Rural, Regional, Remote Residence, Anxiolytic Use, Multiple Site Surgery, Smoking Status Associated With Patient‐Initiated Communication After Mohs Micrographic Surgery

Mohs micrographic surgery is increasingly used for the surgical excision of skin cancers, particularly those located on anatomically complex areas 1-3. Patients may initiate communication following surgery if they have unaddressed concerns relating to their surgery 4. With the rise of telemedicine, phone calls and emails are becoming a more common form of communication, especially for those who live in regional and remote areas with reduced access to face-to-face specialist medical services 5. The aim of this study was to determine reasons why patients initiate contact with the Mohs surgeon's office after surgery and to provide insight into the timing of these contacts, as well as factors that may predispose patients to initiate communication. Data was prospectively collected from 548 consecutive patients who underwent Mohs surgery and reconstruction with a single dermatologist (M.J.L) at The Skin Hospital, Darlinghurst from August 2020 to July 2023. Data on patient self-initiated contact with the hospital within 90 days of their Mohs surgery with a question or concern related to their surgery, as well as the form, timing and outcome of communications and nature of concern were collected. Statistical analysis was performed in IBM SPSS version 23 (Chicago, IBM Corp). Sixty-five patients (11.9%) initiated communication following Mohs surgery. Demographic, medical, tumour and surgical characteristics are summarised in Table 1. In the final multivariate analysis, 4 factors were found to be independently associated with patient-initiated communication (Table 2): rural/regional/remote residence, perioperative anxiolytic use, multiple-site surgery and smoking. Most of the communication was via phone (Table 3). The mean number of encounters was 1.4, and the mean time of communication postoperative was 5.3 days. The main concerns were related to dressings, wound care and surgical site appearance, unrelated to bleeding/infection. There is a significant shortage and geographical maldistribution of dermatologists in Australia. Only 4% of Australian dermatologists work in rural areas (Mohs surgery or non-Mohs clinical practice), and 2% in regional areas 6, meaning patients in these areas face significant challenges in accessing dermatologic care. The Australasian College of Dermatologists approved register of Mohs practitioners in New South Wales (NSW) lists 30 clinicians, of whom only 2 (6.6%) are primarily based in a regional or rural setting (Modified Monash Model MM 2–7) 6, 7. Furthermore, 2 Mohs practitioners also provide regular services to an MM3 location in addition to their primary MM1 site of practice. Most patients in rural/regional/remote Australia who require access to specialist Mohs surgery will need to travel to consult and undertake surgery in a metropolitan setting. In the worst-case scenario, patients may be discharged after day surgery to a region where they may not have access to a local dermatologist, general practitioners or an emergency department. The use of perioperative anxiolytics in this study was used as a surrogate for patient anxiety. Patients who are anxious may require more frequent communication with their Mohs surgical team to allay their concerns during the perioperative period. Furthermore, anxiolytic use may reduce patient comprehension of postoperative instructions. With regards to multiple-site surgery, increased operative sites mean there are more wound sites required to be nursed by the patient postoperatively and an increased risk of wound concerns and complications. Smoking increases the risk of surgical complications, including wound dehiscence, flap or graft failure, prolonged healing times and infections 8 and may also be a correlate with increased baseline patient anxiety, which could increase the likelihood of the patient contacting the medical team after surgery. Most patient-initiated communication in our study was in direct relation to postoperative wound care. All patients received a combination of verbal and written wound care instructions. However, it is possible that these instructions may not have been understood or may have required elaboration or clarification. Paradoxically, information overload may result in decreased retention of information. This study has multiple limitations. The series was based on Mohs surgery cases from a single Mohs surgeon in a single institution, and as such, results may not be applicable across different groups. The included case indications were BCCs and SCCs, whereas other tumour types, including melanoma, were not represented. The size of the cancer/defect, as well as the nature of pre-operative consultation (in-person, teledermatology, on the day of procedure vs. prior separate appointment) are likely to impact rates of patient-initiated communication, which could be further evaluated in future studies. Rural/regional/remote residence cases were grouped together; however, some patients returned home immediately post-operatively, whilst some stayed in Sydney locally for day(s) before and after surgery. Other parameters such as socioeconomic status, health and language literacy and preoperative mental health status were not specifically collected and analysed. Furthermore, the scope of the study was to investigate patient-initiated communication after surgery, and we did not collect data on nurse-initiated communication after surgery. This study demonstrates risk factors associated with patient-initiated communication after Mohs surgery, including rural/regional/remote residence, anxiety, multiple-site surgery and smoking. Understanding these factors may help guide perioperative counselling, enhance the patient experience and improve surgical recovery. Study conception: K.P., M.J.L. Ethics application: K.P., M.J.L. Data collection: M.J.L., Data analysis and interpretation: K.P., M.J.L. Drafting of manuscript: K.P., M.J.L., Approval of final manuscript: K.P., M.J.L. The authors have nothing to report. The authors declare no conflicts of interest. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.