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September 15, 2008

Variation in Care for Recurrent Nonmelanoma Skin Cancer in a University-Based Practice and a Veterans Affairs Clinic

Author Affiliations

Author Affiliations: Department of Dermatology, Stanford University Medical Center, Stanford, California (Dr Clark); Research Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, California (Dr Sahay); Research Enhancement Award Program of the Health Services Research and Development Service, Department of Veterans Affairs, and the San Francisco Veterans Affairs Medical Center, San Francisco, California (Mr Bertenthal, Mss Maddock and Lindquist, and Dr Chren); and Department of Dermatology, University of California at San Francisco (Drs Grekin and Chren).

Arch Dermatol. 2008;144(9):1148-1152. doi:10.1001/archderm.144.9.1148

Objective  To learn if treatment of recurrent nonmelanoma skin cancer (NMSC) varied in different practice settings.

Design  Prospective cohort study of consecutive patients with recurrent NMSC.

Setting  A university-based dermatology practice and the dermatology clinic at the affiliated Veterans Affairs Medical Center (VAMC). Conventional therapies for NMSC were available at both sites.

Patients  All 191 patients diagnosed as having recurrent NMSC in 1999 and 2000 were included in the study. Data were collected from medical record review and surveys mailed to patients.

Main Outcome Measure  Performance of Mohs micrographic surgery (Mohs).

Results  Patients at the VAMC were older, less educated, poorer, and had more comorbid illnesses, but their tumors were similar to those of patients at the university-based practice. Treatment choices differed at the 2 sites: the proportions of tumors treated in the VAMC and university sites were 60% and 14%, respectively, for excisional surgery; and 24% and 61%, respectively, for Mohs (P < .001). In multivariate analyses adjusting for patient, tumor, and physician features that may have affected treatment choice, tumors treated at the university-based site remained significantly more likely to be treated with Mohs (odds ratio, 8.68 [95% confidence interval, 3.66-20.55]; P < .001).

Conclusions  Substantial variation existed in the treatment of recurrent NMSC in different practice settings. This variation was not explained by measured clinical characteristics of the patients or the tumors.