Krishnan Aravind, Xu Tim, Hutfless Susan, Park Angela, Stasko Thomas, Vidimos Allison T, Leshin Barry, Coldiron Brett M, Bennett Richard G, Marks Victor J, Brandt Rebecca, Makary Martin A, Albertini John G
Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.
Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
JAMA Dermatol. 2017 Jun 1;153(6):565-570. doi: 10.1001/jamadermatol.2017.1450.
Outlier physician practices in health care can represent a significant burden to patients and the health system.
To study outlier physician practices in Mohs micrographic surgery (MMS) and the associated factors.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective analysis of publicly available Medicare Part B claims data from January 2012 to December 2014 includes all physicians who received Medicare payments for MMS from any practice performing MMS on the head and neck, genitalia, hands, and feet region of Medicare Part B patients.
Characteristics of outlier physicians, defined as those whose mean number of stages for MMS was 2 standard deviations greater than the mean number for all physicians billing MMS. Logistic regression was used to study the physician characteristics associated with outlier status.
Our analysis included 2305 individual billing physicians performing MMS. The mean number of stages per MMS case for all physicians practicing from January 2012 to December 2014 was 1.74, the median was 1.69, and the range was 1.09 to 4.11. Overall, 137 physicians who perform Mohs surgery were greater than 2 standard deviations above the mean (2 standard deviations above the mean = 2.41 stages per case) in at least 1 of the 3 examined years, and 49 physicians (35.8%) were persistent high outliers in all 3 years. Persistent high outlier status was associated with performing Mohs surgery in a solo practice (odds ratio, 2.35; 95% CI, 1.25-4.35). Volume of cases per year, practice experience, and geographic location were not associated with persistent high outlier status.
Marked variation exists in the number of stages per case for MMS for head and neck, genitalia, hands, and feet skin cancers, which may represent an additional financial burden and unnecessary surgery on individual patients. Providing feedback to physicians may reduce unwarranted variation on this metric of quality.
医疗保健领域中医生的异常医疗行为可能给患者和医疗系统带来重大负担。
研究莫氏显微外科手术（MMS）中医生的异常医疗行为及其相关因素。
设计、设置和参与者：这项对2012年1月至2014年12月公开的医疗保险B部分索赔数据的回顾性分析，纳入了所有因在医疗保险B部分患者的头颈部、生殖器、手部和足部区域进行MMS而从任何医疗机构获得医疗保险支付的医生。
异常医生的特征，定义为其MMS分期的平均数量比所有开具MMS账单的医生的平均数量高出2个标准差的医生。采用逻辑回归研究与异常状态相关的医生特征。
我们的分析包括2305名进行MMS的个体计费医生。2012年1月至2014年执业的所有医生每例MMS的平均分期数为1.74，中位数为1.69，范围为1.09至4.11。总体而言，在3年中的至少1年里，有137名进行莫氏手术的医生高于平均水平2个标准差（高于平均水平2个标准差=每例2.41个分期），49名医生（35.8%）在所有3年中都是持续的高异常值。持续的高异常值状态与独自执业进行莫氏手术相关（比值比，2.35；95%置信区间，1.25 - 4.35）。每年的病例数量、执业经验和地理位置与持续的高异常值状态无关。
头颈部、生殖器、手部和足部皮肤癌的MMS每例分期数量存在显著差异，这可能给个体患者带来额外的经济负担和不必要的手术。向医生提供反馈可能会减少这一质量指标上不必要的差异。
