Wide Local Excision Before Sentinel Lymph Node Biopsy in Melanoma.

BACKGROUND: Current guidelines suggest that wide local excision of thick melanomas be delayed until sentinel lymph node biopsies can be performed. OBJECTIVE: To examine the literature and determine if there is a scientific basis for delaying wide local excision of thick melanomas. MATERIALS AND METHODS: A narrative review of the literature was undertaken to examine all available studies on the subject. RESULTS: There is no evidence that prior excision compromises sentinel lymph node identification. There are multiple unsubstantiated suggestions that large rotation flaps may lead to false negatives. CONCLUSION: There is no basis for delaying wide local excision of thick melanomas until a sentinel lymph node biopsy can be performed.

5-Year Follow-Up of a Physician Performance Feedback Report Intervention to Reduce Overuse and Excess Cost: A National Cohort Study.

BACKGROUND: Mohs micrographic surgery efficiently treats skin cancer through staged resection, but surgeons' varying resection rates may lead to higher medical costs. OBJECTIVE: To evaluate the cost savings associated with a quality improvement. MATERIALS AND METHODS: The authors conducted a retrospective cohort study using 100% Medicare fee-for-service claims data to identify the change of mean stages per case for head/neck (HN) and trunk/extremity (TE) lesions before and after the quality improvement intervention from 2016 to 2021. They evaluated surgeon-level change in mean stages per case between the intervention and control groups, as well as the cost savings to Medicare over the same time period. RESULTS: A total of 2,014 surgeons performed Mohs procedures on HN lesions. Among outlier surgeons who were notified, 31 surgeons (94%) for HN and 24 surgeons (89%) for TE reduced their mean stages per case with a median reduction of 0.16 and 0.21 stages, respectively. Reductions were also observed among outlier surgeons who were not notified, reducing their mean stages per case by 0.1 and 0.15 stages, respectively. The associated total 5-year savings after the intervention was 92 million USD. CONCLUSION: The implementation of this physician-led benchmarking model was associated with broad reductions of physician utilization and significant cost savings.

Analysis of dermatologic procedures billed independently by nonphysician practitioners in the United States.

BACKGROUND: Nonphysician practitioners (NPPS), including nurse practitioners (NPs) and physician assistants (PAs) are expanding their scope of practice outside of primary care and performing more procedures in dermatology. OBJECTIVE: To understand the scope and geographic pattern of practice by NPs and PAs in dermatology in the United States. METHODS: Cross-sectional retrospective cohort analysis of dermatology practices in the 2014 Medicare Physician/Supplier Procedure Summary master file, which reflects Part B carrier and durable medical equipment fee-for-service claims in the United States. RESULTS: Over 4 million procedures were billed independently by NPs and PAs, which accounted for 11.51% of all procedures. Injection, simple repair, and biopsy were the most commonly billed by the nonphysician practitioners, but complex procedures were also increasingly billed independently by NPs and PAs. Proportions of their claims are higher on the East Coast, Midwest, and Mountain states. LIMITATIONS: Data were collected at the state level and limited to Medicare beneficiaries, and did not include billing incident to physicians. CONCLUSIONS: This study demonstrated the increasing scope of practice of NPs and PAs in dermatology; this increase is alarming because of their limited training and the lack of uniform regulations guiding their practices. To ensure quality and safety of care, it is prudent to set benchmarks for proper supervision and utilization of procedures in dermatology.

Skin biopsy and skin cancer treatment use in the Medicare population, 1993 to 2016.

BACKGROUND: Skin biopsies are increasing at a rapid rate, and some may be unnecessary. Although skin cancer incidence is rising, there is varied biopsy accuracy between dermatologists and advanced practice professionals (APPs). A comparison of Current Procedural Terminology code (American Medical Association, Chicago, IL) use for skin biopsy and skin cancer treatment over 18 years and a comparison of provider types is needed. Excess skin biopsies increase health care costs and patient morbidity. OBJECTIVE: To examine changes in skin biopsy and skin cancer treatment utilization rates per year in the Medicare fee-for-service (FFS) population and to compare skin biopsy utilization rates between dermatologists and APPs. METHODS: Retrospective cross-sectional study of Medicare FFS paid claims using the Centers for Medicare and Medicaid Services Physician Claims databases. We calculated the number of skin biopsies and skin cancer treatments in the Medicare FFS population from 1993 to 2016, and percentage use by provider type from 2001 to 2016. Our primary outcome measurements were the number of skin biopsies and skin cancer treatments per 1000 Medicare FFS beneficiaries per year and the number of additional skin biopsies per 1000 Medicare FFS beneficiaries per year, or the difference in the number of skin biopsies and number of skin cancer treatments per 1000 Medicare FFS beneficiaries. Our secondary outcome measurements were the skin biopsy-to-skin cancer treatment ratio and the number of procedures per 1000 Medicare FFS beneficiaries per year by provider type. RESULTS: After adjusting for the number of enrollees in the Medicare FFS population from 1993 to 2016, skin biopsies per 1000 Medicare FFS beneficiaries increased 153% (from 39.31 to 99.33), and skin cancer treatments per 1000 Medicare FFS beneficiaries increased 39% (from 34.67 to 48.26). Between 1993 and 2016, the skin biopsy-to-skin cancer treatment ratio increased 81% (from 1.134 to 2.058), and the number of additional biopsies per 1000 Medicare FFS beneficiaries increased 1001% (from 4.638 to 51.072) between 1993 and 2016. Utilization data by provider type is available from 2001 to 2016. The number of skin biopsies per 1000 Medicare beneficiaries performed by APPs increased from 0.82 to 17.19 or 1996% (nurse practitioners, 2211%; physician assistants, 1916%) and the number of biopsies by dermatologists increased by 41% from 53.98 to 76.17. LIMITATIONS: Medicare claims data do not provide specific information regarding skin biopsy or skin cancer treatment use. CONCLUSION: The number of skin biopsies has risen 153% since 1993, while the number of skin cancer treatments has only increased 39%. Our data highlight the rise of biopsy use and the increase in biopsies that do not result in skin cancer diagnosis or treatment. This suggests APPs may be responsible for increasing the cost of skin cancer management by biopsying significantly more benign lesions than dermatologists.

An expert panel consensus on opioid-prescribing guidelines for dermatologic procedures.

BACKGROUND: Opioid overprescribing is a major contributor to the opioid crisis. The lack of procedure-specific guidelines contributes to the vast differences in prescribing practices. OBJECTIVE: To create opioid-prescribing consensus guidelines for common dermatologic procedures. METHODS: We used a 4-step modified Delphi method to conduct a systematic discussion among a panel of dermatologists in the fields of general dermatology, dermatologic surgery, and cosmetics/phlebology to develop opioid prescribing guidelines for some of the most common dermatologic procedural scenarios. Guidelines were developed for opioid-naive patients undergoing routine procedures. Opioid tablets were defined as oxycodone 5-mg oral equivalents. RESULTS: Postoperative pain after most uncomplicated procedures (76%) can be adequately managed with acetaminophen and/or ibuprofen. Group consensus identified no specific dermatologic scenario that routinely requires more than 15 oxycodone 5-mg oral equivalents to manage postoperative pain. Group consensus found that 23% of the procedural scenarios routinely require 1 to 10 opioid tablets, and only 1 routinely requires 1 to 15 opioid tablets. LIMITATIONS: These recommendations are based on expert consensus in lieu of quality evidence-based outcomes research. These recommendations must be individualized to accommodate patients' comorbidities. CONCLUSIONS: Procedure-specific opioid prescribing guidelines may serve as a foundation to produce effective and responsible postoperative pain management strategies after dermatologic interventions.

Use of Skin Biopsies Among Dermatologists.

BACKGROUND: Skin biopsies are essential to establish a diagnosis in many skin diseases. Utilization has been increasing rapidly and represents a significant health care cost. There are no benchmarks or baselines to guide the practice of skin biopsies. OBJECTIVE: To create a reference data set of biopsy behavior among dermatologists. METHODS: Five hundred eighty-eight dermatologists belonging to the American Dermatological Association (ADA) were surveyed. Two hundred eighty-seven responded with 128 of those providing biopsy data. RESULTS: The mean percentage of biopsies that were malignant was 44.5%. This varied by subspecialty with a mean of 41.7%, 57.4%, and 4.1% of biopsies performed by general dermatologists, Mohs micrographic surgeons, and pediatric dermatologists, respectively. By category or diagnosis, the biopsies were 22.7% basal cell carcinoma, 12.0% SCC, 10.2% benign neoplasms, 10.0% nevi, 8.0% actinic keratosis, 7.6% seborrheic keratosis, 7.5% inflammatory disorders, 6.1% SCC in situ, 5.3% dysplastic nevus, 5.1% benign skin, 1.5% melanoma in situ, 1.4% melanoma, 0.9% lentigines, 0.8% other malignancies, 0.6% infectious, 0.2% not otherwise specified, and 0.1% atypical lesions. There was a statistically significant difference in biopsy results between different dermatological subspecialties. CONCLUSION: These results should help elucidate dermatologic practice patterns and thus create opportunities to improve dermatologic care and reduce health care costs.

Mohs Micrographic Surgery for the Treatment of Merkel Cell Carcinoma.

BACKGROUND: Merkel cell carcinoma (MCC) is a rare, aggressive malignant neoplasm. Traditionally, wide local excision has been used for local control. However, the tissue-sparing capability of Mohs micrographic surgery (MMS) and the greater certainty of complete tumor removal offer a potential advantage over wide local excision if MMS offers acceptable cure rates. OBJECTIVE: This study aims to help elucidate management of MCC and includes one of the largest groups of patients from a single institution. MATERIALS AND METHODS: This study is a retrospective chart review of 22 patients with cutaneous MCC treated with MMS at our practice over 20 years. Clinical characteristics and outcomes were examined. The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in the approval by our institution's human research review committee. RESULTS: The overall local recurrence rate was 5% (1/22). The overall rate of biopsy-proven metastasis to regional lymph nodes was 14% (3/22). No cases of distant metastases were documented. CONCLUSION: To our knowledge, this is the largest group of patients with MCC treated with MMS from a single institution and indicates that MMS may be a useful treatment modality for this rare aggressive disease.

The utility of artificial intelligence platforms for patient-generated questions in Mohs micrographic surgery: a multi-national, blinded expert panel evaluation.

BACKGROUND: Artificial intelligence (AI) and large language models (LLMs) transform how patients inform themselves. LLMs offer potential as educational tools, but their quality depends upon the information generated. Current literature examining AI as an informational tool in dermatology has been limited in evaluating AI's multifaceted roles and diversity of opinions. Here, we evaluate LLMs as a patient-educational tool for Mohs micrographic surgery (MMS) in and out of the clinic utilizing an international expert panel. METHODS: The most common patient MMS questions were extracted from Google and transposed into two LLMs and Google's search engine. 15 MMS surgeons evaluated the generated responses, examining their appropriateness as a patient-facing informational platform, sufficiency of response in a clinical environment, and accuracy of content generated. Validated scales were employed to assess the comprehensibility of each response. RESULTS: The majority of reviewers deemed all LLM responses appropriate. 75% of responses were rated as mostly accurate or higher. ChatGPT had the highest mean accuracy. The majority of the panel deemed 33% of responses sufficient for clinical practice. The mean comprehensibility scores for all platforms indicated a required 10th-grade reading level. CONCLUSIONS: LLM-generated responses were rated as appropriate patient informational sources and mostly accurate in their content. However, these platforms may not provide sufficient information to function in a clinical environment, and complex comprehensibility may represent a barrier to utilization. As the popularity of these platforms increases, it is important for dermatologists to be aware of these limitations.

Dermatologists perform the majority of cutaneous reconstructions in the Medicare population: numbers and trends from 2004 to 2009.

BACKGROUND: Dermatologists are experts in skin cancer treatment. Their experience with cutaneous reconstruction may be underrecognized. OBJECTIVE: We sought to determine the percentage of skin reconstruction claims submitted to Medicare by dermatologists relative to other specialists. METHODS: The Medicare Physician Supplier Procedure Master File from 2004 to 2009 was accessed to determine the proportion of layered closures, grafts, and flaps by specialty. RESULTS: In 2009, dermatologic surgeons' (DS) claims accounted for 60.8% of intermediate closures, 75.1% of complex repairs, 55.5% of local tissue rearrangements, and 57.5% of full-thickness skin grafts in the Medicare population. DS billed for the majority of skin reconstructions except simple repairs, split-thickness skin grafts, and interpolation flaps. DS claims represented far more reconstructions of aesthetically important regions of the head and neck-including ears, eyes, nose, and lips-than other fields including plastic surgery and otolaryngology. Over the study period, DS increased the percentage of skin reconstructions in nearly every category relative to other specialists. LIMITATIONS: This analysis is limited to the Medicare population and addresses claim volumes only. Cosmetic outcomes or appropriateness of closure selection or coding cannot be addressed. CONCLUSIONS: DS perform the highest volumes of repairs in the Medicare population. DS play a primary role in routine and advanced cutaneous reconstructive surgery, especially of aesthetically important regions.

Analysis of skin cancer treatment and costs in the United States Medicare population, 1996-2008.

BACKGROUND: There is a skin cancer epidemic in the United States. OBJECTIVE: To examine skin cancer treatment modality, location, and cost and physician specialty in the Medicare population from 1996 to 2008. METHODS: Centers for Medicare and Medicaid Services databases were used to examine skin cancer treatment procedures performed for Medicare beneficiaries. RESULTS: From 1996 to 2008, the total number of skin cancer treatment procedures [malignant excision, destruction, and Mohs micrographic surgery (MMS)] increased from 1,480,645 to 2,152,615 (53% increase). The numbers of skin cancers treated by excision and destruction increased modestly (20% and 39%, respectively), but the number of MMS procedures increased more rapidly (248% increase). Dermatologists treated an increasing percentage (75-82%) of skin cancers during these years, followed by plastic and general surgery. In 2008, more than 90% of all skin cancers were treated in the office, with the remainder being treated in facility-based settings. Allowable charges paid to physicians by Medicare Part B for skin cancer treatments increased 137% from 1996 to 2008, from $266,960,673 to $633,448,103. CONCLUSIONS: The number of skin cancer treatment procedures increased substantially from 1996 to 2008, as did overall costs to Medicare. Dermatologists treated the vast majority of skin cancers in the Medicare population, using a mix of treatment modalities, almost exclusively in the office setting.

Starting a Solo Practice.

Opening a small private dermatology practice can be a rewarding experience. It may seem like a lot of trouble, but in no other setting will you have so much freedom, control, and directly be able to see the consequences of your efforts. Economically, you must realize that in other settings, all these "chores" you must do in a solo practice are paid for by you out of overhead, which can greatly exceed what it costs if you do it yourself in a small practice. That is, a small private practice can be economically more rewarding and flexible than working for a dermatology group, particularly a multispecialty group. It requires months of preparation, planning, hard work, persistence, and a strong desire to establish a practice that operates on your own terms.

AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery.

The appropriate use criteria process synthesizes evidence-based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California-Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

Mohs micrographic surgery utilization in the Medicare population, 2009.

BACKGROUND: Mohs micrographic surgery (MMS) is the criterion standard treatment for high-risk skin cancers. Few data on current MMS Utilization are available. OBJECTIVE: To better understand current trends in MMS use in the Medicare population. METHODS AND MATERIALS: The 2009 Medicare Limited Data Set Standard Analytic File (LDSSAF), carrier claims, 5% sample and the Physician Supplier Procedure Master File (PSPMF) 100% summary were analyzed. RESULTS: In 2009, 558,447 Medicare MMS cases were performed, with an average of 1.75 stages per case. In the 5% claims sample, 0.3% and 1.3% of MMS cases were performed for melanoma and carcinoma in situ, respectively. Total annual volume predictions for 1,777 providers showed a left-shifted curve. 65.8% of LDSSAF cases had same-day MMS repairs: 48.7% of repairs were complex, 9.8% intermediate, 32.4% flaps, and 7.4% full-thickness skin grafts. CONCLUSIONS: The 5% LDSSAF is highly predictive of total claim volumes and is useful for modeling practice trends. There is wide variation in MMS provider annual case volume. These data reflect only Medicare Part B enrollees in 2009; 5% LDDSAF extrapolations are predictions based on sampling.

Determining the safety of office-based surgery: what 10 years of Florida data and 6 years of Alabama data reveal.

BACKGROUND: This is a continued examination of 10 years of prospectively collected Florida in-office adverse event data and new comparable data from mandatory Alabama in-office adverse event data reporting. OBJECTIVE: To determine which office surgical procedures have resulted in reported complications. METHODS: This study is a compilation of mandatory reporting of office surgical complications by Florida and Alabama physicians to a central agency. Reports resulting in death or a hospital transfer were further investigated over the telephone or on-line to determine the reporting physician's board certification status, hospital privilege status, and office accreditation status. RESULTS: In 10 years in Florida, there were 46 deaths and 263 procedure-related complications and hospital transfers; 56.5% (26/46) of deaths and 49.8% (131/263) of hospital transfers were associated with non-medically necessary (cosmetic) procedures. The majority of deaths (67%) and hospital transfers (74%) related to non-medically necessary (cosmetic) procedures were from procedures performed on patients under general anesthesia. Liposuction and liposuction with abdominoplasty or other cosmetic procedure resulted in 10 deaths and 34 hospital transfers. Thirty-eight percent of offices reporting adverse events were accredited by an independent accrediting agency, 93% of physicians were board certified, and 98% of physicians had hospital privileges. The most common specialty of physicians reporting adverse events was plastic surgery (45% of all reported complications). Dermatologists reported four total complications (no deaths) and accounted for 1.3% of all complications over the 10-year period. In 6 years in Alabama, there were three deaths and 49 procedure-related complications and hospital transfers; 42% (22/52) of hospital transfers and no deaths were associated with non-medically necessary (cosmetic) procedures. The majority of hospital transfers related to cosmetic procedures (86%) were from procedures performed on patients under general anesthesia. Liposuction accounted for no deaths and two hospital transfers. Seventy-one percent of offices reporting adverse events were accredited by an independent accrediting agency, and 100% of physicians were board-certified. Plastic surgery was the most common specialty represented in adverse event reporting (42.3% of all reported complications). Dermatologists reported one complication (no deaths) and accounted for 1.9% of all complications over the 6-year period. CONCLUSIONS: Continued analysis reveals that medically necessary office surgery does not represent an emergent hazard to patients. The data obtained from 10 and 6 years of adverse event reporting in Florida and Alabama, respectively, are comparable and consistent. Medically necessary surgical procedures performed in the office setting by dermatologists have an exceedingly low complication rate, and complications that arose were largely unexpected, isolated, and possibly unpreventable. Cosmetic procedures performed in offices by dermatologists under local and dilute local anesthesia yielded no reported complications. Complications from cosmetic procedures accounted for nearly half of all reported incidents in Florida and Alabama, and in both states, plastic surgeons were most represented in adverse event reports. Liposuction performed under general anesthesia requires further investigation because deaths from this procedure continue to occur despite the ability to use dilute local anesthesia for this procedure. Requiring physician board certification and physician hospital privileges does not seem to increase safety of patients undergoing surgical procedures in the office setting. Mandatory reporting of adverse events in the office setting should continue to be championed. Reporting of delayed deaths after hospital outpatient and ambulatory surgery center procedures should be implemented. All data should be made available for scientific analysis after protecting patient confidentiality.

AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery.

The appropriate use criteria process synthesizes evidence-based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California-Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

Scars after second intention healing.

Second intention healing (SIH) is useful for many defects after skin cancer removal. SIH decreases intraoperative morbidity and reduces procedure costs. Granulating wounds are rarely infected, have minimal pain or bleeding, and care is simple. Location is the key determinant in cosmetic outcomes of SIH. Concavities of the face including the medial canthus and conchal bowl often heal imperceptibly. Defects on convex surfaces such as the nasal tip and malar cheek can heal poorly with depressed scars. Flat areas of the cheeks, forehead, and chin heal favorably but cosmesis can be unpredictable. These regions are often described by NEET (concavities of the nose, eyes, ears, and temple), NOCH (convexities of nose, oral lips, cheek, chin, and helix), and FAIR (flat areas of the forehead, antihelix of the ear, eyelids, and rest of the nose, lips, and cheeks). We review the limited literature describing SIH based on regional anatomy of the face. Complications of SIH include exuberant granulation tissue, hypopigmented or telangiectatic scars, and distortion of free lid margins. SIH should be an integral part of the surgeon's reconstructive algorithm after skin cancer removal.