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Table 4 Factors impacting potential Mohs overuse

From: A process evaluation of the improving wisely intervention: a peer-to-peer data intervention to reduce overuse in surgery

TDF Domain



Participant ID, status

Behavioral Regulation

Overuse driven by lack of regulation/monitoring

If you’re not being audited or you’re not being monitored…then they [surgeons] could justify doing these things to increase their outcome or offset expenses and they may do it again, consciously or subconsciously. I don’t think its an overnight thing

He [colleague] would automatically take two layers with every single patient, whether it had a positive margin or not…we reported him to [regulatory body] many times…the person next door is doing it. – P4, inlier

P1, outlier

P4, inlier


Financial incentives driving overuse

The easiest way to cheat is to just take an extra layer. You can easily justify it to Medicare or the third party insurance. And extra layers are reimbursed you know at 100%, so totally inappropriate use of Mohs goes on all the time

When you’re in fellowship, you’re not necessarily aware of reimbursement issues and so when you’re in more private practice, you’re more keenly aware of reimbursement and numbers so again, consciously or subconsciously, you make decisions that make you more money

P8, inlier P2, inlier

Beliefs about Capabilities

Required improvements in education, training and confidence


If I remember back to when I was just out of my training, I may have been overly cautious…and ended up with extra stages.

There’s been a proliferation of very young Mohs surgeons as there become more training programs. Maybe they’re a little bit less comfortable with their reconstructive skills and afraid to make a too large hole

P18, inlier

P4, inlier


Surgeons stray from original training/ skills need to be re-developed

I feel that I slipped in the way that I do surgery…I felt like okay, what am I doing, like am I doing flaps all the time, am I doing linear complex repairs? You know, a fish doesn’t know its swimming in muddy water

I think part is quality and training. I think a lot of people see a little bit of inflammation and they’re like, ‘oh there’s a tumor here, let me take it out just in case’ and they get another stage out of it

P1, inlier

P3, outlier

Environmental context and resources

Geographic Variation, Clinic Type might impact typical case complexity/ number of stages

I have a low number of stages because I live in Florida. Even though there’s a ton of skin cancer, people have a high utilization of dermatology. They’re plugged in.

We’re the only major Mohs [clinic] in [location retracted to protect clinic anonymity]. So we have patients that come from [many other regions] because we’re experienced

P3, inlier

P8, inlier

Social, Professional Role/Identity

Practicing defensively for patient safety/cosmetic result may lead to increased number of stages

If you more heavily weigh the cosmetic aspect, you’re probably going to be taking more layers per case

P2, inlier