Complications of Mohs Surgery and the Influence of Economic Status on Outcomes

Mohs micrographic surgery (MMS) remains an important part of care for cutaneous cancers. Nevertheless, disparities in access to MMS based on socio-economic status (SES) and geographic location persist. This study examines the relationship between income and complications following MMS. Prior literature has highlighted challenges in the accessibility of Mohs surgeons, with barriers to access in rural and lower-income areas [1, 2]. This discrepancy may influence the complication rates and patient outcomes. Literature is sparse regarding the impacts of SES on MMS outcomes.

Our study queried the All of Us database (AoUDB) from the National Institute of Health for patients with a prior procedural history of MMS. We then queried for complications occurring within 30 and 60 days postoperatively. Survey data was used to group individuals based on annual income brackets. Complications among cohorts were compared using the Chi-square test of independence and the Bonferroni correction for pairwise analyses.

The database queries identified 7999 cases of MMS across 3668 patients. Among those cases, the rate of any of the queried complications occurring in the 30- and 60-day timeframes was 6.04% and 10.65%, respectively. Overall complication rates were inversely related to income bracket, aside from an increase in the highest bracket (p = 0.005 and p = 0.0003 for 30- and 60-day rates, respectively). At 30 days post-op, patients in the < $10,000 annual income bracket (the lowest recorded income bracket) had a rate of 11.02%, while those in the 150,000–200,000annual income bracket (the second highest recorded income bracket) had a rate of 4.58%. At 60 days post-op, patients in the < $10,000 annual income bracket had a rate of 15.25%, while those in the 150,000–200,000annual income bracket had a rate of 8.10%. Patients in the > $200,000 annual income bracket (the highest recorded income bracket) had rates of 8.03% and 13.38% at 30 and 60 days, respectively.

Infections accounted for most complications (occurring in 3.99% of cases and 6.96% of cases at 30 and 60 days, respectively), with significant differences among cohorts (p < 0.001). At 30 days, the < $10 000 annual income bracket had a rate of 9.32%, the $150000–200 000 annual income bracket had a rate of 2.35% and the > $200 000 annual income bracket had a rate of 4.46%. At 60 days, the infection rates were 11.86% for the < $10 000 annual income bracket, 4.21% for the $150000–200 000 annual income bracket and 7.04% for the > $200 000 annual income bracket.

Regarding all other complications, hypertrophic scarring and pigmentation changes displayed a bimodal distribution at the higher and lower brackets. There were significantly lower rates of dehiscence in the lowest brackets (Figure 1).

Upon adjusting for gender, sex, race and ethnicity using multiple linear regression, risk of infection and overall complication continued to show an inverse relationship with income, with the only exception being an increase in hematoma risk in the $150000–200 000 annual income bracket in the 30-day window.

Our study reveals significant socio-economic disparities in complication rates for patients following MMS, with an inverse relationship between annual income brackets and complication rates at both 30 and 60 days post-surgery, barring a deviation with an increase in complication rate for the highest annual income bracket. Infections made up the majority of complications in all cohorts, at all studied time periods. These findings highlight the complex relationship between SES and postoperative complications, adding to the growing body of literature focusing on the influence of SES on outcomes for cutaneous malignancies [3, 4]. Multiple factors may contribute to the bimodal distribution. Disparities in access to care may have contributed in many ways, including differences in the time to presentation for complications and consequently the severity upon presentation. A primary limitation of the AoUDB is the inability to directly assess the severity of a given condition such as infection, or to link it directly back to a given procedure. The observed discrepancies highlight the need for interventions and awareness to help reduce disparities in dermatologic surgical care for patients. Future research should focus on prospective outcome analysis to account for the limitations of large database research. There are no conflicts of interest to declare for all authors.

L.C. and C.G. wrote the main manuscript text and L.C. prepared Fig. 1. C.G. and M.P. conceptualized the study. C.G. wrote all code for data analysis. All authors reviewed the manuscript.

IRB Approval Status: The All of US IRB approved the All of US protocol and materials before recruitment of the participants into the All of US database.

Reprint Requests: Christopher A. Guirguis.

The authors have nothing to report.

The authors declare no conflicts of interest.