A “Dear Colleague” performance evaluation letter successively convinced physicians nationwide to reduce the amount of tissue they removed in a common surgical treatment for skin cancer to meet a professionally recognized benchmark of good practice, researchers suggest in JAMA Dermatology.
In a study, researchers from John Hopkins Medicine and other collaborating health care organizations report an immediate positive change in surgical behavior — an improvement that was sustained for 1 year — for 83% of the physicians notified that they were excising more-than-necessary amounts of tissue on a regular basis during Mohs micrographic surgery (MMS).
The surgery is considered the most effective technique for treating many basal cell and squamous cell carcinomas, the two most common types of skin cancer, according to a media release from Johns Hopkins Medicine.
“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 Martin A. Makary, MD, PhD.
Makary, senior author of the study, is professor of surgery at the Johns Hopkins University School of Medicine and 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 new study, part of the Improving Wisely effort, was supported by a grant from the Robert Wood Johnson foundation.
MMS, a specialized outpatient technique for the treatment of skin cancer, is designed so that the surgeon can methodically remove cancerous tissue on the surface and all of its “roots.”
The surgery is conducted in stages, with stage 1 involving the removal of the visible cancer and a thin layer of surrounding tissue. The excised sample is then cut into sections, stained and examined microscopically while the patient waits. If residual cancer is found, the surgeon can elect right then to remove more tissue in successive stages. The process is repeated as many times as necessary, the release continues.
The American College of Mohs Surgery (ACMS) considers a surgeon’s annual mean stages per MMS case to be the measure of quality and appropriateness for the technique. Using that metric, the organization defines physicians whose practices are two standard deviations or more beyond the overall average as outliers who are performing excessive stages in MMS procedures.
Because previous studies suggest that MMS practices vary widely among surgeons, the study by Makary, his team and the ACMS had two aims: evaluate outlier practice patterns using a big-data approach and then, test whether a peer-to-peer notification could change the behavior of surgeons not meeting the appropriateness standard.
“This was an important goal because overuse of stages per case burdens patients with unnecessary and time-consuming surgical resections, and taxes the health care system with avoidable costs,” says Christine Fahim, PhD, MSc, one of the study authors, a postdoctoral fellow at the Johns Hopkins University School of Medicine and the Johns Hopkins Bloomberg School of Public Health, and implementation and intervention design lead for Improving Wisely.
In the study, the researchers describe how they used Medicare Part B claims to choose their study population of 2,329 US surgeons who each performed more than 10 MMS procedures between January 1 and December 31, 2014. The claim forms included the number of stages done in each case, so individual and overall annual averages were easily calculated. Outliers and inliers (surgeons whose MMS performance was within the accepted range of appropriateness defined by the ACMS) were identified by their performances before they became part of the study population (as measured between January 1, 2016, and January 31, 2017), the release explains.
The study population was then divided into four groups: (1) 53 outliers, each of whom would receive an intervention letter indicating his or her performance, and urging an improvement in practice, (2) 87 outliers, each of whom would not receive an intervention, (3) 992 inliers who would receive a straightforward performance evaluation letter, and (4) 1,197 inliers who would not receive a letter.
The intervention groups received their letters in February 2017. Each surgeon’s MMS performance, defined as annual mean stages per case, was measured pre-intervention (between January 1, 2016, and January 31, 2017) and post-intervention (between March 1, 2017, and March 31, 2018).
The notified outlier group demonstrated a pre- to post-intervention decrease in mean stages per case from 2.55 to 2.31, with 44 of the 53 surgeons (83%) improving their MMS behavior. The non-notified outliers dropped from 2.56 to 2.46, with 69% making positive changes.
The researchers attribute the drop by non-notified outliers to two factors: an awareness campaign by ACMS around the time the intervention letters went out and possible communications between surgeons who received the letters and their colleagues who did not.
The performance of the inlier groups, as expected, remained statistically about the same.
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, the release further continues.
“We observed an immediate and sustained improvement in quality with a simple intervention based on the spirit of physicians helping one another,” Makary says. “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.”
[Source(s): Johns Hopkins Medicine, Newswise]