Demand-based assessment of workforce requirements for orthopaedic services

Orthopaedic Care for Children: Who Provides It? How Has It Changed Over the Past Decade? Analysis of the Database of the American Board of Orthopaedic Surgery

BACKGROUND

The field of orthopaedic surgery has subspecialized over the past decade with an increasing number of graduates of orthopaedic residency programs entering fellowship training. The number of graduates from pediatric orthopaedic fellowships has also increased over the past decade. We hypothesize as the number of pediatric orthopaedic fellowship graduates has increased, the proportion of orthopaedic cases completed by pediatric surgeons in comparison with adult surgeons has also increased. We have used the database of the American Board of Orthopaedic Surgery (ABOS) to analyze the trends in who is providing the orthopaedic care for children.

METHODS

Procedure logs of applicants for ABOS part II certification from 2004 to 2014 were collected and pediatric cases were used for this study. Applicants were divided into pediatric orthopaedic surgeons and adult orthopaedic surgeons based on the self-declared subspecialty for part II examination. CPT codes were used to place the cases into different categories. Descriptive and statistical analysis were performed to evaluate the change in the practice of pediatric orthopaedics over the past decade.

RESULTS

ABOS part II applicants performed 102,424 pediatric cases during this period. In total, 66,745 (65%) cases were performed by nonpediatric surgeons and 35,679 cases (35%) by pediatric surgeons. In total, 82% of the pediatric cases were done by adult surgeons in 2004 which decreased to 69% in 2009 and to 53% in 2014 (r=0.8232, P=0.0019). In pediatric sports medicine, pediatric orthopaedic surgeons performed 7% of the cases in 2004 which increased to 14% in 2009 and to 28% in 2014 (300% increase from 2004). Pediatric surgeons also increased their share of pediatric trauma cases. In total, 12% of lower extremity trauma cases were attended by pediatric surgeons in 2004 compared with 47% in 2014 (235% increase from 2004). In upper extremity trauma, pediatric surgeons increased their share of the cases from 12% in 2004 to 43% in 2014 (175% increase from 2004).

CONCLUSIONS

Over the past decade, pediatric orthopaedic specialists are caring for an increasing share of pediatric cases. Pediatric trauma, pediatric spine, and pediatric sports medicine have seen the greatest increase in the percentage of cases performed by pediatric orthopaedic surgeons.

LEVEL OF EVIDENCE

Level III.

Current Issues Affecting the Practice of Pediatric Orthopaedic Surgeons: Results of the 2014 Workforce Survey of American Academy of Pediatrics Section on Orthopaedics

INTRODUCTION

The opinions of the pediatric orthopaedic workforce are shaped by market forces, regulatory processes, and local experience. The purpose of this report is to summarize the findings of the recent Workforce Survey of the American Academy of Pediatrics (AAP) Section on Orthopaedics (SOOr). This submission has been reviewed and approved by the Board of Directors of the Pediatric Orthopaedic Society of North America (POSNA).

METHODS

In 2014, the AAP generated a survey to assess perceptions of pediatric orthopaedic surgeons about current issues that affect practice. The survey was sent to 856 POSNA and 141 AAP-SOOr members. Responses were topically organized to report current workforce composition, practice patterns, and perceptions about electronic medical records (EMRs).

RESULTS

Responses were collected from August to December, 2014, from 496 (50%) survey recipients including 83 of 141 (59%) AAP-SOOr members and 413 of 856 (48%) POSNA members. Analyses were restricted to the 397 respondents who reported that they are currently practicing pediatric orthopaedics. Nearly all of these (390/391, 100%) indicated that they provide direct patient care and work an average of 60 hours per week. Many (105/378, 28%) indicated that they would soon limit their practice or retire. A majority (299/394, 76%) indicated that they face competition in their geographic area, predominantly due to pediatric orthopaedic subspecialists (269/299, 90%). Major business changes had recently occurred or were anticipated by 21% of participants. Respondents reported that use of EMR makes them less efficient (252/397, 63%) and interferes with the patient-physician relationship (172/397, 43%).

DISCUSSION

This workforce survey suggests that pediatric orthopaedic surgeons are concerned with challenges of competition despite concurrent increasing volume and complexity of referrals. External processes such as EMR changes are perceived to negatively impact practice efficiency and satisfaction.

Pediatric Orthopaedic Workforce in 2014: Current Workforce and Projections for the Future

BACKGROUND

The changing nature of the United States (US) health care system has prompted debate concerning the physician supply. The basic questions are: do we have an adequate number of surgeons to meet current demands and are we training the correct number of surgeons to meet future demands? The purpose of this analysis was to characterize the current pediatric orthopaedic workforce in terms of supply and demand, both present and future.

METHODS

Databases were searched (POSNA, SF Match, KID, MGMA) to determine the current pediatric orthopaedic workforce and workforce distribution, as well as pediatric orthopaedic demand.

RESULTS

The number of active Pediatric Orthopaedic Society of North America (POSNA) members increased over the past 20 years, from 410 in 1993 to 653 in 2014 (155% increase); however, the density of POSNA members is not equally distributed, but correlates to population density. The number of estimated pediatric discharges, orthopaedic and nonorthopaedic, has remained relatively stable from 6,348,537 in 1997 to 5,850,184 in 2012. Between 2003 and 2013, the number of pediatric orthopaedic fellows graduating from Accreditation Council for Graduate Medical Education and non-Accreditation Council for Graduate Medical Education programs increased from 39 to 50 (29%), with a peak of 67 fellows (71%) in 2009.

DISCUSSION

Although predicting the exact need for pediatric orthopaedic surgeons (POS) is impossible because of the complex interplay among macroeconomic, governmental, insurance, and local factors, some trends were identified: the supply of POS has increased, which may offset the expected numbers of experienced surgeons who will be leaving the workforce in the next 10 to 15 years; macroeconomic factors influencing demand for physician services, driven by gross domestic product and population growth, are expected to be stable in the near future; expansion of the scope of practice for POS is expected to continue; and further similar assessments are warranted.

LEVEL OF EVIDENCE

Level II-economic and decision analysis.

Approaches in Health Human Resource Forecasting: A Roadmap for Improvement

INTRODUCTION

Forecasting the demand and supply of health manpower in an accurate manner makes appropriate planning possible. The aim of this paper was to review approaches and methods for health manpower forecasting and consequently propose the features that improve the effectiveness of this important process of health manpower planning.

METHODS

A literature review was conducted for studies published in English from 1990-2014 using Pub Med, Science Direct, Pro Quest, and Google Scholar databases. Review articles, qualitative studies, retrospective and prospective studies describing or applying various types of forecasting approaches and methods in health manpower forecasting were included in the review. The authors designed an extraction data sheet based on study questions to collect data on studies' references, designs, and types of forecasting approaches, whether discussed or applied, with their strengths and weaknesses.

RESULTS

Forty studies were included in the review. As a result, two main categories of approaches (conceptual and analytical) for health manpower forecasting were identified. Each approach had several strengths and weaknesses. As a whole, most of them were faced with some challenges, such as being static and unable to capture dynamic variables in manpower forecasting and causal relationships. They also lacked the capacity to benefit from scenario making to assist policy makers in effective decision making.

CONCLUSIONS

An effective forecasting approach is supposed to resolve all the deficits that exist in current approaches and meet the key features found in the literature in order to develop an open system and a dynamic and comprehensive method necessary for today complex health care systems.

Matching residency numbers to the workforce needs

Matching the number of surgeons to the demands for orthopedic services has been notoriously difficult. Not only does one need to evaluate current trends in the supply and provision of services but anticipate the impact of future reforms on these variables. The British Orthopaedic Association has aspired to provide consultant to population ratio of 1:15,000 by 2020. Currently, the orthopedic community is tasked with providing care for an aging population with soaring levels of obesity; with both of these factors set to grow and also with an overall decline in productivity. Orthopedic surgeons must brace themselves for an explosion in demand. At the same time, a paradigm shift has occurred in the delivery of services with the creation of specialist centers. We are amidst a generational shift in the demographics and psychology of the orthopedic workforce. The orthopedic community must be aware of the effects of these far-reaching changes when tailoring the supply of surgeons for the future needs.

Longitudinal urban-rural discrepancies in the US orthopaedic surgeon workforce

BACKGROUND

It is unclear whether the supply of orthopaedic surgeons can meet the needs of a growing and aging population. This may be especially concerning in rural areas where there are known disparities in overall healthcare provision.

QUESTIONS/PURPOSES

We therefore (1) determined urban-rural trends in the US physician and orthopaedic workforce (including the age of that workforce) from 1995 to 2010; (2) geographically mapped the physician and orthopaedic distribution; and (3) examined urban-rural changes in select nonorthopaedic musculoskeletal provider (chiropractor and podiatrist) workforces from 2000 to 2010.

METHODS

County-level provider data from 1995 to 2010 were obtained from the Department of Health and Human Services. This was aggregated to Hospital Referral Regions and ranked by Rural-Urban Continuum Code. Hospital Referral Region-level data were mapped to identify geographic trends. Total physician and orthopaedic surgeon workforce data were averaged across the most urban and rural regions for the study period.

RESULTS

There were urban-rural discrepancies in the physician and orthopaedic workforce from 1995 to 2010 with fewer orthopaedic surgeons in rural areas than urban areas (6.52 versus 8.73 per 100,000 in 2010; p=0.001). Furthermore, orthopaedic surgeons in rural areas were older than their urban counterparts, with a workforce age ratio (age>55: age<55 years) of 0.92 versus 0.65 in 2010 (p=0.024). From 2000 to 2010, the rural chiropractor and podiatrist workforces showed tremendous growth of 229.6% and 279.9%, respectively.

CONCLUSIONS

There were significant urban-rural orthopaedic surgeon workforce discrepancies from 1995 to 2010. Concurrent growth in chiropractor and podiatrist numbers shows significant trends in the musculoskeletal provider workforce that warrant continuing observation and analysis.

LEVEL OF EVIDENCE

Level IV, economic and decision analyses. See Guidelines for Authors for a complete description of levels of evidence.

Pediatric primary care services in Manitoba: is the health of the next generation of children at risk?

OBJECTIVES

Physician resource planning is an important part of health policy, but to date there are no studies measuring the primary care service needs of a particular population. The aim of this study was to project the expected provision of physician services for the pediatric population of one Canadian province for 2020.

METHODS

A novel standardized measure of physician service provision, the equivalent services measure, was developed using mathematical modeling. Population projections and past use of services were used to calculate the projected service needs for the pediatric population of Manitoba.

RESULTS

Despite projecting a small increase in the pediatric population (2.8%), our model predicted a decrease of 13.4% in the services that would be provided.

CONCLUSIONS

The findings of this study indicate that the health of future generations of children may be at risk. Further research is needed to determine the effect of the reduction in pediatric service provision on the health of the pediatric population.

Provision of orthopaedic workforce and implications for access to orthopaedic services in Ontario

BACKGROUND

The aging population and increasing obesity rates will increase the prevalence of musculoskeletal conditions. Reports of orthopaedic surgeon shortages raise concerns about the ability of the health-care system to meet current and future demand in orthopaedics. A survey of all orthopaedic surgeons in Ontario, Canada, was carried out in 2006 to (1) update provision estimates of orthopaedic surgeons; (2) examine practice characteristics and perceived barriers to service; and (3) relate geographic availability of surgeons to population utilization of office-based and surgical orthopaedic services.

METHODS

A two-part questionnaire was sent to all orthopaedic surgeons in Ontario in 2006. Provision data in hours per week and full-time equivalents and practice patterns were analyzed by health region. Population-based data on the use of orthopaedic services were obtained from health service administrative databases.

RESULTS

There were 396 practicing orthopaedic surgeons in Ontario in 2006, equivalent to 2.43 full-time equivalents per 100,000 population, a finding similar to surveys in 1997 and 2000. Most surgeons were male, with a mean age of forty-nine years, with mainly adult practices; 48% reported having a subspecialty. Provision varied across Ontario, with an average of 112 hours per week of direct clinical time per 100,000 population (50% in the office, 30% in the operating room, 20% working on call). Many surgeons also reported time for administration, teaching, and research. Most respondents reported barriers to timely surgery, notably a lack of resources (operating room time, anesthesia, nursing, and/or bed capacity). Low orthopaedic provision was associated with lower utilization of office-based and surgical services, after controlling for neighborhood income and type of residence (urban or rural).

CONCLUSIONS

Shortages and geographic variation in the supply of surgeons mean that access to care continues to be a challenge in Ontario. In regions with fewer surgeons, residents are more likely to be deprived of office-based services, potentially affecting access to surgery and to orthopaedic expertise. In light of a potential shortage of surgeons, alternative methods of service provision may be needed to respond to the aging of the baby boomer population and an anticipated growth in the demand for surgery.

Joint replacement access in 2016: a supply side crisis

Demand for primary and revision arthroplasty is expected to double in 10 years. Coincident with this is a decreased interest in arthroplasty by residents. Retirement of arthroplasty surgeons further threatens access. This study determines if supply will meet demand. Survey data were used to calculate the 2016 workforce. Demand in 2016 was estimated using the Nationwide Inpatients Sample. Between 2008 and 2016, 400 arthroplasty specialists and 1584 generalists will enter the workforce. By 2016, 1896 arthroplasty surgeons will retire using 65 years as a conservative retirement age, whereas 4239 will retire using 59 years as a baseline retirement age. In 2016, the model estimated a procedural shortfall ranging from 174,409 (↓18.6%) using conservative retirement assumptions (age, 65 years) to 1,177,761 (↓69.4%) using baseline retirement assumptions (age, 59 years). This economic model predicts a supply side crisis that threatens patient access to specialty care. Immediate steps to stimulate supply must be taken.

The current practice of orthopaedic oncology in North America

BACKGROUND

The field of orthopaedic oncology in North America has been formalized over the past 30 years with the development of the Musculoskeletal Tumor Society (MSTS) and fellowship education opportunities.

QUESTIONS/PURPOSES

To characterize current practices we assessed the fellowship education, practice setting, constitution of clinical practice, bone and soft tissue sarcoma treatment volume, perceived challenges and rewards of the career, and the nonclinical activities of orthopaedic oncologists.

METHODS

Members of the MSTS and attendees of the 2009 AAOS-MSTS Specialty Day meeting were invited to participate in a twenty-three question online survey. One hundred and four surgeons including 99 of the 192 (52%) MSTS members completed the online survey.

RESULTS

Sixty-nine of the 104 (66%) responding surgeons completed a 1-year musculoskeletal oncology fellowship. Thirty-eight (37%) completed an additional orthopaedic subspecialty fellowship. Seventy-four (79%) work in an academic practice and 70 (+/- 16) % of clinical time is spent practicing musculoskeletal oncology. An average of 20 (+/- 16) bone and 40 (+/- 36) soft tissue sarcomas were treated annually. Insufficient institutional support, reimbursement, and emotional stresses were perceived as the most important challenges in a musculoskeletal oncology practice. Sixty-seven (64%) of the surgeons reported serving in a leadership position at the departmental or national level.

CONCLUSIONS

Professional time distribution is similar to other academic orthopaedists. The members of the MSTS are responsible for the treatment of more than two-thirds of bone and soft tissue sarcomas in the United States.

CLINICAL RELEVANCE

This information can assist the fellowship directors and related professional societies in tailoring their educational programs and the interested orthopaedic resident to make a more informed career choice.

The pediatric orthopaedics workforce demands, needs, and resources

The Pediatric Orthopaedic Society of North America Practice Management Committee evaluated current and future pediatric orthopaedic workforce needs. The resulting informational article summarizes its findings and makes recommendations for improvement of our workforce. Whereas policy decisions are often in the hands of the government with its emphasis on access and cost containment, the area that we can control, the quality of our workforce should be our primary effort. Specific recommendations include the prospective collection of accurate workforce data, increasing the interest of residents and students to enter our specialty, assisting members to improve practice efficiencies and assuming leadership in the musculoskeletal education of our primary care colleagues. We expect that by improving our workforce and professional work environment, we can make a difference for our young patients and for the society.

Work satisfaction and retirement plans of orthopaedic surgeons 50 years of age and older

Retirement age and practice patterns before retirement are important for making accurate workforce predictions for orthopaedic surgeons. A survey of orthopaedic surgeons 50 years of age and older therefore was conducted by the American Academy of Orthopaedic Surgeons in cooperation with the Association of American Medical Colleges Center for Workforce Studies. The survey focused on three questions: (1) At what age do orthopaedic surgeons retire? (2) Do they stop working abruptly or do they work part time before retirement? (3) What are the major factors that determine when an orthopaedic surgeon retires? According to the survey, the median retirement age for orthopaedic surgeons was 65 years. Nineteen percent of orthopaedic surgeons worked part time before retirement. Decreasing reimbursement and increasing malpractice costs were consistently cited as factors that strongly influenced retirement plans. Career satisfaction was high and was the strongest factor that kept the respondents in the workforce. The option to work part time would have the most impact on keeping orthopaedic surgeons working past the age of 65 years.

LEVEL OF EVIDENCE

Level IV Economic and Decision Analyses. See the Guidelines for Authors for a complete description of levels of evidence.

Workforce analysis in orthopaedic surgery: how can we improve the accuracy of our predictions?

Since the 1970s, workforce analysis for orthopaedic surgery has predicted a surplus of physicians into the 21st century. In 1998, the RAND study predicted a surplus of 4,100 orthopaedists in 2010. As we approach 2010, we find no surplus. The projected population growth during the next 20 years of those older than age 65 years presupposes a greater need for orthopaedists, given an increase in degenerative disease and fragility fractures associated with aging. The federal government predicts an overall shortage of physicians by 2020. Given the current nature of workforce analysis models and the concerns evoked by these disparate predictions, we, the authors, advocate change. Rather than large studies separated by decades, we recommend routine monitoring of the orthopaedic workforce. Further, we suggest that national, regional, and local organizations, as well as subspecialty societies, work together to monitor current and future orthopaedic workforce needs. Orthopaedic organizations should develop collaborative relationships with experts in the field and devise a true working model that allows for ongoing strategic planning.

Critical shortage of orthopaedic services in Ontario, Canada

BACKGROUND

Questions regarding the adequacy of the current orthopaedic workforce in Canada to meet the present and future demands for orthopaedic services raise the need for accurate estimates of the supply and demand for orthopaedic services. The present study provides estimates of current supply of orthopaedic services in Ontario, the largest province of Canada, in order to allow for direct comparisons with data on workforce requirements.

METHODS

All identified orthopaedic surgeons in Ontario were sent a self-administered questionnaire in 2000, which was similar to a previous survey in 1997. The age and gender of eligible respondents were obtained from the College of Physicians and Surgeons of Ontario. One full-time-equivalent orthopaedist was assumed to have 2200 annual hours of direct patient contact and to provide forty-four weeks of clinical work per year.

RESULTS

The response rate was 94%. The mean age of the 337 active orthopaedic surgeons was forty-nine years, an increase of four years since 1997. Six percent of the respondents were women in both survey years. Approximately twenty-three half days of office and surgery time per 100,000 population were reported, which represents approximately two full-time equivalent orthopaedic surgeons per 100,000 population. On the average, eight half days of combined office and surgery time were reported per surgeon per week.

CONCLUSIONS

The estimated supply of orthopaedic surgeons in Ontario (two full-time equivalents per 100,000 population) falls short of the recently calculated requirement in the United States (5.6 full-time equivalents per 100,000 population). These data suggest that there is currently a shortage of orthopaedic services in Ontario, which will be exacerbated by the aging of a profession already working near full capacity.

Expanding the orthopaedist's role in the treatment of foot and ankle disorders

Many opportunities exist and more will become available for expanding the role of orthopaedic surgeons in the treatment of patients with foot and ankle conditions in the United States. The current authors present the main areas of opportunity: giving comprehensive foot care to patients who already are treated by orthopaedic surgeons and the application of advanced scientific biotechnology that will improve outcomes for patients with foot and ankle conditions who currently do not have satisfactory treatment. Orthopaedic surgeons must maintain a high level of commitment in their education and professional availability to patients and primary care physicians to expand their participation in foot and ankle care. Networking with physician and nonphysician primary care providers and volunteering educational services for fellow professionals in the evaluation and treatment of the entire spectrum of foot and ankle conditions is necessary. The general orthopaedist and the orthopaedic foot and ankle specialist can share in the future of treatment of patients with foot and ankle conditions in the United States.

Shared decision-making and the orthopaedic workforce

Studies of physician workforce need a standard of an appropriately sized workforce to compare projections. Although many studies use average rates of healthcare use as a standard, regional benchmarks provide a pragmatic alternative approach to estimating a reasonably sized physician workforce and avoid many of the problems of needs- and demand-based planning. Wide geographic variations in the rates of many procedures, unexplained by differences in population characteristics, suggest that supply-induced demand or physician practice style or both may be the major determinates of the rates for these procedures. In the current study, the authors explore some of these differences in orthopaedic procedure rates and their implications for workforce planning. For example, the rates of hip fracture are fairly uniform across geographic regions, whereas the rates of spine surgery vary sixfold and the rates of spinal fusion vary 10-fold. Shared decision-making is the process of giving patients informed choices about their treatment options based on current best evidence. Careful studies of treatment effectiveness and shared decision-making hold the promise of allowing patients' preferences and values to determine the right rate of healthcare use. These rates could allow workforce projections to be compared with optimal benchmarks for future planning.

Expanding roles of the orthopaedic surgeon

Many sources predict an oversupply of orthopaedic surgeons in the United States continuing into the next 30 years. The most attractive solution to this problem is to expand the scope of orthopaedic practice by regaining direct patient access to orthopaedic specialty care, by developing and bringing new technologies and treatments to the marketplace quickly, and by developing alternatives to the typical orthopaedic practice such as expanding nonoperative care, improving the quality of the office practice, and exploring volunteer opportunities.

The future of orthopaedics in the United States: an analysis of the effects of managed care in the face of an excess supply of orthopaedic surgeons

Recent technological advances in orthopaedic surgery have propelled both the volume of surgical cases and their complexity, resulting in increased costs, which should naturally result in higher incomes for surgeons. However, the transition from a fee-for-service model of physician compensation to a managed care model has resulted in major shifts in economic resource allocation. An economic model of this market based on imperfect competition shows that these changes have shifted market power from surgeons to the managed care organizations. Our model predicts that practicing surgeons will retire earlier, medical students will begin to select other specialties, and innovation will be slowed. Antitrust laws limit surgeons' ability to combat this trend through meaningful collective bargaining, creating the potential for future shortages as the baby boom generation reaches retirement age and the demand for orthopaedic services increases dramatically.

Waiting times for appointments with orthopaedic surgeons in Victoria: 1995-97

BACKGROUND

A number of different models have been proposed for determining surgical workforce requirements.

METHODS

In 1995 the Workforce Subcommittee of the Victorian Regional Branch of the Australian Orthopaedic Association commenced a prospective evaluation of waiting times for both urgent and nonurgent appointments with orthopaedic surgeons in Victoria.

RESULTS

The results for the 3 years, 1995-97, show no significant change in the waiting time for nonurgent appointments and no difference between metropolitan and rural areas. The waiting time for an urgent appointment increased from 1995 to 1997 for the state of Victoria and for metropolitan Melbourne but not for rural areas. However, the median waiting time for an urgent appointment did not change.

CONCLUSION

Overall the waiting times were found to be satisfactory by previously reported standards.