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Predictors of Unplanned Postoperative Visits in a Veterans Affairs Hand Surgery Practice
Predictors of Unplanned Postoperative Visits in a Veterans Affairs Hand Surgery Practice
Patients make unplanned appointments after elective soft tissue hand surgery for real or perceived complications when they experience pain, anxiety, or fear. Unplanned appointments can create travel and financial burdens for patients and families. These appointments take time away from scheduled appointments and can contribute to late arrivals and delays in other clinics. Unscheduled appointments contribute to poor access when staff are diverted from scheduled appointments. If predictive factors can be identified, unplanned appointments may either be ameliorated or avoided with better perioperative risk management or education.
Methods
The US Department of Veterans Affairs (VA) North Florida/South Georgia Veterans Health System (NFSGVAHS) and University of Florida Institutional Review Board approved a retrospective chart review of all plastic surgery cases performed at the Malcom Randall VA Medical Center (MRVAMC) and Lake City VAMC operating rooms from July 1, 2018, through December 31, 2019, and January 1, 2021, through June 30, 2022 (nonurgent surgeries were discouraged during the COVID-19 pandemic). Elective soft tissue hand surgery cases were identified based on the operative description found in the Surgical Service Surgeon Staffing Report reviewed monthly by the Service Chief. Potential indicators of unplanned visits were recorded, including age; sex; diagnosis of diabetes, depression, anxiety, or posttraumatic stress disorder (PTSD); current smoking status; and residential zip code. We used the first 3 digits of the patients’ zip codes, which indicate region, as an estimate of proximity to the MRVAMC, which has a 50-county catchment area across North Florida and South Georgia. Diagnoses were found on the “problem list” from the electronic health record documented in the history and physical examinations before surgery. Clinic notes were examined for 3 months postsurgery to identify unplanned postoperative visits and the reason for the appointment. A χ2 analysis was conducted using Excel Version 2402. P < .05 was used to determine whether age (> 60 years), sex, proximity to MRVAMC, diabetes, smoking, depression, anxiety, or PTSD were statistically significant independent risk factors for these appointments.
Results
A total of 1009 elective soft tissue hand surgeries at MRVAMC were reviewed. The patients median age was 61 years. Patients included 173 women (17.1%) and 836 men (82.9%). Eighty-one patients (8.0%) returned for unplanned visits. Age (P = .82); proximity to MRVAMC (P = .34); and diabetes (P = .60), smoking (P = .55), anxiety (P = .33), or PTSD (P = .37) were not statistically significant predictors of unplanned appointments. Depression diagnosis (P = .04) and female sex (P = .03) were found to be independent risk factors for an unplanned appointment (Table 1). The most common indication for the requested appointment was pain-related, followed closely by noninfectious wound concerns and persistent symptoms (Table 2).
Discussion
Improved access, quality, and efficiency for patients are goals for the VA.1-3 The MRVAMC Plastic and Hand Surgery service provides care for the NFSGVAHS and receives an average of 15 to 20 consultation requests daily. The Veterans Health Administration is frequently challenged by staff shortages, and surgical services struggle to respond to consultation requests and treat patients within reasonable time frames.4,5
The objective of this study was to identify risk factors for unplanned postoperative appointments following elective hand surgery. Unplanned appointments prevent scheduled patients from being seen on time and contribute to backlogs and delays. When patients schedule multiple appointments on the same day, delays in the first clinic’s scheduled appointments create delays for the second and third clinics. Hand surgery clinics can provide a better experience for patients and staff by identifying and mitigating factors prompting unplanned visits.
We anticipated that wound complications would prompt unscheduled visits. Diabetes is a known risk factor for wound healing complications after plastic and hand surgery.6,7 A hemoglobin A1c (HbA1c) screening protocol used by the NFSGVAHS plastic surgery service since 2015 to identify poorly controlled patients with diabetes before surgery may partially explain this finding.8 We did not find a statistically significant difference between patients with diabetes and patients without diabetes for scheduling unplanned appointments. The plastic surgery service does not perform elective hand surgery unless the patient’s HbA1c level is < 9%, or violate the flexor sheath unless HbA1c level is < 8%. However, Zhuang et al found an increase in soft tissue infections after hand surgery with HbA1c levels ≥ 7%.9
Smoking is a potential factor in postoperative hand surgery complications.10,11 Lans et al found an increased incidence of 30-day emergency room visits in current and former smokers after outpatient upper extremity fracture surgery.12 The MRVAMC Plastic Surgery Service counsels patients about the risk of skin necrosis and delayed wound healing, but does not cancel cases or obtain laboratory values to verify abstinence in patients undergoing hand surgery. The VA has multiple resources available for patients interested in smoking cessation through mental health services.13
MRVAMC patients have been known to resist returning for scheduled appointments due to the costs or availability of transportation. We suspected that patients who lived further from MRVAMC would be less likely to return for unscheduled visits. We used the first 3 digits of the patients’ mailing zip code to estimate residential proximity to MRVAMC. An acknowledged limitation to this approach is that some veterans have primary addresses in other regions but still spend significant time in the MRVAMC catchment area and use the facility for their health care during the winter months. These “snowbirds” might reside near the facility despite having official addresses that are more distant. Additionally, there was no increased risk of unplanned visits after hand surgery in patients aged > 61 years (the median age of study participants) (P = .82). Dependence on a third party for transportation in older veterans could impact this finding.
Based on the observation that most patients needed reassurance rather than an intervention when they returned for unscheduled appointments, diagnoses of depression, anxiety, and PTSD were evaluated as separate predictive factors. In previous research, anxiety was found to be a risk factor for problematic recovery following carpal tunnel surgery.14 In the current study, depression was found to be a statistically significant predictor of unscheduled postoperative appointments (P = .04), while anxiety (P = .33) and PTSD (P = .37) were not statistically significant predictors. This is consistent with other studies that have found preexisting depression can predict complications after hand surgery.15,16 Vranceanu et al found that depression predicted pain intensity and disability after elective hand surgery.16 Similarly, Oflazoglu et al found a 12% incidence of depression based on the Patient Health Questionnaire-9 in new and returning hand patients who presented to an academic practice.17 They suggest patients should be assessed at all levels of care and that those with poor responses to surgical or nonsurgical management should be evaluated for depression. MRVAMC has a large mental health service consisting of psychiatrists, psychologists, addiction specialists, social workers, and homeless outreach, and patients tend to already have a diagnosis and mental health practitioner when they present to the clinic.
Recent studies found that wound problems, pain, and stiffness were the most common reasons for return visits.18,19 Shetty et al identified younger age, worse preoperative pain scores, and poor access to transportation as predictors of preventable emergency room visits, which generate higher health care expenditures than an office visit.19 Our study’s top reasons for appointments (pain, wound/scar concerns, persistent symptoms) can be addressed with additional presurgery patient and family education. Additionally, clinicians encourage nonnarcotic pain management strategies including anti-inflammatories, acetaminophen, elevation, splinting, and hand therapy, and the hospital employs experienced, fellowship-trained anesthesia block faculty who help limit perioperative narcotic use. Patients are advised that pain can be used to guide them through the postoperative recovery by preventing overuse and alerting them to a problem that would be masked with narcotics, and long-standing problems such as chronic nerve compressions may continue to cause pain after surgery.
Patients and families can be given consistent and repetitive verbal and written information, instructions, and expectations at the initial consultation, preoperative appointment, and on the day of surgery. Postoperatively, outside their scheduled appointments, patients are encouraged to use the My HealtheVet secure messaging system or call the clinic to access an experienced registered nurse before making a long drive. Access to virtual or phone visits can reduce emergent in-person visits in a VA population.20
Ozdag et al found that 42% of patients who had elective carpal tunnel surgery made unplanned electronic messages or phone contact within 2 weeks postsurgery. The authors point out the uncompensated administrative burden on the staff answering these messages and suggest pre-empting the contacts with more up-front education regarding postoperative pain expectations and management strategies.21
Fisher et al found that attending hand therapy reduced the number of emergency department visits in postoperative infection cases.22 At MRVAMC, a postoperative emergency department visit for a patient prompts an urgent unplanned appointment to the plastic surgery clinic, often on the same day. The MRVAMC occupational therapy clinic employed 3 on-site certified hand therapists during the study period. Because all hand surgery patients at the clinic receive hand therapy on the same day as their first postoperative appointment, attendance at hand therapy was not evaluated as a predictor of unplanned visits. Scheduled hand therapy is another point of contact where the clinic can provide reassurance and patient education.
While females made up 17.1% of the patients in this study, they constituted 12.5% of all veterans in Florida in fiscal year 2023.23 This study found that women were more likely to present for unplanned postoperative appointments (P = .03). This is consistent with existing literature which has found that women are higher users of health care and office-based appointments.24,25 This finding suggests the need for further study into whether our methods of communicating instructions to female patients undergoing plastic surgery may not be optimal.
Strengths and Limitations
As a retrospective review, the authors used information documented by multiple different health care practitioners, including trainees. The electronic medical record problem lists and templates provide consistency of information; however, less seasoned clinicians may interpret what they see and hear differently from more experienced clinicians in the postoperative setting. This study occurred in one part of the country with demographics that may not mirror other VA systems or the general population. The authors hope this study can be a starting point for other health care facilities to investigate ways to minimize the burden of unscheduled appointments. A strength of the study is that it was conducted within a closed system, as patients tend to stay within the VA system and documentation and communication among clinicians, even outside the immediate facility, are easily accessed through the electronic health record.
Conclusions
This study found that depression diagnosis and female sex are statistically significant predictors of unplanned postoperative visits after elective soft tissue hand surgery. More effective patient education during the preoperative period, particularly in patients with depression, may be warranted.
- Apaydin EA, Paige NM, Begashaw MM, et al. Veterans Health Administration (VA) vs. non-VA healthcare quality: a systematic review. J Gen Intern Med. 2023;38:2179-2188. doi:10.1007/s11606-023-08207-2
- Blegen M, Ko J, Salzman G, et al. Comparing quality of surgical care between the US Department of Veterans Affairs and non-Veterans Affairs settings: a systematic review. J Am Coll Surg. 2023;237:352-361. doi:10.1097/XCS.0000000000000720
- Valsangkar NP, Eppstein AC, Lawson RA, et al. Effect of lean processes on surgical wait times and efficiency in a tertiary care veterans affairs medical center. JAMA Surg. 2017;152:42-47. doi:10.1001/jamasurg.2016.2808
- National Association of Veterans Affairs Physicians and Dentists. Physicians remain at top of staffing shortage in VA. NAVAPD. December 20, 2023. Accessed March 16, 2026. https://www.navapd.org/news/physicians-remain-at-top-of-staffing-shortage-in-va
- OIG Determination of Veterans Health Administration’s severe occupational staffing shortages fiscal year 2024. Veterans Affairs Office of Inspector General. August 7, 2024. Accessed February 4, 2026. https://www.vaoig.gov/reports/national-healthcare-review/oig-determination-veterans-health-administrations-severe-0
- Goltsman D, Morrison KA, Ascherman JA. Defining the association between diabetes and plastic surgery outcomes: an analysis of nearly 40,000 patients. Plast Reconstr Surg Glob Open. 2017;5:e1461. doi:10.1097/GOX.0000000000001461 7.
- Cox CT, Sierra S, Egan A, et al. Elevated hemoglobin A1c and the risk of postoperative complications in elective hand and upper extremity surgery. Cureus. 2023;15:e48373. doi:10.7759/cureus.48373
- Coady-Fariborzian L, Anstead C. HbA1c and infection in diabetic elective hand surgery: a Veterans Affair Medical Center experience 2012-2018. Hand (NY). 2023;18:994-998. doi:10.1177/1558944720937363<
- Zhuang T, Shapiro LM, Fogel N, et al. Perioperative laboratory markers as risk factors for surgical site infection after elective hand surgery. J Hand Surg Am. 2021;46:675-684. doi:10.1016/j.jhsa.2021.04.001
- Cho BH, Aziz KT, Giladi AM. The impact of smoking on early postoperative complications in hand surgery. J Hand Surg Am. 2021;46:336.e1-336.e11. doi:10.1016/j.jhsa.2020.07.01411.
- Del Core MA, Ahn J, Golden AS, et al. Effect of smoking on short-term postoperative complications after elective upper extremity surgery. Hand (N Y). 2022;17:231-238. doi:10.1177/1558944720926638
- Lans J, Beagles CB, Watkins IT, et al. Unplanned postoperative emergency department visits after upper extremity fracture surgery. J Orthop Trauma. 2025;39:22-27. doi:10.1097/BOT.0000000000002925
- Tobacco and health - how to quit. US Dept of Veterans Affairs. Updated October 29, 2025. Accessed February 4, 2026. https://www.mentalhealth.va.gov/quit-tobacco/how-to-quit.asp
- Ryan C, Miner H, Ramachandran S, et al. General anxiety is associated with problematic initial recovery after carpal tunnel release. Clin Orthop Relat Res. 2022;480:1576-1581. doi:10.1097/CORR.0000000000002115
- Crijns TJ, Bernstein DN, Ring D, et al. Depression and pain interference correlate with physical function in patients recovering from hand surgery. Hand (N Y). 2019;14:830-835. doi:10.1177/1558944718777814
- Vranceanu AM, Jupiter JB, Mudgal CS, et al. Predictors of pain intensity and disability after minor hand surgery. J Hand Surg Am. 2010;35:956-960. doi:10.1016/j.jhsa.2010.02.00117.
- Oflazoglu K, Mellema JJ, Menendez ME, et al. Prevalence of and factors associated with major depression in patients with upper extremity conditions. J Hand Surg Am. 2016;41:263-269. doi:10.1016/j.jhsa.2015.11.019
- Townsend CB, Henry TW, Lutsky KF, et al. Unplanned office visits following outpatient hand surgery. Hand (N Y). 2022;17:1264-1268. doi:10.1177/15589447211028932
- Shetty PN, Guarino GM, Zhang G, et al. Risk factors for preventable emergency department use after outpatient hand surgery. J Hand Surg Am. 2022;47:855-864. doi:10.1016/j.jhsa.2022.05.012
- Sommers-Olson B, Christianson J, Neumann T, et al. Reducing nonemergent visits to the emergency department in a Veterans Affairs multistate system. J Emerg Nurs. 2023;49:539-545. doi:10.1016/j.jen.2023.02.010
- Ozdag Y, Manzar S, El Koussaify J, et al. Unplanned postoperative phone calls and electronic messages for patients with and without opioid prescriptions after carpal tunnel release. J Hand Surg Glob Online. 2024;6:363-368. doi:10.1016/j.jhsg.2024.02.006
- Fisher AH, Gandhi J, Nelson Z, et al. Immediate interventions after surgery to reduce readmission for upper extremity infections. Ann Plast Surg. 2022;88:S163-S169. doi:10.1097/SAP.0000000000003141
- Florida Department of Veterans Affairs Fast Facts. Florida Department of Veterans Affairs. Accessed February 4, 2026. https://floridavets.org/our-veterans/profilefast-facts/
- Bertakis KD, Azari R, Helms LJ, et al. Gender differences in the utilization of health care services. J Fam Pract. 2000;49:147-152.
- Ashman JJ, Santo L, Okeyode T. Characteristics of office-based physician visits, 2018. NCHS Data Brief. 2021;408:1-8.
Patients make unplanned appointments after elective soft tissue hand surgery for real or perceived complications when they experience pain, anxiety, or fear. Unplanned appointments can create travel and financial burdens for patients and families. These appointments take time away from scheduled appointments and can contribute to late arrivals and delays in other clinics. Unscheduled appointments contribute to poor access when staff are diverted from scheduled appointments. If predictive factors can be identified, unplanned appointments may either be ameliorated or avoided with better perioperative risk management or education.
Methods
The US Department of Veterans Affairs (VA) North Florida/South Georgia Veterans Health System (NFSGVAHS) and University of Florida Institutional Review Board approved a retrospective chart review of all plastic surgery cases performed at the Malcom Randall VA Medical Center (MRVAMC) and Lake City VAMC operating rooms from July 1, 2018, through December 31, 2019, and January 1, 2021, through June 30, 2022 (nonurgent surgeries were discouraged during the COVID-19 pandemic). Elective soft tissue hand surgery cases were identified based on the operative description found in the Surgical Service Surgeon Staffing Report reviewed monthly by the Service Chief. Potential indicators of unplanned visits were recorded, including age; sex; diagnosis of diabetes, depression, anxiety, or posttraumatic stress disorder (PTSD); current smoking status; and residential zip code. We used the first 3 digits of the patients’ zip codes, which indicate region, as an estimate of proximity to the MRVAMC, which has a 50-county catchment area across North Florida and South Georgia. Diagnoses were found on the “problem list” from the electronic health record documented in the history and physical examinations before surgery. Clinic notes were examined for 3 months postsurgery to identify unplanned postoperative visits and the reason for the appointment. A χ2 analysis was conducted using Excel Version 2402. P < .05 was used to determine whether age (> 60 years), sex, proximity to MRVAMC, diabetes, smoking, depression, anxiety, or PTSD were statistically significant independent risk factors for these appointments.
Results
A total of 1009 elective soft tissue hand surgeries at MRVAMC were reviewed. The patients median age was 61 years. Patients included 173 women (17.1%) and 836 men (82.9%). Eighty-one patients (8.0%) returned for unplanned visits. Age (P = .82); proximity to MRVAMC (P = .34); and diabetes (P = .60), smoking (P = .55), anxiety (P = .33), or PTSD (P = .37) were not statistically significant predictors of unplanned appointments. Depression diagnosis (P = .04) and female sex (P = .03) were found to be independent risk factors for an unplanned appointment (Table 1). The most common indication for the requested appointment was pain-related, followed closely by noninfectious wound concerns and persistent symptoms (Table 2).
Discussion
Improved access, quality, and efficiency for patients are goals for the VA.1-3 The MRVAMC Plastic and Hand Surgery service provides care for the NFSGVAHS and receives an average of 15 to 20 consultation requests daily. The Veterans Health Administration is frequently challenged by staff shortages, and surgical services struggle to respond to consultation requests and treat patients within reasonable time frames.4,5
The objective of this study was to identify risk factors for unplanned postoperative appointments following elective hand surgery. Unplanned appointments prevent scheduled patients from being seen on time and contribute to backlogs and delays. When patients schedule multiple appointments on the same day, delays in the first clinic’s scheduled appointments create delays for the second and third clinics. Hand surgery clinics can provide a better experience for patients and staff by identifying and mitigating factors prompting unplanned visits.
We anticipated that wound complications would prompt unscheduled visits. Diabetes is a known risk factor for wound healing complications after plastic and hand surgery.6,7 A hemoglobin A1c (HbA1c) screening protocol used by the NFSGVAHS plastic surgery service since 2015 to identify poorly controlled patients with diabetes before surgery may partially explain this finding.8 We did not find a statistically significant difference between patients with diabetes and patients without diabetes for scheduling unplanned appointments. The plastic surgery service does not perform elective hand surgery unless the patient’s HbA1c level is < 9%, or violate the flexor sheath unless HbA1c level is < 8%. However, Zhuang et al found an increase in soft tissue infections after hand surgery with HbA1c levels ≥ 7%.9
Smoking is a potential factor in postoperative hand surgery complications.10,11 Lans et al found an increased incidence of 30-day emergency room visits in current and former smokers after outpatient upper extremity fracture surgery.12 The MRVAMC Plastic Surgery Service counsels patients about the risk of skin necrosis and delayed wound healing, but does not cancel cases or obtain laboratory values to verify abstinence in patients undergoing hand surgery. The VA has multiple resources available for patients interested in smoking cessation through mental health services.13
MRVAMC patients have been known to resist returning for scheduled appointments due to the costs or availability of transportation. We suspected that patients who lived further from MRVAMC would be less likely to return for unscheduled visits. We used the first 3 digits of the patients’ mailing zip code to estimate residential proximity to MRVAMC. An acknowledged limitation to this approach is that some veterans have primary addresses in other regions but still spend significant time in the MRVAMC catchment area and use the facility for their health care during the winter months. These “snowbirds” might reside near the facility despite having official addresses that are more distant. Additionally, there was no increased risk of unplanned visits after hand surgery in patients aged > 61 years (the median age of study participants) (P = .82). Dependence on a third party for transportation in older veterans could impact this finding.
Based on the observation that most patients needed reassurance rather than an intervention when they returned for unscheduled appointments, diagnoses of depression, anxiety, and PTSD were evaluated as separate predictive factors. In previous research, anxiety was found to be a risk factor for problematic recovery following carpal tunnel surgery.14 In the current study, depression was found to be a statistically significant predictor of unscheduled postoperative appointments (P = .04), while anxiety (P = .33) and PTSD (P = .37) were not statistically significant predictors. This is consistent with other studies that have found preexisting depression can predict complications after hand surgery.15,16 Vranceanu et al found that depression predicted pain intensity and disability after elective hand surgery.16 Similarly, Oflazoglu et al found a 12% incidence of depression based on the Patient Health Questionnaire-9 in new and returning hand patients who presented to an academic practice.17 They suggest patients should be assessed at all levels of care and that those with poor responses to surgical or nonsurgical management should be evaluated for depression. MRVAMC has a large mental health service consisting of psychiatrists, psychologists, addiction specialists, social workers, and homeless outreach, and patients tend to already have a diagnosis and mental health practitioner when they present to the clinic.
Recent studies found that wound problems, pain, and stiffness were the most common reasons for return visits.18,19 Shetty et al identified younger age, worse preoperative pain scores, and poor access to transportation as predictors of preventable emergency room visits, which generate higher health care expenditures than an office visit.19 Our study’s top reasons for appointments (pain, wound/scar concerns, persistent symptoms) can be addressed with additional presurgery patient and family education. Additionally, clinicians encourage nonnarcotic pain management strategies including anti-inflammatories, acetaminophen, elevation, splinting, and hand therapy, and the hospital employs experienced, fellowship-trained anesthesia block faculty who help limit perioperative narcotic use. Patients are advised that pain can be used to guide them through the postoperative recovery by preventing overuse and alerting them to a problem that would be masked with narcotics, and long-standing problems such as chronic nerve compressions may continue to cause pain after surgery.
Patients and families can be given consistent and repetitive verbal and written information, instructions, and expectations at the initial consultation, preoperative appointment, and on the day of surgery. Postoperatively, outside their scheduled appointments, patients are encouraged to use the My HealtheVet secure messaging system or call the clinic to access an experienced registered nurse before making a long drive. Access to virtual or phone visits can reduce emergent in-person visits in a VA population.20
Ozdag et al found that 42% of patients who had elective carpal tunnel surgery made unplanned electronic messages or phone contact within 2 weeks postsurgery. The authors point out the uncompensated administrative burden on the staff answering these messages and suggest pre-empting the contacts with more up-front education regarding postoperative pain expectations and management strategies.21
Fisher et al found that attending hand therapy reduced the number of emergency department visits in postoperative infection cases.22 At MRVAMC, a postoperative emergency department visit for a patient prompts an urgent unplanned appointment to the plastic surgery clinic, often on the same day. The MRVAMC occupational therapy clinic employed 3 on-site certified hand therapists during the study period. Because all hand surgery patients at the clinic receive hand therapy on the same day as their first postoperative appointment, attendance at hand therapy was not evaluated as a predictor of unplanned visits. Scheduled hand therapy is another point of contact where the clinic can provide reassurance and patient education.
While females made up 17.1% of the patients in this study, they constituted 12.5% of all veterans in Florida in fiscal year 2023.23 This study found that women were more likely to present for unplanned postoperative appointments (P = .03). This is consistent with existing literature which has found that women are higher users of health care and office-based appointments.24,25 This finding suggests the need for further study into whether our methods of communicating instructions to female patients undergoing plastic surgery may not be optimal.
Strengths and Limitations
As a retrospective review, the authors used information documented by multiple different health care practitioners, including trainees. The electronic medical record problem lists and templates provide consistency of information; however, less seasoned clinicians may interpret what they see and hear differently from more experienced clinicians in the postoperative setting. This study occurred in one part of the country with demographics that may not mirror other VA systems or the general population. The authors hope this study can be a starting point for other health care facilities to investigate ways to minimize the burden of unscheduled appointments. A strength of the study is that it was conducted within a closed system, as patients tend to stay within the VA system and documentation and communication among clinicians, even outside the immediate facility, are easily accessed through the electronic health record.
Conclusions
This study found that depression diagnosis and female sex are statistically significant predictors of unplanned postoperative visits after elective soft tissue hand surgery. More effective patient education during the preoperative period, particularly in patients with depression, may be warranted.
Patients make unplanned appointments after elective soft tissue hand surgery for real or perceived complications when they experience pain, anxiety, or fear. Unplanned appointments can create travel and financial burdens for patients and families. These appointments take time away from scheduled appointments and can contribute to late arrivals and delays in other clinics. Unscheduled appointments contribute to poor access when staff are diverted from scheduled appointments. If predictive factors can be identified, unplanned appointments may either be ameliorated or avoided with better perioperative risk management or education.
Methods
The US Department of Veterans Affairs (VA) North Florida/South Georgia Veterans Health System (NFSGVAHS) and University of Florida Institutional Review Board approved a retrospective chart review of all plastic surgery cases performed at the Malcom Randall VA Medical Center (MRVAMC) and Lake City VAMC operating rooms from July 1, 2018, through December 31, 2019, and January 1, 2021, through June 30, 2022 (nonurgent surgeries were discouraged during the COVID-19 pandemic). Elective soft tissue hand surgery cases were identified based on the operative description found in the Surgical Service Surgeon Staffing Report reviewed monthly by the Service Chief. Potential indicators of unplanned visits were recorded, including age; sex; diagnosis of diabetes, depression, anxiety, or posttraumatic stress disorder (PTSD); current smoking status; and residential zip code. We used the first 3 digits of the patients’ zip codes, which indicate region, as an estimate of proximity to the MRVAMC, which has a 50-county catchment area across North Florida and South Georgia. Diagnoses were found on the “problem list” from the electronic health record documented in the history and physical examinations before surgery. Clinic notes were examined for 3 months postsurgery to identify unplanned postoperative visits and the reason for the appointment. A χ2 analysis was conducted using Excel Version 2402. P < .05 was used to determine whether age (> 60 years), sex, proximity to MRVAMC, diabetes, smoking, depression, anxiety, or PTSD were statistically significant independent risk factors for these appointments.
Results
A total of 1009 elective soft tissue hand surgeries at MRVAMC were reviewed. The patients median age was 61 years. Patients included 173 women (17.1%) and 836 men (82.9%). Eighty-one patients (8.0%) returned for unplanned visits. Age (P = .82); proximity to MRVAMC (P = .34); and diabetes (P = .60), smoking (P = .55), anxiety (P = .33), or PTSD (P = .37) were not statistically significant predictors of unplanned appointments. Depression diagnosis (P = .04) and female sex (P = .03) were found to be independent risk factors for an unplanned appointment (Table 1). The most common indication for the requested appointment was pain-related, followed closely by noninfectious wound concerns and persistent symptoms (Table 2).
Discussion
Improved access, quality, and efficiency for patients are goals for the VA.1-3 The MRVAMC Plastic and Hand Surgery service provides care for the NFSGVAHS and receives an average of 15 to 20 consultation requests daily. The Veterans Health Administration is frequently challenged by staff shortages, and surgical services struggle to respond to consultation requests and treat patients within reasonable time frames.4,5
The objective of this study was to identify risk factors for unplanned postoperative appointments following elective hand surgery. Unplanned appointments prevent scheduled patients from being seen on time and contribute to backlogs and delays. When patients schedule multiple appointments on the same day, delays in the first clinic’s scheduled appointments create delays for the second and third clinics. Hand surgery clinics can provide a better experience for patients and staff by identifying and mitigating factors prompting unplanned visits.
We anticipated that wound complications would prompt unscheduled visits. Diabetes is a known risk factor for wound healing complications after plastic and hand surgery.6,7 A hemoglobin A1c (HbA1c) screening protocol used by the NFSGVAHS plastic surgery service since 2015 to identify poorly controlled patients with diabetes before surgery may partially explain this finding.8 We did not find a statistically significant difference between patients with diabetes and patients without diabetes for scheduling unplanned appointments. The plastic surgery service does not perform elective hand surgery unless the patient’s HbA1c level is < 9%, or violate the flexor sheath unless HbA1c level is < 8%. However, Zhuang et al found an increase in soft tissue infections after hand surgery with HbA1c levels ≥ 7%.9
Smoking is a potential factor in postoperative hand surgery complications.10,11 Lans et al found an increased incidence of 30-day emergency room visits in current and former smokers after outpatient upper extremity fracture surgery.12 The MRVAMC Plastic Surgery Service counsels patients about the risk of skin necrosis and delayed wound healing, but does not cancel cases or obtain laboratory values to verify abstinence in patients undergoing hand surgery. The VA has multiple resources available for patients interested in smoking cessation through mental health services.13
MRVAMC patients have been known to resist returning for scheduled appointments due to the costs or availability of transportation. We suspected that patients who lived further from MRVAMC would be less likely to return for unscheduled visits. We used the first 3 digits of the patients’ mailing zip code to estimate residential proximity to MRVAMC. An acknowledged limitation to this approach is that some veterans have primary addresses in other regions but still spend significant time in the MRVAMC catchment area and use the facility for their health care during the winter months. These “snowbirds” might reside near the facility despite having official addresses that are more distant. Additionally, there was no increased risk of unplanned visits after hand surgery in patients aged > 61 years (the median age of study participants) (P = .82). Dependence on a third party for transportation in older veterans could impact this finding.
Based on the observation that most patients needed reassurance rather than an intervention when they returned for unscheduled appointments, diagnoses of depression, anxiety, and PTSD were evaluated as separate predictive factors. In previous research, anxiety was found to be a risk factor for problematic recovery following carpal tunnel surgery.14 In the current study, depression was found to be a statistically significant predictor of unscheduled postoperative appointments (P = .04), while anxiety (P = .33) and PTSD (P = .37) were not statistically significant predictors. This is consistent with other studies that have found preexisting depression can predict complications after hand surgery.15,16 Vranceanu et al found that depression predicted pain intensity and disability after elective hand surgery.16 Similarly, Oflazoglu et al found a 12% incidence of depression based on the Patient Health Questionnaire-9 in new and returning hand patients who presented to an academic practice.17 They suggest patients should be assessed at all levels of care and that those with poor responses to surgical or nonsurgical management should be evaluated for depression. MRVAMC has a large mental health service consisting of psychiatrists, psychologists, addiction specialists, social workers, and homeless outreach, and patients tend to already have a diagnosis and mental health practitioner when they present to the clinic.
Recent studies found that wound problems, pain, and stiffness were the most common reasons for return visits.18,19 Shetty et al identified younger age, worse preoperative pain scores, and poor access to transportation as predictors of preventable emergency room visits, which generate higher health care expenditures than an office visit.19 Our study’s top reasons for appointments (pain, wound/scar concerns, persistent symptoms) can be addressed with additional presurgery patient and family education. Additionally, clinicians encourage nonnarcotic pain management strategies including anti-inflammatories, acetaminophen, elevation, splinting, and hand therapy, and the hospital employs experienced, fellowship-trained anesthesia block faculty who help limit perioperative narcotic use. Patients are advised that pain can be used to guide them through the postoperative recovery by preventing overuse and alerting them to a problem that would be masked with narcotics, and long-standing problems such as chronic nerve compressions may continue to cause pain after surgery.
Patients and families can be given consistent and repetitive verbal and written information, instructions, and expectations at the initial consultation, preoperative appointment, and on the day of surgery. Postoperatively, outside their scheduled appointments, patients are encouraged to use the My HealtheVet secure messaging system or call the clinic to access an experienced registered nurse before making a long drive. Access to virtual or phone visits can reduce emergent in-person visits in a VA population.20
Ozdag et al found that 42% of patients who had elective carpal tunnel surgery made unplanned electronic messages or phone contact within 2 weeks postsurgery. The authors point out the uncompensated administrative burden on the staff answering these messages and suggest pre-empting the contacts with more up-front education regarding postoperative pain expectations and management strategies.21
Fisher et al found that attending hand therapy reduced the number of emergency department visits in postoperative infection cases.22 At MRVAMC, a postoperative emergency department visit for a patient prompts an urgent unplanned appointment to the plastic surgery clinic, often on the same day. The MRVAMC occupational therapy clinic employed 3 on-site certified hand therapists during the study period. Because all hand surgery patients at the clinic receive hand therapy on the same day as their first postoperative appointment, attendance at hand therapy was not evaluated as a predictor of unplanned visits. Scheduled hand therapy is another point of contact where the clinic can provide reassurance and patient education.
While females made up 17.1% of the patients in this study, they constituted 12.5% of all veterans in Florida in fiscal year 2023.23 This study found that women were more likely to present for unplanned postoperative appointments (P = .03). This is consistent with existing literature which has found that women are higher users of health care and office-based appointments.24,25 This finding suggests the need for further study into whether our methods of communicating instructions to female patients undergoing plastic surgery may not be optimal.
Strengths and Limitations
As a retrospective review, the authors used information documented by multiple different health care practitioners, including trainees. The electronic medical record problem lists and templates provide consistency of information; however, less seasoned clinicians may interpret what they see and hear differently from more experienced clinicians in the postoperative setting. This study occurred in one part of the country with demographics that may not mirror other VA systems or the general population. The authors hope this study can be a starting point for other health care facilities to investigate ways to minimize the burden of unscheduled appointments. A strength of the study is that it was conducted within a closed system, as patients tend to stay within the VA system and documentation and communication among clinicians, even outside the immediate facility, are easily accessed through the electronic health record.
Conclusions
This study found that depression diagnosis and female sex are statistically significant predictors of unplanned postoperative visits after elective soft tissue hand surgery. More effective patient education during the preoperative period, particularly in patients with depression, may be warranted.
- Apaydin EA, Paige NM, Begashaw MM, et al. Veterans Health Administration (VA) vs. non-VA healthcare quality: a systematic review. J Gen Intern Med. 2023;38:2179-2188. doi:10.1007/s11606-023-08207-2
- Blegen M, Ko J, Salzman G, et al. Comparing quality of surgical care between the US Department of Veterans Affairs and non-Veterans Affairs settings: a systematic review. J Am Coll Surg. 2023;237:352-361. doi:10.1097/XCS.0000000000000720
- Valsangkar NP, Eppstein AC, Lawson RA, et al. Effect of lean processes on surgical wait times and efficiency in a tertiary care veterans affairs medical center. JAMA Surg. 2017;152:42-47. doi:10.1001/jamasurg.2016.2808
- National Association of Veterans Affairs Physicians and Dentists. Physicians remain at top of staffing shortage in VA. NAVAPD. December 20, 2023. Accessed March 16, 2026. https://www.navapd.org/news/physicians-remain-at-top-of-staffing-shortage-in-va
- OIG Determination of Veterans Health Administration’s severe occupational staffing shortages fiscal year 2024. Veterans Affairs Office of Inspector General. August 7, 2024. Accessed February 4, 2026. https://www.vaoig.gov/reports/national-healthcare-review/oig-determination-veterans-health-administrations-severe-0
- Goltsman D, Morrison KA, Ascherman JA. Defining the association between diabetes and plastic surgery outcomes: an analysis of nearly 40,000 patients. Plast Reconstr Surg Glob Open. 2017;5:e1461. doi:10.1097/GOX.0000000000001461 7.
- Cox CT, Sierra S, Egan A, et al. Elevated hemoglobin A1c and the risk of postoperative complications in elective hand and upper extremity surgery. Cureus. 2023;15:e48373. doi:10.7759/cureus.48373
- Coady-Fariborzian L, Anstead C. HbA1c and infection in diabetic elective hand surgery: a Veterans Affair Medical Center experience 2012-2018. Hand (NY). 2023;18:994-998. doi:10.1177/1558944720937363<
- Zhuang T, Shapiro LM, Fogel N, et al. Perioperative laboratory markers as risk factors for surgical site infection after elective hand surgery. J Hand Surg Am. 2021;46:675-684. doi:10.1016/j.jhsa.2021.04.001
- Cho BH, Aziz KT, Giladi AM. The impact of smoking on early postoperative complications in hand surgery. J Hand Surg Am. 2021;46:336.e1-336.e11. doi:10.1016/j.jhsa.2020.07.01411.
- Del Core MA, Ahn J, Golden AS, et al. Effect of smoking on short-term postoperative complications after elective upper extremity surgery. Hand (N Y). 2022;17:231-238. doi:10.1177/1558944720926638
- Lans J, Beagles CB, Watkins IT, et al. Unplanned postoperative emergency department visits after upper extremity fracture surgery. J Orthop Trauma. 2025;39:22-27. doi:10.1097/BOT.0000000000002925
- Tobacco and health - how to quit. US Dept of Veterans Affairs. Updated October 29, 2025. Accessed February 4, 2026. https://www.mentalhealth.va.gov/quit-tobacco/how-to-quit.asp
- Ryan C, Miner H, Ramachandran S, et al. General anxiety is associated with problematic initial recovery after carpal tunnel release. Clin Orthop Relat Res. 2022;480:1576-1581. doi:10.1097/CORR.0000000000002115
- Crijns TJ, Bernstein DN, Ring D, et al. Depression and pain interference correlate with physical function in patients recovering from hand surgery. Hand (N Y). 2019;14:830-835. doi:10.1177/1558944718777814
- Vranceanu AM, Jupiter JB, Mudgal CS, et al. Predictors of pain intensity and disability after minor hand surgery. J Hand Surg Am. 2010;35:956-960. doi:10.1016/j.jhsa.2010.02.00117.
- Oflazoglu K, Mellema JJ, Menendez ME, et al. Prevalence of and factors associated with major depression in patients with upper extremity conditions. J Hand Surg Am. 2016;41:263-269. doi:10.1016/j.jhsa.2015.11.019
- Townsend CB, Henry TW, Lutsky KF, et al. Unplanned office visits following outpatient hand surgery. Hand (N Y). 2022;17:1264-1268. doi:10.1177/15589447211028932
- Shetty PN, Guarino GM, Zhang G, et al. Risk factors for preventable emergency department use after outpatient hand surgery. J Hand Surg Am. 2022;47:855-864. doi:10.1016/j.jhsa.2022.05.012
- Sommers-Olson B, Christianson J, Neumann T, et al. Reducing nonemergent visits to the emergency department in a Veterans Affairs multistate system. J Emerg Nurs. 2023;49:539-545. doi:10.1016/j.jen.2023.02.010
- Ozdag Y, Manzar S, El Koussaify J, et al. Unplanned postoperative phone calls and electronic messages for patients with and without opioid prescriptions after carpal tunnel release. J Hand Surg Glob Online. 2024;6:363-368. doi:10.1016/j.jhsg.2024.02.006
- Fisher AH, Gandhi J, Nelson Z, et al. Immediate interventions after surgery to reduce readmission for upper extremity infections. Ann Plast Surg. 2022;88:S163-S169. doi:10.1097/SAP.0000000000003141
- Florida Department of Veterans Affairs Fast Facts. Florida Department of Veterans Affairs. Accessed February 4, 2026. https://floridavets.org/our-veterans/profilefast-facts/
- Bertakis KD, Azari R, Helms LJ, et al. Gender differences in the utilization of health care services. J Fam Pract. 2000;49:147-152.
- Ashman JJ, Santo L, Okeyode T. Characteristics of office-based physician visits, 2018. NCHS Data Brief. 2021;408:1-8.
- Apaydin EA, Paige NM, Begashaw MM, et al. Veterans Health Administration (VA) vs. non-VA healthcare quality: a systematic review. J Gen Intern Med. 2023;38:2179-2188. doi:10.1007/s11606-023-08207-2
- Blegen M, Ko J, Salzman G, et al. Comparing quality of surgical care between the US Department of Veterans Affairs and non-Veterans Affairs settings: a systematic review. J Am Coll Surg. 2023;237:352-361. doi:10.1097/XCS.0000000000000720
- Valsangkar NP, Eppstein AC, Lawson RA, et al. Effect of lean processes on surgical wait times and efficiency in a tertiary care veterans affairs medical center. JAMA Surg. 2017;152:42-47. doi:10.1001/jamasurg.2016.2808
- National Association of Veterans Affairs Physicians and Dentists. Physicians remain at top of staffing shortage in VA. NAVAPD. December 20, 2023. Accessed March 16, 2026. https://www.navapd.org/news/physicians-remain-at-top-of-staffing-shortage-in-va
- OIG Determination of Veterans Health Administration’s severe occupational staffing shortages fiscal year 2024. Veterans Affairs Office of Inspector General. August 7, 2024. Accessed February 4, 2026. https://www.vaoig.gov/reports/national-healthcare-review/oig-determination-veterans-health-administrations-severe-0
- Goltsman D, Morrison KA, Ascherman JA. Defining the association between diabetes and plastic surgery outcomes: an analysis of nearly 40,000 patients. Plast Reconstr Surg Glob Open. 2017;5:e1461. doi:10.1097/GOX.0000000000001461 7.
- Cox CT, Sierra S, Egan A, et al. Elevated hemoglobin A1c and the risk of postoperative complications in elective hand and upper extremity surgery. Cureus. 2023;15:e48373. doi:10.7759/cureus.48373
- Coady-Fariborzian L, Anstead C. HbA1c and infection in diabetic elective hand surgery: a Veterans Affair Medical Center experience 2012-2018. Hand (NY). 2023;18:994-998. doi:10.1177/1558944720937363<
- Zhuang T, Shapiro LM, Fogel N, et al. Perioperative laboratory markers as risk factors for surgical site infection after elective hand surgery. J Hand Surg Am. 2021;46:675-684. doi:10.1016/j.jhsa.2021.04.001
- Cho BH, Aziz KT, Giladi AM. The impact of smoking on early postoperative complications in hand surgery. J Hand Surg Am. 2021;46:336.e1-336.e11. doi:10.1016/j.jhsa.2020.07.01411.
- Del Core MA, Ahn J, Golden AS, et al. Effect of smoking on short-term postoperative complications after elective upper extremity surgery. Hand (N Y). 2022;17:231-238. doi:10.1177/1558944720926638
- Lans J, Beagles CB, Watkins IT, et al. Unplanned postoperative emergency department visits after upper extremity fracture surgery. J Orthop Trauma. 2025;39:22-27. doi:10.1097/BOT.0000000000002925
- Tobacco and health - how to quit. US Dept of Veterans Affairs. Updated October 29, 2025. Accessed February 4, 2026. https://www.mentalhealth.va.gov/quit-tobacco/how-to-quit.asp
- Ryan C, Miner H, Ramachandran S, et al. General anxiety is associated with problematic initial recovery after carpal tunnel release. Clin Orthop Relat Res. 2022;480:1576-1581. doi:10.1097/CORR.0000000000002115
- Crijns TJ, Bernstein DN, Ring D, et al. Depression and pain interference correlate with physical function in patients recovering from hand surgery. Hand (N Y). 2019;14:830-835. doi:10.1177/1558944718777814
- Vranceanu AM, Jupiter JB, Mudgal CS, et al. Predictors of pain intensity and disability after minor hand surgery. J Hand Surg Am. 2010;35:956-960. doi:10.1016/j.jhsa.2010.02.00117.
- Oflazoglu K, Mellema JJ, Menendez ME, et al. Prevalence of and factors associated with major depression in patients with upper extremity conditions. J Hand Surg Am. 2016;41:263-269. doi:10.1016/j.jhsa.2015.11.019
- Townsend CB, Henry TW, Lutsky KF, et al. Unplanned office visits following outpatient hand surgery. Hand (N Y). 2022;17:1264-1268. doi:10.1177/15589447211028932
- Shetty PN, Guarino GM, Zhang G, et al. Risk factors for preventable emergency department use after outpatient hand surgery. J Hand Surg Am. 2022;47:855-864. doi:10.1016/j.jhsa.2022.05.012
- Sommers-Olson B, Christianson J, Neumann T, et al. Reducing nonemergent visits to the emergency department in a Veterans Affairs multistate system. J Emerg Nurs. 2023;49:539-545. doi:10.1016/j.jen.2023.02.010
- Ozdag Y, Manzar S, El Koussaify J, et al. Unplanned postoperative phone calls and electronic messages for patients with and without opioid prescriptions after carpal tunnel release. J Hand Surg Glob Online. 2024;6:363-368. doi:10.1016/j.jhsg.2024.02.006
- Fisher AH, Gandhi J, Nelson Z, et al. Immediate interventions after surgery to reduce readmission for upper extremity infections. Ann Plast Surg. 2022;88:S163-S169. doi:10.1097/SAP.0000000000003141
- Florida Department of Veterans Affairs Fast Facts. Florida Department of Veterans Affairs. Accessed February 4, 2026. https://floridavets.org/our-veterans/profilefast-facts/
- Bertakis KD, Azari R, Helms LJ, et al. Gender differences in the utilization of health care services. J Fam Pract. 2000;49:147-152.
- Ashman JJ, Santo L, Okeyode T. Characteristics of office-based physician visits, 2018. NCHS Data Brief. 2021;408:1-8.
Predictors of Unplanned Postoperative Visits in a Veterans Affairs Hand Surgery Practice
Predictors of Unplanned Postoperative Visits in a Veterans Affairs Hand Surgery Practice
Surgical Treatment of Nonmelanoma Skin Cancer in Older Adult Veterans
Skin cancer is the most diagnosed cancer in the United States. Nonmelanoma skin cancers (NMSC), which include basal cell carcinoma and squamous cell carcinoma, are usually cured with removal.1 The incidence of NMSC increases with age and is commonly found in nursing homes and geriatric units. These cancers are not usually metastatic or fatal but can cause local destruction and disfigurement if neglected.2 The current standard of care is to treat diagnosed NMSC; however, the dermatology and geriatric care literature have questioned the logic of treating asymptomatic skin cancers that will not affect a patient’s life expectancy.2-4
Forty-seven percent of the current living veteran population is aged ≥ 65 years.5 Older adult patients are frequently referred to the US Department of Veterans Affairs (VA) surgical service for the treatment of NMSC. The veteran population includes a higher percentage of individuals at an elevated risk of skin cancers (older, White, and male) compared with the general population.6 World War II veterans deployed in regions closer to the equator have been found to have an elevated risk of melanoma and nonmelanoma skin carcinomas.7 A retrospective study of Vietnam veterans exposed to Agent Orange (2,3,7,8-tetrachlorodibenzodioxin) found a significantly higher risk of invasive NMSC in Fitzpatrick skin types I-IV compared with an age-matched subset of the general population.8 Younger veterans who were deployed in Afghanistan and Iraq for Operation Enduring Freedom/Operation Iraqi Freedom worked at more equatorial latitudes than the rest of the US population and may be at increased risk of NMSC. Inadequate sunscreen access, immediate safety concerns, outdoor recreational activities, harsh weather, and insufficient emphasis on sun protection have created a multifactorial challenge for the military population. Riemenschneider and colleagues recommended targeted screening for at-risk veteran patients and prioritizing annual skin cancer screenings during medical mission physical examinations for active military.7
The plastic surgery service regularly receives consults from dermatology, general surgery, and primary care to remove skin cancers on the face, scalp, hands, and forearms. Skin cancer treatment can create serious hardships for older adult patients and their families with multiple appointments for the consult, procedure, and follow-up. Patients are often told to hold their anticoagulant medications when the surgery will be performed on a highly vascular region, such as the scalp or face. This can create wide swings in their laboratory test values and result in life-threatening complications from either bleeding or clotting. The appropriateness of offering surgery to patients with serious comorbidities and a limited life expectancy has been questioned.2-4 The purpose of this study was to measure the morbidity and unrelated 5-year mortality for patients with skin cancer referred to the plastic surgery service to help patients and families make a more informed treatment decision, particularly when the patients are aged > 80 years and have significant life-threatening comorbidities.
Methods
The University of Florida and Malcom Randall VA Medical Center Institutional review board in Gainesville, approved a retrospective review of all consults completed by the plastic surgery service for the treatment of NMSC performed from July 1, 2011 to June 30, 2015. Data collected included age and common life-limiting comorbidities at the time of referral. Morbidities were found on the electronic health record, including coronary artery disease (CAD), congestive heart failure (CHF), cerebral vascular disease (CVD), peripheral vascular disease, dementia, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), tobacco use, diabetes mellitus (DM), liver disease, alcohol use, and obstructive sleep apnea.
Treatment, complications, and 5-year mortality were recorded. A χ2 analysis with P value < .05 was used to determine statistical significance between individual risk factors and 5-year mortality. The relative risk of 5-year mortality was calculated by combining advanced age (aged > 80 years) with the individual comorbidities.
Results
Over 4 years, 800 consults for NMSC were completed by the plastic surgery service. Treatment decisions included 210 excisions (with or without reconstruction) in the operating room, 402 excisions (with or without reconstruction) under local anesthesia in clinic, 55 Mohs surgical dermatology referrals, 21 other service or hospital referrals, and 112 patient who were observed, declined intervention, or died prior to intervention. Five-year mortality was 28.6%. No patients died of NMSC. The median age at consult submission for patients deceased 5 years later was 78 years. Complication rate was 5% and included wound infection, dehiscence, bleeding, or graft loss. Two patients, both deceased within 5 years, had unplanned admissions due to bleeding from either a skin graft donor site or recipient bleeding. Aged ≥ 80 years, CAD, CHF, CVD, peripheral vascular disease, dementia, CKD, COPD, and DM were all found individually to be statistically significant predictors of 5-year mortality (Table 1). Combining aged ≥ 80 years plus CAD, CHF, or dementia all increased the 5-year mortality by a relative risk of > 3 (Table 2).
Discussion
The standard of care is to treat NMSC. Most NMSCs are treated surgically without consideration of patient age or life expectancy.2,4,9,10 A prospective cohort study involving a university-based private practice and a VA medical center in San Francisco found a 22.6% overall 5-year mortality and a 43.3% mortality in the group defined as limited life expectancy (LLE) based on age (≥ 85 years) and medical comorbidities. None died due to the NMSC. Leading cause of death was cardiac, cerebrovascular, and respiratory disease, lung and prostate cancer, and Alzheimer disease. The authors suggested the LLE group may be exposed to wound complications without benefiting from the treatment.4
Another study of 440 patients receiving excision for biopsy-proven facial NMSC at the Roudebush VA Medical Center in Indianapolis, Indiana, found no residual carcinoma in 35.3% of excisions, and in patients aged > 90 years, more than half of the excisions had no residual carcinoma. More than half of the patients aged > 90 years died within 1 year, not as a result of the NMSC. The authors argued for watchful waiting in select patients to maximize comfort and outcomes.10
NMSCs are often asymptomatic and not immediately life threatening. Although NMSCs tend to have a favorable prognosis, studies have found that NMSC may be a marker for other poor health outcomes. A significant increased risk for all-cause mortality was found for patients with a history of SCC, which may be attributed to immune status.11 The aging veteran population has more complex health care needs to be considered when developing surgical treatment plans. These medical problems may limit their life expectancy much sooner than the skin cancer will become symptomatic. We found that individuals aged ≥ 80 years who had CAD, CHF, or dementia had a relative risk of 3 or higher for 5-year mortality. The leading cause of death in the United States in years 2011 to 2015 was heart disease. Alzheimer disease was the sixth leading cause of death in those same years.12-14
Skin cancer excisions do not typically require general anesthesia, deep sedation, or large fluid shifts; however, studies have found that when frail patients undergo low-risk procedures, they tend to have a higher mortality rate than their healthier counterparts.15 Frailty is a concept that identifies patients who are at increased risk of dying in 6 to 60 months due to a decline in their physical reserve. Frail patients have increased rates of perioperative mortality and complications. Various tools have been used to assess the components of physical performance, speed, mobility, nutrition status, mental health, and cognition.16 Frailty screening has been initiated in several VA hospitals, including our own in Gainesville, Florida, with the goal of decreasing postoperative morbidity and mortality in older adult patients.17 The patients are given a 1-page screening assessment that asks about their living situation, medical conditions, nutrition status, cognition, and activities of daily living. The results can trigger the clinician to rethink the surgical plan and mobilize more resources to optimize the patient’s health. This study period precedes the initiative at our institution.
The plastic surgery service’s routine practice is to excise skin cancers in the operating room if sedation or general anesthesia will be needed (Figure 1A), for optimal control of bleeding (Figure 1B) in a patient who cannot safely stop blood thinners, or for excision of a highly vascularized area such as the scalp. Surgery is offered in an office-based setting if the area can be closed primarily, left open to close secondarily, or closed with a small skin graft under local anesthesia only (Figure 2). We prefer treating frail patients in the minor procedure clinic, when possible, to avoid the risks of sedation and the additional preoperative visits and transportation requirements. NMSC with unclear margins (Figure 3A) or in cosmetically sensitive areas where tissue needs to be preserved (Figure 3B) are referred to the Mohs dermatologist. The skin cancers in this study were most frequently found on the face, scalp, hands, and forearms based on referral patterns.
Other treatment options for NMSC include curettage and electrodessication, cryotherapy, and radiation; however, ours is a surgical service and patients are typically referred to us by primary care or dermatology when those are not reasonable or desirable options.18 Published complication rates of patients having skin cancer surgery without age restriction have a rate of 3% to 6%, which is consistent with our study of 5%.19-21 Two bleeding complications that needed to be admitted did not require more than a bedside procedure and neither required transfusions. One patient had been instructed to continue taking coumadin during the perioperative office-based procedure due to a recent carotid stent placement in the setting of a rapidly growing basal cell on an easily accessible location.
The most noted comorbidity in patients with wound complications was found to be DM; however, this was not found to be a statistically significant risk factor for wound complications (P = .10). We do not have a set rule for advising for or against NMSC surgery. We do counsel frail patients and their families that not all cancer is immediately life threatening and will work with them to do whatever makes the most sense to achieve their goals, occasionally accepting positive margins in order to debulk a symptomatic growth. The objective of this paper is to contribute to the discussion of performing invasive procedures on older adult veterans with life-limiting comorbidities. Patients and their families will have different thresholds for what they feel needs intervention, especially if other medical problems are consuming much of their time. We also have the community care referral option for patients whose treatment decisions are being dictated by travel hardships.
Strengths and Limitations
A strength of this study is that the data were obtained from a closed system. Patients tend to stay long-term within the VA and their health record is accessible throughout the country as long as they are seen at a VA facility. Complications, therefore, return to the treating service or primary care, who would route the patient back to the surgeon.
One limitation of the study is that this is a retrospective review from 2011. The authors are limited to data that are recorded in the patient record. Multiple health care professionals saw the patients and notes lack consistency in detail. Size of the lesions were not consistently recorded and did not get logged into our database for that reason.
Conclusions
Treatment of NMSC in older adult patients has a low morbidity but needs to be balanced against a patient and family’s goals when the patient presents with life-limiting comorbidities. An elevated 5-year mortality in patients aged > 80 years with serious unrelated medical conditions is intuitive, but this study may help put treatment plans into perspective for families and health care professionals who want to provide an indicated service while maximizing patient quality of life.
Acknowledgments
This manuscript is the result of work supported with resources and the use of facilities at the North Florida/South Georgia Veterans Health System, Gainesville, Florida.
1. American Cancer Society. Cancer Facts & Figures 2021. Accessed May 26, 2022. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2021/cancer-facts-and-figures-2021.pdf
2. Albert A, Knoll MA, Conti JA, Zbar RIS. Non-melanoma skin cancers in the older patient. Curr Oncol Rep. 2019;21(9):79. Published 2019 Jul 29. doi:10.1007/s11912-019-0828-9
3. Linos E, Chren MM, Stijacic Cenzer I, Covinsky KE. Skin cancer in U.S. elderly adults: does life expectancy play a role in treatment decisions? J Am Geriatr Soc. 2016;64(8):1610-1615. doi:10.1111/jgs.14202
4. Linos E, Parvataneni R, Stuart SE, Boscardin WJ, Landefeld CS, Chren MM. Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer. JAMA Intern Med. 2013;173(11):1006-1012. doi:10.1001/jamainternmed.2013.639
5. O’Malley KA, Vinson L, Kaiser AP, Sager Z, Hinrichs K. Mental health and aging veterans: how the Veterans Health Administration meets the needs of aging veterans. Public Policy Aging Rep. 2020;30(1):19-23. doi:10.1093/ppar/prz027
6. US Department of Veterans Affairs, National Center for Veterans Analysis and Statistics. Profile of veterans: 2017. Accessed May 26, 2022. https://www.va.gov/vetdata/docs/SpecialReports/Profile_of_Veterans_2017.pdf 7. Riemenschneider K, Liu J, Powers JG. Skin cancer in the military: a systematic review of melanoma and nonmelanoma skin cancer incidence, prevention, and screening among active duty and veteran personnel. J Am Acad Dermatol. 2018;78(6):1185-1192. doi:10.1016/j.jaad.2017.11.062
8. Clemens MW, Kochuba AL, Carter ME, Han K, Liu J, Evans K. Association between Agent Orange exposure and nonmelanotic invasive skin cancer: a pilot study. Plast Reconstr Surg. 2014;133(2):432-437. doi:10.1097/01.prs.0000436859.40151.cf
9. Cameron MC, Lee E, Hibler BP, et al. Basal cell carcinoma: epidemiology; pathophysiology; clinical and histological subtypes; and disease associations. J Am Acad Dermatol. 2019;80(2):303-317. doi:10.1016/j.jaad.2018.03.060
10. Chauhan R, Munger BN, Chu MW, et al. Age at diagnosis as a relative contraindication for intervention in facial nonmelanoma skin cancer. JAMA Surg. 2018;153(4):390-392. doi:10.1001/jamasurg.2017.5073
11. Barton V, Armeson K, Hampras S, et al. Nonmelanoma skin cancer and risk of all-cause and cancer-related mortality: a systematic review. Arch Dermatol Res. 2017;309(4):243-251. doi:10.1007/s00403-017-1724-5
12. Kochanek KD, Murphy SL, Xu JQ, Arias E. Mortality in the United States, 2013. NCHS Data Brief 178. Accessed May 26, 2022. https://www.cdc.gov/nchs/products/databriefs/db178.htm
13. Xu JQ, Kochanek KD, Murphy SL, Arias E. Mortality in the United States, 2012. NCHS Data Brief 168. Accessed May 26, 2022. https://www.cdc.gov/nchs/products/databriefs/db168.htm
14. Xu JQ, Murphy SL, Kochanek KD, Arias E. Mortality in the United States, 2015. NCHS Data Brief 267. Accessed May 26, 2022. https://www.cdc.gov/nchs/products/databriefs/db267.htm
15. Varley PR , Borrebach JD, Arya S, et al. Clinical utility of the risk analysis index as a prospective frailty screening tool within a multi-practice, multi-hospital integrated healthcare system. Ann Surg. 2021;274(6):e1230-e1237. doi:10.1097/SLA.0000000000003808
16. Hall DE, Arya S , Schmid KK, et al. Development and initial validation of the risk analysis index for measuring frailty in surgical populations. JAMA Surg. 2017;152(2):175-182. doi:10.1001/jamasurg.2016.4202
17. US Department of Veterans Affairs, Health Services Research & Development. Improving healthcare for aging veterans. Updated August 30, 2017. Accessed May 26, 2022. https://www.hsrd.research.va.gov/news/feature/aging0917.cfm
18. Leus AJG, Frie M, Haisma MS, et al. Treatment of keratinocyte carcinoma in elderly patients – a review of the current literature. J Eur Acad Dermatol Venereol. 2020;34(9):1932-1943. doi:10.1111/jdv.16268
19. Amici JM, Rogues AM, Lasheras A, et al. A prospective study of the incidence of complications associated with dermatological surgery. Br J Dermatol. 2005;153(5):967-971. doi:10.1111/j.1365-2133.2005.06861.x
20. Arguello-Guerra L, Vargas-Chandomid E, Díaz-González JM, Méndez-Flores S, Ruelas-Villavicencio A, Domínguez-Cherit J. Incidence of complications in dermatological surgery of melanoma and non-melanoma skin cancer in patients with multiple comorbidity and/or antiplatelet-anticoagulants. Five-year experience in our hospital. Cir Cir. 2019;86(1):15-23. doi:10.24875/CIRUE.M18000003
21. Keith DJ, de Berker DA, Bray AP, Cheung ST, Brain A, Mohd Mustapa MF. British Association of Dermatologists’ national audit on nonmelanoma skin cancer excision, 2014. Clin Exp Dermatol. 2017;42(1):46-53. doi:10.1111/ced.12990
Skin cancer is the most diagnosed cancer in the United States. Nonmelanoma skin cancers (NMSC), which include basal cell carcinoma and squamous cell carcinoma, are usually cured with removal.1 The incidence of NMSC increases with age and is commonly found in nursing homes and geriatric units. These cancers are not usually metastatic or fatal but can cause local destruction and disfigurement if neglected.2 The current standard of care is to treat diagnosed NMSC; however, the dermatology and geriatric care literature have questioned the logic of treating asymptomatic skin cancers that will not affect a patient’s life expectancy.2-4
Forty-seven percent of the current living veteran population is aged ≥ 65 years.5 Older adult patients are frequently referred to the US Department of Veterans Affairs (VA) surgical service for the treatment of NMSC. The veteran population includes a higher percentage of individuals at an elevated risk of skin cancers (older, White, and male) compared with the general population.6 World War II veterans deployed in regions closer to the equator have been found to have an elevated risk of melanoma and nonmelanoma skin carcinomas.7 A retrospective study of Vietnam veterans exposed to Agent Orange (2,3,7,8-tetrachlorodibenzodioxin) found a significantly higher risk of invasive NMSC in Fitzpatrick skin types I-IV compared with an age-matched subset of the general population.8 Younger veterans who were deployed in Afghanistan and Iraq for Operation Enduring Freedom/Operation Iraqi Freedom worked at more equatorial latitudes than the rest of the US population and may be at increased risk of NMSC. Inadequate sunscreen access, immediate safety concerns, outdoor recreational activities, harsh weather, and insufficient emphasis on sun protection have created a multifactorial challenge for the military population. Riemenschneider and colleagues recommended targeted screening for at-risk veteran patients and prioritizing annual skin cancer screenings during medical mission physical examinations for active military.7
The plastic surgery service regularly receives consults from dermatology, general surgery, and primary care to remove skin cancers on the face, scalp, hands, and forearms. Skin cancer treatment can create serious hardships for older adult patients and their families with multiple appointments for the consult, procedure, and follow-up. Patients are often told to hold their anticoagulant medications when the surgery will be performed on a highly vascular region, such as the scalp or face. This can create wide swings in their laboratory test values and result in life-threatening complications from either bleeding or clotting. The appropriateness of offering surgery to patients with serious comorbidities and a limited life expectancy has been questioned.2-4 The purpose of this study was to measure the morbidity and unrelated 5-year mortality for patients with skin cancer referred to the plastic surgery service to help patients and families make a more informed treatment decision, particularly when the patients are aged > 80 years and have significant life-threatening comorbidities.
Methods
The University of Florida and Malcom Randall VA Medical Center Institutional review board in Gainesville, approved a retrospective review of all consults completed by the plastic surgery service for the treatment of NMSC performed from July 1, 2011 to June 30, 2015. Data collected included age and common life-limiting comorbidities at the time of referral. Morbidities were found on the electronic health record, including coronary artery disease (CAD), congestive heart failure (CHF), cerebral vascular disease (CVD), peripheral vascular disease, dementia, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), tobacco use, diabetes mellitus (DM), liver disease, alcohol use, and obstructive sleep apnea.
Treatment, complications, and 5-year mortality were recorded. A χ2 analysis with P value < .05 was used to determine statistical significance between individual risk factors and 5-year mortality. The relative risk of 5-year mortality was calculated by combining advanced age (aged > 80 years) with the individual comorbidities.
Results
Over 4 years, 800 consults for NMSC were completed by the plastic surgery service. Treatment decisions included 210 excisions (with or without reconstruction) in the operating room, 402 excisions (with or without reconstruction) under local anesthesia in clinic, 55 Mohs surgical dermatology referrals, 21 other service or hospital referrals, and 112 patient who were observed, declined intervention, or died prior to intervention. Five-year mortality was 28.6%. No patients died of NMSC. The median age at consult submission for patients deceased 5 years later was 78 years. Complication rate was 5% and included wound infection, dehiscence, bleeding, or graft loss. Two patients, both deceased within 5 years, had unplanned admissions due to bleeding from either a skin graft donor site or recipient bleeding. Aged ≥ 80 years, CAD, CHF, CVD, peripheral vascular disease, dementia, CKD, COPD, and DM were all found individually to be statistically significant predictors of 5-year mortality (Table 1). Combining aged ≥ 80 years plus CAD, CHF, or dementia all increased the 5-year mortality by a relative risk of > 3 (Table 2).
Discussion
The standard of care is to treat NMSC. Most NMSCs are treated surgically without consideration of patient age or life expectancy.2,4,9,10 A prospective cohort study involving a university-based private practice and a VA medical center in San Francisco found a 22.6% overall 5-year mortality and a 43.3% mortality in the group defined as limited life expectancy (LLE) based on age (≥ 85 years) and medical comorbidities. None died due to the NMSC. Leading cause of death was cardiac, cerebrovascular, and respiratory disease, lung and prostate cancer, and Alzheimer disease. The authors suggested the LLE group may be exposed to wound complications without benefiting from the treatment.4
Another study of 440 patients receiving excision for biopsy-proven facial NMSC at the Roudebush VA Medical Center in Indianapolis, Indiana, found no residual carcinoma in 35.3% of excisions, and in patients aged > 90 years, more than half of the excisions had no residual carcinoma. More than half of the patients aged > 90 years died within 1 year, not as a result of the NMSC. The authors argued for watchful waiting in select patients to maximize comfort and outcomes.10
NMSCs are often asymptomatic and not immediately life threatening. Although NMSCs tend to have a favorable prognosis, studies have found that NMSC may be a marker for other poor health outcomes. A significant increased risk for all-cause mortality was found for patients with a history of SCC, which may be attributed to immune status.11 The aging veteran population has more complex health care needs to be considered when developing surgical treatment plans. These medical problems may limit their life expectancy much sooner than the skin cancer will become symptomatic. We found that individuals aged ≥ 80 years who had CAD, CHF, or dementia had a relative risk of 3 or higher for 5-year mortality. The leading cause of death in the United States in years 2011 to 2015 was heart disease. Alzheimer disease was the sixth leading cause of death in those same years.12-14
Skin cancer excisions do not typically require general anesthesia, deep sedation, or large fluid shifts; however, studies have found that when frail patients undergo low-risk procedures, they tend to have a higher mortality rate than their healthier counterparts.15 Frailty is a concept that identifies patients who are at increased risk of dying in 6 to 60 months due to a decline in their physical reserve. Frail patients have increased rates of perioperative mortality and complications. Various tools have been used to assess the components of physical performance, speed, mobility, nutrition status, mental health, and cognition.16 Frailty screening has been initiated in several VA hospitals, including our own in Gainesville, Florida, with the goal of decreasing postoperative morbidity and mortality in older adult patients.17 The patients are given a 1-page screening assessment that asks about their living situation, medical conditions, nutrition status, cognition, and activities of daily living. The results can trigger the clinician to rethink the surgical plan and mobilize more resources to optimize the patient’s health. This study period precedes the initiative at our institution.
The plastic surgery service’s routine practice is to excise skin cancers in the operating room if sedation or general anesthesia will be needed (Figure 1A), for optimal control of bleeding (Figure 1B) in a patient who cannot safely stop blood thinners, or for excision of a highly vascularized area such as the scalp. Surgery is offered in an office-based setting if the area can be closed primarily, left open to close secondarily, or closed with a small skin graft under local anesthesia only (Figure 2). We prefer treating frail patients in the minor procedure clinic, when possible, to avoid the risks of sedation and the additional preoperative visits and transportation requirements. NMSC with unclear margins (Figure 3A) or in cosmetically sensitive areas where tissue needs to be preserved (Figure 3B) are referred to the Mohs dermatologist. The skin cancers in this study were most frequently found on the face, scalp, hands, and forearms based on referral patterns.
Other treatment options for NMSC include curettage and electrodessication, cryotherapy, and radiation; however, ours is a surgical service and patients are typically referred to us by primary care or dermatology when those are not reasonable or desirable options.18 Published complication rates of patients having skin cancer surgery without age restriction have a rate of 3% to 6%, which is consistent with our study of 5%.19-21 Two bleeding complications that needed to be admitted did not require more than a bedside procedure and neither required transfusions. One patient had been instructed to continue taking coumadin during the perioperative office-based procedure due to a recent carotid stent placement in the setting of a rapidly growing basal cell on an easily accessible location.
The most noted comorbidity in patients with wound complications was found to be DM; however, this was not found to be a statistically significant risk factor for wound complications (P = .10). We do not have a set rule for advising for or against NMSC surgery. We do counsel frail patients and their families that not all cancer is immediately life threatening and will work with them to do whatever makes the most sense to achieve their goals, occasionally accepting positive margins in order to debulk a symptomatic growth. The objective of this paper is to contribute to the discussion of performing invasive procedures on older adult veterans with life-limiting comorbidities. Patients and their families will have different thresholds for what they feel needs intervention, especially if other medical problems are consuming much of their time. We also have the community care referral option for patients whose treatment decisions are being dictated by travel hardships.
Strengths and Limitations
A strength of this study is that the data were obtained from a closed system. Patients tend to stay long-term within the VA and their health record is accessible throughout the country as long as they are seen at a VA facility. Complications, therefore, return to the treating service or primary care, who would route the patient back to the surgeon.
One limitation of the study is that this is a retrospective review from 2011. The authors are limited to data that are recorded in the patient record. Multiple health care professionals saw the patients and notes lack consistency in detail. Size of the lesions were not consistently recorded and did not get logged into our database for that reason.
Conclusions
Treatment of NMSC in older adult patients has a low morbidity but needs to be balanced against a patient and family’s goals when the patient presents with life-limiting comorbidities. An elevated 5-year mortality in patients aged > 80 years with serious unrelated medical conditions is intuitive, but this study may help put treatment plans into perspective for families and health care professionals who want to provide an indicated service while maximizing patient quality of life.
Acknowledgments
This manuscript is the result of work supported with resources and the use of facilities at the North Florida/South Georgia Veterans Health System, Gainesville, Florida.
Skin cancer is the most diagnosed cancer in the United States. Nonmelanoma skin cancers (NMSC), which include basal cell carcinoma and squamous cell carcinoma, are usually cured with removal.1 The incidence of NMSC increases with age and is commonly found in nursing homes and geriatric units. These cancers are not usually metastatic or fatal but can cause local destruction and disfigurement if neglected.2 The current standard of care is to treat diagnosed NMSC; however, the dermatology and geriatric care literature have questioned the logic of treating asymptomatic skin cancers that will not affect a patient’s life expectancy.2-4
Forty-seven percent of the current living veteran population is aged ≥ 65 years.5 Older adult patients are frequently referred to the US Department of Veterans Affairs (VA) surgical service for the treatment of NMSC. The veteran population includes a higher percentage of individuals at an elevated risk of skin cancers (older, White, and male) compared with the general population.6 World War II veterans deployed in regions closer to the equator have been found to have an elevated risk of melanoma and nonmelanoma skin carcinomas.7 A retrospective study of Vietnam veterans exposed to Agent Orange (2,3,7,8-tetrachlorodibenzodioxin) found a significantly higher risk of invasive NMSC in Fitzpatrick skin types I-IV compared with an age-matched subset of the general population.8 Younger veterans who were deployed in Afghanistan and Iraq for Operation Enduring Freedom/Operation Iraqi Freedom worked at more equatorial latitudes than the rest of the US population and may be at increased risk of NMSC. Inadequate sunscreen access, immediate safety concerns, outdoor recreational activities, harsh weather, and insufficient emphasis on sun protection have created a multifactorial challenge for the military population. Riemenschneider and colleagues recommended targeted screening for at-risk veteran patients and prioritizing annual skin cancer screenings during medical mission physical examinations for active military.7
The plastic surgery service regularly receives consults from dermatology, general surgery, and primary care to remove skin cancers on the face, scalp, hands, and forearms. Skin cancer treatment can create serious hardships for older adult patients and their families with multiple appointments for the consult, procedure, and follow-up. Patients are often told to hold their anticoagulant medications when the surgery will be performed on a highly vascular region, such as the scalp or face. This can create wide swings in their laboratory test values and result in life-threatening complications from either bleeding or clotting. The appropriateness of offering surgery to patients with serious comorbidities and a limited life expectancy has been questioned.2-4 The purpose of this study was to measure the morbidity and unrelated 5-year mortality for patients with skin cancer referred to the plastic surgery service to help patients and families make a more informed treatment decision, particularly when the patients are aged > 80 years and have significant life-threatening comorbidities.
Methods
The University of Florida and Malcom Randall VA Medical Center Institutional review board in Gainesville, approved a retrospective review of all consults completed by the plastic surgery service for the treatment of NMSC performed from July 1, 2011 to June 30, 2015. Data collected included age and common life-limiting comorbidities at the time of referral. Morbidities were found on the electronic health record, including coronary artery disease (CAD), congestive heart failure (CHF), cerebral vascular disease (CVD), peripheral vascular disease, dementia, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), tobacco use, diabetes mellitus (DM), liver disease, alcohol use, and obstructive sleep apnea.
Treatment, complications, and 5-year mortality were recorded. A χ2 analysis with P value < .05 was used to determine statistical significance between individual risk factors and 5-year mortality. The relative risk of 5-year mortality was calculated by combining advanced age (aged > 80 years) with the individual comorbidities.
Results
Over 4 years, 800 consults for NMSC were completed by the plastic surgery service. Treatment decisions included 210 excisions (with or without reconstruction) in the operating room, 402 excisions (with or without reconstruction) under local anesthesia in clinic, 55 Mohs surgical dermatology referrals, 21 other service or hospital referrals, and 112 patient who were observed, declined intervention, or died prior to intervention. Five-year mortality was 28.6%. No patients died of NMSC. The median age at consult submission for patients deceased 5 years later was 78 years. Complication rate was 5% and included wound infection, dehiscence, bleeding, or graft loss. Two patients, both deceased within 5 years, had unplanned admissions due to bleeding from either a skin graft donor site or recipient bleeding. Aged ≥ 80 years, CAD, CHF, CVD, peripheral vascular disease, dementia, CKD, COPD, and DM were all found individually to be statistically significant predictors of 5-year mortality (Table 1). Combining aged ≥ 80 years plus CAD, CHF, or dementia all increased the 5-year mortality by a relative risk of > 3 (Table 2).
Discussion
The standard of care is to treat NMSC. Most NMSCs are treated surgically without consideration of patient age or life expectancy.2,4,9,10 A prospective cohort study involving a university-based private practice and a VA medical center in San Francisco found a 22.6% overall 5-year mortality and a 43.3% mortality in the group defined as limited life expectancy (LLE) based on age (≥ 85 years) and medical comorbidities. None died due to the NMSC. Leading cause of death was cardiac, cerebrovascular, and respiratory disease, lung and prostate cancer, and Alzheimer disease. The authors suggested the LLE group may be exposed to wound complications without benefiting from the treatment.4
Another study of 440 patients receiving excision for biopsy-proven facial NMSC at the Roudebush VA Medical Center in Indianapolis, Indiana, found no residual carcinoma in 35.3% of excisions, and in patients aged > 90 years, more than half of the excisions had no residual carcinoma. More than half of the patients aged > 90 years died within 1 year, not as a result of the NMSC. The authors argued for watchful waiting in select patients to maximize comfort and outcomes.10
NMSCs are often asymptomatic and not immediately life threatening. Although NMSCs tend to have a favorable prognosis, studies have found that NMSC may be a marker for other poor health outcomes. A significant increased risk for all-cause mortality was found for patients with a history of SCC, which may be attributed to immune status.11 The aging veteran population has more complex health care needs to be considered when developing surgical treatment plans. These medical problems may limit their life expectancy much sooner than the skin cancer will become symptomatic. We found that individuals aged ≥ 80 years who had CAD, CHF, or dementia had a relative risk of 3 or higher for 5-year mortality. The leading cause of death in the United States in years 2011 to 2015 was heart disease. Alzheimer disease was the sixth leading cause of death in those same years.12-14
Skin cancer excisions do not typically require general anesthesia, deep sedation, or large fluid shifts; however, studies have found that when frail patients undergo low-risk procedures, they tend to have a higher mortality rate than their healthier counterparts.15 Frailty is a concept that identifies patients who are at increased risk of dying in 6 to 60 months due to a decline in their physical reserve. Frail patients have increased rates of perioperative mortality and complications. Various tools have been used to assess the components of physical performance, speed, mobility, nutrition status, mental health, and cognition.16 Frailty screening has been initiated in several VA hospitals, including our own in Gainesville, Florida, with the goal of decreasing postoperative morbidity and mortality in older adult patients.17 The patients are given a 1-page screening assessment that asks about their living situation, medical conditions, nutrition status, cognition, and activities of daily living. The results can trigger the clinician to rethink the surgical plan and mobilize more resources to optimize the patient’s health. This study period precedes the initiative at our institution.
The plastic surgery service’s routine practice is to excise skin cancers in the operating room if sedation or general anesthesia will be needed (Figure 1A), for optimal control of bleeding (Figure 1B) in a patient who cannot safely stop blood thinners, or for excision of a highly vascularized area such as the scalp. Surgery is offered in an office-based setting if the area can be closed primarily, left open to close secondarily, or closed with a small skin graft under local anesthesia only (Figure 2). We prefer treating frail patients in the minor procedure clinic, when possible, to avoid the risks of sedation and the additional preoperative visits and transportation requirements. NMSC with unclear margins (Figure 3A) or in cosmetically sensitive areas where tissue needs to be preserved (Figure 3B) are referred to the Mohs dermatologist. The skin cancers in this study were most frequently found on the face, scalp, hands, and forearms based on referral patterns.
Other treatment options for NMSC include curettage and electrodessication, cryotherapy, and radiation; however, ours is a surgical service and patients are typically referred to us by primary care or dermatology when those are not reasonable or desirable options.18 Published complication rates of patients having skin cancer surgery without age restriction have a rate of 3% to 6%, which is consistent with our study of 5%.19-21 Two bleeding complications that needed to be admitted did not require more than a bedside procedure and neither required transfusions. One patient had been instructed to continue taking coumadin during the perioperative office-based procedure due to a recent carotid stent placement in the setting of a rapidly growing basal cell on an easily accessible location.
The most noted comorbidity in patients with wound complications was found to be DM; however, this was not found to be a statistically significant risk factor for wound complications (P = .10). We do not have a set rule for advising for or against NMSC surgery. We do counsel frail patients and their families that not all cancer is immediately life threatening and will work with them to do whatever makes the most sense to achieve their goals, occasionally accepting positive margins in order to debulk a symptomatic growth. The objective of this paper is to contribute to the discussion of performing invasive procedures on older adult veterans with life-limiting comorbidities. Patients and their families will have different thresholds for what they feel needs intervention, especially if other medical problems are consuming much of their time. We also have the community care referral option for patients whose treatment decisions are being dictated by travel hardships.
Strengths and Limitations
A strength of this study is that the data were obtained from a closed system. Patients tend to stay long-term within the VA and their health record is accessible throughout the country as long as they are seen at a VA facility. Complications, therefore, return to the treating service or primary care, who would route the patient back to the surgeon.
One limitation of the study is that this is a retrospective review from 2011. The authors are limited to data that are recorded in the patient record. Multiple health care professionals saw the patients and notes lack consistency in detail. Size of the lesions were not consistently recorded and did not get logged into our database for that reason.
Conclusions
Treatment of NMSC in older adult patients has a low morbidity but needs to be balanced against a patient and family’s goals when the patient presents with life-limiting comorbidities. An elevated 5-year mortality in patients aged > 80 years with serious unrelated medical conditions is intuitive, but this study may help put treatment plans into perspective for families and health care professionals who want to provide an indicated service while maximizing patient quality of life.
Acknowledgments
This manuscript is the result of work supported with resources and the use of facilities at the North Florida/South Georgia Veterans Health System, Gainesville, Florida.
1. American Cancer Society. Cancer Facts & Figures 2021. Accessed May 26, 2022. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2021/cancer-facts-and-figures-2021.pdf
2. Albert A, Knoll MA, Conti JA, Zbar RIS. Non-melanoma skin cancers in the older patient. Curr Oncol Rep. 2019;21(9):79. Published 2019 Jul 29. doi:10.1007/s11912-019-0828-9
3. Linos E, Chren MM, Stijacic Cenzer I, Covinsky KE. Skin cancer in U.S. elderly adults: does life expectancy play a role in treatment decisions? J Am Geriatr Soc. 2016;64(8):1610-1615. doi:10.1111/jgs.14202
4. Linos E, Parvataneni R, Stuart SE, Boscardin WJ, Landefeld CS, Chren MM. Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer. JAMA Intern Med. 2013;173(11):1006-1012. doi:10.1001/jamainternmed.2013.639
5. O’Malley KA, Vinson L, Kaiser AP, Sager Z, Hinrichs K. Mental health and aging veterans: how the Veterans Health Administration meets the needs of aging veterans. Public Policy Aging Rep. 2020;30(1):19-23. doi:10.1093/ppar/prz027
6. US Department of Veterans Affairs, National Center for Veterans Analysis and Statistics. Profile of veterans: 2017. Accessed May 26, 2022. https://www.va.gov/vetdata/docs/SpecialReports/Profile_of_Veterans_2017.pdf 7. Riemenschneider K, Liu J, Powers JG. Skin cancer in the military: a systematic review of melanoma and nonmelanoma skin cancer incidence, prevention, and screening among active duty and veteran personnel. J Am Acad Dermatol. 2018;78(6):1185-1192. doi:10.1016/j.jaad.2017.11.062
8. Clemens MW, Kochuba AL, Carter ME, Han K, Liu J, Evans K. Association between Agent Orange exposure and nonmelanotic invasive skin cancer: a pilot study. Plast Reconstr Surg. 2014;133(2):432-437. doi:10.1097/01.prs.0000436859.40151.cf
9. Cameron MC, Lee E, Hibler BP, et al. Basal cell carcinoma: epidemiology; pathophysiology; clinical and histological subtypes; and disease associations. J Am Acad Dermatol. 2019;80(2):303-317. doi:10.1016/j.jaad.2018.03.060
10. Chauhan R, Munger BN, Chu MW, et al. Age at diagnosis as a relative contraindication for intervention in facial nonmelanoma skin cancer. JAMA Surg. 2018;153(4):390-392. doi:10.1001/jamasurg.2017.5073
11. Barton V, Armeson K, Hampras S, et al. Nonmelanoma skin cancer and risk of all-cause and cancer-related mortality: a systematic review. Arch Dermatol Res. 2017;309(4):243-251. doi:10.1007/s00403-017-1724-5
12. Kochanek KD, Murphy SL, Xu JQ, Arias E. Mortality in the United States, 2013. NCHS Data Brief 178. Accessed May 26, 2022. https://www.cdc.gov/nchs/products/databriefs/db178.htm
13. Xu JQ, Kochanek KD, Murphy SL, Arias E. Mortality in the United States, 2012. NCHS Data Brief 168. Accessed May 26, 2022. https://www.cdc.gov/nchs/products/databriefs/db168.htm
14. Xu JQ, Murphy SL, Kochanek KD, Arias E. Mortality in the United States, 2015. NCHS Data Brief 267. Accessed May 26, 2022. https://www.cdc.gov/nchs/products/databriefs/db267.htm
15. Varley PR , Borrebach JD, Arya S, et al. Clinical utility of the risk analysis index as a prospective frailty screening tool within a multi-practice, multi-hospital integrated healthcare system. Ann Surg. 2021;274(6):e1230-e1237. doi:10.1097/SLA.0000000000003808
16. Hall DE, Arya S , Schmid KK, et al. Development and initial validation of the risk analysis index for measuring frailty in surgical populations. JAMA Surg. 2017;152(2):175-182. doi:10.1001/jamasurg.2016.4202
17. US Department of Veterans Affairs, Health Services Research & Development. Improving healthcare for aging veterans. Updated August 30, 2017. Accessed May 26, 2022. https://www.hsrd.research.va.gov/news/feature/aging0917.cfm
18. Leus AJG, Frie M, Haisma MS, et al. Treatment of keratinocyte carcinoma in elderly patients – a review of the current literature. J Eur Acad Dermatol Venereol. 2020;34(9):1932-1943. doi:10.1111/jdv.16268
19. Amici JM, Rogues AM, Lasheras A, et al. A prospective study of the incidence of complications associated with dermatological surgery. Br J Dermatol. 2005;153(5):967-971. doi:10.1111/j.1365-2133.2005.06861.x
20. Arguello-Guerra L, Vargas-Chandomid E, Díaz-González JM, Méndez-Flores S, Ruelas-Villavicencio A, Domínguez-Cherit J. Incidence of complications in dermatological surgery of melanoma and non-melanoma skin cancer in patients with multiple comorbidity and/or antiplatelet-anticoagulants. Five-year experience in our hospital. Cir Cir. 2019;86(1):15-23. doi:10.24875/CIRUE.M18000003
21. Keith DJ, de Berker DA, Bray AP, Cheung ST, Brain A, Mohd Mustapa MF. British Association of Dermatologists’ national audit on nonmelanoma skin cancer excision, 2014. Clin Exp Dermatol. 2017;42(1):46-53. doi:10.1111/ced.12990
1. American Cancer Society. Cancer Facts & Figures 2021. Accessed May 26, 2022. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2021/cancer-facts-and-figures-2021.pdf
2. Albert A, Knoll MA, Conti JA, Zbar RIS. Non-melanoma skin cancers in the older patient. Curr Oncol Rep. 2019;21(9):79. Published 2019 Jul 29. doi:10.1007/s11912-019-0828-9
3. Linos E, Chren MM, Stijacic Cenzer I, Covinsky KE. Skin cancer in U.S. elderly adults: does life expectancy play a role in treatment decisions? J Am Geriatr Soc. 2016;64(8):1610-1615. doi:10.1111/jgs.14202
4. Linos E, Parvataneni R, Stuart SE, Boscardin WJ, Landefeld CS, Chren MM. Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer. JAMA Intern Med. 2013;173(11):1006-1012. doi:10.1001/jamainternmed.2013.639
5. O’Malley KA, Vinson L, Kaiser AP, Sager Z, Hinrichs K. Mental health and aging veterans: how the Veterans Health Administration meets the needs of aging veterans. Public Policy Aging Rep. 2020;30(1):19-23. doi:10.1093/ppar/prz027
6. US Department of Veterans Affairs, National Center for Veterans Analysis and Statistics. Profile of veterans: 2017. Accessed May 26, 2022. https://www.va.gov/vetdata/docs/SpecialReports/Profile_of_Veterans_2017.pdf 7. Riemenschneider K, Liu J, Powers JG. Skin cancer in the military: a systematic review of melanoma and nonmelanoma skin cancer incidence, prevention, and screening among active duty and veteran personnel. J Am Acad Dermatol. 2018;78(6):1185-1192. doi:10.1016/j.jaad.2017.11.062
8. Clemens MW, Kochuba AL, Carter ME, Han K, Liu J, Evans K. Association between Agent Orange exposure and nonmelanotic invasive skin cancer: a pilot study. Plast Reconstr Surg. 2014;133(2):432-437. doi:10.1097/01.prs.0000436859.40151.cf
9. Cameron MC, Lee E, Hibler BP, et al. Basal cell carcinoma: epidemiology; pathophysiology; clinical and histological subtypes; and disease associations. J Am Acad Dermatol. 2019;80(2):303-317. doi:10.1016/j.jaad.2018.03.060
10. Chauhan R, Munger BN, Chu MW, et al. Age at diagnosis as a relative contraindication for intervention in facial nonmelanoma skin cancer. JAMA Surg. 2018;153(4):390-392. doi:10.1001/jamasurg.2017.5073
11. Barton V, Armeson K, Hampras S, et al. Nonmelanoma skin cancer and risk of all-cause and cancer-related mortality: a systematic review. Arch Dermatol Res. 2017;309(4):243-251. doi:10.1007/s00403-017-1724-5
12. Kochanek KD, Murphy SL, Xu JQ, Arias E. Mortality in the United States, 2013. NCHS Data Brief 178. Accessed May 26, 2022. https://www.cdc.gov/nchs/products/databriefs/db178.htm
13. Xu JQ, Kochanek KD, Murphy SL, Arias E. Mortality in the United States, 2012. NCHS Data Brief 168. Accessed May 26, 2022. https://www.cdc.gov/nchs/products/databriefs/db168.htm
14. Xu JQ, Murphy SL, Kochanek KD, Arias E. Mortality in the United States, 2015. NCHS Data Brief 267. Accessed May 26, 2022. https://www.cdc.gov/nchs/products/databriefs/db267.htm
15. Varley PR , Borrebach JD, Arya S, et al. Clinical utility of the risk analysis index as a prospective frailty screening tool within a multi-practice, multi-hospital integrated healthcare system. Ann Surg. 2021;274(6):e1230-e1237. doi:10.1097/SLA.0000000000003808
16. Hall DE, Arya S , Schmid KK, et al. Development and initial validation of the risk analysis index for measuring frailty in surgical populations. JAMA Surg. 2017;152(2):175-182. doi:10.1001/jamasurg.2016.4202
17. US Department of Veterans Affairs, Health Services Research & Development. Improving healthcare for aging veterans. Updated August 30, 2017. Accessed May 26, 2022. https://www.hsrd.research.va.gov/news/feature/aging0917.cfm
18. Leus AJG, Frie M, Haisma MS, et al. Treatment of keratinocyte carcinoma in elderly patients – a review of the current literature. J Eur Acad Dermatol Venereol. 2020;34(9):1932-1943. doi:10.1111/jdv.16268
19. Amici JM, Rogues AM, Lasheras A, et al. A prospective study of the incidence of complications associated with dermatological surgery. Br J Dermatol. 2005;153(5):967-971. doi:10.1111/j.1365-2133.2005.06861.x
20. Arguello-Guerra L, Vargas-Chandomid E, Díaz-González JM, Méndez-Flores S, Ruelas-Villavicencio A, Domínguez-Cherit J. Incidence of complications in dermatological surgery of melanoma and non-melanoma skin cancer in patients with multiple comorbidity and/or antiplatelet-anticoagulants. Five-year experience in our hospital. Cir Cir. 2019;86(1):15-23. doi:10.24875/CIRUE.M18000003
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