American College of Mohs Surgery (ACMS): Annual Meeting

LAS VEGAS – A simple purse string stitch can provide an elegant closure of challenging lip defects after Mohs surgery.

"It's quite easy to perform. It's useful for numerous areas of the lip. It's low-risk, with low morbidity, and requires little down time," yet provides an excellent aesthetic outcome, Dr. Kenny J. Omlin said at the annual meeting of the American College of Mohs Surgery.

The keys to reconstruction using the purse string stitch start with undermining the entire surgical wound in the subdermal plane to decrease sheering forces.

Photos courtesy Dr. Kenny Omlin

Next, uniformly place an absorbable suture in the deep dermis using a small needle, with circumferential tissue advancement to distribute the tension uniformly, explained Dr. Omlin, chief of Mohs surgery for Kaiser Permanente Napa-Solano County, Vacaville, Calif.

"There is a uniform stitch all the way around the perimeter" of the wound with particular attention to precisely aligning the vermilion/cutaneous lip junction, he said.

The purse string stitch creates a trestle-like framework that supports normal wound healing.

As with any reconstructions on the lower cosmetic subunits of the face, he tells patients to practice a "ventriloquist act" while healing and not talk much or move their mouths much.

One of his patients provided an excellent case-control comparison of wound closures. She initially presented with a basal cell carcinoma that intersected both the cutaneous and vermilion margins of her left upper lip.

After Mohs surgery, Dr. Omlin did a standard, complex linear closure, followed later by two pulsed-dye laser treatments. At 1-year follow-up, the patient was satisfied with an acceptable cosmetic outcome.

Six months later, she presented with a nearly identical basal cell carcinoma on the right upper lip. This time, Dr. Omlin used a purse string stitch after Mohs surgery. "It takes all of 5-10 minutes," he noted. The aesthetic result was "nearly perfect" a month later, said Dr. Omlin, also of the University of California, Davis.

On the central upper lip, "a lot of our older patients tend to have absent philtral columns or an absent Cupid's bow. Again, this is an excellent place for a purse string stitch," he said.

For patients on warfarin, the purse string stitch is great for hemostasis when repairing Mohs defects of the lip, Dr. Omlin added.

He also likes to use it for defects at the oral commissure. "Sure, you can use an elaborate cross-lip commissuroplasty or other elaborate techniques," but a simple purse string stitch reproduces the accordion-like structure of the oral commissure.

After wound granulation and healing, at 3 months it's hard to tell that a defect was ever there, he said.

In an interview after his presentation, he said he was pleased by the enthusiasm expressed by other attendees at the meeting for his simple surgical pearl.

Dr. Omlin said he has no relevant financial disclosures.

LAS VEGAS – A simple purse string stitch can provide an elegant closure of challenging lip defects after Mohs surgery.

"It's quite easy to perform. It's useful for numerous areas of the lip. It's low-risk, with low morbidity, and requires little down time," yet provides an excellent aesthetic outcome, Dr. Kenny J. Omlin said at the annual meeting of the American College of Mohs Surgery.

The keys to reconstruction using the purse string stitch start with undermining the entire surgical wound in the subdermal plane to decrease sheering forces.

Photos courtesy Dr. Kenny Omlin

Next, uniformly place an absorbable suture in the deep dermis using a small needle, with circumferential tissue advancement to distribute the tension uniformly, explained Dr. Omlin, chief of Mohs surgery for Kaiser Permanente Napa-Solano County, Vacaville, Calif.

"There is a uniform stitch all the way around the perimeter" of the wound with particular attention to precisely aligning the vermilion/cutaneous lip junction, he said.

The purse string stitch creates a trestle-like framework that supports normal wound healing.

As with any reconstructions on the lower cosmetic subunits of the face, he tells patients to practice a "ventriloquist act" while healing and not talk much or move their mouths much.

One of his patients provided an excellent case-control comparison of wound closures. She initially presented with a basal cell carcinoma that intersected both the cutaneous and vermilion margins of her left upper lip.

After Mohs surgery, Dr. Omlin did a standard, complex linear closure, followed later by two pulsed-dye laser treatments. At 1-year follow-up, the patient was satisfied with an acceptable cosmetic outcome.

Six months later, she presented with a nearly identical basal cell carcinoma on the right upper lip. This time, Dr. Omlin used a purse string stitch after Mohs surgery. "It takes all of 5-10 minutes," he noted. The aesthetic result was "nearly perfect" a month later, said Dr. Omlin, also of the University of California, Davis.

On the central upper lip, "a lot of our older patients tend to have absent philtral columns or an absent Cupid's bow. Again, this is an excellent place for a purse string stitch," he said.

For patients on warfarin, the purse string stitch is great for hemostasis when repairing Mohs defects of the lip, Dr. Omlin added.

He also likes to use it for defects at the oral commissure. "Sure, you can use an elaborate cross-lip commissuroplasty or other elaborate techniques," but a simple purse string stitch reproduces the accordion-like structure of the oral commissure.

After wound granulation and healing, at 3 months it's hard to tell that a defect was ever there, he said.

In an interview after his presentation, he said he was pleased by the enthusiasm expressed by other attendees at the meeting for his simple surgical pearl.

Dr. Omlin said he has no relevant financial disclosures.

LAS VEGAS – A simple purse string stitch can provide an elegant closure of challenging lip defects after Mohs surgery.

"It's quite easy to perform. It's useful for numerous areas of the lip. It's low-risk, with low morbidity, and requires little down time," yet provides an excellent aesthetic outcome, Dr. Kenny J. Omlin said at the annual meeting of the American College of Mohs Surgery.

The keys to reconstruction using the purse string stitch start with undermining the entire surgical wound in the subdermal plane to decrease sheering forces.

Photos courtesy Dr. Kenny Omlin

Next, uniformly place an absorbable suture in the deep dermis using a small needle, with circumferential tissue advancement to distribute the tension uniformly, explained Dr. Omlin, chief of Mohs surgery for Kaiser Permanente Napa-Solano County, Vacaville, Calif.

"There is a uniform stitch all the way around the perimeter" of the wound with particular attention to precisely aligning the vermilion/cutaneous lip junction, he said.

The purse string stitch creates a trestle-like framework that supports normal wound healing.

As with any reconstructions on the lower cosmetic subunits of the face, he tells patients to practice a "ventriloquist act" while healing and not talk much or move their mouths much.

One of his patients provided an excellent case-control comparison of wound closures. She initially presented with a basal cell carcinoma that intersected both the cutaneous and vermilion margins of her left upper lip.

After Mohs surgery, Dr. Omlin did a standard, complex linear closure, followed later by two pulsed-dye laser treatments. At 1-year follow-up, the patient was satisfied with an acceptable cosmetic outcome.

Six months later, she presented with a nearly identical basal cell carcinoma on the right upper lip. This time, Dr. Omlin used a purse string stitch after Mohs surgery. "It takes all of 5-10 minutes," he noted. The aesthetic result was "nearly perfect" a month later, said Dr. Omlin, also of the University of California, Davis.

On the central upper lip, "a lot of our older patients tend to have absent philtral columns or an absent Cupid's bow. Again, this is an excellent place for a purse string stitch," he said.

For patients on warfarin, the purse string stitch is great for hemostasis when repairing Mohs defects of the lip, Dr. Omlin added.

He also likes to use it for defects at the oral commissure. "Sure, you can use an elaborate cross-lip commissuroplasty or other elaborate techniques," but a simple purse string stitch reproduces the accordion-like structure of the oral commissure.

After wound granulation and healing, at 3 months it's hard to tell that a defect was ever there, he said.

In an interview after his presentation, he said he was pleased by the enthusiasm expressed by other attendees at the meeting for his simple surgical pearl.

Dr. Omlin said he has no relevant financial disclosures.

LAS VEGAS – Traditional techniques for anchoring cartilage grafts after Mohs surgery on the nose might be more complicated than necessary.

Well-known textbook descriptions of cartilage grafting for alar rim reconstruction involve harvesting a large piece of cartilage and securing the grafted cartilage with multiple sutures medially to the lower lateral cartilage and laterally to the periosteum of the piriform aperture of the maxilla.

This technique is appropriate for large defects that require reconstruction of the entire alar subunit, but is unnecessary for many of the smaller alar defects that commonly are encountered in Mohs surgery, Dr. Ravi S. Krishnan said.

"While this does produce nice results, I don't like it for two reasons," he said at the annual meeting of the American College of Mohs Surgery. "It requires a very large cartilage graft, and it often requires more effort than you sometimes need."

In his approach to performing a cartilage graft with a skin graft on top of it, he starts the conventional way by making some stab incisions on either side of the wound to create a pocket for the cartilage graft. What most surgeons would do next is to place either a figure-of-eight suture or some interrupted sutures to hold the graft in place.

"While these techniques are fine, I sometimes still have problems with them getting the cartilage graft flush against the alar remnant," noted Dr. Krishnan of Virginia Mason Medical Center, Seattle.

Instead, he starts suturing from inside the nose, pushing the suture through the nose behind the cartilage graft, then pulling it back through the cartilage graft and the nose, finally pulling inferiorly as the knot is tied. He repeats this process, so that there are two sutures anchoring the cartilage graft along the alar rim. These sutures are left in place for 2 weeks to allow some fibrosis to occur.

"The reason I like this technique is because it pulls the graft inferiorly so that it's perfectly flush against the alar rim remnant," he said. It also leaves more of the wound base exposed so that any overlying skin graft will be well perfused.

This is not necessarily a new technique, Dr. Krishnan said, but he could find no published description of it. It doesn't necessarily give better results, but it's easier to execute than are traditional methods, he added.

His techniques for anchoring cartilage grafts along the alar rim also work well with flaps including nasolabial transposition flaps, bilobed flaps, and interpolated paranasal flaps, resulting in good contour and symmetry and very acceptable results, he believes.

He typically follows these patients for 6 months after surgery, and while it's possible that the cartilage graft could shift after 6 months, "I doubt this would be the case."

One small drawback is that epithelium can start growing over the anchoring sutures during the 2 weeks that they are left in place, making them difficult to remove.

"Some people worry about infection, but I've never seen an infection with this technique," he added. All patients in his practice that receive cartilage grafts get perioperative antibiotics.

The advantages outweigh any potential drawbacks of the technique, in his opinion. It's easy to perform, and results are at least as good as those with more difficult techniques. His method precisely places the cartilage "exactly where you want it" along the alar rim, and apposes the cartilage graft to the mucosal lining, he said. When used in conjunction with a full-thickness skin graft, it allows the skin graft to come into contact with as much of the base of the wound as possible.

"It is important to remember that this technique is applicable only to smaller alar defects," he said. "For larger alar defects, using a large cartilage graft secured in the traditional manner is the preferred approach."

Dr. Krishnan said he has no relevant financial disclosures.

LAS VEGAS – Traditional techniques for anchoring cartilage grafts after Mohs surgery on the nose might be more complicated than necessary.

Well-known textbook descriptions of cartilage grafting for alar rim reconstruction involve harvesting a large piece of cartilage and securing the grafted cartilage with multiple sutures medially to the lower lateral cartilage and laterally to the periosteum of the piriform aperture of the maxilla.

This technique is appropriate for large defects that require reconstruction of the entire alar subunit, but is unnecessary for many of the smaller alar defects that commonly are encountered in Mohs surgery, Dr. Ravi S. Krishnan said.

"While this does produce nice results, I don't like it for two reasons," he said at the annual meeting of the American College of Mohs Surgery. "It requires a very large cartilage graft, and it often requires more effort than you sometimes need."

In his approach to performing a cartilage graft with a skin graft on top of it, he starts the conventional way by making some stab incisions on either side of the wound to create a pocket for the cartilage graft. What most surgeons would do next is to place either a figure-of-eight suture or some interrupted sutures to hold the graft in place.

"While these techniques are fine, I sometimes still have problems with them getting the cartilage graft flush against the alar remnant," noted Dr. Krishnan of Virginia Mason Medical Center, Seattle.

Instead, he starts suturing from inside the nose, pushing the suture through the nose behind the cartilage graft, then pulling it back through the cartilage graft and the nose, finally pulling inferiorly as the knot is tied. He repeats this process, so that there are two sutures anchoring the cartilage graft along the alar rim. These sutures are left in place for 2 weeks to allow some fibrosis to occur.

"The reason I like this technique is because it pulls the graft inferiorly so that it's perfectly flush against the alar rim remnant," he said. It also leaves more of the wound base exposed so that any overlying skin graft will be well perfused.

This is not necessarily a new technique, Dr. Krishnan said, but he could find no published description of it. It doesn't necessarily give better results, but it's easier to execute than are traditional methods, he added.

His techniques for anchoring cartilage grafts along the alar rim also work well with flaps including nasolabial transposition flaps, bilobed flaps, and interpolated paranasal flaps, resulting in good contour and symmetry and very acceptable results, he believes.

He typically follows these patients for 6 months after surgery, and while it's possible that the cartilage graft could shift after 6 months, "I doubt this would be the case."

One small drawback is that epithelium can start growing over the anchoring sutures during the 2 weeks that they are left in place, making them difficult to remove.

"Some people worry about infection, but I've never seen an infection with this technique," he added. All patients in his practice that receive cartilage grafts get perioperative antibiotics.

The advantages outweigh any potential drawbacks of the technique, in his opinion. It's easy to perform, and results are at least as good as those with more difficult techniques. His method precisely places the cartilage "exactly where you want it" along the alar rim, and apposes the cartilage graft to the mucosal lining, he said. When used in conjunction with a full-thickness skin graft, it allows the skin graft to come into contact with as much of the base of the wound as possible.

"It is important to remember that this technique is applicable only to smaller alar defects," he said. "For larger alar defects, using a large cartilage graft secured in the traditional manner is the preferred approach."

Dr. Krishnan said he has no relevant financial disclosures.

LAS VEGAS – Traditional techniques for anchoring cartilage grafts after Mohs surgery on the nose might be more complicated than necessary.

Well-known textbook descriptions of cartilage grafting for alar rim reconstruction involve harvesting a large piece of cartilage and securing the grafted cartilage with multiple sutures medially to the lower lateral cartilage and laterally to the periosteum of the piriform aperture of the maxilla.

This technique is appropriate for large defects that require reconstruction of the entire alar subunit, but is unnecessary for many of the smaller alar defects that commonly are encountered in Mohs surgery, Dr. Ravi S. Krishnan said.

"While this does produce nice results, I don't like it for two reasons," he said at the annual meeting of the American College of Mohs Surgery. "It requires a very large cartilage graft, and it often requires more effort than you sometimes need."

In his approach to performing a cartilage graft with a skin graft on top of it, he starts the conventional way by making some stab incisions on either side of the wound to create a pocket for the cartilage graft. What most surgeons would do next is to place either a figure-of-eight suture or some interrupted sutures to hold the graft in place.

"While these techniques are fine, I sometimes still have problems with them getting the cartilage graft flush against the alar remnant," noted Dr. Krishnan of Virginia Mason Medical Center, Seattle.

Instead, he starts suturing from inside the nose, pushing the suture through the nose behind the cartilage graft, then pulling it back through the cartilage graft and the nose, finally pulling inferiorly as the knot is tied. He repeats this process, so that there are two sutures anchoring the cartilage graft along the alar rim. These sutures are left in place for 2 weeks to allow some fibrosis to occur.

"The reason I like this technique is because it pulls the graft inferiorly so that it's perfectly flush against the alar rim remnant," he said. It also leaves more of the wound base exposed so that any overlying skin graft will be well perfused.

This is not necessarily a new technique, Dr. Krishnan said, but he could find no published description of it. It doesn't necessarily give better results, but it's easier to execute than are traditional methods, he added.

His techniques for anchoring cartilage grafts along the alar rim also work well with flaps including nasolabial transposition flaps, bilobed flaps, and interpolated paranasal flaps, resulting in good contour and symmetry and very acceptable results, he believes.

He typically follows these patients for 6 months after surgery, and while it's possible that the cartilage graft could shift after 6 months, "I doubt this would be the case."

One small drawback is that epithelium can start growing over the anchoring sutures during the 2 weeks that they are left in place, making them difficult to remove.

"Some people worry about infection, but I've never seen an infection with this technique," he added. All patients in his practice that receive cartilage grafts get perioperative antibiotics.

The advantages outweigh any potential drawbacks of the technique, in his opinion. It's easy to perform, and results are at least as good as those with more difficult techniques. His method precisely places the cartilage "exactly where you want it" along the alar rim, and apposes the cartilage graft to the mucosal lining, he said. When used in conjunction with a full-thickness skin graft, it allows the skin graft to come into contact with as much of the base of the wound as possible.

"It is important to remember that this technique is applicable only to smaller alar defects," he said. "For larger alar defects, using a large cartilage graft secured in the traditional manner is the preferred approach."

Dr. Krishnan said he has no relevant financial disclosures.

LAS VEGAS – Preoperative scrubs before nail avulsion fail to reduce postoperative infection, recent data suggest.

However, studies have identified best practices for reducing bacterial counts – such as irrigating after nail plate avulsion though there is no evidence that the measures reduce postoperative infection rates.

Photo credit: Dr. Nathaniel J. Jellinek

"Every study that has looked at rates of colonization or recolonization after your scrub showed significant bacterial presence. As good as our scrubs are, they're probably not good enough," Dr. Nathaniel J. Jellinek said at the annual meeting of the American College of Mohs Surgery.

A recent study measured bacterial counts after a 7-minute surgical scrub and again after avulsion of the nail plate. The bacterial counts were essentially the same. "It's as if the surgical scrub didn't do any good," said Dr. Jellinek, who was not involved in the study (Dermatol. Surg. 2010;36:1258-65).

The investigators then irrigated the nail bed with saline, which reduced bacterial counts by 95%. That's "an easy thing to do intraoperatively that you might consider for your practice," said Dr. Jellinek of the department of dermatology at Brown University, Providence, R.I.

Studies published mainly in the podiatric and orthopedic literature show that postoperative infection rates are higher after nail surgery than after skin surgery. Rates of bacterial colonization before and after surgical preparation of nails make the term "sterile surgery" inaccurate for these procedures, which might better be considered clean-contaminated or even contaminated surgery, he said in an interview after his presentation.

Photo credit: Dr. Nathaniel J. Jellinek

Other studies have shown that applying alcohol and chlorhexidine may be superior to chloroxylenol and povidone-iodine to reduce bacterial counts before nail surgery. Bacterial persistence and recolonization also can be reduced by the use of bristled brushes, soaked gauze pads, scrubbing to the interdigital webs, and repeat scrubs.

"At this point, it's all hypothetical whether it decreases infection. But we know that infection rates are unacceptably high, so it can only help if you decrease the bacterial count," Dr. Jellinek said.

He has added multiple prophylactic measures to his practice, where he performs a lot of nail surgery.

First, Dr. Jellinek informs the patient that the nail is a dirty site, he reviews wound care, and educates the patient to pay attention to risk factors for infection and avoid putting fingers or toes in dirty places.

He recommends strict sterile preoperative and intraoperative techniques. A nurse or medical assistant should scrub the surgical area for several minutes. "We're talking not 10 or 30 seconds, but 2, 3, 5 minutes," he said.

The scrub should use multiple agents. He prefers using a bristle brush to scrub with chlorhexidine, gauze pads soaked in 70% isopropyl alcohol, and maybe even povidone-iodine paint. He lets all that sit, and applies a sterile glove over the digit, hand, or foot after the scrub.

During surgery, once the nail plate is avulsed, he recommends either performing a repeat scrub or at least irrigating the nail bed with sterile saline.

Dr. Jellinek said recent data have lowered his threshold for using prophylactic antibiotics. He has come to appreciate that nail infections may be caused by different organisms than those that cause most skin infections and require different antibiotics for treatment.

As a result, "I actually have very few nail infections, but I can't pinpoint which of those five or six things that I've done give me those results," he said.

Studies of prophylactic measures to avoid postoperative nail infections include:

• Preoperative skin and nail preparation of the foot: Comparison of the efficacy of 4 different methods in reducing bacterial load (J. Am. Acad. Dermatol. 2009;61:986-92).

• Chlorhexidine Provides Superior Skin Decontamination in Foot and Ankle Surgery: A Prospective Randomized Study (Clin. Orthop. Relat. Res. 2005;438:204-8).

• Preoperative Skin Preparation of the Foot and Ankle: Bristles and Alcohol Are Better (J. Bone Joint Surg. 2005;87:986-92).

• Efficacy of Surgical Preparation in Solutions in Foot and Ankle Surgery (J. Bone Joint Surg. 2005;87:980-5).

Dr. Jellinek said he had no relevant financial disclosures.

LAS VEGAS – Preoperative scrubs before nail avulsion fail to reduce postoperative infection, recent data suggest.

However, studies have identified best practices for reducing bacterial counts – such as irrigating after nail plate avulsion though there is no evidence that the measures reduce postoperative infection rates.

Photo credit: Dr. Nathaniel J. Jellinek

"Every study that has looked at rates of colonization or recolonization after your scrub showed significant bacterial presence. As good as our scrubs are, they're probably not good enough," Dr. Nathaniel J. Jellinek said at the annual meeting of the American College of Mohs Surgery.

A recent study measured bacterial counts after a 7-minute surgical scrub and again after avulsion of the nail plate. The bacterial counts were essentially the same. "It's as if the surgical scrub didn't do any good," said Dr. Jellinek, who was not involved in the study (Dermatol. Surg. 2010;36:1258-65).

The investigators then irrigated the nail bed with saline, which reduced bacterial counts by 95%. That's "an easy thing to do intraoperatively that you might consider for your practice," said Dr. Jellinek of the department of dermatology at Brown University, Providence, R.I.

Studies published mainly in the podiatric and orthopedic literature show that postoperative infection rates are higher after nail surgery than after skin surgery. Rates of bacterial colonization before and after surgical preparation of nails make the term "sterile surgery" inaccurate for these procedures, which might better be considered clean-contaminated or even contaminated surgery, he said in an interview after his presentation.

Photo credit: Dr. Nathaniel J. Jellinek

Other studies have shown that applying alcohol and chlorhexidine may be superior to chloroxylenol and povidone-iodine to reduce bacterial counts before nail surgery. Bacterial persistence and recolonization also can be reduced by the use of bristled brushes, soaked gauze pads, scrubbing to the interdigital webs, and repeat scrubs.

"At this point, it's all hypothetical whether it decreases infection. But we know that infection rates are unacceptably high, so it can only help if you decrease the bacterial count," Dr. Jellinek said.

He has added multiple prophylactic measures to his practice, where he performs a lot of nail surgery.

First, Dr. Jellinek informs the patient that the nail is a dirty site, he reviews wound care, and educates the patient to pay attention to risk factors for infection and avoid putting fingers or toes in dirty places.

He recommends strict sterile preoperative and intraoperative techniques. A nurse or medical assistant should scrub the surgical area for several minutes. "We're talking not 10 or 30 seconds, but 2, 3, 5 minutes," he said.

The scrub should use multiple agents. He prefers using a bristle brush to scrub with chlorhexidine, gauze pads soaked in 70% isopropyl alcohol, and maybe even povidone-iodine paint. He lets all that sit, and applies a sterile glove over the digit, hand, or foot after the scrub.

During surgery, once the nail plate is avulsed, he recommends either performing a repeat scrub or at least irrigating the nail bed with sterile saline.

Dr. Jellinek said recent data have lowered his threshold for using prophylactic antibiotics. He has come to appreciate that nail infections may be caused by different organisms than those that cause most skin infections and require different antibiotics for treatment.

As a result, "I actually have very few nail infections, but I can't pinpoint which of those five or six things that I've done give me those results," he said.

Studies of prophylactic measures to avoid postoperative nail infections include:

• Preoperative skin and nail preparation of the foot: Comparison of the efficacy of 4 different methods in reducing bacterial load (J. Am. Acad. Dermatol. 2009;61:986-92).

• Chlorhexidine Provides Superior Skin Decontamination in Foot and Ankle Surgery: A Prospective Randomized Study (Clin. Orthop. Relat. Res. 2005;438:204-8).

• Preoperative Skin Preparation of the Foot and Ankle: Bristles and Alcohol Are Better (J. Bone Joint Surg. 2005;87:986-92).

• Efficacy of Surgical Preparation in Solutions in Foot and Ankle Surgery (J. Bone Joint Surg. 2005;87:980-5).

Dr. Jellinek said he had no relevant financial disclosures.

LAS VEGAS – Preoperative scrubs before nail avulsion fail to reduce postoperative infection, recent data suggest.

However, studies have identified best practices for reducing bacterial counts – such as irrigating after nail plate avulsion though there is no evidence that the measures reduce postoperative infection rates.

Photo credit: Dr. Nathaniel J. Jellinek

"Every study that has looked at rates of colonization or recolonization after your scrub showed significant bacterial presence. As good as our scrubs are, they're probably not good enough," Dr. Nathaniel J. Jellinek said at the annual meeting of the American College of Mohs Surgery.

A recent study measured bacterial counts after a 7-minute surgical scrub and again after avulsion of the nail plate. The bacterial counts were essentially the same. "It's as if the surgical scrub didn't do any good," said Dr. Jellinek, who was not involved in the study (Dermatol. Surg. 2010;36:1258-65).

The investigators then irrigated the nail bed with saline, which reduced bacterial counts by 95%. That's "an easy thing to do intraoperatively that you might consider for your practice," said Dr. Jellinek of the department of dermatology at Brown University, Providence, R.I.

Studies published mainly in the podiatric and orthopedic literature show that postoperative infection rates are higher after nail surgery than after skin surgery. Rates of bacterial colonization before and after surgical preparation of nails make the term "sterile surgery" inaccurate for these procedures, which might better be considered clean-contaminated or even contaminated surgery, he said in an interview after his presentation.

Photo credit: Dr. Nathaniel J. Jellinek

Other studies have shown that applying alcohol and chlorhexidine may be superior to chloroxylenol and povidone-iodine to reduce bacterial counts before nail surgery. Bacterial persistence and recolonization also can be reduced by the use of bristled brushes, soaked gauze pads, scrubbing to the interdigital webs, and repeat scrubs.

"At this point, it's all hypothetical whether it decreases infection. But we know that infection rates are unacceptably high, so it can only help if you decrease the bacterial count," Dr. Jellinek said.

He has added multiple prophylactic measures to his practice, where he performs a lot of nail surgery.

First, Dr. Jellinek informs the patient that the nail is a dirty site, he reviews wound care, and educates the patient to pay attention to risk factors for infection and avoid putting fingers or toes in dirty places.

He recommends strict sterile preoperative and intraoperative techniques. A nurse or medical assistant should scrub the surgical area for several minutes. "We're talking not 10 or 30 seconds, but 2, 3, 5 minutes," he said.

The scrub should use multiple agents. He prefers using a bristle brush to scrub with chlorhexidine, gauze pads soaked in 70% isopropyl alcohol, and maybe even povidone-iodine paint. He lets all that sit, and applies a sterile glove over the digit, hand, or foot after the scrub.

During surgery, once the nail plate is avulsed, he recommends either performing a repeat scrub or at least irrigating the nail bed with sterile saline.

Dr. Jellinek said recent data have lowered his threshold for using prophylactic antibiotics. He has come to appreciate that nail infections may be caused by different organisms than those that cause most skin infections and require different antibiotics for treatment.

As a result, "I actually have very few nail infections, but I can't pinpoint which of those five or six things that I've done give me those results," he said.

Studies of prophylactic measures to avoid postoperative nail infections include:

• Preoperative skin and nail preparation of the foot: Comparison of the efficacy of 4 different methods in reducing bacterial load (J. Am. Acad. Dermatol. 2009;61:986-92).

• Chlorhexidine Provides Superior Skin Decontamination in Foot and Ankle Surgery: A Prospective Randomized Study (Clin. Orthop. Relat. Res. 2005;438:204-8).

• Preoperative Skin Preparation of the Foot and Ankle: Bristles and Alcohol Are Better (J. Bone Joint Surg. 2005;87:986-92).

• Efficacy of Surgical Preparation in Solutions in Foot and Ankle Surgery (J. Bone Joint Surg. 2005;87:980-5).

Dr. Jellinek said he had no relevant financial disclosures.

LAS VEGAS – A perioperative hemorrhage in a patient undergoing Mohs surgery is a bloody mess, but a thrombosis causing a stroke is a catastrophe.

"Bleeding is overemphasized in our specialty, because it's dramatic. But it is very inconsequential in contrast to thrombosis, which is probably underappreciated," Dr. Clark C. Otley said at the annual meeting of the American College of Mohs Surgery.

Photo credit: Courtesy Dr. Clark C. Otley 

He reviewed the literature on the risks for hemorrhage in patients on anticoagulant therapy who undergo Mohs surgery and the risks for thrombosis in patients who stop their anticoagulant therapy before Mohs.

"The bottom line is that bleeding happens, but nobody dies. That's in contrast to the thrombotic data, where people do die," said Dr. Otley, professor of dermatology at the Mayo Clinic, Rochester, Minn.

The consequences of a thrombotic episode are so much greater than the impact of a hemorrhagic complication that he recommended continuing medically necessary anticoagulants in most cases. "Take extra care with clopidogrel plus aspirin and with warfarin. Taking patients off these, especially if they have a fresh stent, is not the right thing to do," he said.

A survey of 168 American College of Mohs Surgery members in 2003 gathered reports of thrombotic complications within 3 days of Mohs surgery in 46 patients who had stopped anticoagulant therapy, Dr. Otley noted. These included stroke in 24 patients, transient ischemic attack in 8, MI in 5, cerebral emboli or death in 3 patients each, pulmonary embolus in 2, and blindness in 1 patient (J. Am. Acad. Dermatol 2003;48:233-7).

A separate survey of more than 270 dermasurgeons in 2005 found thrombotic complications in 126 patients who stopped anticoagulants for Mohs surgery, including stroke in 39 patients, transient ischemic attack in 25, MI in 19, unstable angina in 17, death in 15, deep venous thrombosis in 7, and pulmonary embolus in 4 patients (Dermatol. Surg. 2007;33:1189-97).

Case reports are emerging of thrombotic episodes in patients on newer anticoagulants who stop therapy for cutaneous surgery. For instance, he noted, a patient who stopped ticlopidine and aspirin developed a deep venous thrombosis. A patient who stopped clopidogrel and ardeparin thrombosed a prosthetic valve. A patient who stopped clopidogrel and aspirin had an MI.

These problems typically present as emergencies, which the Mohs surgeon may not see, Dr. Otley noted. "You may have had more patients experience this than you know about," he said.

Most of the data on the risk of hemorrhagic complications in patients undergoing superficial cutaneous surgery while on anticoagulants focus on traditional agents such as warfarin, aspirin, and NSAIDs, with some data on heparin. Little or no data exist on the risks with newer, more potent anticoagulants.

A total of 10 of 11 studies of patients on warfarin, aspirin, or NSAIDs found no increased risk of perioperative severe hemorrhagic complications, Dr. Otley said. One study of 21 patients on warfarin found an increased risk of complications including persistent bleeding, hematoma, infection, or graft loss. The most severe complication observed in any of the 11 studies was hematoma.

A meta-analysis of the data found a significantly increased risk if moderate and severe hemorrhagic complications were combined as an outcome, but not for severe complications alone, he noted (Dermatol. Surg. 2008;34:160-5).

Clopidogrel (Plavix) is new enough that there is little consensus on how to manage patients on this potent anticoagulant during cutaneous surgery. "This is the one that we’re seeing a ton of patients on," Dr. Otley said. "If your patient has a fresh stent, you would be insane to take that patient off this medication."

Patients on clopidogrel usually are on other anticoagulants, too. Data suggest there is a significant 28-fold higher risk of severe hemorrhagic complications in patients on any clopidogrel-containing regimen, compared with patients not taking anticoagulants, and a significant eightfold higher risk in patients on clopidogrel plus aspirin, compared with patients on aspirin alone. If you compare patients on clopidogrel with patients not on anticoagulant therapy, the difference in risk for severe hemorrhagic complications is not significant, probably due to the small number of patients on clopidogrel alone, he said.

"Nobody has died of hemorrhagic complications, to my knowledge," while having cutaneous surgery on clopidogrel. However, stopping the drug increases the risk of death from thrombotic complications, Dr. Otley said.

There are no data yet on cutaneous surgery complications in patients on dabigatran, "the new kid on the block," and a drug that "you're going to be hearing a lot about," he said. Dabigatran is as effective as warfarin for preventing stroke in high-risk patients.

If patients scheduled for Mohs surgery are on dabigatran, "I'd probably have them continue it unless your hematologist says otherwise," Dr. Otley said. He urged Mohs surgeons to start collecting data on any complications in patients on dabigatran.

To prevent bleeding complications from Mohs surgery, pay attention to hematologic parameters and monitor blood pressure. Hypertension is the leading cause of excessive intraoperative bleeding, he said. Administer sedatives for anxiolysis, use epinephrine as needed, apply pressure dressings, and put in a drain if you think a patient is going to bleed. Use blood products if needed.

In the OR, dislodge temporary clots, eliminate dead space, apply pressure dressings, and use other techniques for secondary prevention of bleeding complications, he advised. "There's no better time to have someone bleed than while you have them open, so rub all those clots off and recoagulate," he said.

Patients with hemorrhagic complications often apologize to Dr. Otley, thinking they did something that caused the bleeding. "I can guarantee you thrombotic patients will not be apologizing to you," he said.

Dr. Otley said he has no relevant conflicts of interest.

LAS VEGAS – A perioperative hemorrhage in a patient undergoing Mohs surgery is a bloody mess, but a thrombosis causing a stroke is a catastrophe.

"Bleeding is overemphasized in our specialty, because it's dramatic. But it is very inconsequential in contrast to thrombosis, which is probably underappreciated," Dr. Clark C. Otley said at the annual meeting of the American College of Mohs Surgery.

Photo credit: Courtesy Dr. Clark C. Otley 

He reviewed the literature on the risks for hemorrhage in patients on anticoagulant therapy who undergo Mohs surgery and the risks for thrombosis in patients who stop their anticoagulant therapy before Mohs.

"The bottom line is that bleeding happens, but nobody dies. That's in contrast to the thrombotic data, where people do die," said Dr. Otley, professor of dermatology at the Mayo Clinic, Rochester, Minn.

The consequences of a thrombotic episode are so much greater than the impact of a hemorrhagic complication that he recommended continuing medically necessary anticoagulants in most cases. "Take extra care with clopidogrel plus aspirin and with warfarin. Taking patients off these, especially if they have a fresh stent, is not the right thing to do," he said.

A survey of 168 American College of Mohs Surgery members in 2003 gathered reports of thrombotic complications within 3 days of Mohs surgery in 46 patients who had stopped anticoagulant therapy, Dr. Otley noted. These included stroke in 24 patients, transient ischemic attack in 8, MI in 5, cerebral emboli or death in 3 patients each, pulmonary embolus in 2, and blindness in 1 patient (J. Am. Acad. Dermatol 2003;48:233-7).

A separate survey of more than 270 dermasurgeons in 2005 found thrombotic complications in 126 patients who stopped anticoagulants for Mohs surgery, including stroke in 39 patients, transient ischemic attack in 25, MI in 19, unstable angina in 17, death in 15, deep venous thrombosis in 7, and pulmonary embolus in 4 patients (Dermatol. Surg. 2007;33:1189-97).

Case reports are emerging of thrombotic episodes in patients on newer anticoagulants who stop therapy for cutaneous surgery. For instance, he noted, a patient who stopped ticlopidine and aspirin developed a deep venous thrombosis. A patient who stopped clopidogrel and ardeparin thrombosed a prosthetic valve. A patient who stopped clopidogrel and aspirin had an MI.

These problems typically present as emergencies, which the Mohs surgeon may not see, Dr. Otley noted. "You may have had more patients experience this than you know about," he said.

Most of the data on the risk of hemorrhagic complications in patients undergoing superficial cutaneous surgery while on anticoagulants focus on traditional agents such as warfarin, aspirin, and NSAIDs, with some data on heparin. Little or no data exist on the risks with newer, more potent anticoagulants.

A total of 10 of 11 studies of patients on warfarin, aspirin, or NSAIDs found no increased risk of perioperative severe hemorrhagic complications, Dr. Otley said. One study of 21 patients on warfarin found an increased risk of complications including persistent bleeding, hematoma, infection, or graft loss. The most severe complication observed in any of the 11 studies was hematoma.

A meta-analysis of the data found a significantly increased risk if moderate and severe hemorrhagic complications were combined as an outcome, but not for severe complications alone, he noted (Dermatol. Surg. 2008;34:160-5).

Clopidogrel (Plavix) is new enough that there is little consensus on how to manage patients on this potent anticoagulant during cutaneous surgery. "This is the one that we’re seeing a ton of patients on," Dr. Otley said. "If your patient has a fresh stent, you would be insane to take that patient off this medication."

Patients on clopidogrel usually are on other anticoagulants, too. Data suggest there is a significant 28-fold higher risk of severe hemorrhagic complications in patients on any clopidogrel-containing regimen, compared with patients not taking anticoagulants, and a significant eightfold higher risk in patients on clopidogrel plus aspirin, compared with patients on aspirin alone. If you compare patients on clopidogrel with patients not on anticoagulant therapy, the difference in risk for severe hemorrhagic complications is not significant, probably due to the small number of patients on clopidogrel alone, he said.

"Nobody has died of hemorrhagic complications, to my knowledge," while having cutaneous surgery on clopidogrel. However, stopping the drug increases the risk of death from thrombotic complications, Dr. Otley said.

There are no data yet on cutaneous surgery complications in patients on dabigatran, "the new kid on the block," and a drug that "you're going to be hearing a lot about," he said. Dabigatran is as effective as warfarin for preventing stroke in high-risk patients.

If patients scheduled for Mohs surgery are on dabigatran, "I'd probably have them continue it unless your hematologist says otherwise," Dr. Otley said. He urged Mohs surgeons to start collecting data on any complications in patients on dabigatran.

To prevent bleeding complications from Mohs surgery, pay attention to hematologic parameters and monitor blood pressure. Hypertension is the leading cause of excessive intraoperative bleeding, he said. Administer sedatives for anxiolysis, use epinephrine as needed, apply pressure dressings, and put in a drain if you think a patient is going to bleed. Use blood products if needed.

In the OR, dislodge temporary clots, eliminate dead space, apply pressure dressings, and use other techniques for secondary prevention of bleeding complications, he advised. "There's no better time to have someone bleed than while you have them open, so rub all those clots off and recoagulate," he said.

Patients with hemorrhagic complications often apologize to Dr. Otley, thinking they did something that caused the bleeding. "I can guarantee you thrombotic patients will not be apologizing to you," he said.

Dr. Otley said he has no relevant conflicts of interest.

LAS VEGAS – A perioperative hemorrhage in a patient undergoing Mohs surgery is a bloody mess, but a thrombosis causing a stroke is a catastrophe.

"Bleeding is overemphasized in our specialty, because it's dramatic. But it is very inconsequential in contrast to thrombosis, which is probably underappreciated," Dr. Clark C. Otley said at the annual meeting of the American College of Mohs Surgery.

Photo credit: Courtesy Dr. Clark C. Otley 

He reviewed the literature on the risks for hemorrhage in patients on anticoagulant therapy who undergo Mohs surgery and the risks for thrombosis in patients who stop their anticoagulant therapy before Mohs.

"The bottom line is that bleeding happens, but nobody dies. That's in contrast to the thrombotic data, where people do die," said Dr. Otley, professor of dermatology at the Mayo Clinic, Rochester, Minn.

The consequences of a thrombotic episode are so much greater than the impact of a hemorrhagic complication that he recommended continuing medically necessary anticoagulants in most cases. "Take extra care with clopidogrel plus aspirin and with warfarin. Taking patients off these, especially if they have a fresh stent, is not the right thing to do," he said.

A survey of 168 American College of Mohs Surgery members in 2003 gathered reports of thrombotic complications within 3 days of Mohs surgery in 46 patients who had stopped anticoagulant therapy, Dr. Otley noted. These included stroke in 24 patients, transient ischemic attack in 8, MI in 5, cerebral emboli or death in 3 patients each, pulmonary embolus in 2, and blindness in 1 patient (J. Am. Acad. Dermatol 2003;48:233-7).

A separate survey of more than 270 dermasurgeons in 2005 found thrombotic complications in 126 patients who stopped anticoagulants for Mohs surgery, including stroke in 39 patients, transient ischemic attack in 25, MI in 19, unstable angina in 17, death in 15, deep venous thrombosis in 7, and pulmonary embolus in 4 patients (Dermatol. Surg. 2007;33:1189-97).

Case reports are emerging of thrombotic episodes in patients on newer anticoagulants who stop therapy for cutaneous surgery. For instance, he noted, a patient who stopped ticlopidine and aspirin developed a deep venous thrombosis. A patient who stopped clopidogrel and ardeparin thrombosed a prosthetic valve. A patient who stopped clopidogrel and aspirin had an MI.

These problems typically present as emergencies, which the Mohs surgeon may not see, Dr. Otley noted. "You may have had more patients experience this than you know about," he said.

Most of the data on the risk of hemorrhagic complications in patients undergoing superficial cutaneous surgery while on anticoagulants focus on traditional agents such as warfarin, aspirin, and NSAIDs, with some data on heparin. Little or no data exist on the risks with newer, more potent anticoagulants.

A total of 10 of 11 studies of patients on warfarin, aspirin, or NSAIDs found no increased risk of perioperative severe hemorrhagic complications, Dr. Otley said. One study of 21 patients on warfarin found an increased risk of complications including persistent bleeding, hematoma, infection, or graft loss. The most severe complication observed in any of the 11 studies was hematoma.

A meta-analysis of the data found a significantly increased risk if moderate and severe hemorrhagic complications were combined as an outcome, but not for severe complications alone, he noted (Dermatol. Surg. 2008;34:160-5).

Clopidogrel (Plavix) is new enough that there is little consensus on how to manage patients on this potent anticoagulant during cutaneous surgery. "This is the one that we’re seeing a ton of patients on," Dr. Otley said. "If your patient has a fresh stent, you would be insane to take that patient off this medication."

Patients on clopidogrel usually are on other anticoagulants, too. Data suggest there is a significant 28-fold higher risk of severe hemorrhagic complications in patients on any clopidogrel-containing regimen, compared with patients not taking anticoagulants, and a significant eightfold higher risk in patients on clopidogrel plus aspirin, compared with patients on aspirin alone. If you compare patients on clopidogrel with patients not on anticoagulant therapy, the difference in risk for severe hemorrhagic complications is not significant, probably due to the small number of patients on clopidogrel alone, he said.

"Nobody has died of hemorrhagic complications, to my knowledge," while having cutaneous surgery on clopidogrel. However, stopping the drug increases the risk of death from thrombotic complications, Dr. Otley said.

There are no data yet on cutaneous surgery complications in patients on dabigatran, "the new kid on the block," and a drug that "you're going to be hearing a lot about," he said. Dabigatran is as effective as warfarin for preventing stroke in high-risk patients.

If patients scheduled for Mohs surgery are on dabigatran, "I'd probably have them continue it unless your hematologist says otherwise," Dr. Otley said. He urged Mohs surgeons to start collecting data on any complications in patients on dabigatran.

To prevent bleeding complications from Mohs surgery, pay attention to hematologic parameters and monitor blood pressure. Hypertension is the leading cause of excessive intraoperative bleeding, he said. Administer sedatives for anxiolysis, use epinephrine as needed, apply pressure dressings, and put in a drain if you think a patient is going to bleed. Use blood products if needed.

In the OR, dislodge temporary clots, eliminate dead space, apply pressure dressings, and use other techniques for secondary prevention of bleeding complications, he advised. "There's no better time to have someone bleed than while you have them open, so rub all those clots off and recoagulate," he said.

Patients with hemorrhagic complications often apologize to Dr. Otley, thinking they did something that caused the bleeding. "I can guarantee you thrombotic patients will not be apologizing to you," he said.

Dr. Otley said he has no relevant conflicts of interest.

LAS VEGAS – The use of Mohs surgery in Medicare beneficiaries increased steeply in the past decade, mainly for nonmelanoma skin cancers on the face and with great variation in treatment practices, two new studies show.

The majority of physicians who billed Medicare for Mohs surgeries do relatively few of the procedures per year, raising questions about the optimal volume of Mohs surgeries to ensure good outcomes and cost-effectiveness, one of the studies suggested.

The United States is experiencing an epidemic of nonmelanoma skin cancer, which has grown in numbers from approximately 1 million in 1994 to approximately 4 million per year today, Dr. Matthew Donaldson said at the annual meeting of the American College of Mohs Surgery.

The rate of Mohs surgery per 1,000 Medicare beneficiaries increased by 236% between 1999 and 2009, while excisions and destructions of lesions increased by approximately 20%, said Dr. Donaldson, who is training in Mohs surgery under Dr. Brett Coldiron at the skin cancer center of TriHealth Good Samaritan Hospital, Cincinnati.

He and his associates analyzed the Medicare claims database for 2009 to examine who is doing Mohs surgery, and why. They utilized both the Physician/Supplier Procedure Summary Master File (which contains data on all claims for procedures) and a random sample of 5% of claims called the Medicare Limited Data Set Standard Analytic File.

For CPT code 17311 (Mohs surgery on the head, neck, hands, feet, genitalia, or any location directly involving muscles, cartilage, bone, tendon, major nerves, or vessels), Florida and Arizona had more than twice the rate of claims, compared with the national average of 14 claims per 1,000 Medicare beneficiaries.

For CPT code 17313 (Mohs surgery on the trunk, arms or legs), Florida and Arizona had three times the national average of two claims per 1,000 Medicare beneficiaries.

Only 0.1% of CPT 17311 claims and 0.4% of CPT 17313 claims were for malignant melanoma. Carcinoma in situ made up 1% of CPT 17311 claims and 2% of CPT 17313 claims. The rest were for malignant neoplasms, "predominantly for basal cell and squamous cell" carcinomas, he said.

Of the 1,777 medical providers who billed for Mohs surgery in 2009, 97% were dermatologists, accounting for approximately 18% of all practicing dermatologists in the United States.

Dr. Donaldson and his associates used the data to estimate how many Mohs cases each claimant performed. Approximately 44% of physicians who billed Medicare for Mohs surgery did fewer than 200 cases that year, approximately 35% did 300-1,000 cases, and only 5% did more than 1,000 cases, he predicted.

"A full 27% of surgeons in the country are doing, on average, 47 cases in Medicare" beneficiaries, "and probably 100 cases overall for the entire year," Dr. Donaldson said. "Is that a sufficient number to really maximize" cure rates, cosmetic outcomes, and cost-effectiveness?

The physicians who did large volumes of Mohs surgeries in Medicare beneficiaries were more likely to take additional stages beyond the initial surgery, and were more likely to repair defects themselves, compared with low-volume surgeons, he said.

Dr. Kate V. Viola reported in a separate presentation that a minority of nonmelanoma skin cancers in the Medicare population is treated with Mohs, but the use of Mohs for these cancers is increasing at a much faster rate than the use of excisions.

She and her associates looked at a 5% sample of Medicare claims from 2001-2006 in the SEER (Surveillance, Epidemiology and End Results) database representing 26% of the U.S. population in 16 registries.

Of the 26,931 Medicare beneficiaries who were treated for nonmelanoma skin cancers, 36% were treated with Mohs surgery and 64% were treated with wide local excision or simple excision.

The rate of Mohs surgery for nonmelanoma skin cancer "doubled – yes, doubled – by 2006," increasing from 0.7 per 100 beneficiaries in 2001 to 1.5 per 100 beneficiaries, said Dr. Viola of Albert Einstein College of Medicine, New York. During that period, the rate of excisions for nonmelanoma skin cancers increased only slightly, from 1.8 to 2.1 per 100 beneficiaries.

Mohs surgery was more likely than excisional surgery on the face and less likely elsewhere. Mohs surgery was used to treat 47% of facial lesions and 15% of lesions on the rest of the body, she said.

Patient age, race, and geographic region were significantly associated with the likelihood of Mohs surgery. The use of Mohs for these cancers decreased with patient age (from 41% of patients aged 67-69 years to 34% of patients 85 years or older). Mohs was used in 37% of white patients, 23% of black patients, and 29% of patients of other races.

The SEER data did not include some states such as Florida and New York, but among the regions that were represented, the areas with high densities of Mohs surgeons were likely to have higher rates of Mohs surgery for nonmelanoma skin cancers. These areas included San Jose, San Francisco, and Oakland, Calif.

The opposite, however, was not true. Some areas with low densities of Mohs surgeons still had high rates of Mohs utilization, such as in Los Angeles and Detroit.

"There was wide variation in regional Mohs micrographic surgery utilization and geographical disparity that warrants further investigation," Dr. Viola said.

For instance, the density of Mohs surgeons in the Washington, D.C. area was so high – more than six times greater than the next-highest density – that the D.C. region had to be excluded from the analysis as an outlier, she noted.

Mohs surgeries in the Medicare population account for approximately half of all Mohs surgeries in the United States, Dr. Donaldson said.

Dr. Donaldson and Dr. Viola said they have no relevant conflicts of interest.

LAS VEGAS – The use of Mohs surgery in Medicare beneficiaries increased steeply in the past decade, mainly for nonmelanoma skin cancers on the face and with great variation in treatment practices, two new studies show.

The majority of physicians who billed Medicare for Mohs surgeries do relatively few of the procedures per year, raising questions about the optimal volume of Mohs surgeries to ensure good outcomes and cost-effectiveness, one of the studies suggested.

The United States is experiencing an epidemic of nonmelanoma skin cancer, which has grown in numbers from approximately 1 million in 1994 to approximately 4 million per year today, Dr. Matthew Donaldson said at the annual meeting of the American College of Mohs Surgery.

The rate of Mohs surgery per 1,000 Medicare beneficiaries increased by 236% between 1999 and 2009, while excisions and destructions of lesions increased by approximately 20%, said Dr. Donaldson, who is training in Mohs surgery under Dr. Brett Coldiron at the skin cancer center of TriHealth Good Samaritan Hospital, Cincinnati.

He and his associates analyzed the Medicare claims database for 2009 to examine who is doing Mohs surgery, and why. They utilized both the Physician/Supplier Procedure Summary Master File (which contains data on all claims for procedures) and a random sample of 5% of claims called the Medicare Limited Data Set Standard Analytic File.

For CPT code 17311 (Mohs surgery on the head, neck, hands, feet, genitalia, or any location directly involving muscles, cartilage, bone, tendon, major nerves, or vessels), Florida and Arizona had more than twice the rate of claims, compared with the national average of 14 claims per 1,000 Medicare beneficiaries.

For CPT code 17313 (Mohs surgery on the trunk, arms or legs), Florida and Arizona had three times the national average of two claims per 1,000 Medicare beneficiaries.

Only 0.1% of CPT 17311 claims and 0.4% of CPT 17313 claims were for malignant melanoma. Carcinoma in situ made up 1% of CPT 17311 claims and 2% of CPT 17313 claims. The rest were for malignant neoplasms, "predominantly for basal cell and squamous cell" carcinomas, he said.

Of the 1,777 medical providers who billed for Mohs surgery in 2009, 97% were dermatologists, accounting for approximately 18% of all practicing dermatologists in the United States.

Dr. Donaldson and his associates used the data to estimate how many Mohs cases each claimant performed. Approximately 44% of physicians who billed Medicare for Mohs surgery did fewer than 200 cases that year, approximately 35% did 300-1,000 cases, and only 5% did more than 1,000 cases, he predicted.

"A full 27% of surgeons in the country are doing, on average, 47 cases in Medicare" beneficiaries, "and probably 100 cases overall for the entire year," Dr. Donaldson said. "Is that a sufficient number to really maximize" cure rates, cosmetic outcomes, and cost-effectiveness?

The physicians who did large volumes of Mohs surgeries in Medicare beneficiaries were more likely to take additional stages beyond the initial surgery, and were more likely to repair defects themselves, compared with low-volume surgeons, he said.

Dr. Kate V. Viola reported in a separate presentation that a minority of nonmelanoma skin cancers in the Medicare population is treated with Mohs, but the use of Mohs for these cancers is increasing at a much faster rate than the use of excisions.

She and her associates looked at a 5% sample of Medicare claims from 2001-2006 in the SEER (Surveillance, Epidemiology and End Results) database representing 26% of the U.S. population in 16 registries.

Of the 26,931 Medicare beneficiaries who were treated for nonmelanoma skin cancers, 36% were treated with Mohs surgery and 64% were treated with wide local excision or simple excision.

The rate of Mohs surgery for nonmelanoma skin cancer "doubled – yes, doubled – by 2006," increasing from 0.7 per 100 beneficiaries in 2001 to 1.5 per 100 beneficiaries, said Dr. Viola of Albert Einstein College of Medicine, New York. During that period, the rate of excisions for nonmelanoma skin cancers increased only slightly, from 1.8 to 2.1 per 100 beneficiaries.

Mohs surgery was more likely than excisional surgery on the face and less likely elsewhere. Mohs surgery was used to treat 47% of facial lesions and 15% of lesions on the rest of the body, she said.

Patient age, race, and geographic region were significantly associated with the likelihood of Mohs surgery. The use of Mohs for these cancers decreased with patient age (from 41% of patients aged 67-69 years to 34% of patients 85 years or older). Mohs was used in 37% of white patients, 23% of black patients, and 29% of patients of other races.

The SEER data did not include some states such as Florida and New York, but among the regions that were represented, the areas with high densities of Mohs surgeons were likely to have higher rates of Mohs surgery for nonmelanoma skin cancers. These areas included San Jose, San Francisco, and Oakland, Calif.

The opposite, however, was not true. Some areas with low densities of Mohs surgeons still had high rates of Mohs utilization, such as in Los Angeles and Detroit.

"There was wide variation in regional Mohs micrographic surgery utilization and geographical disparity that warrants further investigation," Dr. Viola said.

For instance, the density of Mohs surgeons in the Washington, D.C. area was so high – more than six times greater than the next-highest density – that the D.C. region had to be excluded from the analysis as an outlier, she noted.

Mohs surgeries in the Medicare population account for approximately half of all Mohs surgeries in the United States, Dr. Donaldson said.

Dr. Donaldson and Dr. Viola said they have no relevant conflicts of interest.

LAS VEGAS – The use of Mohs surgery in Medicare beneficiaries increased steeply in the past decade, mainly for nonmelanoma skin cancers on the face and with great variation in treatment practices, two new studies show.

The majority of physicians who billed Medicare for Mohs surgeries do relatively few of the procedures per year, raising questions about the optimal volume of Mohs surgeries to ensure good outcomes and cost-effectiveness, one of the studies suggested.

The United States is experiencing an epidemic of nonmelanoma skin cancer, which has grown in numbers from approximately 1 million in 1994 to approximately 4 million per year today, Dr. Matthew Donaldson said at the annual meeting of the American College of Mohs Surgery.

The rate of Mohs surgery per 1,000 Medicare beneficiaries increased by 236% between 1999 and 2009, while excisions and destructions of lesions increased by approximately 20%, said Dr. Donaldson, who is training in Mohs surgery under Dr. Brett Coldiron at the skin cancer center of TriHealth Good Samaritan Hospital, Cincinnati.

He and his associates analyzed the Medicare claims database for 2009 to examine who is doing Mohs surgery, and why. They utilized both the Physician/Supplier Procedure Summary Master File (which contains data on all claims for procedures) and a random sample of 5% of claims called the Medicare Limited Data Set Standard Analytic File.

For CPT code 17311 (Mohs surgery on the head, neck, hands, feet, genitalia, or any location directly involving muscles, cartilage, bone, tendon, major nerves, or vessels), Florida and Arizona had more than twice the rate of claims, compared with the national average of 14 claims per 1,000 Medicare beneficiaries.

For CPT code 17313 (Mohs surgery on the trunk, arms or legs), Florida and Arizona had three times the national average of two claims per 1,000 Medicare beneficiaries.

Only 0.1% of CPT 17311 claims and 0.4% of CPT 17313 claims were for malignant melanoma. Carcinoma in situ made up 1% of CPT 17311 claims and 2% of CPT 17313 claims. The rest were for malignant neoplasms, "predominantly for basal cell and squamous cell" carcinomas, he said.

Of the 1,777 medical providers who billed for Mohs surgery in 2009, 97% were dermatologists, accounting for approximately 18% of all practicing dermatologists in the United States.

Dr. Donaldson and his associates used the data to estimate how many Mohs cases each claimant performed. Approximately 44% of physicians who billed Medicare for Mohs surgery did fewer than 200 cases that year, approximately 35% did 300-1,000 cases, and only 5% did more than 1,000 cases, he predicted.

"A full 27% of surgeons in the country are doing, on average, 47 cases in Medicare" beneficiaries, "and probably 100 cases overall for the entire year," Dr. Donaldson said. "Is that a sufficient number to really maximize" cure rates, cosmetic outcomes, and cost-effectiveness?

The physicians who did large volumes of Mohs surgeries in Medicare beneficiaries were more likely to take additional stages beyond the initial surgery, and were more likely to repair defects themselves, compared with low-volume surgeons, he said.

Dr. Kate V. Viola reported in a separate presentation that a minority of nonmelanoma skin cancers in the Medicare population is treated with Mohs, but the use of Mohs for these cancers is increasing at a much faster rate than the use of excisions.

She and her associates looked at a 5% sample of Medicare claims from 2001-2006 in the SEER (Surveillance, Epidemiology and End Results) database representing 26% of the U.S. population in 16 registries.

Of the 26,931 Medicare beneficiaries who were treated for nonmelanoma skin cancers, 36% were treated with Mohs surgery and 64% were treated with wide local excision or simple excision.

The rate of Mohs surgery for nonmelanoma skin cancer "doubled – yes, doubled – by 2006," increasing from 0.7 per 100 beneficiaries in 2001 to 1.5 per 100 beneficiaries, said Dr. Viola of Albert Einstein College of Medicine, New York. During that period, the rate of excisions for nonmelanoma skin cancers increased only slightly, from 1.8 to 2.1 per 100 beneficiaries.

Mohs surgery was more likely than excisional surgery on the face and less likely elsewhere. Mohs surgery was used to treat 47% of facial lesions and 15% of lesions on the rest of the body, she said.

Patient age, race, and geographic region were significantly associated with the likelihood of Mohs surgery. The use of Mohs for these cancers decreased with patient age (from 41% of patients aged 67-69 years to 34% of patients 85 years or older). Mohs was used in 37% of white patients, 23% of black patients, and 29% of patients of other races.

The SEER data did not include some states such as Florida and New York, but among the regions that were represented, the areas with high densities of Mohs surgeons were likely to have higher rates of Mohs surgery for nonmelanoma skin cancers. These areas included San Jose, San Francisco, and Oakland, Calif.

The opposite, however, was not true. Some areas with low densities of Mohs surgeons still had high rates of Mohs utilization, such as in Los Angeles and Detroit.

"There was wide variation in regional Mohs micrographic surgery utilization and geographical disparity that warrants further investigation," Dr. Viola said.

For instance, the density of Mohs surgeons in the Washington, D.C. area was so high – more than six times greater than the next-highest density – that the D.C. region had to be excluded from the analysis as an outlier, she noted.

Mohs surgeries in the Medicare population account for approximately half of all Mohs surgeries in the United States, Dr. Donaldson said.

Dr. Donaldson and Dr. Viola said they have no relevant conflicts of interest.

LAS VEGAS – The use of Mohs surgery in Medicare beneficiaries increased steeply in the past decade, mainly for nonmelanoma skin cancers on the face and with great variation in treatment practices, two new studies show.

The majority of physicians who billed Medicare for Mohs surgeries do relatively few of the procedures per year, raising questions about the optimal volume of Mohs surgeries to ensure good outcomes and cost-effectiveness, one of the studies suggested.

The United States is experiencing an epidemic of nonmelanoma skin cancer, which has grown in numbers from approximately 1 million in 1994 to approximately 4 million per year today, Dr. Matthew Donaldson said at the annual meeting of the American College of Mohs Surgery.

The rate of Mohs surgery per 1,000 Medicare beneficiaries increased by 236% between 1999 and 2009, while excisions and destructions of lesions increased by approximately 20%, said Dr. Donaldson, who is training in Mohs surgery under Dr. Brett Coldiron at the skin cancer center of TriHealth Good Samaritan Hospital, Cincinnati.

He and his associates analyzed the Medicare claims database for 2009 to examine who is doing Mohs surgery, and why. They utilized both the Physician/Supplier Procedure Summary Master File (which contains data on all claims for procedures) and a random sample of 5% of claims called the Medicare Limited Data Set Standard Analytic File.

For CPT code 17311 (Mohs surgery on the head, neck, hands, feet, genitalia, or any location directly involving muscles, cartilage, bone, tendon, major nerves, or vessels), Florida and Arizona had more than twice the rate of claims, compared with the national average of 14 claims per 1,000 Medicare beneficiaries.

For CPT code 17313 (Mohs surgery on the trunk, arms or legs), Florida and Arizona had three times the national average of two claims per 1,000 Medicare beneficiaries.

Only 0.1% of CPT 17311 claims and 0.4% of CPT 17313 claims were for malignant melanoma. Carcinoma in situ made up 1% of CPT 17311 claims and 2% of CPT 17313 claims. The rest were for malignant neoplasms, "predominantly for basal cell and squamous cell" carcinomas, he said.

Of the 1,777 medical providers who billed for Mohs surgery in 2009, 97% were dermatologists, accounting for approximately 18% of all practicing dermatologists in the United States.

Dr. Donaldson and his associates used the data to estimate how many Mohs cases each claimant performed. Approximately 44% of physicians who billed Medicare for Mohs surgery did fewer than 200 cases that year, approximately 35% did 300-1,000 cases, and only 5% did more than 1,000 cases, he predicted.

"A full 27% of surgeons in the country are doing, on average, 47 cases in Medicare" beneficiaries, "and probably 100 cases overall for the entire year," Dr. Donaldson said. "Is that a sufficient number to really maximize" cure rates, cosmetic outcomes, and cost-effectiveness?

The physicians who did large volumes of Mohs surgeries in Medicare beneficiaries were more likely to take additional stages beyond the initial surgery, and were more likely to repair defects themselves, compared with low-volume surgeons, he said.

Dr. Kate V. Viola reported in a separate presentation that a minority of nonmelanoma skin cancers in the Medicare population is treated with Mohs, but the use of Mohs for these cancers is increasing at a much faster rate than the use of excisions.

She and her associates looked at a 5% sample of Medicare claims from 2001-2006 in the SEER (Surveillance, Epidemiology and End Results) database representing 26% of the U.S. population in 16 registries.

Of the 26,931 Medicare beneficiaries who were treated for nonmelanoma skin cancers, 36% were treated with Mohs surgery and 64% were treated with wide local excision or simple excision.

The rate of Mohs surgery for nonmelanoma skin cancer "doubled – yes, doubled – by 2006," increasing from 0.7 per 100 beneficiaries in 2001 to 1.5 per 100 beneficiaries, said Dr. Viola of Albert Einstein College of Medicine, New York. During that period, the rate of excisions for nonmelanoma skin cancers increased only slightly, from 1.8 to 2.1 per 100 beneficiaries.

Mohs surgery was more likely than excisional surgery on the face and less likely elsewhere. Mohs surgery was used to treat 47% of facial lesions and 15% of lesions on the rest of the body, she said.

Patient age, race, and geographic region were significantly associated with the likelihood of Mohs surgery. The use of Mohs for these cancers decreased with patient age (from 41% of patients aged 67-69 years to 34% of patients 85 years or older). Mohs was used in 37% of white patients, 23% of black patients, and 29% of patients of other races.

The SEER data did not include some states such as Florida and New York, but among the regions that were represented, the areas with high densities of Mohs surgeons were likely to have higher rates of Mohs surgery for nonmelanoma skin cancers. These areas included San Jose, San Francisco, and Oakland, Calif.

The opposite, however, was not true. Some areas with low densities of Mohs surgeons still had high rates of Mohs utilization, such as in Los Angeles and Detroit.

"There was wide variation in regional Mohs micrographic surgery utilization and geographical disparity that warrants further investigation," Dr. Viola said.

For instance, the density of Mohs surgeons in the Washington, D.C. area was so high – more than six times greater than the next-highest density – that the D.C. region had to be excluded from the analysis as an outlier, she noted.

Mohs surgeries in the Medicare population account for approximately half of all Mohs surgeries in the United States, Dr. Donaldson said.

Dr. Donaldson and Dr. Viola said they have no relevant conflicts of interest.

LAS VEGAS – The use of Mohs surgery in Medicare beneficiaries increased steeply in the past decade, mainly for nonmelanoma skin cancers on the face and with great variation in treatment practices, two new studies show.

The majority of physicians who billed Medicare for Mohs surgeries do relatively few of the procedures per year, raising questions about the optimal volume of Mohs surgeries to ensure good outcomes and cost-effectiveness, one of the studies suggested.

The United States is experiencing an epidemic of nonmelanoma skin cancer, which has grown in numbers from approximately 1 million in 1994 to approximately 4 million per year today, Dr. Matthew Donaldson said at the annual meeting of the American College of Mohs Surgery.

The rate of Mohs surgery per 1,000 Medicare beneficiaries increased by 236% between 1999 and 2009, while excisions and destructions of lesions increased by approximately 20%, said Dr. Donaldson, who is training in Mohs surgery under Dr. Brett Coldiron at the skin cancer center of TriHealth Good Samaritan Hospital, Cincinnati.

He and his associates analyzed the Medicare claims database for 2009 to examine who is doing Mohs surgery, and why. They utilized both the Physician/Supplier Procedure Summary Master File (which contains data on all claims for procedures) and a random sample of 5% of claims called the Medicare Limited Data Set Standard Analytic File.

For CPT code 17311 (Mohs surgery on the head, neck, hands, feet, genitalia, or any location directly involving muscles, cartilage, bone, tendon, major nerves, or vessels), Florida and Arizona had more than twice the rate of claims, compared with the national average of 14 claims per 1,000 Medicare beneficiaries.

For CPT code 17313 (Mohs surgery on the trunk, arms or legs), Florida and Arizona had three times the national average of two claims per 1,000 Medicare beneficiaries.

Only 0.1% of CPT 17311 claims and 0.4% of CPT 17313 claims were for malignant melanoma. Carcinoma in situ made up 1% of CPT 17311 claims and 2% of CPT 17313 claims. The rest were for malignant neoplasms, "predominantly for basal cell and squamous cell" carcinomas, he said.

Of the 1,777 medical providers who billed for Mohs surgery in 2009, 97% were dermatologists, accounting for approximately 18% of all practicing dermatologists in the United States.

Dr. Donaldson and his associates used the data to estimate how many Mohs cases each claimant performed. Approximately 44% of physicians who billed Medicare for Mohs surgery did fewer than 200 cases that year, approximately 35% did 300-1,000 cases, and only 5% did more than 1,000 cases, he predicted.

"A full 27% of surgeons in the country are doing, on average, 47 cases in Medicare" beneficiaries, "and probably 100 cases overall for the entire year," Dr. Donaldson said. "Is that a sufficient number to really maximize" cure rates, cosmetic outcomes, and cost-effectiveness?

The physicians who did large volumes of Mohs surgeries in Medicare beneficiaries were more likely to take additional stages beyond the initial surgery, and were more likely to repair defects themselves, compared with low-volume surgeons, he said.

Dr. Kate V. Viola reported in a separate presentation that a minority of nonmelanoma skin cancers in the Medicare population is treated with Mohs, but the use of Mohs for these cancers is increasing at a much faster rate than the use of excisions.

She and her associates looked at a 5% sample of Medicare claims from 2001-2006 in the SEER (Surveillance, Epidemiology and End Results) database representing 26% of the U.S. population in 16 registries.

Of the 26,931 Medicare beneficiaries who were treated for nonmelanoma skin cancers, 36% were treated with Mohs surgery and 64% were treated with wide local excision or simple excision.

The rate of Mohs surgery for nonmelanoma skin cancer "doubled – yes, doubled – by 2006," increasing from 0.7 per 100 beneficiaries in 2001 to 1.5 per 100 beneficiaries, said Dr. Viola of Albert Einstein College of Medicine, New York. During that period, the rate of excisions for nonmelanoma skin cancers increased only slightly, from 1.8 to 2.1 per 100 beneficiaries.

Mohs surgery was more likely than excisional surgery on the face and less likely elsewhere. Mohs surgery was used to treat 47% of facial lesions and 15% of lesions on the rest of the body, she said.

Patient age, race, and geographic region were significantly associated with the likelihood of Mohs surgery. The use of Mohs for these cancers decreased with patient age (from 41% of patients aged 67-69 years to 34% of patients 85 years or older). Mohs was used in 37% of white patients, 23% of black patients, and 29% of patients of other races.

The SEER data did not include some states such as Florida and New York, but among the regions that were represented, the areas with high densities of Mohs surgeons were likely to have higher rates of Mohs surgery for nonmelanoma skin cancers. These areas included San Jose, San Francisco, and Oakland, Calif.

The opposite, however, was not true. Some areas with low densities of Mohs surgeons still had high rates of Mohs utilization, such as in Los Angeles and Detroit.

"There was wide variation in regional Mohs micrographic surgery utilization and geographical disparity that warrants further investigation," Dr. Viola said.

For instance, the density of Mohs surgeons in the Washington, D.C. area was so high – more than six times greater than the next-highest density – that the D.C. region had to be excluded from the analysis as an outlier, she noted.

Mohs surgeries in the Medicare population account for approximately half of all Mohs surgeries in the United States, Dr. Donaldson said.

Dr. Donaldson and Dr. Viola said they have no relevant conflicts of interest.

LAS VEGAS – The use of Mohs surgery in Medicare beneficiaries increased steeply in the past decade, mainly for nonmelanoma skin cancers on the face and with great variation in treatment practices, two new studies show.

The majority of physicians who billed Medicare for Mohs surgeries do relatively few of the procedures per year, raising questions about the optimal volume of Mohs surgeries to ensure good outcomes and cost-effectiveness, one of the studies suggested.

The United States is experiencing an epidemic of nonmelanoma skin cancer, which has grown in numbers from approximately 1 million in 1994 to approximately 4 million per year today, Dr. Matthew Donaldson said at the annual meeting of the American College of Mohs Surgery.

The rate of Mohs surgery per 1,000 Medicare beneficiaries increased by 236% between 1999 and 2009, while excisions and destructions of lesions increased by approximately 20%, said Dr. Donaldson, who is training in Mohs surgery under Dr. Brett Coldiron at the skin cancer center of TriHealth Good Samaritan Hospital, Cincinnati.

He and his associates analyzed the Medicare claims database for 2009 to examine who is doing Mohs surgery, and why. They utilized both the Physician/Supplier Procedure Summary Master File (which contains data on all claims for procedures) and a random sample of 5% of claims called the Medicare Limited Data Set Standard Analytic File.

For CPT code 17311 (Mohs surgery on the head, neck, hands, feet, genitalia, or any location directly involving muscles, cartilage, bone, tendon, major nerves, or vessels), Florida and Arizona had more than twice the rate of claims, compared with the national average of 14 claims per 1,000 Medicare beneficiaries.

For CPT code 17313 (Mohs surgery on the trunk, arms or legs), Florida and Arizona had three times the national average of two claims per 1,000 Medicare beneficiaries.

Only 0.1% of CPT 17311 claims and 0.4% of CPT 17313 claims were for malignant melanoma. Carcinoma in situ made up 1% of CPT 17311 claims and 2% of CPT 17313 claims. The rest were for malignant neoplasms, "predominantly for basal cell and squamous cell" carcinomas, he said.

Of the 1,777 medical providers who billed for Mohs surgery in 2009, 97% were dermatologists, accounting for approximately 18% of all practicing dermatologists in the United States.

Dr. Donaldson and his associates used the data to estimate how many Mohs cases each claimant performed. Approximately 44% of physicians who billed Medicare for Mohs surgery did fewer than 200 cases that year, approximately 35% did 300-1,000 cases, and only 5% did more than 1,000 cases, he predicted.

"A full 27% of surgeons in the country are doing, on average, 47 cases in Medicare" beneficiaries, "and probably 100 cases overall for the entire year," Dr. Donaldson said. "Is that a sufficient number to really maximize" cure rates, cosmetic outcomes, and cost-effectiveness?

The physicians who did large volumes of Mohs surgeries in Medicare beneficiaries were more likely to take additional stages beyond the initial surgery, and were more likely to repair defects themselves, compared with low-volume surgeons, he said.

Dr. Kate V. Viola reported in a separate presentation that a minority of nonmelanoma skin cancers in the Medicare population is treated with Mohs, but the use of Mohs for these cancers is increasing at a much faster rate than the use of excisions.

She and her associates looked at a 5% sample of Medicare claims from 2001-2006 in the SEER (Surveillance, Epidemiology and End Results) database representing 26% of the U.S. population in 16 registries.

Of the 26,931 Medicare beneficiaries who were treated for nonmelanoma skin cancers, 36% were treated with Mohs surgery and 64% were treated with wide local excision or simple excision.

The rate of Mohs surgery for nonmelanoma skin cancer "doubled – yes, doubled – by 2006," increasing from 0.7 per 100 beneficiaries in 2001 to 1.5 per 100 beneficiaries, said Dr. Viola of Albert Einstein College of Medicine, New York. During that period, the rate of excisions for nonmelanoma skin cancers increased only slightly, from 1.8 to 2.1 per 100 beneficiaries.

Mohs surgery was more likely than excisional surgery on the face and less likely elsewhere. Mohs surgery was used to treat 47% of facial lesions and 15% of lesions on the rest of the body, she said.

Patient age, race, and geographic region were significantly associated with the likelihood of Mohs surgery. The use of Mohs for these cancers decreased with patient age (from 41% of patients aged 67-69 years to 34% of patients 85 years or older). Mohs was used in 37% of white patients, 23% of black patients, and 29% of patients of other races.

The SEER data did not include some states such as Florida and New York, but among the regions that were represented, the areas with high densities of Mohs surgeons were likely to have higher rates of Mohs surgery for nonmelanoma skin cancers. These areas included San Jose, San Francisco, and Oakland, Calif.

The opposite, however, was not true. Some areas with low densities of Mohs surgeons still had high rates of Mohs utilization, such as in Los Angeles and Detroit.

"There was wide variation in regional Mohs micrographic surgery utilization and geographical disparity that warrants further investigation," Dr. Viola said.

For instance, the density of Mohs surgeons in the Washington, D.C. area was so high – more than six times greater than the next-highest density – that the D.C. region had to be excluded from the analysis as an outlier, she noted.

Mohs surgeries in the Medicare population account for approximately half of all Mohs surgeries in the United States, Dr. Donaldson said.

Dr. Donaldson and Dr. Viola said they have no relevant conflicts of interest.

LAS VEGAS – The use of Mohs surgery in Medicare beneficiaries increased steeply in the past decade, mainly for nonmelanoma skin cancers on the face and with great variation in treatment practices, two new studies show.

The majority of physicians who billed Medicare for Mohs surgeries do relatively few of the procedures per year, raising questions about the optimal volume of Mohs surgeries to ensure good outcomes and cost-effectiveness, one of the studies suggested.

The United States is experiencing an epidemic of nonmelanoma skin cancer, which has grown in numbers from approximately 1 million in 1994 to approximately 4 million per year today, Dr. Matthew Donaldson said at the annual meeting of the American College of Mohs Surgery.

The rate of Mohs surgery per 1,000 Medicare beneficiaries increased by 236% between 1999 and 2009, while excisions and destructions of lesions increased by approximately 20%, said Dr. Donaldson, who is training in Mohs surgery under Dr. Brett Coldiron at the skin cancer center of TriHealth Good Samaritan Hospital, Cincinnati.

He and his associates analyzed the Medicare claims database for 2009 to examine who is doing Mohs surgery, and why. They utilized both the Physician/Supplier Procedure Summary Master File (which contains data on all claims for procedures) and a random sample of 5% of claims called the Medicare Limited Data Set Standard Analytic File.

For CPT code 17311 (Mohs surgery on the head, neck, hands, feet, genitalia, or any location directly involving muscles, cartilage, bone, tendon, major nerves, or vessels), Florida and Arizona had more than twice the rate of claims, compared with the national average of 14 claims per 1,000 Medicare beneficiaries.

For CPT code 17313 (Mohs surgery on the trunk, arms or legs), Florida and Arizona had three times the national average of two claims per 1,000 Medicare beneficiaries.

Only 0.1% of CPT 17311 claims and 0.4% of CPT 17313 claims were for malignant melanoma. Carcinoma in situ made up 1% of CPT 17311 claims and 2% of CPT 17313 claims. The rest were for malignant neoplasms, "predominantly for basal cell and squamous cell" carcinomas, he said.

Of the 1,777 medical providers who billed for Mohs surgery in 2009, 97% were dermatologists, accounting for approximately 18% of all practicing dermatologists in the United States.

Dr. Donaldson and his associates used the data to estimate how many Mohs cases each claimant performed. Approximately 44% of physicians who billed Medicare for Mohs surgery did fewer than 200 cases that year, approximately 35% did 300-1,000 cases, and only 5% did more than 1,000 cases, he predicted.

"A full 27% of surgeons in the country are doing, on average, 47 cases in Medicare" beneficiaries, "and probably 100 cases overall for the entire year," Dr. Donaldson said. "Is that a sufficient number to really maximize" cure rates, cosmetic outcomes, and cost-effectiveness?

The physicians who did large volumes of Mohs surgeries in Medicare beneficiaries were more likely to take additional stages beyond the initial surgery, and were more likely to repair defects themselves, compared with low-volume surgeons, he said.

Dr. Kate V. Viola reported in a separate presentation that a minority of nonmelanoma skin cancers in the Medicare population is treated with Mohs, but the use of Mohs for these cancers is increasing at a much faster rate than the use of excisions.

She and her associates looked at a 5% sample of Medicare claims from 2001-2006 in the SEER (Surveillance, Epidemiology and End Results) database representing 26% of the U.S. population in 16 registries.

Of the 26,931 Medicare beneficiaries who were treated for nonmelanoma skin cancers, 36% were treated with Mohs surgery and 64% were treated with wide local excision or simple excision.

The rate of Mohs surgery for nonmelanoma skin cancer "doubled – yes, doubled – by 2006," increasing from 0.7 per 100 beneficiaries in 2001 to 1.5 per 100 beneficiaries, said Dr. Viola of Albert Einstein College of Medicine, New York. During that period, the rate of excisions for nonmelanoma skin cancers increased only slightly, from 1.8 to 2.1 per 100 beneficiaries.

Mohs surgery was more likely than excisional surgery on the face and less likely elsewhere. Mohs surgery was used to treat 47% of facial lesions and 15% of lesions on the rest of the body, she said.

Patient age, race, and geographic region were significantly associated with the likelihood of Mohs surgery. The use of Mohs for these cancers decreased with patient age (from 41% of patients aged 67-69 years to 34% of patients 85 years or older). Mohs was used in 37% of white patients, 23% of black patients, and 29% of patients of other races.

The SEER data did not include some states such as Florida and New York, but among the regions that were represented, the areas with high densities of Mohs surgeons were likely to have higher rates of Mohs surgery for nonmelanoma skin cancers. These areas included San Jose, San Francisco, and Oakland, Calif.

The opposite, however, was not true. Some areas with low densities of Mohs surgeons still had high rates of Mohs utilization, such as in Los Angeles and Detroit.

"There was wide variation in regional Mohs micrographic surgery utilization and geographical disparity that warrants further investigation," Dr. Viola said.

For instance, the density of Mohs surgeons in the Washington, D.C. area was so high – more than six times greater than the next-highest density – that the D.C. region had to be excluded from the analysis as an outlier, she noted.

Mohs surgeries in the Medicare population account for approximately half of all Mohs surgeries in the United States, Dr. Donaldson said.

Dr. Donaldson and Dr. Viola said they have no relevant conflicts of interest.

LAS VEGAS – The use of Mohs surgery in Medicare beneficiaries increased steeply in the past decade, mainly for nonmelanoma skin cancers on the face and with great variation in treatment practices, two new studies show.

The majority of physicians who billed Medicare for Mohs surgeries do relatively few of the procedures per year, raising questions about the optimal volume of Mohs surgeries to ensure good outcomes and cost-effectiveness, one of the studies suggested.

The United States is experiencing an epidemic of nonmelanoma skin cancer, which has grown in numbers from approximately 1 million in 1994 to approximately 4 million per year today, Dr. Matthew Donaldson said at the annual meeting of the American College of Mohs Surgery.

The rate of Mohs surgery per 1,000 Medicare beneficiaries increased by 236% between 1999 and 2009, while excisions and destructions of lesions increased by approximately 20%, said Dr. Donaldson, who is training in Mohs surgery under Dr. Brett Coldiron at the skin cancer center of TriHealth Good Samaritan Hospital, Cincinnati.

He and his associates analyzed the Medicare claims database for 2009 to examine who is doing Mohs surgery, and why. They utilized both the Physician/Supplier Procedure Summary Master File (which contains data on all claims for procedures) and a random sample of 5% of claims called the Medicare Limited Data Set Standard Analytic File.

For CPT code 17311 (Mohs surgery on the head, neck, hands, feet, genitalia, or any location directly involving muscles, cartilage, bone, tendon, major nerves, or vessels), Florida and Arizona had more than twice the rate of claims, compared with the national average of 14 claims per 1,000 Medicare beneficiaries.

For CPT code 17313 (Mohs surgery on the trunk, arms or legs), Florida and Arizona had three times the national average of two claims per 1,000 Medicare beneficiaries.

Only 0.1% of CPT 17311 claims and 0.4% of CPT 17313 claims were for malignant melanoma. Carcinoma in situ made up 1% of CPT 17311 claims and 2% of CPT 17313 claims. The rest were for malignant neoplasms, "predominantly for basal cell and squamous cell" carcinomas, he said.

Of the 1,777 medical providers who billed for Mohs surgery in 2009, 97% were dermatologists, accounting for approximately 18% of all practicing dermatologists in the United States.

Dr. Donaldson and his associates used the data to estimate how many Mohs cases each claimant performed. Approximately 44% of physicians who billed Medicare for Mohs surgery did fewer than 200 cases that year, approximately 35% did 300-1,000 cases, and only 5% did more than 1,000 cases, he predicted.

"A full 27% of surgeons in the country are doing, on average, 47 cases in Medicare" beneficiaries, "and probably 100 cases overall for the entire year," Dr. Donaldson said. "Is that a sufficient number to really maximize" cure rates, cosmetic outcomes, and cost-effectiveness?

The physicians who did large volumes of Mohs surgeries in Medicare beneficiaries were more likely to take additional stages beyond the initial surgery, and were more likely to repair defects themselves, compared with low-volume surgeons, he said.

Dr. Kate V. Viola reported in a separate presentation that a minority of nonmelanoma skin cancers in the Medicare population is treated with Mohs, but the use of Mohs for these cancers is increasing at a much faster rate than the use of excisions.

She and her associates looked at a 5% sample of Medicare claims from 2001-2006 in the SEER (Surveillance, Epidemiology and End Results) database representing 26% of the U.S. population in 16 registries.

Of the 26,931 Medicare beneficiaries who were treated for nonmelanoma skin cancers, 36% were treated with Mohs surgery and 64% were treated with wide local excision or simple excision.

The rate of Mohs surgery for nonmelanoma skin cancer "doubled – yes, doubled – by 2006," increasing from 0.7 per 100 beneficiaries in 2001 to 1.5 per 100 beneficiaries, said Dr. Viola of Albert Einstein College of Medicine, New York. During that period, the rate of excisions for nonmelanoma skin cancers increased only slightly, from 1.8 to 2.1 per 100 beneficiaries.

Mohs surgery was more likely than excisional surgery on the face and less likely elsewhere. Mohs surgery was used to treat 47% of facial lesions and 15% of lesions on the rest of the body, she said.

Patient age, race, and geographic region were significantly associated with the likelihood of Mohs surgery. The use of Mohs for these cancers decreased with patient age (from 41% of patients aged 67-69 years to 34% of patients 85 years or older). Mohs was used in 37% of white patients, 23% of black patients, and 29% of patients of other races.

The SEER data did not include some states such as Florida and New York, but among the regions that were represented, the areas with high densities of Mohs surgeons were likely to have higher rates of Mohs surgery for nonmelanoma skin cancers. These areas included San Jose, San Francisco, and Oakland, Calif.

The opposite, however, was not true. Some areas with low densities of Mohs surgeons still had high rates of Mohs utilization, such as in Los Angeles and Detroit.

"There was wide variation in regional Mohs micrographic surgery utilization and geographical disparity that warrants further investigation," Dr. Viola said.

For instance, the density of Mohs surgeons in the Washington, D.C. area was so high – more than six times greater than the next-highest density – that the D.C. region had to be excluded from the analysis as an outlier, she noted.

Mohs surgeries in the Medicare population account for approximately half of all Mohs surgeries in the United States, Dr. Donaldson said.

Dr. Donaldson and Dr. Viola said they have no relevant conflicts of interest.

LAS VEGAS – The use of Mohs surgery in Medicare beneficiaries increased steeply in the past decade, mainly for nonmelanoma skin cancers on the face and with great variation in treatment practices, two new studies show.

The majority of physicians who billed Medicare for Mohs surgeries do relatively few of the procedures per year, raising questions about the optimal volume of Mohs surgeries to ensure good outcomes and cost-effectiveness, one of the studies suggested.

The United States is experiencing an epidemic of nonmelanoma skin cancer, which has grown in numbers from approximately 1 million in 1994 to approximately 4 million per year today, Dr. Matthew Donaldson said at the annual meeting of the American College of Mohs Surgery.

The rate of Mohs surgery per 1,000 Medicare beneficiaries increased by 236% between 1999 and 2009, while excisions and destructions of lesions increased by approximately 20%, said Dr. Donaldson, who is training in Mohs surgery under Dr. Brett Coldiron at the skin cancer center of TriHealth Good Samaritan Hospital, Cincinnati.

He and his associates analyzed the Medicare claims database for 2009 to examine who is doing Mohs surgery, and why. They utilized both the Physician/Supplier Procedure Summary Master File (which contains data on all claims for procedures) and a random sample of 5% of claims called the Medicare Limited Data Set Standard Analytic File.

For CPT code 17311 (Mohs surgery on the head, neck, hands, feet, genitalia, or any location directly involving muscles, cartilage, bone, tendon, major nerves, or vessels), Florida and Arizona had more than twice the rate of claims, compared with the national average of 14 claims per 1,000 Medicare beneficiaries.

For CPT code 17313 (Mohs surgery on the trunk, arms or legs), Florida and Arizona had three times the national average of two claims per 1,000 Medicare beneficiaries.

Only 0.1% of CPT 17311 claims and 0.4% of CPT 17313 claims were for malignant melanoma. Carcinoma in situ made up 1% of CPT 17311 claims and 2% of CPT 17313 claims. The rest were for malignant neoplasms, "predominantly for basal cell and squamous cell" carcinomas, he said.

Of the 1,777 medical providers who billed for Mohs surgery in 2009, 97% were dermatologists, accounting for approximately 18% of all practicing dermatologists in the United States.

Dr. Donaldson and his associates used the data to estimate how many Mohs cases each claimant performed. Approximately 44% of physicians who billed Medicare for Mohs surgery did fewer than 200 cases that year, approximately 35% did 300-1,000 cases, and only 5% did more than 1,000 cases, he predicted.

"A full 27% of surgeons in the country are doing, on average, 47 cases in Medicare" beneficiaries, "and probably 100 cases overall for the entire year," Dr. Donaldson said. "Is that a sufficient number to really maximize" cure rates, cosmetic outcomes, and cost-effectiveness?

The physicians who did large volumes of Mohs surgeries in Medicare beneficiaries were more likely to take additional stages beyond the initial surgery, and were more likely to repair defects themselves, compared with low-volume surgeons, he said.

Dr. Kate V. Viola reported in a separate presentation that a minority of nonmelanoma skin cancers in the Medicare population is treated with Mohs, but the use of Mohs for these cancers is increasing at a much faster rate than the use of excisions.

She and her associates looked at a 5% sample of Medicare claims from 2001-2006 in the SEER (Surveillance, Epidemiology and End Results) database representing 26% of the U.S. population in 16 registries.

Of the 26,931 Medicare beneficiaries who were treated for nonmelanoma skin cancers, 36% were treated with Mohs surgery and 64% were treated with wide local excision or simple excision.

The rate of Mohs surgery for nonmelanoma skin cancer "doubled – yes, doubled – by 2006," increasing from 0.7 per 100 beneficiaries in 2001 to 1.5 per 100 beneficiaries, said Dr. Viola of Albert Einstein College of Medicine, New York. During that period, the rate of excisions for nonmelanoma skin cancers increased only slightly, from 1.8 to 2.1 per 100 beneficiaries.

Mohs surgery was more likely than excisional surgery on the face and less likely elsewhere. Mohs surgery was used to treat 47% of facial lesions and 15% of lesions on the rest of the body, she said.

Patient age, race, and geographic region were significantly associated with the likelihood of Mohs surgery. The use of Mohs for these cancers decreased with patient age (from 41% of patients aged 67-69 years to 34% of patients 85 years or older). Mohs was used in 37% of white patients, 23% of black patients, and 29% of patients of other races.

The SEER data did not include some states such as Florida and New York, but among the regions that were represented, the areas with high densities of Mohs surgeons were likely to have higher rates of Mohs surgery for nonmelanoma skin cancers. These areas included San Jose, San Francisco, and Oakland, Calif.

The opposite, however, was not true. Some areas with low densities of Mohs surgeons still had high rates of Mohs utilization, such as in Los Angeles and Detroit.

"There was wide variation in regional Mohs micrographic surgery utilization and geographical disparity that warrants further investigation," Dr. Viola said.

For instance, the density of Mohs surgeons in the Washington, D.C. area was so high – more than six times greater than the next-highest density – that the D.C. region had to be excluded from the analysis as an outlier, she noted.

Mohs surgeries in the Medicare population account for approximately half of all Mohs surgeries in the United States, Dr. Donaldson said.

Dr. Donaldson and Dr. Viola said they have no relevant conflicts of interest.

LAS VEGAS – Counties that have up to two dermatologists per 100,000 people have the lowest mortality from melanoma, compared with counties with no dermatologists, according to an analysis of national data.

The analysis also found that having more dermatologists does not decrease melanoma mortality further.

A "dermatologist density" greater than zero and up to one dermatologist per 100,000 people was associated with a 35% reduction in deaths from melanoma compared with counties with no dermatologists, Dr. Jeremy S. Bordeaux reported at the annual meeting of the American College of Mohs Surgery.

Counties with more than one and up to two dermatologists per 100,000 people had an even greater reduction in melanoma mortality – 53% lower than counties with no dermatologists, the multivariate analysis showed. Beyond that, counties with more than two dermatologists had slightly but not significantly higher melanoma mortality rates, compared with counties with more than one and up to two dermatologists.

"Once you get past two per 100,000, it didn't make any difference. If you had 10 per 100,000, it didn't change mortality," said Dr. Bordeaux of the department of dermatology at Case Western Reserve University, Cleveland.

A map of dermatologist density created from U.S. Department of Health and Human Services data showed huge swaths of counties in the middle part of the country with no dermatologists. The study's findings suggest that enticing some dermatologists on the East and West coasts to move to those counties could reduce melanoma mortality.

"If we could get people to go where people don't want to live, I guess that could save lives, but people don’t want to live there for a reason," he said. Perhaps dermatology residency programs could place dermatologists in underserved counties, or loan repayment programs could be tied to contracts to serve in those counties, he suggested.

Dr. Bordeaux and his associates analyzed data from 3,141 U.S. counties from multiple databases, including the National Cancer Institute's Surveillance, Epidemiology and End Results database, the National Program of Cancer Registries, the Centers for Disease Control and Prevention’s National Vital Statistics System, and the U.S. Census Bureau.

Two other factors were associated with decreased melanoma mortality. Counties classified as metropolitan had a 30% lower death rate from melanoma, compared with nonmetropolitan counties. Each hospital that provided oncology services conferred nearly a 2% reduction in melanoma mortality. In Dr. Bordeaux’s county, for example, which has a dozen or so hospitals that offer oncology services, melanoma mortality would be more than 20% lower than in a county with no hospital-based oncology services.

Several factors were associated with higher melanoma mortality. For every 1% increase in the proportion of the population that was white, the melanoma mortality increased 1.5%. Not surprisingly, a higher incidence of melanoma was associated with higher mortality; for each additional case of melanoma per 100,000 people, mortality increased 2.3%. A third factor puzzled Dr. Bordeaux. For each additional percent of the population covered by health insurance, the melanoma mortality rate increased by 1.5%.

Factors that appeared to have no effect on melanoma mortality included the density of primary care providers, the percentage of the population older than 65 years, education level, median household income, and unemployment rate.

Dr. Bordeaux speculated the "plateau effect" that limited mortality reductions to a density of two dermatologists per 100,000 people may reflect the limitations of current therapeutics. Or, areas with greater dermatologist density may represent academic centers, and dermatologists may not be working full time.

Multiple studies have found the need to increase the number of primary care physicians, but the density of primary care physicians did not affect melanoma mortality in the current study, Dr. Bordeaux noted. Other articles in the literature, however, have shown specialist care to be associated with better cancer outcomes in both urology and dermatology.

In one study, higher densities of either dermatologists or internists were associated with better prognosis in patients with melanoma, but a higher density of family physicians was associated with a worse prognosis (J. Amer. Acad. Dermatol. 2009;60:51-8).

Dr. Bordeaux and his fellow investigators had no relevant conflicts of interest to report.

LAS VEGAS – Counties that have up to two dermatologists per 100,000 people have the lowest mortality from melanoma, compared with counties with no dermatologists, according to an analysis of national data.

The analysis also found that having more dermatologists does not decrease melanoma mortality further.

A "dermatologist density" greater than zero and up to one dermatologist per 100,000 people was associated with a 35% reduction in deaths from melanoma compared with counties with no dermatologists, Dr. Jeremy S. Bordeaux reported at the annual meeting of the American College of Mohs Surgery.

Counties with more than one and up to two dermatologists per 100,000 people had an even greater reduction in melanoma mortality – 53% lower than counties with no dermatologists, the multivariate analysis showed. Beyond that, counties with more than two dermatologists had slightly but not significantly higher melanoma mortality rates, compared with counties with more than one and up to two dermatologists.

"Once you get past two per 100,000, it didn't make any difference. If you had 10 per 100,000, it didn't change mortality," said Dr. Bordeaux of the department of dermatology at Case Western Reserve University, Cleveland.

A map of dermatologist density created from U.S. Department of Health and Human Services data showed huge swaths of counties in the middle part of the country with no dermatologists. The study's findings suggest that enticing some dermatologists on the East and West coasts to move to those counties could reduce melanoma mortality.

"If we could get people to go where people don't want to live, I guess that could save lives, but people don’t want to live there for a reason," he said. Perhaps dermatology residency programs could place dermatologists in underserved counties, or loan repayment programs could be tied to contracts to serve in those counties, he suggested.

Dr. Bordeaux and his associates analyzed data from 3,141 U.S. counties from multiple databases, including the National Cancer Institute's Surveillance, Epidemiology and End Results database, the National Program of Cancer Registries, the Centers for Disease Control and Prevention’s National Vital Statistics System, and the U.S. Census Bureau.

Two other factors were associated with decreased melanoma mortality. Counties classified as metropolitan had a 30% lower death rate from melanoma, compared with nonmetropolitan counties. Each hospital that provided oncology services conferred nearly a 2% reduction in melanoma mortality. In Dr. Bordeaux’s county, for example, which has a dozen or so hospitals that offer oncology services, melanoma mortality would be more than 20% lower than in a county with no hospital-based oncology services.

Several factors were associated with higher melanoma mortality. For every 1% increase in the proportion of the population that was white, the melanoma mortality increased 1.5%. Not surprisingly, a higher incidence of melanoma was associated with higher mortality; for each additional case of melanoma per 100,000 people, mortality increased 2.3%. A third factor puzzled Dr. Bordeaux. For each additional percent of the population covered by health insurance, the melanoma mortality rate increased by 1.5%.

Factors that appeared to have no effect on melanoma mortality included the density of primary care providers, the percentage of the population older than 65 years, education level, median household income, and unemployment rate.

Dr. Bordeaux speculated the "plateau effect" that limited mortality reductions to a density of two dermatologists per 100,000 people may reflect the limitations of current therapeutics. Or, areas with greater dermatologist density may represent academic centers, and dermatologists may not be working full time.

Multiple studies have found the need to increase the number of primary care physicians, but the density of primary care physicians did not affect melanoma mortality in the current study, Dr. Bordeaux noted. Other articles in the literature, however, have shown specialist care to be associated with better cancer outcomes in both urology and dermatology.

In one study, higher densities of either dermatologists or internists were associated with better prognosis in patients with melanoma, but a higher density of family physicians was associated with a worse prognosis (J. Amer. Acad. Dermatol. 2009;60:51-8).

Dr. Bordeaux and his fellow investigators had no relevant conflicts of interest to report.

LAS VEGAS – Counties that have up to two dermatologists per 100,000 people have the lowest mortality from melanoma, compared with counties with no dermatologists, according to an analysis of national data.

The analysis also found that having more dermatologists does not decrease melanoma mortality further.

A "dermatologist density" greater than zero and up to one dermatologist per 100,000 people was associated with a 35% reduction in deaths from melanoma compared with counties with no dermatologists, Dr. Jeremy S. Bordeaux reported at the annual meeting of the American College of Mohs Surgery.

Counties with more than one and up to two dermatologists per 100,000 people had an even greater reduction in melanoma mortality – 53% lower than counties with no dermatologists, the multivariate analysis showed. Beyond that, counties with more than two dermatologists had slightly but not significantly higher melanoma mortality rates, compared with counties with more than one and up to two dermatologists.

"Once you get past two per 100,000, it didn't make any difference. If you had 10 per 100,000, it didn't change mortality," said Dr. Bordeaux of the department of dermatology at Case Western Reserve University, Cleveland.

A map of dermatologist density created from U.S. Department of Health and Human Services data showed huge swaths of counties in the middle part of the country with no dermatologists. The study's findings suggest that enticing some dermatologists on the East and West coasts to move to those counties could reduce melanoma mortality.

"If we could get people to go where people don't want to live, I guess that could save lives, but people don’t want to live there for a reason," he said. Perhaps dermatology residency programs could place dermatologists in underserved counties, or loan repayment programs could be tied to contracts to serve in those counties, he suggested.

Dr. Bordeaux and his associates analyzed data from 3,141 U.S. counties from multiple databases, including the National Cancer Institute's Surveillance, Epidemiology and End Results database, the National Program of Cancer Registries, the Centers for Disease Control and Prevention’s National Vital Statistics System, and the U.S. Census Bureau.

Two other factors were associated with decreased melanoma mortality. Counties classified as metropolitan had a 30% lower death rate from melanoma, compared with nonmetropolitan counties. Each hospital that provided oncology services conferred nearly a 2% reduction in melanoma mortality. In Dr. Bordeaux’s county, for example, which has a dozen or so hospitals that offer oncology services, melanoma mortality would be more than 20% lower than in a county with no hospital-based oncology services.

Several factors were associated with higher melanoma mortality. For every 1% increase in the proportion of the population that was white, the melanoma mortality increased 1.5%. Not surprisingly, a higher incidence of melanoma was associated with higher mortality; for each additional case of melanoma per 100,000 people, mortality increased 2.3%. A third factor puzzled Dr. Bordeaux. For each additional percent of the population covered by health insurance, the melanoma mortality rate increased by 1.5%.

Factors that appeared to have no effect on melanoma mortality included the density of primary care providers, the percentage of the population older than 65 years, education level, median household income, and unemployment rate.

Dr. Bordeaux speculated the "plateau effect" that limited mortality reductions to a density of two dermatologists per 100,000 people may reflect the limitations of current therapeutics. Or, areas with greater dermatologist density may represent academic centers, and dermatologists may not be working full time.

Multiple studies have found the need to increase the number of primary care physicians, but the density of primary care physicians did not affect melanoma mortality in the current study, Dr. Bordeaux noted. Other articles in the literature, however, have shown specialist care to be associated with better cancer outcomes in both urology and dermatology.

In one study, higher densities of either dermatologists or internists were associated with better prognosis in patients with melanoma, but a higher density of family physicians was associated with a worse prognosis (J. Amer. Acad. Dermatol. 2009;60:51-8).

Dr. Bordeaux and his fellow investigators had no relevant conflicts of interest to report.