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Sharing practice pattern data between Mohs surgeons reduces overuse, costs

In Mohs micrographic surgery, a low-cost behavioral intervention using key opinion leaders and an audit with feedback resulted in a sustained reduction in overuse with an estimated reduction of $11.1 million in Medicare spending.

“We believe that having peers from the specialty association prepare members in the intervention group to receive their notification reports was critical to surgeons being receptive to them,” John G. Albertini, MD, of the Skin Surgery Center in Winston-Salem, North Carolina, and colleagues wrote.

The primary outcome was a surgeon-level change in mean stages per Mohs micrographic surgery (MMS) case before the notification and after the notification.

The nonrandomized controlled intervention study included 2,329 U.S. surgeons using Medicare Part B claims who performed MMS from January 2016 to March 2018.

The intervention group included physicians affiliated with the American College of Mohs Surgery (ACMS) and the control group included physicians not affiliated with the group.

The ACMS developed a workgroup of its executives along with national experts and clinicians to introduce the Improving Wisely collaborative, in print and e-newsletter format, which uses national data to identify overuse patterns in medical care.

Surgeons in the intervention cohort received an email detailing the upcoming audit-and-feedback report 2 weeks in advance of the mailing. The intervention physicians were mailed an individualized performance report and a cover letter signed by specialty leaders describing the program goals. Each report included the surgeon’s mean number of stages per case, the national mean of stages per case and the consensus metric definition.

Physician outliers were defined as a physician’s annual mean stages per case for MMS for skin cancers of the head, neck, genitalia, hands and feet being greater than 2 standard deviations above the national mean.

The researchers identified 140 outliers, with 53 outliers in the intervention group and 87 in the control group. Inliers totaled 2,189, with 992 inliers in the intervention group and 1,197 in the control group.

After the intervention, outliers exhibited a decreased in mean stages per case in the first quarter of 2017, which was sustained through the first quarter of 2018, according to researchers. “The overall mean stages per case decreased from 2.55 to 2.31 among outliers in the intervention group and decreased from 2.56 to 2.46 among outliers in the control group,” they wrote.

Within the control group, outliers showed a smaller decrease in mean stages per case from the second quarter of 2017, which remained constant throughout the study period.

In the post-notification period, 44 of the 53 intervention group outliers (83%) demonstrated a reduction in mean stages per case.

In the intervention group, outlier surgeons showed a mean reduction of 0.26 stages per case and outliers in the control group had a mean reduction of 0.11 stages per case, which researchers reported a differential reduction of 0.14 stages per case (95% CI, –0.23 to –0.05).

The intervention was associated with an additional 0.14 reduction in mean stages per case among outliers (95% CI, –0.19 to –0.09) and an additional 0.02 reduction in mean stages per case among inliers (95% CI, –0.03 to –0.001), the researchers wrote.

The post-notification period stage reduction was associated with a total Medicare cost savings of $11,431,882.

Quality improvement interventions that utilize opinion leaders and those that employ audit and feedback have the greatest effect on physician behavior, according to the researchers. – by Abigail Sutton

Disclosures: Albertini reports he has received grants and nonfinancial support from the American College of Mohs Surgery. He received personal fees from Novascan for serving on a scientific advisory board and serves on the board of directors. He is a shareholder of QualDerm partners. Please see the study for all other authors’ relevant financial disclosures.