Fewer cuts in Mohs surgery may improve patient care and reduce costs

The number of stages or cuts per case for Mohs micrographic surgery (MMS) varies greatly among individual physicians when treating dermatologic cancers of the head and neck, genitalia, hands, and feet, and this variation may translate into additional financial burden and unnecessary surgery in patients, according to results from a recent study published in the April 28 issue of JAMA Dermatology.

“Outlier practice patterns in health care, and specifically Mohs surgery, can represent a burden on patients and the medical system,” said senior author John Albertini, MD, immediate past president of the American College of Mohs Surgery. “By studying the issue of variation in practice patterns, the Mohs College hopes to improve the quality and value of care we provide our patients.”

In performing MMS, the ideal is to make as few cuts or slices and preserve as much of the normal tissue as possible, while completely removing the cancer. Variations in the number of cuts made by individual physicians, however, varies. Recently, the American College of Mohs Surgery (ACMS) endorsed the measurement of a surgeon’s average number of cuts as a clinical quality metric to assess its members.

Dr. Albertini and colleagues retrospectively analyzed Medicare Part B claims data from January 2012 to December 2014, which includes all physicians who receive Medicare payments for MMS from any practice performing MMS on the head and neck, genitalia, hands, and feet of Medicare Part B patients.

They defined outlier status as physicians whose mean number of stages for MMS equals two standard deviations greater than the mean number for all physicians billing MMS.

In all, researchers included 2,305 individual billing physicians who performed MMS, and the mean number of stages per MMS case for all physicians was 1.74 (median: 1.69; range: 1.09-4.11).

They found that 137 physicians had a greater than two standard deviation above the mean (2.41 stages per case) in at least 1 of the 3 years they analyzed. Furthermore, they found 49 physicians (35.85%) who were consistently high outliers during all 3 years studied, and this status was associated with performing Mohs in a solo practice (OR: 2.35; 95% CI, 1.25-4.35), and not volume of cases per year, practice experience, or geographic location.

In addition, physicians in a solo practice were 2.35 more likely to be persistent high outliers compared with those in a group practice, and this was true for all 3 years of the study. To reduce this variation, these researchers suggested that perhaps feedback would be effective.

Low extreme outliers, defined as having an average per case in the bottom 2.5% of the group distribution, included 92 physicians in at least 1 year and 20 were persistently low during all 3 years.

Funding for this study was provided by a grant from the Robert Wood Johnson Foundation (grant No. 73417) and the American College of Mohs Surgery.