A Cost Analysis of Mohs and Total Surgical Excision: A Retrospective Review of Skin Cancer Treatments.

PURPOSE: Skin cancer risk is elevated in veterans, Whites, and males older than 50 years, who comprise the majority of patients at the Miami VA healthcare system.Treatments include total surgical excision (TSE) with frozen section or permanent pathology, and Mohs surgery. Our protocol consists of Mohs procedures performed offsite followed by reconstruction at the VA. This retrospective study examines the cost difference between TSE and Mohs surgery. METHODS: A retrospective chart review was performed of VA patients who underwent TSE or Mohs surgery between 2017 and 2019. Patients younger than 18 or those without malignancy on final pathology were excluded. Patients were subdivided into TSE versus Mohs. Cost per operating room minute was determined using published data for similar institutions. Pathology costs were estimated using institution specific Medicare data. T test was performed using SPSS. RESULTS: Of 130 patients identified, 82 underwent TSE and 48 underwent Mohs with reconstruction. Cost per operating room minute for inpatient government-owned facilities was $37.94. A flat fee of $1400 for the Mohs surgery was the contracted rate with the offsite institution. Average cost of Mohs surgery with reconstruction was $3534.12. Average cost of TSE with pathology was $2643.85. Total surgical excision was significantly more cost efficient than Mohs with reconstruction (P < 0.01). CONCLUSIONS: At our institution, TSE seems more cost effective than Mohs with subsequent reconstruction. While these are generalized costs, and data specific to our institution, cost efficiency is an important consideration in improving the value of care for VA patients.

Management strategies following slightly out-of-range INRs: watchful waiting vs dose changes.

Patients' international normalized ratios (INRs) often fall slightly out of range. In these cases, the American College of Chest Physicians (ACCP) guidelines suggest maintaining the current warfarin dose and retesting the INR within the following 2 weeks (watchful waiting). We sought to determine whether watchful waiting or dose changes for slightly out-of-range INRs is more effective in obtaining in-range INRs at follow-up. INRs and management strategies of warfarin-treated patients within the Michigan Anticoagulation Quality Improvement Initiative registry were analyzed. Management strategies included watchful waiting or dose changes. INRs slightly out of range (target range 2.0-3.0) and their associated management were identified. Multilevel mixed-effects logistic regression was used to estimate the probability of the next INR being in range, adjusted for clustering due to multiple out-of-range INRs per patient. A total of 45 351 slightly out-of-range INRs (ranging 1.50-1.99 and 3.01-3.49) from 8288 patients were identified. The next INR was slightly less likely to be in range with watchful waiting than with a dose change (predicted probabilities 58.9% vs 60.0%, P = 0.024). Although a significant statistical difference was detected in the probabilities of the next INR being back in range when managed by a dose change compared with watchful waiting following a slightly out-of-range INR, the magnitude of the difference was small and unlikely to represent clinical importance. Our study supports the current guideline recommendations for watchful waiting in cases of slightly out-of-range INRs values.