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.

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.

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.

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.

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.

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.

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.

Outcome of 6 years of protocol use for preventing wrong site office surgery.

BACKGROUND: Patient safety is emerging as an integral part of the overall strategy to improve health care in the United States. Wrong site surgery is correctly noted to be a sentinel event and great efforts must be made to avoid it. OBJECTIVE: We sought to determine the incidence of wrong site surgery after implementation of a preoperative protocol in patients presenting for treatment of skin cancer at a high-volume, Joint Commission-accredited, tertiary referral center for dermatologic surgery. METHODS: A retrospective chart review was performed of 7983 cases performed on patients presenting for treatment of skin cancer in the office setting. RESULTS: There were no cases of wrong site surgery. There were, however, 18 cases of failure to identify the original biopsy site (cancer site). LIMITATIONS: This was a retrospective study done at one cancer center. CONCLUSION: Integration of a correct surgery site protocol into a daily patient care model is a useful step in preventing occurrences of wrong site dermatologic surgery.

Mohs micrographic surgery for the treatment of cutaneous leiomyosarcoma.

BACKGROUND: Cutaneous leiomyosarcoma is an extremely rare, malignant mesenchymal tumor of smooth muscle origin. Although generally considered a low-grade malignancy, there may be significant local invasion and subclinical extension. Rare cases of metastasis have been reported. OBJECTIVE: We sought to review the clinical characteristics and outcome of patients with cutaneous leiomyosarcoma treated with Mohs micrographic surgery (MMS) at our practice. METHODS: This study is a retrospective chart review of 11 consecutive patients with cutaneous leiomyosarcoma treated with MMS from 1995 through 2009. Patient demographic data, tumor size, location, previous treatment, number of Mohs stages to obtain clearance, surgical defect size, follow-up data, and presence or absence of recurrence were compiled and tabulated. RESULTS: The average age of our 11 patients at time of diagnosis was 54.5 years. Three lesions were located on the head/neck and trunk, respectively, and 5 lesions were located on the extremities. Average preoperative clinical lesion size was 4.69 cm(2). Average number of MMS stages required for tumor clearance was 2.4. Average size of the surgical defect was 14.95 cm(2). One lesion was recurrent at the time of presentation. All remaining tumors were untreated. Mean follow-up after diagnosis was 4.47 years. No tumors recurred after MMS. LIMITATIONS: Our retrospective study had a small patient population, and follow-up data were less extensive for some patients. CONCLUSIONS: These data represent the largest series in the literature of leiomyosarcoma treated with MMS, and establish that MMS is a useful modality for treating cutaneous leiomyosarcoma, a rare spindle cell malignancy that is not commonly encountered by physicians.

Concordance of frozen and permanent sections for the diagnosis of skin lesions.

BACKGROUND: There has been little written concerning the use of frozen sections to diagnose skin lesions. OBJECTIVE: To compare the concordance between frozen and permanent sections of the same diagnostic skin biopsy specimen. METHODS AND MATERIALS: Over 3 months, all non-melanocytic skin lesions that were biopsied in a skin cancer clinic were examined using frozen and permanent sections. Diagnoses from a dermatologist and dermatopathologist were recorded for each specimen and later examined for concordance. RESULTS: There was rare (0.5% of specimens) disagreement recorded between interpretations of the dermatologist and dermatopathologist. Permanent and frozen section pathology agreed with one another 90.4% of the time. Specimen processing was the most probable cause of discordance. Most discordance was not clinically relevant, although the patient was clinically affected in 35 of 2009 specimens (1.7%). CONCLUSION: Although there is a high concordance rate between diagnostic frozen and permanent sections, there are significant quality assurance and patient care advantages to following up initial diagnostic frozen sections with permanent sections of the same specimen.

A relative value unit-based cost comparison of treatment modalities for nonmelanoma skin cancer: effect of the loss of the Mohs multiple surgery reduction exemption.

BACKGROUND: The incidence of skin cancer has increased dramatically, with as many as 2.8 million skin cancers treated in 2005. In an era of decreasing reimbursement, insurer policy changes, and increasing pressure to deliver cost effective care, physicians should understand the total cost of different skin cancer treatment modalities in order to determine which yields the best value for patients. OBJECTIVE: To estimate the costs of treating nonmelanoma skin cancers by multiple modalities based on their assigned relative value unit (RVU) values. METHODS: The cost analysis was performed for the treatment of two skin cancer examples, a basal cell carcinoma (BCC) on the central cheek and a squamous cell carcinoma (SCC) on the forearm of varying sizes. The estimated costs of treatment of each of the skin cancers was calculated for treatment with electrodessication and curettage (EDC), imiquimod immunotherapy, Mohs micrographic surgery, traditional surgical excision with permanent section margin evaluation in an office setting (with immediate repair or with repair delayed until clear margins are confirmed), surgical excision with frozen section margin control in both an ambulatory surgery center and hospital-based setting, and radiation therapy. The effect of the loss of exemption from multiple surgery reduction on the cost of Mohs surgery is also examined. RESULTS: Our estimation of costs for each of the treatment modalities reveals that EDC is the least expensive option, with average costs of $471 (BCC cheek) and $392 (SCC arm). Imiquimod treatment and office-based excision with immediate repair of the surgical defect have similar total average costs of $959 (BCC cheek) and $931 (SCC arm) and $1006 (BCC cheek) and $907 (SCC arm), respectively. If repair of the defect is delayed until negative surgical margins are confirmed by permanent section, the cost of excision increases to $1170 and $1041. The average cost of Mohs micrographic surgery is $1263 (BCC cheek) and $1131 (SCC arm). Mohs surgery's recent loss of multiple surgery reduction exemption has decreased the cost of Mohs surgery by 9% to 25%. Excision with frozen section margin control in an ambulatory surgery center results in costs of $2334 (BCC cheek) and $2200 (SCC arm). However, if the excision is performed in a hospital operating room, the procedure is substantially more expensive, at $3085 and $2680. The cost of radiation therapy treatment is $2591 to $3460 for the BCC of the cheek and $2559 to $3431 for the SCC of the arm, depending on the fractional dose used. LIMITATIONS: These are cost estimates based on literature examples and 2008 RVU values; variations related to individual practices and procedure valuations by private insurers are expected. CONCLUSION: Tumor destruction by EDC or imiquimod and office-based procedures, such as traditional surgical excision or Mohs surgery, are the lowest cost options for treatment of nonmelanoma skin cancer.

Evaluation of a Peer-to-Peer Data Transparency Intervention for Mohs Micrographic Surgery Overuse.

IMPORTANCE: Mohs micrographic surgery (MMS) is a skin cancer treatment that uses staged excisions based on margin status. Wide surgeon-level variation exists in the mean number of staged resections used to treat a tumor, resulting in a cost disparity and question of appropriateness. OBJECTIVE: To evaluate the effectiveness of a behavioral intervention aimed at reducing extreme overuse in MMS, as defined by the specialty society, by confidentially sharing stages-per-case performance data with individual surgeons benchmarked to their peers nationally. DESIGN, SETTING, AND PARTICIPANTS: This nonrandomized controlled intervention study included 2329 US surgeons who performed MMS procedures from January 1, 2016, to March 31, 2018. Physicians were identified using a 100% capture of Medicare Part B claims. The intervention group included physicians affiliated with the American College of Mohs Surgery, and the control group included physicians not affiliated with the American College of Mohs Surgery. INTERVENTIONS: Individualized performance reports were delivered to all outlier surgeons, defined by the specialty society as those with mean stages per case 2 SDs above the mean, and inlier surgeons in the intervention group. MAIN OUTCOMES AND MEASURES: The primary outcome was surgeon-level change in mean stages per case between the prenotification (January 2016 to January 2017) and postnotification (March 2017 to March 2018) periods. A multivariable linear regression model was used to evaluate the association of notification with this surgeon-level outcome. The surgeon-level metric of mean stages per case was not risk adjusted. The mean Medicare cost savings associated with changes in practice patterns were calculated. RESULTS: Of the 2329 included surgeons, 1643 (70.5%) were male and 2120 (91.0%) practiced in metropolitan areas. In the intervention group (n = 1045), 53 surgeons (5.1%) were outliers; in the control group (n = 1284), 87 surgeons (6.8%) were outliers. Among the outliers in the intervention group, 44 (83%) demonstrated a reduction in mean stages per case compared with 60 outliers in the control group (69%; difference, 14%; 95% CI of difference, -1 to 27; P = .07). There was a mean stages-per-case reduction of 12.6% among outliers in the intervention group compared with 9.0% among outliers in the control group, and outliers in the intervention group had an adjusted postintervention differential decrease of 0.14 stages per case (95% CI, -0.19 to -0.09; P = .002). The total administrative cost of the intervention program was $150 000, and the estimated reduction in Medicare spending was $11.1 million. CONCLUSIONS AND RELEVANCE: Sharing personalized practice pattern data with physicians benchmarked to their peers can reduce overuse of MMS among outlier physicians.

Mohs micrographic surgery is accurate 95.1% of the time for melanoma in situ: a prospective study of 167 cases.

BACKGROUND: Mohs micrographic surgery (MMS) represents a promising option for treatment of melanoma in situ (MIS). However, interpretation of melanocytic lesions by fresh frozen sections may be difficult. OBJECTIVE: The objective of this study was to determine if margins called clear by MMS were clear by subsequent paraffin-embedded sections and to compare cure rate with available data for MMS and standard excision. MATERIALS AND METHODS: A total of 167 patients with MIS, including 116 patients with MIS in sun-exposed skin of lentigo maligna (LM) type, were treated by MMS with subsequent evaluation of the final margin with paraffin-embedded sections that were cut en face, over a period of 12 years. A total of 143 patients were available for follow-up from 6 months to 12 years (mean, 50 months; median 48 months; 594.5 patient-years), and 109 patients were available for follow-up from 2 to 12 years (mean, 63 months; median, 60 months; 569 patient-years). RESULTS: The clearance rate by MMS technique using frozen sections was 94.1% for MIS non-LM type, 95.7% for MIS LM type, and 95.1% for both. The cure rate was 97.8% for MIS non-LM type, 99.0% for MIS LM type, and 98.6% for both for mean follow-up of 50 months and 97.4% for MIS non-LM type, 98.6% for MIS LM type, and 98.2% for both for mean follow-up of 63 months. CONCLUSION: MMS is a viable option for treatment of MIS that may increase cure rate and reduce the size of the defect especially in cosmetically and functionally sensitive areas.

Office surgery incidents: what seven years of Florida data show us.

BACKGROUND: In the wake of increased media attention focusing on human error in medicine, numerous state medical boards and legislatures have drafted, and are continuing to draft, regulations aimed at protecting patients undergoing procedures in the office setting. These regulations will have a considerable impact on patient access to medically necessary procedures, and any regulations should be based on good data. This report summarizes 7 years of prospective data from the state of Florida, the best data available on office surgery incidents. OBJECTIVE: The objective was to determine the nature and incidence of hospital transfers and deaths resulting from office procedures. METHODS: This study is a compilation of mandatory reporting by Florida physicians to a central agency of all in-office adverse incidents resulting in death, serious injury, or hospital transfer in the State of Florida from March 2000 to March 2007. Telephone and internet follow-up was conducted to determine reporting physician board certification, hospital privileges, and office accreditation. RESULTS: In 7 years there were 31 deaths and 143 procedure-related complications and hospital transfers. Liposuction and liposuction with abdominoplasty or another cosmetic procedure resulted in 24 complications and 8 deaths. Of the offices reporting adverse incidents, 38.5% were accredited by an independent accrediting agency, 92.5% of the physicians were board-certified, and 96.6% had hospital privileges. A total of 58% (18/31) of the deaths and 61% (87/143) of the complications were associated with nonmedically necessary (cosmetic) procedures. A total of 78% (14/18) of these deaths were in ASA Class 1 patients. Plastic surgeons were responsible for 48% of all deaths (83% of cosmetic surgery deaths) and for 52% of all hospital transfers (83% of cosmetic surgery complications and hospital transfers). CONCLUSION: Plastic surgeons were responsible for an inordinate number of deaths and hospital transfers. Requiring physician board certification and physician hospital privileges would not seem to increase safety, because most physicians already have these credentials, and physicians without these credentials were not responsible for a disproportionate share of incidents. These data do not show an emergent hazard to patients from medically necessary office surgery. Liposuction under general anesthesia deserves continued scrutiny because deaths due to this procedure continue to occur and this procedure can be performed with dilute local anesthesia, with which no deaths were reported. Mandatory reporting of office incidents should be strongly supported, as well as reporting of incidents that occur after surgery in the hospital outpatient department and ambulatory surgery center. These data should be available for analysis after protecting patient confidentiality. A national debate needs to occur to determine how many deaths and injuries are acceptable from cosmetic procedures performed under general and intravenous anesthesia.