Cost-effectiveness of skin biopsies performed by non-physician clinicians for Medicare beneficiaries.

An increasing number of non-physician clinicians (NPCs) are providing dermatologic care. We compared the cost-effectiveness of skin biopsies performed by dermatologists and dermatology NPCs using publicly-available Medicare claims data and numbers needed to biopsy (NNBs) published in the literature. We estimated that dermatology NPCs performed slightly greater mean numbers of skin biopsies per beneficiary (0.51 versus 0.47) at a lower payment per biopsy ($44.93 versus $55.10) as compared to dermatologists. However, we estimated a higher mean cost per malignancy diagnosed by dermatology NPCs relative to dermatologists (range based on literature NNB values, $39.08 to $190.23). This translated to a $16.7M-$43.3M aggregate cost of additional, benign biopsies performed by NPCs on Medicare beneficiaries. Although this preliminary analysis has several limitations, including the reliance on NNB values for calculations, it likely highlights the importance of training, education, and supervision to promote diagnostic accuracy. Further investigation is needed so that the potential cost of additional skin biopsies performed by NPCs can be appropriately weighed against the improvement in dermatologic access by including NPCs in the dermatology workforce.

Characteristics of Opioid Prescriptions by Mohs Surgeons in the Medicare Population.

BACKGROUND: Prescription opioid use often precedes opioid misuse, abuse, and addiction. OBJECTIVE: To characterize the national opioid prescription practices of Mohs surgeons, with general dermatologists serving as a comparison group. METHODS: A retrospective cross-sectional study using Medicare prescription data to analyze opioid prescription characteristics. RESULTS: In 2014, 2,190 Mohs surgeons prescribed a total of 86,526 opioids, whereas 10,347 non-Mohs dermatologists prescribed 45,033 opioids. Among Mohs surgeons, 51.8% prescribed more than 10 opioids, whereas 93.3% of non-Mohs dermatologists prescribed 0 to 10. The estimated opioid prescription rates for Mohs surgeons and non-Mohs dermatologists were 5.9% and 0.7%, respectively. Among those prescribing at least 10 opioid claims, the mean number of opioids supplied and mean opioid prescription rate was 72.4 and 13.5, respectively, for Mohs surgeons versus 32.5 and 5.1 , respectively, for non-Mohs dermatologists. The mean days' supply of opioids was 3.9 for Mohs surgeons versus 7.9 for non-Mohs dermatologists. There was a minimal-to-moderate association between the number of procedures performed and the number of opioids prescribed. Men and Mohs surgeons located in southern states tend to prescribe a greater number of opioids. CONCLUSION: Mohs surgeons prescribed short courses of opioids and less than both the national average and providers that care for patients in pain.

Micrographic Surgery and Dermatologic Oncology Fellowship Selection Criteria.

BACKGROUND: Obtaining a fellowship position for Micrographic Surgery and Dermatologic Oncology (MSDO) is becoming very competitive. Applicant qualities desired by MSDO fellowship directors have not been previously explored in a systematic way. OBJECTIVE: To characterize the prevailing practices of selecting MSDO fellows. METHODS AND MATERIALS: Cross-sectional study based on an anonymous online survey of MSDO fellowship directors. RESULTS: There were 34 completed surveys. Selection criteria with the highest importance to fellowship directors were the ability to work well and get along with others, interview, work ethic, and letter of recommendation from the Mohs micrographic surgery director at the applicant's residency. The criteria with the lowest importance were advanced degrees, medical licensing examination scores, and membership in Alpha Omega Alpha. Specific applicant factors that were looked upon most positively by fellowship directors include applicant from own institution and applicant's personal reasons and circumstances, whereas factors that were most unfavorable include applicant's desire to practice in the same city/area as the fellowship location and graduate of foreign medical school. CONCLUSION: Although variations existed, MSDO fellowship directors collectively placed greater importance on criteria that reflect interpersonal skills than on objective measures of academic performance, which highlights the importance of "fit."

Opioid Prescribing Patterns Among American Society of Ophthalmic Plastic and Reconstructive Surgery Members in the Medicare Part D Database.

PURPOSE: To assess opioid prescribing patterns among American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) members. METHODS: An observational, retrospective, cohort study of ASOPRS members' prescribing patterns in the 2013-2016 Medicare Part D Prescriber database. These prescribers were stratified by years in practice, sex, and geography. The ASOPRS member cohort was compared with all ophthalmologists, as a group, and other surgeons. RESULTS: The authors identified 617 surgeons in the 2017 ASOPRS directory. Members wrote an average of 45 opioid prescriptions/year. Almost half (45%) wrote <10 prescriptions. Those with >10 prescriptions averaged 78 annually. A minority wrote >100 prescriptions per year (14.8%). Overall, opioids comprised 16.5% of all prescriptions written by ASOPRS members. Despite seeing a similar number of beneficiaries (p = 0.20), male members prescribed a greater number (p < 0.05) and a higher rate (p < 0.05) of opioids than female members. Older members had a lower opioid prescription rate (p < 0.0001). Many heavy opioid prescribers practiced in states with high opioid overdose deaths. CONCLUSIONS: American Society of Ophthalmic Plastic and Reconstructive Surgery members prescribe moderate amounts of opioids at a rate (16.5%) higher than all of ophthalmology (4%), above the national mean (6.8%), but lower than other surgical services (36.5%). Male gender, younger age, and practice in states with high opioid-related deaths were correlated to number of prescriptions. Prescribing patterns may naturally relate to the type of surgical intervention and population. Further research is warranted to understand opioid prescriptions and their role in the opioid epidemic.

Dog bite injuries of the eye and ocular adnexa.

Dog bites result in a diverse range of injuries and complications in the periocular region, particularly in school aged children. It is therefore incumbent on the oculoplastic surgeon to be well versed in both acute and long-term management. The intent of this review is to provide a systematic evaluation of the epidemiology, principles of dog bite wound care, and specific considerations related to common patterns of ophthalmic injury. Review of clinical literature from 1976 to 2014. The majority of periocular injuries result from seemingly benign interactions between young children and familiar dogs. Aggressive saline lavage combined with selective debridement of devitalized tissue is essential. High-risk wounds and vulnerable patient groups may benefit from preventive antibiotic coverage as well as appropriate rabies and tetanus prophylaxis. While the nuances of surgical repair are variable given the heterogeneity of presentation, systematic examination and an algorithm-driven approach underlie the optimal management of these complex injuries.