American College Of Mohs Surgery Research Articles

Growing Adoption of Immunohistochemistry by Mohs Micrographic Surgeons: A National Medicare Trend Analysis

BACKGROUND Immunohistochemical (IHC) staining can be used alongside Mohs micrographic surgery to aid in margin assessment of subtle tumors, yet existing estimates of IHC utilization have primarily relied on survey or older data that lacks stratification. OBJECTIVE To characterize national IHC utilization trends by Mohs surgeons, stratifying by surgeon characteristics and modeling future adoption. METHODS Longitudinal analysis of 2014 to 2021 Medicare Public Use Files. RESULTS In 2021, 158 of 2,058 Mohs surgeons (7.7%) used IHC as compared with 4.0% in 2014 (average annual growth rate [AAGR] +3.6%). Adoption change was highest in the Northeast (AAGR +19.9%), whereas volume growth was greatest in the West (AAGR +25.2%). Multivariable regression revealed significantly greater utilization propensity among Mohs surgeons in academics (adjusted odds ratio [aOR] 3.36), American College of Mohs Surgery (ACMS) members (aOR 2.12), and Micrographic Dermatologic Surgery (MDS)-certified surgeons (aOR 1.66). CONCLUSION Mohs surgeons are steadily incorporating IHC into practice across all regions, with volume growth driven by higher adoption rates. Greater utilization among ACMS members, recipients of MDS certification, and those in academics suggests value of formalized training in enhancing comfort. Additional educational opportunities at conferences may aid in recognition of value and help identify solutions to address integration challenges.

Evidence-Based Performance Measures for Reconstruction after Skin Cancer Resection: A Multidisciplinary Performance Measure Set.

The American Society of Plastic Surgeons commissioned the multidisciplinary Performance Measure Development Work Group on Reconstruction after Skin Cancer Resection to identify and draft quality measures for the care of patients undergoing skin cancer reconstruction. Included stakeholders were the American Academy of Otolaryngology-Head and Neck Surgery, the American Academy of Facial Plastic and Reconstructive Surgery, the American Academy of Dermatology, the American Society of Dermatologic Surgery, the American College of Mohs Surgery, the American Society for Mohs Surgery, and a patient representative. Two outcome measures and five process measures were identified. The outcome measures included the following: (1) patient satisfaction with information provided by their surgeon before their facial procedure, and (2) postprocedural urgent care or emergency room use. The process measures focus on antibiotic stewardship, anticoagulation continuation and/or coordination of care, opioid avoidance, and verification of clear margins. All measures in this report were approved by the American Society of Plastic Surgeons Quality and Performance Measures Work Group and Executive Committee, and the stakeholder societies. The work group recommends the use of these measures for quality initiatives, Continuing Medical Education, Continuous Certification, Qualified Clinical Data Registry reporting, and national quality reporting programs.

Dermatologic surgeons' approaches to acral lentiginous melanoma: a survey of the American College of Mohs Surgery.

Acral lentiginous melanoma (ALM) is a subtype of melanoma that primarily affects ethnic minorities and is associated with poor outcomes. Racial inequalities in melanoma survival, particularly between Blacks and Whites, have been well documented in the literature. There are limited data on the role of surgical approach to ALM and its contribution to the existing disparities in ALM survival. Thus, this study aimed to investigate the role of surgical approach to ALM among Mohs surgeons. The survey was distributed to members of the American College of Mohs Surgery (ACMS), with 43 physicians completing the survey. The results showed that there was no consensus among Mohs surgeons regarding the surgical approach for ALM, even for advanced stages. 74% respondents performed complete circumferential peripheral and deep margin assessment (CCPDMA) for ALM, including Mohs micrographic surgery (MMS) or en face staged excision. However, barriers such as limited training, low comfort operating on acral sites, and inadequate access to specialized biopsies were reported. Treatment recommendations varied widely regardless of the ALM stage, with no significant differences based on exposure to ALM during training, practice setting, or percent of skin of color patients served. These findings highlight the lack of guidelines and the need for more data on outcomes to support optimal management of ALM. The study emphasizes the importance of addressing healthcare disparities and improving survival outcomes, particularly for ethnic minorities affected by ALM. Consensus guidelines could help standardize treatment approaches and potentially reduce disparities in ALM management.

Mohs surgeon workforce survey: a spectrum of clinical, academic, and leadership activities.

Workforce adequacy for Mohs micrographic surgery (MMS) is not fully understood. The purpose of this study was to describe the current spectrum of clinical, academic, advocacy and leadership activities through a survey of members of the American College of Mohs Surgery (ACMS). The ACMS membership was electronically sent a 43-question anonymous survey between January and May 2023 and there was a 10.7% response rate representing 184 members across 37 states. Nearly 90% are board certified in micrographic dermatologic surgery and 10.3% indicate that they practice in a rural setting (57.1% suburban and 32.6% urban). The median number of half-day surgeons performed Mohs surgery is 6 and nearly half of Mohs surgeons work in a dermatology-only medical group (48.4%), do no use immunohistochemical stains (60.3%), and do not participate in a multidisciplinary tumor board (58.7%). Many respondents indicate they have capacity in their clinical schedules to accommodate more cases and the reasons are multifactorial.

Education and Perspectives on the Use of Oral Skin Cancer Chemoprophylaxis: A Cross-Sectional Survey of Current Fellows in Mohs Micrographic Surgery & Dermatologic Oncology.

According to the curriculum guidelines of the Accreditation Council of Graduate Medical Education and the American Board of Dermatology, Mohs micrographic surgery & dermatologic oncology (MSDO) fellows must demonstrate competency in the use of oral skin cancer chemoprophylaxis. The current level of education in this area is unknown. To characterize oral skin cancer chemoprophylaxis education for acitretin and nicotinamide among current MSDO fellows and to compare the clinical indications felt most appropriate for prescribing to a previously published expert consensus. An electronic survey was distributed to all active MSDO fellows by the American College of Mohs Surgery. Responses were received from 63 (69.2%) MSDO fellows. Twenty (31.7%) and 37 (58.7%) fellows reported receiving fellowship training on acitretin and nicotinamide, respectively. Fifty-seven (90.5%) intend to prescribe chemoprophylaxis after training. Sixteen (28.1%) and 43 (75.4%) report feeling very comfortable prescribing acitretin and nicotinamide, respectively. Fellow concordance with a previously published expert consensus opinion on appropriate prescribing indications is variable. Forty-one (65.1%) indicated that additional education would increase the likelihood to prescribe after training. Although most MSDO fellows intend to prescribe oral skin cancer chemoprophylaxis, a standardized curriculum may promote increased use and concordance with expert consensus recommendations.

A Cross-Sectional Analysis of Sharps Injuries Among Dermatologic Surgeons: A Survey of American College of Mohs Surgery Members.

There is a paucity of data on sharps injuries and bloodborne pathogen exposure among Dermatologic Surgeons. Quantify occupational risks from sharps injuries among Mohs surgeons. Determine rate of injury, reporting, and confidence in staff's sharps handling. A cross-sectional analysis performed using survey responses from Mohs surgeons with membership in the American College of Mohs Surgery (ACMS). A total of 60 ACMS members completed the survey. Overall, 56.7% reported at least 1 sharps injury within the past year, of which 14.7% resulted in a bloodborne exposure (odds of exposure: 7.5% per year). The most common type of injury was self-inflicted suture needlestick (76.5%). Forty-four-point-one percent did not report their injuries. Ninety-five percent reported access to postexposure prophylaxis at their workplace. In addition, respondents in academic and single-specialty practices were more likely to report high or moderate confidence in staff sharps handling knowledge and in injury reporting compared with respondents from multispecialty and solo practices (88% vs 54% p = .02, 76%-81% vs 27% p = .0004, respectively). Sharps injuries and under-reporting of these injuries are common among Mohs surgeons. Despite reporting of higher confidence in staff knowledge and training in academic and single-specialty practices, there was no correlation with surgeon's rate of injury.

Performance and Quality Measure Selection by Mohs Surgeons in the 2020 Merit-Based Incentive Payment System.

The Merit-Based Incentive Payment System (MIPS) seeks to promote value-based care through quality-adjusted Medicare payments. To assess 2020 MIPS performance and quality measure selection by Mohs surgeons. Retrospective, cross-sectional review of Medicare Quality Payment Program and Part B billing data sets. In 2020, 8,778 dermatologists and 2,148 Mohs surgeons received a MIPS score. Mohs surgeons primarily participated through groups (51.6%) or individuals (36.4%). Most of them (77.4%) received a final score enabling a positive payment adjustment in 2022, with a notable proportion (22.3%) being eligible for a neutral payment adjustment in the setting of COVID-19 exemptions. The members of the American College of Mohs Surgery were more likely to meet the exceptional performance threshold (71.5% vs 59.0%, p < .0001), as were Mohs surgeons with <15 years of experience (73.3% vs 54.8%, p < .0001). Measures related to dermatology or Mohs surgery were reported by most individuals (92.0%) and dermatology groups (90.4%), yet less frequently by multispecialty groups (5.9%). Many Mohs surgeons exceeded the performance threshold and used dermatology- or Mohs-related quality measures in 2020. Further assessments correlating quality measures with patient outcomes are needed to better understand the utility and appropriateness of the current value-based payment system and guide further policies.

Management of Scalp Squamous Cell Carcinoma Involving Bone: A Survey of the American College of Mohs Surgery.

Blumenthal, Shoshana R. MD*; Chen, Henry W. BS†; Maher, Ian MD*; Nijhawan, Rajiv I. MD† Author Information

Clinical outcomes of squamous cell carcinomas following complete saucerization with negative margins: Retrospective case series from 2010-2022

Clinical outcomes of squamous cell carcinomas following complete saucerization with negative margins: Retrospective case series from 2010-2022

Concordance in Distinguishing Actinic Keratosis from Squamous Cell Carcinoma in Situ on Mohs Histological Frozen Sections.

Mohs surgeons routinely encounter squamous cell carcinoma at surgical margins and often base the decision to take another layer on the severity of atypia observed. Currently, no criteria exists for distinguishing borderline histological patterns that could be interpreted differently as actinic keratosis (AK), squamous cell carcinoma in situ (SCCIS), or AK with focal SCCIS. To assess interrater concordance amongst Mohs surgeons in distinguishing AK from SCCIS when evaluating Mohs frozen sections. Seventeen slides were selected and converted into digitally formatted cases. They were compiled into an electronic survey and distributed to the American College of Mohs Surgery. Overall &kappa; was 0.26 corresponding to weak agreement between raters compared to the standard, with &kappa; of 0.34 for AK and 0.37 for SCCIS. There exists notable variability among Mohs surgeons who interpret the spectrum of in situ carcinoma differently. Ongoing learning and consensus building among Mohs surgeons and trainees can aid in quality patient care, even if there may not be agreement on every case. J Drugs Dermatol. 2023;22(2):199-194. doi:10.36849/JDD.7084.

Margin Size for Unique Skin Tumors Treated With Mohs Micrographic Surgery: A Survey of Practice Patterns.

Mohs micrographic surgery (MMS) has shown lower recurrence rates for unique skin tumors compared with wide local excision, but there is a lack of standardization on margin size. We aimed to assess MMS practice patterns of margin sizes for unique skin tumors. A survey was distributed to members of the American College of Mohs Surgery (ACMS). Demographic information on participants was collected in addition to initial/subsequent MMS margin size for unique skin tumors, including dermatofibrosarcoma protuberans (DFSP), atypical fibroxanthoma (AFX), melanoma, sebaceous carcinoma, microcystic adnexal carcinoma (MAC), poorly differentiated squamous cell carcinoma (SCC), and Merkel cell carcinoma. Eighty-seven respondents completed the survey (response rate <10%). Given that no guidelines exist on MMS margins for less commonly treated skin tumors, this study helps give Mohs surgeons perspective on current practice patterns for margin sizes. Mohs surgeons are more likely to take larger initial margins for these common skin tumors compared with BCCs or SCCs.

Perioperative Practices in Dermatologic Surgery.

Mohs micrographic surgery is generally safe and well tolerated. Various perioperative practices are employed with the aim of reducing adverse events; however, implementation is variable, and limited efficacy data are available. This study sought to assess perioperative practice patterns among dermatologic surgeons with regards to antibiotic prophylaxis (AP), anticoagulation, activity restrictions, and antiseptic choice. Two surveys were distributed by the American College of Mohs Surgery (ACMS) and the American Society for Mohs Surgery (ASMS) to their membership via email. One hundres seventy-seven surgeons participated, with membership from ACMS (61%), ASMS (35%), or both organizations (4%) represented. Systemic AP is prescribed preoperatively by 96% (162/168) and postoperatively by 91% (161/177) of surgeons for variable clinical indications. Therapeutic antiplatelet and anticoagulant medications are rarely held (3%-5%, 4-7/149), whereas preventative aspirin (30%, 45/149), NSAIDs (25%, 36/145), and supplements known to have an anticoagulant effect (54%, 80/149) are more commonly held. Antiseptic choice and recommended activity restrictions vary. Perioperative practices of dermatologic surgeons are variable and, where applicable, may deviate from guidelines. These findings underscore the need for standardization and updated guidelines for perioperative practices in dermatologic surgery.

Immunohistochemistry Use in Mohs Micrographic Surgery: A Survey of the American College of Mohs Surgery.

Kobic, Ajdin MD*; Sutton, Elizabeth MD†; Demer, Addison MD*,‡; Vidal, Nahid Y. MD*,‡ Author Information

Review of Mohs Surgeons' Intraoperative Anxiolytic Practices: A Survey of the American College of Mohs Surgery.

Review of Mohs Surgeons' Intraoperative Anxiolytic Practices: A Survey of the American College of Mohs Surgery.

Implementation of immunohistochemical staining among mohs micrographic surgeons

AbstractBackgroundImmunohistochemical staining has been used as part of Mohs micrographic surgery (MMS) to improve sensitivity for the detection of subtle residual tumors. It is typically used in the histopathologic detection of tumors such as malignant melanoma, extramammary Paget disease, and poorly differentiated and spindle cell neoplasms.Materials and MethodsThe study involved a questionnaire link emailed by the American College of Mohs Surgery to its members. The survey sought demographic information and asked about the use of immunohistochemistry (IHC) stains during fellowship training and in current practice as well as reasons why IHC staining is not incorporated into certain practices. The data were tabulated and analyzed.ResultsA total of 84 surveys were completed. Of these, 30 (35.7%) indicated having received training in IHC during the fellowship, whereas 54 (64.3%) did not. Currently, 32 (38.1%) respondents utilize IHC in their practice, whereas 52 (61.9%) do not. Among those who trained in IHC during the fellowship, 60% (n = 18) continue to utilize IHC, whereas among those whose fellowship did not incorporate IHC, 74.1% (n = 40) do not utilize IHC. A number of different immunostains were reportedly utilized during fellowship and in current practice. Among those not utilizing IHC, the top reasons cited were lack of sufficient volume to justify use (n = 38, 70.3%), cost of implementation (n = 38, 70.3%), the stains being time‐consuming (n = 36, 66.7%), and lack of familiarity with reading immunohistochemical stains (n = 29, 53.7%).ConclusionsThe use of IHC among Mohs surgeons appears to be rising compared to previous historical studies, but significant barriers remain to widespread implementation.

Micrographic dermatologic surgery (MDS) diplomates: a demographic evaluation and comparison of Medicare case volume.

Micrographic dermatologic surgery (MDS) recently became a board-certified field within dermatology with the first board examination administered in October 2021. To be eligible,dermatologists must have completed a fellowship through the Accreditation Council for Graduate Medical Education (ACGME) or attest to active practice of Mohs micrographic surgery. Attestation of active practice is available from 2021-2025, after which, those sitting for the certifying examination must demonstrate completion of an ACGME-accredited fellowship. This study aimedto compile demographic information on physicians who passed the MDS board certification examination. Medicare Mohs micrographic surgery case volume was compared between fellowship-trained and non-fellowship-trained physicians as well as between members and non-members of Mohs organizations. Names of physicians who passed the examination were accessed on the publicly available American Board of Dermatology website. The Medicare database was used to screen for Mohs surgery case numbers from 2019, and the American College of Mohs Surgery (ACMS) and American Society for Mohs Surgery (ASMS) physician finder tools were used to determine active membership.Physicians not in the Medicare database and those who completed an ACGME-accredited fellowship within the past three years were excluded from case volume analysis. 1673 dermatologists passed the first certifying examination. Medicare Mohscase volumes were compared for1310 of these physicians. The median number (interquartile range (IQR)) of Mohs surgery cases was significantly higher for physicians who were ACMS/ACGME-fellowship-trained compared to those who were not (370 cases (IQR: 211-560) vs 138 cases (IQR: 37-284), p < 0.001). Members of ACMS and/or ASMS also performed a higher median number of cases compared tonon-members (334 cases (IQR: 160-526) vs 95 cases (IQR: 6-246), p < 0.001). Given the 5-year window to take the MDS examination without having completed an ACMS/ACGME-accredited fellowship, more physicians without formal training may choose to become board certified. In addition, less dermatologists may choose to complete an ACMS/ACGME-accredited fellowship since it is not required for board certification. As more dermatologists become board certified in MDS, it may become important to assess for active practice of Mohs surgery and define proficiencymetrics.

Risk Factors That Are Associated With Outliers in Mohs Micrographic Surgery in the National Medicare Population, 2018.

Physician variation exists in the mean number of stages performed per Mohs micrographic surgery (MMS) case. Physicians who are outliers in medical practice may be leading to a higher health care cost burden. To identify factors that influence being a high outlier in the mean stages per MMS case. The study comprised a retrospective analysis of 2018 data from physicians who billed Medicare Part B for Current Procedural Terminology (CPT) 17311 and 17312 (MMS of the head, neck, hands, feet, or genitalia) and/or CPT 17313 and 17314 (MMS of the trunk, arms, or legs). For CPT 17311 and 17312, the odds ratio for being an outlier for a physician in a solo practice relative to a multiphysician facility is 2.4 (1.6-3.8), for a physician who is not an American College of Mohs Surgery (ACMS) member relative to a ACMS member is 2.0 (1.2-3.2), and for a practice located in the West, Northeast, and South is 7.7 (2.8-21.6), 6.2 (2.1-18.6), and 1.8 (0.6-5.4), respectively, relative to in the Midwest. Physicians who are practicing solo, practicing in the West or Northeast, and are not ACMS members are more likely to be a high outlier in the mean stages per MMS case.

The effectiveness of an electronic clinical-decision support tool embedded into the patient medical record at the point of care to guide Mohs surgery utilization: A cohort study

The effectiveness of an electronic clinical-decision support tool embedded into the patient medical record at the point of care to guide Mohs surgery utilization: A cohort study

Use of Antiseptic Solutions in Postoperative Wound Care: An American College of Mohs Surgery (ACMS) Member Survey

Bogner, Ryan MD; Nielson, Colton B. MD; Thompson, Carol MD; Brown, Timothy MD* Author Information

Communication Strategies in Mohs Micrographic Surgery: A Survey of Methods, Time Savings, and Perceived Patient Satisfaction

Mohs micrographic surgery (MMS) entails multiple time-consuming surgical and histological examinations for each patient. Efficient communication is key in improving clinic flow, and we surveyed members of the American College of Mohs Surgery to evaluate the efficacy of different techniques utilized by Mohs surgeons across the nation.