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.

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.

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.

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.

Understanding Mohs Micrographic Surgery: A Review and Practical Guide for the Nondermatologist.

The incidence and diagnosis of cutaneous malignancies are steadily rising. In addition, with the aging population and increasing use of organ transplant and immunosuppressive medications, subsets of patients are now more susceptible to skin cancer. Mohs micrographic surgery (MMS) has become the standard of care for the treatment of high-risk nonmelanoma skin cancers and is increasingly used to treat melanoma. Mohs micrographic surgery has the highest cure rates, spares the maximal amount of normal tissue, and is cost-effective for the treatment of cutaneous malignancies. As in other medical fields, appropriate use criteria were developed for MMS and have become an evolving guideline for determining which patients and tumors are appropriate for referral to MMS. Patients with cutaneous malignancies often require multidisciplinary care. With the changing landscape of medicine and the rapidly increasing incidence of skin cancer, primary care providers and specialists who do not commonly manage cutaneous malignancies will need to have an understanding of MMS and its role in patient care. This review better familiarizes the medical community with the practice of MMS, its utilization and capabilities, differences from wide excision and vertical section pathology, and cost-effectiveness, and it guides practitioners in the process of appropriately evaluating and determining when patients with skin cancer might be appropriate candidates for MMS.

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.

Outlier Practice Patterns in Mohs Micrographic Surgery: Defining the Problem and a Proposed Solution.

Importance: Outlier physician practices in health care can represent a significant burden to patients and the health system. Objective: To study outlier physician practices in Mohs micrographic surgery (MMS) and the associated factors. Design, Setting, and Participants: This retrospective analysis of publicly available Medicare Part B claims data from January 2012 to December 2014 includes all physicians who received Medicare payments for MMS from any practice performing MMS on the head and neck, genitalia, hands, and feet region of Medicare Part B patients. Main Outcomes and Measures: Characteristics of outlier physicians, defined as those whose mean number of stages for MMS was 2 standard deviations greater than the mean number for all physicians billing MMS. Logistic regression was used to study the physician characteristics associated with outlier status. Results: Our analysis included 2305 individual billing physicians performing MMS. The mean number of stages per MMS case for all physicians practicing from January 2012 to December 2014 was 1.74, the median was 1.69, and the range was 1.09 to 4.11. Overall, 137 physicians who perform Mohs surgery were greater than 2 standard deviations above the mean (2 standard deviations above the mean = 2.41 stages per case) in at least 1 of the 3 examined years, and 49 physicians (35.8%) were persistent high outliers in all 3 years. Persistent high outlier status was associated with performing Mohs surgery in a solo practice (odds ratio, 2.35; 95% CI, 1.25-4.35). Volume of cases per year, practice experience, and geographic location were not associated with persistent high outlier status. Conclusions and Relevance: Marked variation exists in the number of stages per case for MMS for head and neck, genitalia, hands, and feet skin cancers, which may represent an additional financial burden and unnecessary surgery on individual patients. Providing feedback to physicians may reduce unwarranted variation on this metric of quality.

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.

Incidence Estimate of Nonmelanoma Skin Cancer (Keratinocyte Carcinomas) in the U.S. Population, 2012.

IMPORTANCE: Understanding skin cancer incidence is critical for planning prevention and treatment strategies and allocating medical resources. However, owing to lack of national reporting and previously nonspecific diagnosis classification, accurate measurement of the US incidence of nonmelanoma skin cancer (NMSC) has been difficult. OBJECTIVE: To estimate the incidence of NMSC (keratinocyte carcinomas) in the US population in 2012 and the incidence of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) in the 2012 Medicare fee-for-service population. DESIGN, SETTING, AND PARTICIPANTS: This study analyzes US government administrative data including the Centers for Medicare & Medicaid Services Physicians Claims databases to calculate totals of skin cancer procedures performed for Medicare beneficiaries from 2006 through 2012 and related parameters. The population-based National Ambulatory Medical Care Survey database was used to estimate NMSC-related office visits for 2012. We combined these analyses to estimate totals of new skin cancer diagnoses and affected individuals in the overall US population. MAIN OUTCOMES AND MEASURES: Incidence of NMSC in the US population in 2012 and BCC and SCC in the 2012 Medicare fee-for-service population. RESULTS: The total number of procedures for skin cancer in the Medicare fee-for-service population increased by 13% from 2,048,517 in 2006 to 2,321,058 in 2012. The age-adjusted skin cancer procedure rate per 100,000 beneficiaries increased from 6075 in 2006 to 7320 in 2012. The number of procedures in Medicare beneficiaries specific for NMSC increased by 14% from 1,918,340 in 2006 to 2,191,100 in 2012. The number of persons with at least 1 procedure for NMSC increased by 14% (from 1,177,618 to 1,336,800) from 2006 through 2012. In the 2012 Medicare fee-for-service population, the age-adjusted procedure rate for BCC and SCC were 3280 and 3278 per 100,000 beneficiaries, respectively. The ratio of BCC to SCC treated in Medicare beneficiaries was 1.0. We estimate the total number of NMSCs in the US population in 2012 at 5,434,193 and the total number of persons in the United States treated for NMSC at 3,315,554. CONCLUSIONS AND RELEVANCE: This study is a thorough nationwide estimate of the incidence of NMSC and provides evidence of continued increases in numbers of skin cancer diagnoses and affected patients in the United States. This study also demonstrates equal incidence rates for BCC and SCC in the Medicare population.

Scope of physician procedures independently billed by mid-level providers in the office setting.

IMPORTANCE: Mid-level providers (nurse practitioners and physician assistants) were originally envisioned to provide primary care services in underserved areas. This study details the current scope of independent procedural billing to Medicare of difficult, invasive, and surgical procedures by medical mid-level providers. OBJECTIVE: To understand the scope of independent billing to Medicare for procedures performed by mid-level providers in an outpatient office setting for a calendar year. DESIGN: Analyses of the 2012 Medicare Physician/Supplier Procedure Summary Master File, which reflects fee-for-service claims that were paid by Medicare, for Current Procedural Terminology procedures independently billed by mid-level providers. SETTING AND PARTICIPANTS: Outpatient office setting among health care providers. MAIN OUTCOMES AND MEASURES: The scope of independent billing to Medicare for procedures performed by mid-level providers. RESULTS: In 2012, nurse practitioners and physician assistants billed independently for more than 4 million procedures at our cutoff of 5000 paid claims per procedure. Most (54.8%) of these procedures were performed in the specialty area of dermatology. CONCLUSIONS AND RELEVANCE: The findings of this study are relevant to safety and quality of care. Recently, the shortage of primary care clinicians has prompted discussion of widening the scope of practice for mid-level providers. It would be prudent to temper widening the scope of practice of mid-level providers by recognizing that mid-level providers are not solely limited to primary care, and may involve procedures for which they may not have formal training.