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Hidradenitis suppurativa (HS) is a painful inflammatory disorder that confers significant distress to patients, with surgery as an integral treatment modality.
To inform improvements in care, patterns in HS surgery were assessed.
A retrospective population-based analysis was performed on Ontario billing claims for HS surgery across a period of 10 years from January 1, 2008 to December 31, 2017. HS surgery was defined as the excision of inguinal, perineal, or axillary skin and sweat glands for hidradenitis. The top 5 billing specialties, including general and plastic surgery, were analyzed. The total number of procedures performed as well as the number performed per physician were investigated. Patient and physician locations were compared.
A total of 7195 claims for the excision of inguinal, perineal, or axillary skin and sweat glands for HS were submitted across the study period. Annual HS surgery claims showed an increasing trend across 10 years, ranging between 4.9 and 5.8 per 100,000 population. However, overall, for every additional year, the number of claims per 100,000 population only increased slightly, by 0.03 claims. The number of providers steadily decreased, ranging between 1.7 and 1.9 per 100,000, with approximately twice as many general than plastic surgeons. However, again overall, for every additional year, the number of providers per 100,000 population decreased slightly, by 0.002 physicians. The mean annual number of procedures per physician rose from 2.8 to 3.1. In rural areas, analyzed per claim, general surgeons performed the majority of surgeries (1318/2003, 65.8%), while in urban areas, surgeries were more equally performed by general (2616/5192, 50.4%) and plastic (2495/5192, 48.1%) surgeons. Of HS surgery claims, 25.7%-35.9% were provided by a physician residing in a different area than the patient receiving care.
No significant improvements in access to HS surgery were seen across the study period, with access potentially worsening with annual HS claims rising overall and number of providers decreasing, with patients travelling further to access surgery. System barriers across the continuum of HS diagnosis and management must be evaluated to improve access to surgical care.
Hidradenitis suppurativa (HS) is a painful, inflammatory disorder involving a dysfunction of the pilosebaceous unit, which confers significant distress to patients due to its relapsing and remitting nature [
Unfortunately, the diagnosis of HS is relatively rare, and it is often mistaken for a simple infection, limiting access to proper treatment [
The prevalence of HS has been reported to range from 0.03% to 4.10% [
To inform improvements in HS care, patterns in current and past HS surgery must be assessed. The objectives of this study were to evaluate patient access to surgical procedures for HS and investigate trends in HS surgery across different specialties and geographical regions.
Ontario was chosen as the study setting as it is the most populous province in Canada with approximately 14.7 million inhabitants [
A retrospective, population-based analysis was performed on Ontario physicians who surgically treated HS. Data were collected across 10 years from January 1, 2008 to December 31, 2017. Physicians who surgically treated HS or hyperhidrosis were identified by procedure codes R059 (unilateral excision of inguinal, perineal, or axillary skin and sweat glands for hyperhidrosis and/or hidradenitis) and R060 (excision of inguinal, perineal, or axillary skin and sweat glands for hyperhidrosis and/or hidradenitis with skin graft(s) or rotation flap(s)) [
Data were exported from IntelliHealth’s online system and analyzed using Microsoft Excel version 16.36. Physician specialty was defined as the specialty billed for the procedure. The number, location, and specialty of physicians who performed the excision of inguinal, perineal, or axillary skin and sweat glands for HS were analyzed. The total number of procedures performed as well as the number performed per physician were investigated. Patient and physician locations were compared. Location was determined based on the assigned Local Health Integration Network (LHIN). Each LHIN was further classified as rural or urban following previously applied methodology in which a LHIN is deemed rural if its population is less than 1,000,000 and urban if greater [
Across the study period, a total of 12,539 claims were submitted for the excision of inguinal, perineal, or axillary skin and sweat glands for hyperhidrosis and/or HS. Of these cases, 1758 were excluded because they were submitted for hyperhidrosis (excessive sweating). A further 3586 claims were excluded based on specialty billed. A final total of 7195 claims was included in the study (
Cohort formation flowchart. OHIP: Ontario Health Insurance Plan.
Ontario hidradenitis suppurativa surgery patient demographics.
Characteristics | 2008 (n=569) | 2009 (n=628) | 2010 (n=624) | 2011 (n=631) | 2012 (n=704) | 2013 (n=667) | 2014 (n=669) | 2015 (n=640) | 2016 (n=668) | 2017 (n=670) | |
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Female | 366 (64.3) | 427 (68.0) | 441 (70.7) | 433 (68.6) | 458 (65.1) | 453 (67.9) | 454 (67.9) | 415 (64.8) | 426 (63.8) | 419 (62.5) |
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Male | 203 (35.7) | 201 (32.0) | 183 (29.3) | 198 (31.4) | 246 (34.9) | 214 (32.1) | 215 (32.1) | 225 (35.2) | 242 (36.2) | 251 (37.5) |
Age (years), mean | 40.4 | 40.8 | 41.0 | 40.7 | 40.2 | 40.3 | 39.9 | 41.8 | 41.6 | 42.8 | |
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0-19 | 41 (7.2) | 26 (4.1) | 31 (5.0) | 36 (5.7) | 55 (7.8) | 36 (5.4) | 32 (4.8) | 30 (4.7) | 30 (4.5) | 31 (4.6) |
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20-44 | 306 (53.8) | 350 (55.7) | 349 (55.9) | 351 (55.6) | 386 (54.8) | 372 (55.8) | 396 (59.2) | 347 (54.2) | 381 (57.0) | 340 (50.7) |
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45-64 | 181 (31.8) | 215 (34.2) | 203 (32.5) | 194 (30.7) | 216 (30.7) | 217 (32.5) | 192 (28.7) | 219 (34.2) | 197 (29.5) | 234 (34.9) |
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65-74 | 23 (4.0) | 24 (3.8) | 25 (4.0) | 36 (5.7) | 29 (4.1) | 29 (4.3) | 36 (5.4) | 28 (4.4) | 35 (5.2) | 46 (6.9) |
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≥75 | 18 (3.2) | 13 (2.1) | 16 (2.6) | 14 (2.2) | 18 (2.6) | 13 (1.9) | 13 (1.9) | 16 (2.5) | 25 (3.7) | 19 (2.8) |
The top 5 billing specialties for HS surgery were general surgery, plastic surgery, obstetrics and gynecology, urology, and dermatology (
Submission of claims for hidradenitis suppurativa surgery over time per 100,000 population.
By specialty, annual claims submitted by general surgeons increased slightly more than those by plastic surgeons. The number of HS surgery providers per 100,000 population ranged from 1.7 to 1.9, with general surgeons ranging from 1.1 to 1.3 and plastic surgeons ranging from 0.5 to 0.6 (
Providers of hidradenitis suppurativa surgery over time per 100,000 population.
The mean number of procedures performed annually per physician rose from 2.8 to 3.1 across 10 years (
Annual hidradenitis suppurativa surgeries performed per physician.
In total, analyzed per claim, more patients (2281/7195, 31.7%) than physicians (2003/7195, 27.8%) resided in a rural area, while more physicians (5192/7195, 72.2%) than patients (4914/7195, 68.3%) resided in an urban area (see
In this population-based analysis of HS surgical care in Canada, there was a slight trend towards increasing number of claims for HS surgery per 100,000 population over the 10-year study period, while the number of providers per 100,000 population decreased, particularly in general surgery. However, procedures performed per physician increased overall, although the increase was not statistically significant. Geographically, patients were also travelling further to access surgery. These findings suggest that overall access to HS surgery has not significantly improved over the study period and in fact may be decreasing as more and more patients seek care away from home as the number of clinicians providing surgery decreases.
The female:male ratio of patients included in this study was similar to that of a previous report on surgical interventions for HS patients in Ontario [
The mean age of disease onset has been reported as 20.5 (SD 9.3) years, with a mean age at diagnosis of 30.7 (SD 10.9) years, representing a mean delay from onset of symptoms to diagnosis of 10.2 (SD 8.9) years [
Other recent advances in HS care have focused on new systemic drugs that target different immune mediators in the pathogenesis of HS [
HS surgery was found to be primarily performed by general and plastic surgeons, consistent with previous literature [
Furthermore, it is likely that more surgeons are choosing narrower scopes of practice, especially in general surgery where broader scopes of surgical services are diminishing with highly specialized postresidency fellowships [
This study benefited from the use of a comprehensive, large, longitudinal database, allowing for future comparison studies. However, a limitation to this study was the lack of a specific diagnostic code for HS. Therefore, we were unable to evaluate and compare changes in HS surgery over time to changes in HS claims. Future studies should explore this association, to further help characterize patient access to HS surgical care. Second, the two billing codes used in this study, R059 and R060, do not reflect the entirety of procedures that can be offered for HS, such as abscess drainage, laser treatments, or electrosurgical peeling procedures [
Barriers to seeking HS care have previously been reported to include a lack of knowledge about HS among providers, difficulty accessing specialists, poor patient-physician communication, distrust in the medical community, and patients’ experiences with HS [
Unfortunately, no significant improvements in patient access to surgery were seen across the study period, with annual HS claims rising overall, number of providers decreasing, and patients travelling further to access surgery. A lack of access to operating room time and narrowing scopes of practice may be contributing factors potentially worsening access over time. Further research on HS surgery, including evaluation into system barriers across the continuum of HS diagnosis and management, are required in order to improve access to surgical care for HS patients.
Supplemental Table 1. Claims submitted for hidradenitis suppurativa (HS) surgery by specialty.
Supplemental Figure 1. (a) Percentage of claims submitted by physician and patient location. (b) Percentage of claims billed by specialty using physician location.
Supplemental Figure 2. Percentage of claims submitted by physician and patient location (defined as their Local Health Integration Network [LHIN]) over time. Shown by claims submitted by physicians who resided in the same location as the patient at the time of surgery, and by those who did not.
hidradenitis suppurativa
Local Health Integration Network
Ontario Health Insurance Plan
This study made use of data from the Ontario Ministry of Health and Long-Term Care: IntelliHealth Ontario. No financial support was provided.
RA conceived the study. All authors contributed to the study design. AF acquired the data through IntelliHealth. AF and AL contributed to analysis and interpretation of data and drafting of the article. RA and RG critically revised the article. All authors approved the final version to be published.
None declared.