient population combined with a larger number of surgical residents opting to enter the subspecialties will lead to an access to care crisis for general surgery patients. Furthermore, as more patients obtain health insurance coverage under the Affordable Care Act, we may see a gradual growth in the demand for elective general surgery procedures as patients and insurers seek out the most cost-effective methods for curing diseases and achieving long-term relief from health care conditions. Therefore, it is imperative that the surgical community provide incentives for young physicians to pursue general surgery as a career path.

On a surface level, the data presented in this study would seem to negate this hypothesis. After all, if fewer general surgery procedures are being performed, why would the nation need more general surgeons? However, a more reasonable and realistic conclusion is that we need to provide general surgeons with a broader skills set that extends well beyond performing surgical procedures, so that they are better able to provide the full range of services that their patients will need. The ACS and other members of the surgical community have been making this claim for some time, and this study, if anything, should demonstrate that the need to move in this direction is increasingly urgent.

With regard to surgical training specifically, “These broader trends mean that teaching programs for some specialties, especially general and thoracic surgery, may find it difficult to give surgeons the volume of work they need to develop excellent surgical skills,” added Dr. Ricketts, who is also deputy director of the Cecil G. Sheps Center for Health Services Research at UNC. As a result, we may need to expand the use of simulation and other innovations in surgical training to ensure that residents do have ample opportunity to hone their operative skills.
The ACS Health Policy Research Institute and the College’s leadership intend to study these data and their potential effects on the surgical profession and training in greater detail. We will work with the surgical education community to ensure that this and future generations of surgeons have the technical skills and knowledge necessary to provide high-quality care in our evolving practice environment.


* Weiss AJ, Elixhauser A. Trends in Operating Room Procedures in U.S. Hospitals, 2001–2011. Healthcare Cost and Utilization Project Statistical Brief #171. March 2014, Agency for Healthcare Research and Quality. Rockville, MD. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb171-Operating-Room-Procedure-Trends.pdf. Accessed March 31, 2014.

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