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Letters from colleagues reduce Mohs excision area, cost

Photo by SnowBink, via Wikimedia Commons

A peer-to-peer performance evaluation letter successfully convinced U.S. surgeons to reduce the amount of tissue they removed during Mohs micrographic surgery (MMS) for skin cancer, in order to meet a professionally recognized benchmark of good practice.

Previous research had shown a wide variability in MMS practices among surgeons, so researchers conducted a study—now published online ahead of print in JAMA Dermatology (May 5, 2019)—to evaluate outlier practice patterns and to test whether a peer-to-peer notification could change the behaviour of surgeons not meeting the appropriateness standard.

The study included 2,329 U.S. surgeons who had performed MMS procedures from Jan. 1, 2016 to Mar. 31, 2018. The intervention group included physicians affiliated with the American College of Mohs Surgery, and the control group included physicians not affiliated with the American College of Mohs Surgery.

Individualized performance reports were delivered to all outlier surgeons—defined by the specialty society as those with mean stages per case 2 SDs above the mean—and inlier surgeons in the intervention group.

Researchers reported an immediate positive change in surgical behaviour, which was sustained for one year, for 83% of the physicians notified that they were excising more-than-necessary amounts of tissue on a regular basis during MMS.

“This study demonstrates the tremendous power of physicians within a specialty to create peer-to-peer accountability and of using that accountability to reduce unnecessary treatment and lower health care costs,” says Dr. Martin A. Makary, in a press release from Johns Hopkins Medicine. Dr. Makary is the senior author of the study, professor of surgery at the Johns Hopkins University School of Medicine and an authority on health care quality. He also serves as principal investigator of Improving Wisely, a national project to lower medical costs in the United States by implementing measures of appropriateness in health care. The researchers also estimated that the relatively inexpensive—$150,000 or about $144 per surgeon—peer-to-peer intervention saved $11 million in Medicare costs during the study period.

“We observed an immediate and sustained improvement in quality with a simple intervention based on the spirit of physicians helping one another,” Dr. Makary said. “The low cost to implement the program relative to the significant savings achievable suggests that this model could be applied to other areas of medicine with broad financial implications. More importantly, we found that even small improvements in a physician’s performance can positively impact the many patients he or she treats.”

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