To the Editor: Studies have found that up to 20% of Mohs micrographic surgeries (MMS) performed at academic medical centers are considered “inappropriate” as per the MMS appropriate use criteria (AUC).1–4 A point-of-care clinical-decision support (CDS) tool embedded in a patient’s electronic medical record (EMR) may help providers determine the appropriate use of MMS. However, the utility of such a tool in guiding point-of-care dermatologic care delivery is unknown.
An institutional review board-approved cohort study was performed to assess the effectiveness of an electronic CDS tool, which is based on the Mohs AUC and embedded in the EMR, in guiding a clinician’s appropriate use of MMS. We retrospectively applied the Mohs AUC to all the Mohs surgeries pre-tool implementation (April-July 2015) and prospectively tracked the appropriateness of the Mohs surgeries post-tool implementation (August 2015–2019) at the Massachusetts General Hospital. The CDS tool was internally developed as an icon in the EMR and launched in August 2015. It consisted of multiple-choice questions that used a branching logic based on the Mohs AUC scoring and each case was termed as “appropriate,” “uncertain,” or “inappropriate” to check if MMS is warranted4 and storing the entry into the patient’s EMR.
The percentage of “inappropriate” and “uncertain” MMS performed before and after tool implementation was calculated and the descriptive statistics of patient and tumor characteristics associated with “inappropriate” MMS were ascertained. The tool’s monthly adoption rate (number of Mohs cases using the CDS tool/total number of Mohs cases) was also calculated.
The study cohort consisted of 6829 tumors, of which 541 were in the pre-tool cohort and 6288 were in the post-tool cohort (Table I). Men comprised 62.7% and 56.4% of the pre- and post-tool cohorts, respectively. Patients’ mean ages (SD) were 70.1 (13.2) years and 69.2 (12.3) years, respectively, with >88% of the tumor locations in areas H or M.
Table I.
Baseline characteristics of the cohorts
| Variable | N (%) Pre-tool cohort (N = 541) | N (%) Post-tool cohort (N = 6288) |
|---|---|---|
| Gender | ||
| Male | 339 (62.7) | 3547 (56.4) |
| Female | 202 (37.3) | 2741 (43.6) |
| Age at Mohs surgery, y, mean (SD) | 70.1 (13.2) | 69.2 (12.3) |
| AUC rating | ||
| “Appropriate” | 527 (97.4) | 6254 (99.5) |
| “Uncertain” | 10 (1.8) | 20 (0.3) |
| “Inappropriate” | 4 (0.7) | 14 (0.2) |
| Tumor histology | ||
| Basal cell carcinoma | 330 (61.0) | 3981 (63.3) |
| Squamous cell carcinoma | 209 (38.6) | 2281 (36.3) |
| Lentigo maligna or melanoma in situ | 0 (0) | 5 (0.1) |
| Less common skin cancers | 2 (0.4) | 21 (0.3) |
| AUC tumor location* | ||
| Area H | 210 (38.8) | 2887 (45.9) |
| Area M | 277 (51.2) | 2648 (42.1) |
| Area L | 54 (10.0) | 753 (12.0) |
AUC, Appropriate use criteria; N, number.
Area H: “Mask areas” of face (central face, eyelids, eyebrows, nose, lips, chin, ear, periauricular skin/sulci, and temple), genitalia, hands, feet, nail units, ankles, and nipples/areola. Area M: Cheeks, forehead, scalp, neck, jawline, and pretibial surface. Area L: Trunk and extremities.
The rate of tool adoption in the Mohs clinic increased rapidly from 65% to between 92% and 99%. The rate of “inappropriate” MMS cases decreased from 0.74% to 0.22% (P = .023) and the rate of “uncertain” cases reduced from 1.85% to 0.32% (P < .001) (Fig 1). Post-tool implementation and characteristics associated with “inappropriate” MMS included superficial basal cell carcinoma tumor type (13/14, 93%), the diameter of half of which were ≥ 2 cm; tumor location on the trunk or proximal extremities (13/14, 93%); prior treatment failure (10/14, 71%); and immunosuppression (1/14, 7%). In conclusion, an electronic point-of-care CDS tool that incorporates Mohs AUC can be rapidly and sustainably adopted and can improve provider adherence to the clinical guidelines. This tool is intended to serve as an aid, rather than a replacement, for clinical judgment. Similar electronic point-of-care CDS tools have been adopted in radiology and cardiology and have similarly demonstrated a higher clinical guideline concordance after implementation.5 However, the cost of implementing CDS tools needs to be considered. Limitations of this study include its single-institution design and low pre-implementation rate of “inappropriate” MMS. This electronic CDS tool can improve patient care delivery in skin cancer treatment by aiding clinician decision-making through knowledge promotion of the clinical guidelines, enablement of efficient resource allocation, and alleviation of prior authorization burdens.
Fig 1.
Changes in the percentage of uncertain and inappropriate Mohs surgeries before and after tool implementation. Error bars show standard errors. Two-sided z-proportion test was performed, and all the differences were statistically significant (P < .05).
Funding sources:
This work was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (K24 AR069760 to MA).
Footnotes
IRB approval status: Reviewed and approved by the Massachusetts General Brigham Institutional Review Board.
Conflicts of interest
None disclosed.
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