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Background: Head and neck cancer constitutes a substantial portion of the burden of disease in South Asia, and there is an undersupply of surgical capacity in this region. The purpose of this study was to estimate the economic welfare losses due to head and neck cancer in India, Pakistan, and Bangladesh in 2010., Methods: We used publicly available estimates of head and neck cancer morbidity and mortality along with a concept termed the value of a statistical life to estimate economic welfare losses in the aforementioned countries in 2010., Results: Economic losses because of head and neck cancer in India, Pakistan, and Bangladesh totaled $16.9 billion (2010 US dollars [USD]), equivalent to 0.26% of the region's economic output. Bangladesh, the poorest country, experienced the greatest proportional losses., Conclusion: The economic consequences of head and neck cancer in South Asia are significant, and building surgical capacity is essential to begin to address this burden. © 2016 Wiley Periodicals, Inc. Head Neck 38:1242-1247, 2016., (© 2016 Wiley Periodicals, Inc.)

Background: Endovascular aneurysm repair (EVAR) and Thoracic endovascular aortic repair (TEVAR) are commonly performed by interventional radiologists, cardiologists, general surgeons, cardiothoracic surgeons, and vascular surgeons, with each specialty having differences in residency structure, operative experience, and subspecialty training. The aim of this study is to evaluate the impact of surgeon specialty on outcomes following EVAR and TEVAR., Methods: Patients who underwent EVAR and TEVAR were identified from the 2007 to 2009 Nationwide Inpatient Sample (NIS). Physician identifiers in the NIS were used to determine surgical specialty and operative experience. Multivariate analysis adjusted for mortality risk was used to compare differences in demographics, complications, outcomes, and hospital covariates., Results: A total of 5147 EVARs were identified within the NIS, of which 88.3% were completed by vascular surgeons. There were no significant differences in demographics between the specialties. Cardiothoracic surgeons were more likely to have a postoperative stroke (3.1% vs. 0.2%, odds ratio [OR] 14.6, 95% confidence interval [CI] 1.8-117.8, P < 0.05) and cardiac complications (9.4% vs. 2.0%, OR 5.0, 95% CI 1.5-16.6, P < 0.01) compared with other specialties. Costs were lowest for vascular surgeons ($32,094), and highest for cardiothoracic surgeons ($41,663, P < 0.05). Only vascular surgeons completed more than 10 EVARs per year. A total of 2531 TEVAR cases were completed during the study period, of which 73.8% were completed by vascular surgeons, 15.8% by cardiothoracic surgeons, 8.0% by interventional radiologists, and the remainder by interventional cardiologists and general surgeons. Interventional radiologists had significantly more elective cases (77.8%, P < 0.001) than cardiothoracic surgeons (47.2%) or vascular surgeons (53.8%), but had a significantly higher rate of stroke (7.6% vs. 1.1%, P < 0.001) and cardiac events (7.2% vs. 3.6%, P < 0.001). Length of stay (LOS, 10.7 days) and median costs ($52,156) were similar across specialties. Vascular surgeons have a low stroke rate (1.1%, P < 0.05 vs. interventional radiologists) and lower rate of cardiac events (3.6% vs. 6.1%, P < 0.01) despite caring for patients with higher diagnosis-related group mortality scores (3.6 vs. 3.4, P < 0.05)., Conclusions: Vascular surgeons appear to have a comparative advantage over other specialties for EVAR because not only are their complication and mortality rates comparable but overall LOS and hospital charges are lower. Furthermore, primarily only vascular surgeons are performing the high volume of annual EVARs necessary to ensure optimal patient outcomes. For TEVAR, vascular surgeons have the lowest overall morbidity compared with the other specialties, and lower mortality compared with cardiothoracic surgeons. These findings may impact patient referral patterns and hospital privileges for providers., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Financial relationships between physicians and industry are vital to biomedical innovation yet create the potential for conflicts of interest in medical practice. I consider an inducement model of the role of financial relationships in health care markets, where consulting payments induce physicians to use more devices of the firms that sponsor them. To test the model, I exploit a policy shock, whereby government monitoring of payments to joint replacement surgeons resulted in declines of over 60% in both total payments and in the number of physicians receiving payments from 2007 to 2008. Using hospital discharge data from three states, I find that the loss of payments leads physicians to switch 7 percentage points of their device utilization from their sponsoring firms' devices to other firms' devices, an effect which is concentrated among surgeons with low switching costs. These results offer support for the inducement model. I also find evidence of an increase in medical productivity following the policy intervention, which suggests conditions under which regulation of financial relationships would be socially beneficial. Copyright © 2015 John Wiley & Sons, Ltd., (Copyright © 2015 John Wiley & Sons, Ltd.)

Background: In Japan, gender inequality between males and females in the medical profession still exists. We examined gender gaps in surgeons' incomes., Methods: Among 8,316 surgeons who participated in a 2012 survey by the Japan Surgical Society, 546 women and 1,092 men within the same postgraduation year were selected randomly with a female-to-male sampling ratio of 1:2 (mean age, 36 years; mean time since graduation, 10.6 years)., Results: Average annual income was 9.2 million JPY for women and 11.3 million JPY for men (P < .0001). A general linear regression model showed that the average income of men remained 1.5 million JPY greater after adjusting for gender, age, marital status, number of children, number of beds, current position, and working hours (Model 1). In Model 2, in which 2 statistical interaction terms between annual income and gender with marital status and number of children were added together with variables in Model 1, both interactions became significant, and the gender effect became nonsignificant. For men, average annual income increased by 1.1 million JPY (P < .0001) when they were married and by 0.36 million JPY per child (P = .0014). In contrast, for women, annual income decreased by 0.73 million JPY per child (P = .0005)., Conclusions: Male surgeons earn more than female surgeons, even after adjusting for other factors that influenced a surgeon's salary. In addition, married men earn more than unmarried men, but no such trend is observed for women. Furthermore, as the number of children increases, annual income increases for men but decreases for women., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: According to current guidelines, pancreatic cancer patients should be strictly selected for surgery, either palliative or resective., Methods: Population-based study, including all patients undergoing surgery for pancreatic cancer in Italy between 2010 and 2012. Hospitals were divided into five volume groups (quintiles), to search for differences among volume categories., Results: There were 544 hospitals performing 10 936 pancreatic cancer operations. The probability of undergoing palliative/explorative surgery was inversely related to volume, being 24.4% in very high-volume hospitals and 62.5% in very low-volume centres (adjusted OR 5.175). Contrarily, the resection rate in patients without metastases decreased from 86.9% to 46.1% (adjusted OR 7.429). As for resections, the mortality of non-resective surgery was inversely related to volume (p < 0.001). Surprisingly, mortality of non-resective surgery was higher than that for resections (8.2% vs. 6.7%; p < 0.01). Approximately 9% of all resections were performed on patients with distant metastases, irrespective of hospital volume group. The excess cost for the National Health System from surgery overuse was estimated at 12.5 million euro., Discussion: Discrepancies between guidelines on pancreatic cancer treatment and surgical practice were observed. An overuse of surgery was detected, with serious clinical and economic consequences., (Copyright © 2016 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: The U.S. Centers for Medicare & Medicaid Services (CMS) recently released the Open Payments database (OPD) detailing payments from industry to physicians and teaching hospitals. We seek here to provide an overview of the data with a focus on the orthopaedic community., Methods: We analyzed payments in the OPD from August 1 to December 31, 2013. The OPD consists of three individual databases: General Payments, Research Payments, and Ownership. Physician identification number, physician specialty, payment type, and payment value were collected. Physicians assigned to multiple specialties were excluded. Comparisons were made between orthopaedic surgeons and the remainder of the top fifteen specialties by payment value., Results: In all, 2,697,015 payments with physicians were recorded; 491,223 of these payments (18.2%) were made to physicians with multiple listed specialties and were excluded. Excluding these potentially misattributed payments did not have a significant impact on the trends identified, and $394.5 million in payments remained. Orthopaedic surgeons represented 3.4% of payments but 25.6% of value, and 13,347 orthopaedic surgeons (68.9% of all active orthopaedic surgeons) were listed in the OPD. Payments over $10,000 represented only 1.6% of payments to orthopaedic surgeons but 75.5% of value. The majority of these payments (56.1%) were royalties. The median payment value for orthopaedic surgeons listed in the OPD was $38.11, with two payments per surgeon; the median aggregated value was $132.56 per surgeon. Orthopaedic surgeons listed in the OPD were more likely to receive payments for travel compared with all other specialties (p < 0.001) and more likely to receive payments for royalties compared with all other specialties (p < 0.001) except neurological surgery., Conclusions: Financial interactions between orthopaedic surgeons and industry are highly prevalent. A small subset of orthopaedic surgeons received large royalties, which accounted for a majority of the transactional value provided by industry. Orthopaedic surgeons were the recipients of more payments for travel and for royalties than all other specialties except neurological surgery; however, the median value of these and other payments was similar to that for other specialties., (Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.)

The economic situation in German Hospitals is tense and needs the implementation of differentiated controlling instruments. Accordingly, parameters of revenue development of different organizational units within a hospital are needed. This is particularly necessary in the revenue and cost-intensive operating theater field. So far there are only barely established productivity data for the control of operating room (OR) revenues during the year available. This article describes a valid method for the calculation of case-related revenues per OR minute conform to the diagnosis-related groups (DRG).For this purpose the relevant datasets from the OR information system and the § 21 productivity report (DRG grouping) of the University Medical Center Göttingen were combined. The revenues defined in the DRG browser of the Institute for Hospital Reimbursement (InEK) were assigned to the corresponding process times--incision-suture time (SNZ), operative preparation time and anesthesiology time--according to the InEK system. All full time stationary DRG cases treated within the OR were included and differentiated according to the surgical department responsible. The cost centers "OR section" and "anesthesia" were isolated to calculate the revenues of the operating theater. SNZ clusters and cost type groups were formed to demonstrate their impact on the revenues per OR minute. A surgical personal simultaneity factor (GZF) was calculated by division of the revenues for surgeons and anesthesiologists. This factor resembles the maximum DRG financed personnel deployment for surgeons in German hospitals.The revenue per OR minute including all cost types and DRG was 16.63 €/min. The revenues ranged from 10.45 to 24.34 €/min depending on the surgical field. The revenues were stable when SNZ clusters were analyzed. The differentiation of cost type groups revealed a revenue reduction especially after exclusion of revenues for implants and infrastructure. The calculated GZF over all surgical departments was 2.2 (range 1.9-3.6). A calculation of this factor at the DRG level can give economically relevant information about the case-related personnel deployment.This analysis shows for the first time the DRG-conform calculation of revenues per OR minute. There is a strong dependency on the considered cost type and the performing surgical field. Repetitive analyses are necessary due to the lack of reference values and are a suitable tool to monitor the revenue development after measures for process optimization. Comparative analyses within different surgical fields on this data base should be avoided. The demonstrated method can be used as a guideline for other hospitals to calculate the DRG revenues within the OR. This enables pursuing cost-effectiveness analysis by comparing these revenues with cost data from the cost unit accounting at a DRG or case level.

Summary: Many Canadians pursue surgical treatment for severe obesity outside of their province or country - so-called "medical tourism." We have managed many complications related to this evolving phenomenon. The costs associated with this care seem substantial but have not been previously quantified. We surveyed Alberta general surgeons and postoperative medical tourists to estimate costs of treating complications related to medical tourism in bariatric surgery and to understand patients' motivations for pursuing medical tourism. Our analysis suggests more than $560 000 was spent treating 59 bariatric medical tourists by 25 surgeons between 2012 and 2013. Responses from medical tourists suggest that they believe their surgeries were successful despite some having postoperative complications and lacking support from medical or surgical teams. We believe that the financial cost of treating complications related to medical tourism in Alberta is substantial and impacts existing limited resources.

Background: Cost estimates derived from traditional hospital cost accounting systems have inherent limitations that restrict their usefulness for measuring process and quality improvement. Newer approaches such as time-driven activity-based costing (TDABC) may offer more precise estimates of true cost, but to our knowledge, the differences between this TDABC and more traditional approaches have not been explored systematically in arthroplasty surgery., Questions/purposes: The purposes of this study were to compare the costs associated with (1) primary total hip arthroplasty (THA); (2) primary total knee arthroplasty (TKA); and (3) three surgeons performing these total joint arthroplasties (TJAs) as measured using TDABC versus traditional hospital accounting (TA)., Methods: Process maps were developed for each phase of care (preoperative, intraoperative, and postoperative) for patients undergoing primary TJA performed by one of three surgeons at a tertiary care medical center. Personnel costs for each phase of care were measured using TDABC based on fully loaded labor rates, including physician compensation. Costs associated with consumables (including implants) were calculated based on direct purchase price. Total costs for 677 primary TJAs were aggregated over 17 months (January 2012 to May 2013) and organized into cost categories (room and board, implant, operating room services, drugs, supplies, other services). Costs derived using TDABC, based on actual time and intensity of resources used, were compared with costs derived using TA techniques based on activity-based costing and indirect costs calculated as a percentage of direct costs from the hospital decision support system., Results: Substantial differences between cost estimates using TDABC and TA were found for primary THA (USD 12,982 TDABC versus USD 23,915 TA), primary TKA (USD 13,661 TDABC versus USD 24,796 TA), and individually across all three surgeons for both (THA: TDABC = 49%-55% of TA total cost; TKA: TDABC = 53%-55% of TA total cost). Cost categories with the most variability between TA and TDABC estimates were operating room services and room and board., Conclusions: Traditional hospital cost accounting systems overestimate the costs associated with many surgical procedures, including primary TJA. TDABC provides a more accurate measure of true resource use associated with TJAs and can be used to identify high-cost/high-variability processes that can be targeted for process/quality improvement., Level of Evidence: Level III, therapeutic study.

Objectives: To assess the views, knowledge, and experience of Dutch physicians with regard to the general objectives and values of the pay-for-performance (P4P) system, as the Dutch healthcare industry might find it useful, in terms of governance, to explore this approach further., Methods: A quantitative cross-sectional survey study was conducted among 48 physicians in surgical specialties in the Netherlands between May 2014 and July 2014. The survey questionnaire was designed to gather information regarding the intensity of feelings, on a 7-point Likert scale, toward statements that address the P4P system. Confidence intervals were calculated using the bootstrap technique with 1000 iterations., Results: Physicians see a positive value in P4P for their organizations rather than for personal attainment (mean = 5.00; 95% CI = 4.62-5.39), even though they feared that P4P might put financial pressure on them (mean = 5.03; 95% CI = 4.50-5.54). They strongly share the view that other colleagues will resist adopting P4P as a business model (mean = 5.74; 95% CI = 5.43-6.04). Respondents stated that they would not leave their current jobs if P4P were to be incorporated in their organization., Conclusions: Physicians see value in P4P for their organizations, and consider that P4P could provide an incentive for improving medical outcomes. There seems to be potential for the P4P system in the Netherlands as participants expressed positive support for its values. There is an intersection of interests between the value of P4P and the physicians' aim of achieving quality outcomes; however, further studies would be needed to investigate perceptions about specific design features in a larger sample. In addition, prior to implementing P4P, broad education about the system should be provided in order to counteract pre-conceptions and prevent resistance.

The Open Payments Program (OPP) was recently implemented to publicly disclose industry payments to physicians, with the goal of enabling patient awareness of potential conflicts of interests. Awareness of OPP, its data, and its implications for transplantation are critical. We used the first wave of OPP data to describe industry payments made to transplant surgeons. Transplant surgeons (N = 297) received a total of $759 654. The median (interquartile range [IQR]) payment to a transplant surgeon was $125 ($39-1018), and the highest payment to an individual surgeon was $83 520; 122 surgeons received <$100, and 17 received >$10 000. A higher h-index was associated with 30% higher chance of receiving >$1000 (relative risk/10 unit h-index increase = 1.18 1.301.44 , p < 0.001). The highest payment category was consulting fees, with a total of $314 448 paid in this reported category. Recipients of consulting fees had higher h-indices, median (IQR) of 20 (10-35) versus nine (3-17) (p < 0.001). Ten of 122 companies accounted for 62% of all payments. Kidney transplant and liver transplant (LT) centers that received >$1000 had higher center volumes (p < 0.001). LT centers that received payments of >$1000 had a higher percentage of private-insurance/self-pay patients (p < 0.01). Continued surveillance of industry payments may further elucidate the relationship between industry payments and physician practices., (© Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Background: The cost disparity between the United States and other advanced health care systems, including France, is expanding. In this report we identified the management of papillary thyroid cancer (PTC) that contribute to reimbursement disparity., Methods: A tri-institutional, retrospective review included 200 patients with PTC (100 from the United States, 100 from France) treated by total thyroidectomy with/without central neck dissection. A cost model was generated incorporating perioperative management variables (within 1 year) and their reimbursement rates according to the 2014 US Medicare and French government fee-schedules., Results: In the United States, total thyroidectomy with central neck dissection was more frequent (92% vs 35%, P < .001), median duration of stay was less (1 vs 3 days, P < .001), and use of radioactive iodine was less (66% vs 93%, P < .001), although Thyrogen stimulation was more prevalent (100% vs 43%, P < .001). Overall, the median cost per patient was greater in the United States ($14,069 vs $4,590, P < .001). Reimbursements to the hospital facility accounted for 70% of the disparity, despite lesser durations of stay. Nuclear medicine accounted for 19%, mostly from Thyrogen reimbursement despite less use of radioactive iodine. Surgeon fees accounted for 6%, followed by office visits, laboratory/imaging, anesthesia/pathology fees, and medications., Conclusion: The costs of management of PTC are substantially greater in the US compared with France. Efforts to decrease this disparity should focus on reimbursements for hospital facility and use of nuclear medicine imaging., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The study aim was to understand patient impressions of reimbursement to orthopedic spine surgeons. Our findings revealed that the majority of patients significantly overestimate the amount surgeons are reimbursed per procedure. Despite this, most feel that surgeons are appropriately compensated. Additionally, many patients are unaware of the global billing period., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: During the past decade, cardiothoracic surgery (CTS) education has undergone tremendous change with the advent of new technologies and the implementation of integrated programs, to name a few. The goal of this study was to assess how residents' career paths, training, and perceptions changed during this period., Methods: The 2006 to 2014 surveys accompanying the Thoracic Surgery Residents Association/Thoracic Surgery Directors' Association in-training examination taken by CTS residents were analyzed, along with a 2003 survey of graduating CTS residents. Of 2,563 residents surveyed, 2,434 (95%) responded., Results: During the decade, fewer residents were interested in mixed adult cardiac/thoracic practice (20% in 2014 vs 52% in 2003, p = 0.004), more planned on additional training (10% in 2003 vs 41% to 47% from 2011 to 2014), and the frequent use of simulation increased from 1% in 2009 to 24% in 2012 (p < 0.001). More residents recommended CTS to potential trainees (79% in 2014 vs 65% in 2010, p = 0.007). Job offers increased from a low of 12% in 2008 with three or more offers to 34% in 2014. Debt increased from 0% with more than $200,000 in 2003 to 40% in 2013 (p < 0.001). Compared with residents in traditional programs, more integrated residents in 2014 were interested in adult cardiac surgery (53% vs 31%) and congenital surgery (22% vs 7%), fewer were interested in general thoracic surgery (5% vs 31%, p < 0.001), and more planned on additional training (66% vs 36%, p < 0.001)., Conclusions: With the evolution in CTS over the last decade, residents' training and career paths have changed substantially, with increased specialization and simulation accompanied by increased resident satisfaction and an improved job market., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Breast surgeons negotiating employment agreements have little national data available. To reduce this knowledge gap, the Education Committee of the American Society of Breast Surgeons conducted a survey of its membership., Methods: In 2014, survey questionnaires were sent to society members. Data collected included gender, type of practice, percentage devoted to breast surgery, volume of breast cases, work relative value units, location, benefits, and salary. Descriptive statistics were provided, and a multinomial logistic regression was performed to analyze the impact of various potential factors on salary., Results: Of the 2784 members, a total of 843 observations were included. Overall, 54% of respondents dedicated 100 % of their practice to breast surgery, 64.3% were female, and 40% were fellowship-trained in breast surgery or surgical oncology. The mean income in 2013 was $330.7k. Results from a multinomial model showed gender (p < 0.0001), ownership (p = 0.03), years of practice (p < 0.0001), practice setting (p < 0.0001), practice volume (p < 0.0001), and geographic location (p = 0.05) were statistically significant. After adjusting for other variables, the expected income was higher for males ($378k vs. $310k). The lowest expected income by practice setting was in solo private practice ($249.2k), followed by single-specialty private practice ($285.8k), and academic ($308.5k), with the highest being multispecialty group private practice ($346.6k) and hospital-employed practice ($368.0k). Practice 100% dedicated to breast surgery had a lower than expected income ($326k vs. $343k)., Conclusions: Salary-specific data for breast surgeons are limited, and differences in salary were seen across geographic regions, type of practice, and gender. This type of breast-surgeon-specific data may be helpful in ensuring equitable compensation.

Background: Management of operating room inventory has substantial cost-saving opportunities if surgeons agree to standardize supplies used to perform procedures; however, there is no incentive for surgeons to participate in these decisions, because the cost-savings are realized only by the hospital, not the practitioner. In an attempt to engage surgeons with the management of the operating room supply chain, a shared-savings programs was instituted that returned 50% of money saved to the surgery divisions., Methods: Opportunities for savings in the use of biologic mesh, cranial plating systems, and neurostimulators was identified. Each item was assigned a physician champion responsible for ensuring that there was clinical equipoise between the products being used. Any cost-savings realized during the fiscal year were shared 50-50 between the hospital and the surgery divisions., Results: The total cost-savings was $893,865 with $446,932 being shared across 15 surgery divisions. Standardization of cranial plating systems ($374,805) generated the greatest amounts of savings followed by neurostimulators ($278,404) and biologic mesh ($240,655)., Conclusion: Aligning hospital and surgeon incentives led to dramatic cost-savings and standardization of the operative inventory used. Quality of care is not compromised by this approach, and no conflicts of interest are created., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: Collaboration between specialists is essential for achieving high-value care in patients with complex cancer needs. We explore how collaboration between oncologists and surgeons affects mortality and cost for patients requiring multispecialty cancer care., Patients and Methods: This was a retrospective cohort study of patients with stage III colon cancer from SEER-Medicare diagnosed between 2000 and 2009. Patients were assigned to a primary treating surgeon and oncologist. Collaboration between surgeon and oncologist was measured as the number of patients shared between them; this has been shown to reflect advice seeking and referral relationships between physicians. Outcomes included hazards for all-cause mortality, subhazards for colon cancer-specific mortality, and cost of care at 12 months., Results: A total of 9,329 patients received care from 3,623 different surgeons and 2,319 medical oncologists, representing 6,827 unique surgeon-medical oncologist pairs. As the number of patients shared between specialists increased from to one to five (25th to 75th percentile), patients experienced an approximately 20% improved survival benefit from all-cause and colon cancer-specific mortalities. Specifically, for each additional patient shared between oncologist and surgeon, all-cause mortality improved by 5% (hazard ratio, 0.95; 95%CI, 0.92 to 0.97), and colon cancer-specific mortality improved by 5% (subhazard ratio, 0.95; 95% CI, 0.91 to 0.97). There was no association with cost., Conclusion: Specialist collaboration is associated with lower mortality without increased cost among patients with stage III colon cancer. Facilitating formal and informal collaboration between specialists may be an important strategy for improving the care of patients with complex cancers., (Copyright © 2015 by American Society of Clinical Oncology.)

Importance: Racial differences in breast cancer treatment may result in part from differences in the surgeons and hospitals from whom patients receive their care. However, little is known about differences in patients' selection of surgeons and hospitals., Objective: To examine racial/ethnic differences in how women selected their surgeons and hospitals for breast cancer surgery., Design, Setting, and Participants: We surveyed 500 women (222 non-Hispanic white, 142 non-Hispanic black, 89 English-speaking Hispanic, and 47 Spanish-speaking Hispanic) from northern California cancer registries with stage 0 to III breast cancer diagnosed during 2010 through 2011. We used multivariable logistic regression to assess the reasons for surgeon and hospital selection by race/ethnicity, adjusting for other patient characteristics. We also assessed the association between reasons for physician selection and patients' ratings of their surgeon and hospital., Main Outcomes and Measures: Reasons for surgeon and hospital selection and ratings of surgeon and hospital., Results: The 500 participants represented a response rate of 47.8% and a participation rate of 69%. The most frequently reported reason for surgeon selection was referral by another physician (78%); the most frequently reported reason for hospital selection was because it was a part of a patient's health plan (58%). After adjustment, 79% to 87% of black and Spanish-speaking Hispanic women reported selecting their surgeon based on a physician's referral vs 76% of white women (P = .007). Black and Hispanic patients were less likely than white patients to report selecting their surgeon based on reputation (adjusted rates, 18% and 22% of black and Hispanic women, respectively, vs 32% of white women; P = .02). Black and Hispanic women were also less likely than white women to select their hospital based on reputation (adjusted rates, 7% and 15% vs 23%, respectively; P = .003). Women who selected their surgeon based on reputation more often rated the care from their surgeon as excellent (adjusted odds ratio, 2.21; 95% CI, 1.24-3.93); those reporting their surgeon was one of the only surgeons available through the health plan less often reported excellent quality of surgical care (adjusted odds ratio, 0.56; 95% CI, 0.34-0.91)., Conclusions and Relevance: Compared with white patients with breast cancer, minority patients were less actively involved in physician and hospital selection, relying more on physician referral and health plans rather than on reputation. Interventions to promote involvement in surgeon and hospital selection may have potential for addressing disparities related to lower-quality care from surgeons and hospitals.

Objective: The introduction of carotid stenting has led to a rapid rise in the number of vascular specialists performing this procedure. The Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) has shown that carotid stenting can be performed with an equivalent major event rate compared with carotid endarterectomy. However, there is still controversy about the appropriate training and experience required to safely perform this procedure. This observational study examined the performance of carotid stenting with regard to specialty and case volume., Methods: From 2004 to 2011, inpatients diagnosed with carotid stenosis who had a carotid stenting procedure were extracted from the Nationwide Inpatient Sample database. The cohort was separated on the basis of the provider performing the procedure (surgeon vs interventionalist), hospital location, and volume. Surgeons were defined as providers who also performed either a carotid endarterectomy or femoral-popliteal bypass during the same time interval. Primary end points analyzed included stroke, myocardial infarction, and 30-day mortality. Length of stay and hospital costs were also analyzed as secondary outcomes., Results: A total of 20,663 cases of carotid stenting were found; 15,305 (74%) cases were identified to be performed by a "surgeon," whereas 5358 (26%) were done by an "interventionalist." The majority of cases were done at hospitals in urban locations (96.51%) and designated teaching institutions (61.47%). Unadjusted outcomes were similar between surgeons and interventionalists in terms of stroke (4.33% and 4.41%), myocardial infarction (2.10% and 2.13%), and mortality (0.84% and 1.03%) respectively. Qualitatively, volume per 10 cases was shown to decrease the risk of stroke. Adjusted multivariate analysis demonstrated no statistical significance between primary end point outcomes. However, length of stay (2.81 vs 3.08 days) and total charges ($48,087.61 and $51,718.77) were lower for procedures performed by surgeons., Conclusions: Surgeons are performing the majority of carotid stent procedures in the United States. The volume of cases performed by a provider, rather than the provider's specialty, appears to be a stronger predictor of adverse outcomes for carotid stenting. There were, however, significant cost differences between surgeons and interventionalists, which needs to be further evaluated at an institutional level., (Published by Elsevier Inc.)

The Society for Vascular Surgery (SVS) Foundation partnered with the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) in 1999 to initiate a competitive career development program that provides a financial supplement to surgeon-scientists receiving NIH K08 or K23 career development awards. Because the program has been in existence for 15 years, a review of the program's success has been performed. Between 1999 and 2013, 41 faculty members applied to the SVS Foundation program, and 29 from 21 different institutions were selected as awardees, resulting in a 71% success rate. Three women (10%) were among the 29 awardees. Nine awardees (31%) were supported by prior NIH F32 or T32 training grants. Awardees received their K award at an average of 3.5 years from the start of their faculty position, at the average age of 39.8 years. Thirteen awardees (45%) have subsequently received NIH R01 awards and five (17%) have received Veterans Affairs Merit Awards. Awardees received their first R01 at an average of 5.8 years after the start of their K award at the average age of 45.2 years. The SVS Foundation committed $9,350,000 to the Career Development Award Program. Awardees subsequently secured $45,108,174 in NIH and Veterans Affairs funds, resulting in a 4.8-fold financial return on investment for the SVS Foundation program. Overall, 23 awardees (79%) were promoted from assistant to associate professor in an average of 5.9 years, and 10 (34%) were promoted from associate professor to professor in an average of 5.2 years. Six awardees (21%) hold endowed professorships and four (14%) have secured tenure. Many of the awardees hold positions of leadership, including 12 (41%) as division chief and two (7%) as vice chair within a department of surgery. Eight (28%) awardees have served as president of a regional or national society. Lastly, 47 postdoctoral trainees have been mentored by recipients of the SVS Foundation Career Development Program on training grants or postdoctoral research fellowships. The SVS Foundation Career Development Program has been an effective vehicle to promote the development and independence of vascular surgeon-scientists in the field of academic vascular surgery., (Published by Elsevier Inc.)

Background: Surgeon ownership in medical device distribution is a new model that proposes to reduce the costs associated with surgical implants. In surgeon-owned distributorships (SDs), the surgeon becomes the purchaser through ownership and management of a distributorship. The purpose of this study is to determine whether significant cost savings can result from SDs., Methods: Five existing SDs were retrospectively reviewed, and their implant pricing was compared with non-SDs. The hospital pricing for implants supplied by the SDs was compared with 2010 pricing from the best contract/capitated rate for like implants from non-SDs., Results: The average first-year cost savings for the SDs was 36%, with US$2,456,521 total savings in 2010. For distributorships in business for over 2 years, the average annual price from the SDs actually decreased by 1.41%., Conclusions: This study demonstrates that SDs are capable of providing substantial healthcare savings through lower implant costs and reduced annual price escalations.

Background: Experience and application of recruitment packages can be critical in leadership efforts of surgical chairpersons in promoting research, although attrition of these efforts can happen over time due to lack of new resources. We aimed to examine the impact of experience of surgical chairpersons on departmental National Institutes of Health (NIH) funding., Methods: Experience as a chairperson defined as the number of years spent as an interim or permanent chair was abstracted from the department Web site (US medical schools only). The NIH funding (US dollars) of the departments were obtained from the Blue Ridge Medical Institute (www.brimr.org). The change in NIH funding from the immediate previous financial year (2010-2009 and 2011-2010) was used to classify chairpersons into four groups: group 1 (-/-), group 2 (-/+), group 3 (+/+), and group 4 (+/-) for analysis., Results: Median NIH funding were $1.9 (0.7-6) million, $1.8 (0.6-5) million, and $1.7 (0.7-5) million for 2009, 2010, and 2011, respectively, and the median experience as a surgical chairperson was 6 y (3-10). Recent chairpersons (<1 y) inherited departments that usually lost NIH funding (62%) and were frequently unable to develop a positive trend for growth over the next fiscal year ([-/-] n = 4 and [+/-] n = 2, 75%). Chairpersons who held their positions for 4-6 y were most likely to be associated with trends of positive funding growth, whereas chairpersons >10 y were most likely to have lost funding (66%, P = 0.07)., Conclusions: Provision of new development dollars later in their tenure and retention of chairpersons might lead to more positive trends in increase in NIH funding., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Employment, either by an academic entity or a hospital, is increasingly becoming a feature of surgical practice. Independent practices receive indirect subsidies to support their revenue. A survey of the extent of employment and the forms of indirect subsidies by which hospitals support independent practices, not previously done, would be of interest to all clinicians. A 2012 Internet survey of pediatric surgeons, asking practice description, hospital support, governance and management, conditions of compensation, selected contractual obligations, and arrangements for part-time coverage was conducted. Response rate was 21.8 per cent (253 of 1,163). Employed surgeons comprised 80 per cent: 60 per cent academic (152 of 253) and 20 per cent nonacademic (51). Only eight per cent (19) were in private practice. Half (47% [106 of 226]) had administrative tasks. One-fifth (20% [45 of 223]) was in a system without physician input in governance. The rest were in practices with physicians involved in management: on boards of directors (35% [78]), in management positions (31% [69]), and entirely physician-run (14% [31]). Most salaries were independent of external benchmarks. Productivity measures, when applied to compensation (54% [117 of 218]), used relative value units (71% [83 of 117]) more often than revenue production (29% [34]). Patient contact minimums (4% [nine of 217]) and penalties were less common (20% [43 of 218]) than bonus provisions (53% [116 of 218]). Most surgeons in private practice (75% [14 of 19]) received nonsalary hospital support. Pediatric surgery reflects the current trend of physician employment and hospital subsidies. Surgeon participation in governance and strategic system decisions will be necessary as healthcare systems evolve.

The Affordable Care Act supports the growth of accountable care organizations (ACOs) as a potentially powerful model for health care delivery and payment. The model focuses on primary care. However, surgeons and other specialists have a large role to play in caring for ACOs' patients. No studies have yet investigated the role of surgical care in the ACO model. Using case studies and a survey, we examined the early experience of fifty-nine Medicare-approved ACOs in providing surgical care. We found that ACOs have so far devoted little attention to surgical care. Instead, they have emphasized coordinating care for patients with chronic conditions and reducing unnecessary hospital readmissions and ED visits. In the years to come, ACOs will likely focus more on surgical care. Some ACOs have the ability to affect surgical practice patterns through referral pressures, but local market conditions may limit ACOs' abilities to alter surgeons' behavior. Policy makers, ACO administrators, and surgeons need to be aware of these trends because they have the potential to affect the surgical care provided to ACO patients as well as the success of ACOs themselves., (Project HOPE—The People-to-People Health Foundation, Inc.)