Dermatologic Surgery and Cutaneous Oncology

Mohs Surgery Quality Metrics

Mohs micrographic surgery provides superior cure rates and tissue sparing in high-risk skin cancers frequently arising in functionally and cosmetically crucial sites. It is most commonly used to treat basal cell and squamous cell carcinomas, as well as other tumors associated with high recurrence rates after wide local excision.

In 2019, the Department of Dermatology’s 6 full-time fellowship-trained Mohs surgeons treated 4966 skin cancer cases at 4 Cleveland Clinic Mohs surgery locations, all of which are certified by the Clinical Laboratory Improvement Amendments. The Mohs surgeons performed 94% of the wound reconstructions for these patients, including primary complex closures (52%), primary intermediate closures (17%), flaps (11%), and grafts (3%). Eighteen percent of wounds were left to heal by secondary intention.

The Center for Medicare & Medicaid Services reported a national mean of 1.7 Mohs stages required to obtain tumor-free margins from 2012 to 2014¹ and 1.7 stages in 2017.² Cleveland Clinic Mohs surgeons performed within 1 standard deviation of this mean, requiring an average of 1.6 stages per case to achieve a tumor-free plane in 2017, 1.4 stages in 2018, and 1.4 stages in 2019. The national mean for stages required to clear high-risk skin cancers located on the trunk and extremities was 1.4; all surgeons performed within 1 standard deviation of this metric. The mean national percentage of trunk and extremity Mohs surgery cases was 16% in 2017; at Cleveland Clinic, the range for this metric was 0-16%. Since formally tracking adherence to Appropriate Use Criteria for Mohs micrographic surgery in 2018 all surgeons have performed at 100%.

Number of Mohs Micrographic Surgery Cases (N = 19,366)

2015-2019

Number of Mohs Micrographic Surgery Cases (N = 19,366)

Number of Tumors by Type (N = 19,366)

2015 – 2019

YearBasal Cell CarcinomaSquamous Cell CarcinomaSquamous Cell Carcinoma in SituDermatofibrosarcoma ProtuberansMicrocystic Adnexal CarcinomaSebaceous CarcinomaMerkel Cell CarcinomaOtherᵃ
20141882916134933538
20152083879300603150
201622611101401513325
201724681236546657240
201827781449647526715
2019273913518101417341

ᵃtumors showed both basal cell carcinoma and squamous cell carcinoma.

ᵇIncluding but not limited to porocarcinoma, mucinous carcinoma, hidroadenocarcinoma, adnexal carcinoma, squamoid eccrine ductal carcinoma, malignant epitheliod carcinoma, cribiform carcinoma, pleomorphic sweat gland tumor, spindle cell tumor

References
  1. Krishnan A, Xu T, Hutfless S, Park A, Stasko T, Vidimos AT, Leshin B, Coldiron BM, Bennett RG, Marks VJ, Brandt R, Makary MA, Albertini JG; and the American College of Mohs Surgery Improving Wisely Study Group. Outlier practice patterns in Mohs micrographic surgery: defining the problem and a proposed solution. JAMA Dermatol. 2017 Jun 1; 153(6):565-570. doi:10.1001/jamadermatol.2017.1450.
  2. Albertini JG, Wang P, Fahim C, Hutfless S, Stasko T, Vidimos AT, Leshin B, Billingsley EM, Coldiron BM, Bennett RG, Marks VJ, Park A, Overton HN, Bruhn WE, Xu T, Krishnan A, Makary MA. Evaluation of a Peer-to-Peer Data Transparency Intervention for Mohs Micrographic Surgery Overuse. JAMA Dermatol. 2019 May 5. doi: 10.1001/jamadermatol.2019.1259. [Epub ahead of print]
  3. Connolly SM, Baker DR, Coldiron BM, Fazio MJ, Storrs PA, Vidimos AT, Zalla MJ, Brewer JD, Smith Begolka W; Ratings Panel, Berger TG, Bigby M, Bolognia JL, Brodland DG, Collins S, Cronin TA Jr, Dahl MV, Grant-Kels JM, Hanke CW, Hruza GJ, James WD, Lober CW, McBurney EI, Norton SA, Roenigk RK, Wheeland RG, Wisco OJ. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Scoiety for Dermatologic Surgery Association, and the American Society for Mohs Surgery. J Am Acad Dermatol. 2012 Oct;67(4):531-50. doi: 10.1016/j.jaad.2012.06.009. Epub 2012 Sep 5. Erratum in: J Am Acad Dermatol. 2015 Apr;72(4):748.