Mohs Micrographic Surgery in the VHA

Results

The authors identified and surveyed 74 dermatology service and section chiefs across the VHA. Of these chiefs, 52 (70.3%) completed the survey. Completed surveys represented 49 hospital sites and 3 community-based outpatient clinics (CBOCs), including an integrated community-based clinic-hospital.

Sites That Provided MMS

Of the 52 sites with a completed survey, 19 provided MMS. These 19 sites were in 13 states and the District of Columbia, and the majority were in major cities along the coasts. All 19 sites were hospital medical centers, not community-based outpatient clinics, and all provided MMS through the dermatology department. In 2015, an estimated 6,686 MMS cases were performed, or an average of 371 per site (range, 40-1,000 cases/site) or 4.9 MMS cases per day (range, 3-8). These 19 sites were divided by yearly volume: high (> 500 cases/y), medium (200-500 cases/y), and low (< 200 cases/y).

Physical Space. On average, each site used 2.89 patient rooms (SD, 1.1; range, 1-6) for MMS. The Table lists numbers of patient rooms based on case volume.

The MMS laboratory was adjacent to the surgical suite at 18 of the MMS sites and in the same building as the surgical suite, but not next to it, at 1 site. For their samples, 11 sites used an automated staining method, 7 used hand staining, and 2 used other methods (1 site used both automated and hand staining). Fourteen sites used hematoxlyin-eosin only, 1 used toluidine blue only, 3 used both hematoxlyin-eosin and toluidine blue, and 1 used MART-1 (melanoma antigen recognized by T cells 1) with hematoxlyin-eosin.

Related: Systemic Therapy in Metastatic Melanoma

Mohs Micrographic Surgeons. Sites with higher case volumes had more Mohs surgeons and more Mohs surgeons with VA appointments (captured as “eighths” or fraction of 8/8 full-time equivalent [FTE]). Information on fellowships and professional memberships was available for 30 Mohs surgeons: Ten (33.3%) were trained in fellowships accredited by both the American College of Mohs Surgery (ACMS) and the Accreditation Council for Graduate Medical Education (ACGME), 8 (26.7%) were trained in ACMS-recognized fellowships only, 7 (23.3%) were trained at ACGME-accredited fellowships only, 2 (6.7%) were trained elsewhere, and 3 (10.0%) had training listed as “uncertain.”

The majority of Mohs surgeons were members of professional societies, and many were members of more than one. Of the 30 Mohs surgeons, 24 (80.0%) were ACMS members, 5 (16.7%) were members of the American Society of Mohs Surgery, and 22 (73.3%) were members of the American Society of Dermatologic Surgery. Twenty-five (89.3%) were affiliated with an academic program.

Of the 30 surgeons, 19 (63.3%) were VHA employees hired by eighths, with an average eighths of 3.9 (SD, 2.7), or 49% of a FTE. Data on these surgeons’ pay tables and tiers were insufficient (only 3 provided the information). Of the other 11 surgeons, 10 (33.3%) were contracted, and 1 (3.3%) volunteered without compensation.

Support Staff. Of the 19 MMS sites, 17 (89.5%) used 1 histotechnician, and 2 (10.5%) used more than 1. Ten sites (52.6%) hired histotechnicians as contractors, 8 (42.1%) as employees, and 1 (5.3%) on a fee basis. In general, sites with higher case volumes had more nursing and support staff. Thirteen sites (68.4%) participated in the training of dermatology residents, and 5 sites (26.3%) trained Mohs fellows.

Wait Time Estimate. The survey also asked for estimates of the average amount of time patients waited for MMS. Of the 19 sites, 8 (42.1%) reported a wait time of less than 1 month, 10 (52.6%) reported 2 to 6 months, and 1 (5.3%) reported 7 months to 1 year. Seventeen (89.5%) of the 19 sites had a grading or triage system for expediting certain cancer types. At 7 sites, cases were prioritized on the basis of physician assessment; at 3 sites, aggressive or invasive squamous cell carcinoma received priority; other sites gave priority to patients with melanoma, patients with carcinoma near the nose or eye, organ transplant recipients, and other immunosuppressed patients.

Sites That Did Not Provide MMS

Of the 52 sites with a completed survey, 33 (63.5%) did not provide on-site MMS. Of these 33 sites, 28 (84.8%) used purchased care to refer patients to fee-basis non-VA dermatologists. In addition, 30 sites (90.9%) had patients activate Veterans Choice. Three sites referred patients to VA sites in another VISN.

Surgeon Recruitment

Five sites (9.6%) had an unfilled Mohs micrographic surgeon position. The average FTE of these unfilled positions was 0.6. One position had been open for less than 6 months, and the other 4 for more than 1 year. All 5 respondents with unfilled positions strongly agreed with the statement, “The position is unfilled because the salary is not competitive with the local market.”