Practice Variation in Utilization of Flap or Graft Reconstruction Among Veterans Affairs Surgeons After Extirpation of Keratinocyte Carcinoma on the Nose

BACKGROUNDPractice variation has been well documented across the US health care system but has not been explored in reconstructive surgical choice after keratinocyte carcinoma (KC) extirpation.OBJECTIVEAssess practice variation in utilization of complex (flap or graft) reconstruction after excision of KC on the nose among a multidisciplinary group of reconstructive surgeons (Mohs micrographic and plastic surgery).MATERIALS AND METHODSA randomly selected subset of surgically treated, routine, primary, invasive KCs on the nose between 2000 to 2012 at the Veterans Affairs (VA)-Boston Healthcare System were assessed. Patient factors, tumor factors, and individual surgeons with sufficient case volume were fit to a multivariate logistic regression model to assess between-surgeon differences in the odds of performing a complex reconstruction.RESULTSTen surgeons met the case volume threshold for analysis, encompassing 338 KC on the nose excised and reconstructed from 2000 to 2012. After adjusting for patient age, tumor diameter, and location, 6 surgeons performed significantly more complex reconstructions than the reference surgeon, and the case-adjusted predicted probability of complex reconstruction ranged from 7% to 99% (p ≤.0001).CONCLUSIONMarked practice variation in reconstruction choice exists among surgeons after extirpation of KC on the nose at one VA health care system. High-quality comparative studies regarding optimal nasal reconstruction after extirpation of KC are needed.