Leveraging Google Trends to Analyze Spatiotemporal Disparities in Public Interest and Demand for Mohs Surgery

Leveraging Google Trends to Analyze Spatiotemporal Disparities in Public Interest and Demand for Mohs Surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Leveraging Google Trends to Analyze Spatiotemporal Disparities in Public Interest and Demand for Mohs Surgery Aman Nihal, Kevin Yang, Eric C. Olsen, Conway Huang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7104611/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background – Google Trends (GT) assesses public interest in search terms using “Relative Search Volume” (RSV), which represents the proportion of searches for a term relative to total search activity. Objective– To analyze GT data for “Mohs surgery” to identify spatiotemporal trends and evaluate RSV as a potential proxy marker for Mohs surgery demand. Methods and Materials – GT was queried for data on “Mohs surgery” (2004-2024). RSV was correlated against demographic factors from the U.S. Census and Centers for Medicare and Medicaid Services (CMS) data for Mohs first-layers (codes 17311 and 17313). A novel metric for Mohs demand, the Mohs Relative Demand (MoRD), was created. Results - Interest in “Mohs surgery” increased over time. RSV correlated with urban population (p=0.046), white population (p=0.006), age over 65 (p<0.001), daily ultraviolet irradiance (p=0.048) and CMS coding for Mohs first-layers (p=0.0026). MoRD was lowest in Arkansas, South Dakota, and Kansas, and highest in Maine, Hawaii, and Alaska. Conclusion - RSV serves as a valuable proxy for Mohs surgery interest, offering an alternative to traditional methods such as claims data analysis. MoRD provides insights on demand for surgery, highlighting potential unmet needs. Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Since its introduction in the 1930s and its refinement into its modern form in the 1950s, MMS has gained widespread adoption and is now considered first-line treatment of nonmelanoma skin cancers (NMSC). Medicare billing data indicate that MMS procedures per 1,000 Medicare beneficiaries increased from 5 to 15 between 2000 and 2015 [1]. Similar trends have been observed globally, with countries like Australia reporting significant growth in MMS cases [2]. Demographic studies have identified factors associated with higher rates of MMS utilization. Nationally, 74% of counties where MMS cases are performed are urban, reflecting higher procedure volume in metropolitan areas [3]. Higher household income and education levels have also been associated with increased MMS use [3]. While these data highlight where and on whom MMS is performed, they do not reveal areas with unmet demand, underscoring the need for additional methods to assess Mohs surgery accessibility. This study aims to leverage Google Trends (GT) to identify spatiotemporal disparities in public interest in Mohs surgery and explore factors contributing to these differences. Additionally, it seeks to introduce a metric for MMS “demand” to determine regions where an increased presence of Mohs surgeons may be warranted. GT is a powerful, publicly accessible tool that analyzes Google search queries to track trends over time and across regions for specific search terms [4]. It accounts for variations in spelling, acronyms, and language translations, ensuring comprehensive search analysis. GT quantifies search interest using “Relative Search Volume” (RSV), which represents the proportion of searches for a given term relative to all Google search activity within specified parameters. By reporting RSV as a proportion, GT normalized for differences in gross search volume across regions and time periods, creating a per capita metric. RSV is presented on a scale from 0 to 100, with 100 representing the peak search volume for the term within the selected parameters. For example, when analyzing search trends for “COVID-19” from 2018–2024, an RSV of 100 corresponds to the period with the highest relative search interest - March 2020 in this case. In comparison, an RSV of 19 in July of 2020, indicates that searches for “COVID-19” at that time were 19% of the peak volume recorded in March 2020. When comparing RSV across geographic regions, a value of 100 represents the area the specified term has the highest relative search interest. For instance, when analyzing searches for “college football” from 2004 to 2024, Alabama has an RSV of 100, indicating the highest concentration of searches, whereas Maine has an RSV of 14, reflecting significantly lower interest in the topic. Methods A Google Trends query was conducted on January 1, 2025, to analyze search interest in “Mohs surgery”. Data were collected for searches from January 1, 2004, to December 31, 2024, with the start date chosen as the earliest available in GT records. Three RSV datasets were obtained: one tracking U.S. search interest over time, another comparing RSV between states over the full study period, and a third comparing RSV across countries. State-level RSV data were analyzed in relation to various demographic factors, including percentage of population uninsured, healthcare expenditure per capita, median household income, poverty rate, and education level (categorized as the percentage of population with high school, college, or advanced degrees). Additional factors included the percentage living in an urban environment, aged 65 and older, identifying as non-Hispanic white, median UV index, and average daily UV irradiance. Whenever possible, these data were sourced from the U.S. Census Bureau. Healthcare expenditure per capita was obtained from Centers for Medicare and Medicaid Services (CMS) data and data on UV index and average daily UV irradiance was obtained from the Centers for Disease Control’s National Environmental Public Health Tracking Network. Mohs surgery volume per capita was estimated at the state-level using CMS data for Current Procedural Terminology (CPT) codes 17311 and 17313 (Mohs first-layers) from 2022, normalized by state population. A novel metric, the Mohs Relative Demand (MoRD), was introduced to contextualize search interest relative to surgical volume, defined as the RSV for a given state divided by CMS coding for first-layers per capita. Statistical analyses were conducted using R, version 4.3.0. Comprehensive demographic data and sources are available in Supplemental File 1. Results Search interest for the term “Mohs surgery” in the United States steadily increased over the study period (Fig. 1 ). The highest RSV was recorded in October 2024 (100), while the lowest occurred in December 2005 (19). Similar trends were observed globally. Among countries, the United States had the highest search interest (100), followed by the U.S. Virgin Islands (77), Cayman Islands (67), Bermuda (59), and Bahamas (35). When limited to countries with high Google search volumes, the United States is followed by New Zealand (31), Australia (25), Canada (23), Ireland (17) and the United Kingdom (16). At the state level, RSV was highest in Florida (100), Rhode Island (100), and Pennsylvania (98), and lowest in Alaska (40), Nevada (44), and Mississippi (44). First-layer Mohs coding per capita was highest in South Dakota (0.0058), Florida (0.0057), and Arizona (0.0050), and lowest in Alaska (0.0008), Hawaii (0.0010), and Washington D.C. (0.0012). RSV correlated significantly with the percentage of the state populations living in urban areas (p = 0.046), identifying as non-Hispanic white (p = 0.005), aged over 65 (p < 0.001), average daily ultraviolet (UV) irradiance (p = 0.048) and Mohs first-layer coding per capita (p = 0.0026). Results neared significance for healthcare expenditure per capita (p = 0.074). No significant correlation was found between RSV and education level (p = 0.136 for high school, p = 0.138 for college, and p = 0.809 for an advanced degree), median household income (p = 0.59), poverty rate (p = 0.77), percentage of the population uninsured (p = 0.31), or median UV index (p = 0.11). The states with the highest Mohs Relative Demand (MoRD), in order, were Maine, Hawaii, Alaska, Michigan, Vermont, Washington D.C., Connecticut, Illinois, and Minnesota. The ten states with the lowest MoRD were Arkansas, South Dakota, Kansas, Nevada, Arizona, Florida, Georgia, California, Mississippi, and North Dakota. Geographically, MoRD was noted to be higher in the Midwest and Northeast, and lower in the Southeast, South Central, and Southwest. Conclusions GT has been proven to be a valuable tool in medicine. Among other things, GT has aided in the prediction of influenza outbreaks, identification of previously unknown Lyme disease risk areas, and tracking of trends in substance use disorder [5,6,7]. In dermatology, GT data have been linked to cancer incidence and mortality rates for NMSC [8]. This study adds to the growing body of GT research by applying it to MMS. Our findings align with previous studies reporting a steady rise in public interest in Mohs surgery over time [9]. A notable decline in RSV occurred starting in March of 2020, coinciding with the onset of the COVID-19 pandemic. This likely represents a combination of decreased procedural volume during this time (i.e. fewer patients researching their procedure) and a surge in overall volume of Google searches related to COVID-19. Prior research has also noted seasonal trends, with RSV for dermatologic topics peaking in summer and declining in winter [10,11]. This pattern was found to hold true for MMS, except for January and February 2023, when a surge in interest was likely driven by increased media attention following First Lady Jill Biden's MMS procedure [12]. Globally, search interest in MMS was highest in the United States and tended to be higher in North American countries. The United States had far higher search interest than other large, developed, English-speaking countries, with the next highest country, New Zealand, recording only 31% of the U.S. search interest. This discrepancy is notable given the higher incidence of NMSC in Australia and New Zealand and the geographical and cultural proximity of the U.S. and Canada [13]. A limiting factor of this analysis is the usage of alternative search engines in some countries (e.g. Baidu in China). These findings suggest that the U.S. has a higher interest in MMS and potentially a greater overall utilization of MMS than comparable countries. At the state level, RSV was noted to have an east-coast predominance and was found to correlate with several demographic factors. Search interest was significantly higher in states with larger proportions of elderly and non-Hispanic white populations, and those with higher average daily UV irradiance. These factors are well established to correlate with risk of NMSC and therefore MMS, indicating that RSV may reflect MMS volume [14]. This claim is strengthened by the significant correlation between RSV and the percentage of state population living in urban areas, another factor known to correlate with MMS volume [3]. Lastly, RSV was found to correlate with procedural volume per capita itself. Together, these factors suggest that search interest is largely driven by individuals considering or preparing for MMS. This highlights the potential of RSV as a proxy for procedural demand, offering a more accessible alternative to traditional measures such as claims data analysis and surgeon surveys. To further contextualize the relationship between RSV and MMS volume, we developed MoRD as a metric to highlight potential unmet needs. To reiterate, MoRD is the RSV divided by the surgical volume per capita. A high MoRD indicates a higher search volume than expected compared to procedural volume performed, indicating a potential unmet demand for MMS (i.e. more people searching for the procedure than having the procedure). Conversely, a low MoRD suggests a well-matched supply-and-demand balance. This metric may be valuable for individual surgeons evaluating practice locations and for professional organizations involved in workforce planning and resource allocation. In contrast to previous studies, RSV did not correlate with common economic indicators such as median household income, percentage uninsured, education level, or poverty rate, though it did have near significance for healthcare expenditure per capita [3]. The lack of correlation with these factors may be a positive sign for the field, as a significant correlation would suggest that MMS is primarily accessible to wealthier populations. A limitation of this study is the reliance on Medicare CPT data to estimate procedural volume. Since only an estimated 16.7% of the U.S. population is covered by Medicare and this population skews older, the generalizability of these findings to younger populations is limited [15]. However, studies have estimated that around 40% of NMSCs occur in Medicare patients, somewhat mitigating this shortcoming [16]. In conclusion, this study reinforces the utility of Google Trends in medical research and demonstrates that RSV can serve as a proxy for procedural volume. Additionally, the MoRD metric provides insights into potential unmet demand for Mohs surgery at the state level. While our analysis focuses on national and state trends, GT also enables search analysis at the metropolitan and local levels, offering valuable applications for demand forecasting, workforce planning, and resource distribution, both for the individual surgeon and for professional organizations. Future studies leveraging GT data may help refine strategies for optimizing Mohs surgery access and addressing regional disparities in dermatologic care. Declarations Disclosures: The authors have no relevant conflicts of interest to disclose Author Contribution AN conceived the study and was the primary author of the manuscript. AN and KY conducted all data analysis. All authors contributed to the interpretation of results, critical revision of the manuscript, and approved the final version. References Wang DM, Morgan FC, Besaw RJ, Schmults CD. An ecological study of skin biopsies and skin cancer treatment procedures in the United States Medicare population, 2000 to 2015. J Am Acad Dermatol. 2018 Jan;78(1):47-53. doi: 10.1016/j.jaad.2017.09.031. Epub 2017 Sep 22. PMID: 28947293. Stewart TJ, Moreno Bonilla G, Venning VL, Lee S, Fernandez-Peñas P. Mohs Micrographic Surgery at the Skin and Cancer Foundation Australia, 20 Years Later (1997-2017). Dermatol Surg. 2020 Feb;46(2):165-168. doi: 10.1097/DSS.0000000000002010. PMID: 31274529. Sharma AN, Peterman N, Juhasz M, Shive M. MMS hotspots: a cross-sectional comparison of U.S. counties with and without Mohs micrographic surgery. Arch Dermatol Res. 2023 Dec 7;316(1):21. doi: 10.1007/s00403-023-02751-x. PMID: 38060044; PMCID: PMC10703960. Google Trends [Internet]. Mountain View (CA): Google Inc.; [cited 2025 Apr 20]. Available from: https://trends.google.com Wychgram C, Aucott JN, Rebman AW, Curriero FC. Identifying the geographic leading edge of Lyme disease in the United States with internet searches: A spatiotemporal analysis of Google Health Trends data. PLoS One. 2024 Nov 13;19(11):e0312277. doi: 10.1371/journal.pone.0312277. PMID: 39535983; PMCID: PMC11560046. Patton T, Abramovitz D, Johnson D, Leas E, Nobles A, Caputi T, Ayers J, Strathdee S, Bórquez A. Characterizing Help-Seeking Searches for Substance Use Treatment From Google Trends and Assessing Their Use for Infoveillance: Longitudinal Descriptive and Validation Statistical Analysis. J Med Internet Res. 2022 Dec 1;24(12):e41527. doi: 10.2196/41527. PMID: 36454620; PMCID: PMC9756118. Zhang Y, Bambrick H, Mengersen K, Tong S, Hu W. Using Google Trends and ambient temperature to predict seasonal influenza outbreaks. Environ Int. 2018 Aug;117:284-291. doi: 10.1016/j.envint.2018.05.016. Epub 2018 May 16. PMID: 29778013. Wehner MR, Nead KT, Linos E. Correlation Among Cancer Incidence and Mortality Rates and Internet Searches in the United States. JAMA Dermatol. 2017 Sep 1;153(9):911-914. doi: 10.1001/jamadermatol.2017.1870. PMID: 28658470; PMCID: PMC5817428. Callaghan DJ 3rd. Use of Google Trends to Examine Interest in Mohs Micrographic Surgery: 2004 to 2016. Dermatol Surg. 2018 Feb;44(2):186-192. doi: 10.1097/DSS.0000000000001270. PMID: 28930787. Seth D, Gittleman H, Barnholtz-Sloan J, Bordeaux JS. Association of Socioeconomic and Geographic Factors With Google Trends for Tanning and Sunscreen. Dermatol Surg. 2018 Feb;44(2):236-240. doi: 10.1097/DSS.0000000000001324. PMID: 28902024. Kamiński M, Tizek L, Zink A. 'Dr. Google, What Is That on My Skin?'-Internet Searches Related to Skin Problems: Google Trends Data from 2004 to 2019. Int J Environ Res Public Health. 2021 Mar 4;18(5):2541. doi: 10.3390/ijerph18052541. PMID: 33806391; PMCID: PMC7967401. Ordoñez F, Archie A. Jill Biden had three skin lesions removed [Internet]. NPR; 2023 Jan 11 [cited 2025 Apr 20]. Available from: https://www.npr.org/2023/01/11/1148332417/jill-biden-skin-cancer-surgery Lomas A, Leonardi-Bee J, Bath-Hextall F. A systematic review of worldwide incidence of nonmelanoma skin cancer. Br J Dermatol. 2012 May;166(5):1069-80. doi: 10.1111/j.1365-2133.2012.10830.x. PMID: 22251204. Nehal KS, Bichakjian CK. Update on Keratinocyte Carcinomas. N Engl J Med. 2018 Jul 26;379(4):363-374. doi: 10.1056/NEJMra1708701. PMID: 30044931. Vangsness CT Jr, Adamson TC 3rd, Daley MJ. Consequences on Private Insurance Coverage: The AAOS Clinical Practice Guidelines and Hyaluronic Acid Injections. J Bone Joint Surg Am. 2020 May 20;102(10):920-926. doi: 10.2106/JBJS.19.00272. PMID: 32079873; PMCID: PMC7508284. Rogers HW, Weinstock MA, Feldman SR, Coldiron BM. Incidence Estimate of Nonmelanoma Skin Cancer (Keratinocyte Carcinomas) in the U.S. Population, 2012. JAMA Dermatol. 2015 Oct;151(10):1081-6. doi: 10.1001/jamadermatol.2015.1187. PMID: 25928283. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 13 Jan, 2026 Reviewers agreed at journal 13 Jan, 2026 Reviewers agreed at journal 10 Jan, 2026 Reviewers invited by journal 28 Aug, 2025 Editor assigned by journal 12 Jul, 2025 Submission checks completed at journal 12 Jul, 2025 First submitted to journal 11 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7104611","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":509260186,"identity":"72652c5c-c271-487a-a858-60f602e372f6","order_by":0,"name":"Aman Nihal","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYBACNjBpcICBj5n5AJAlIUNQCz9MCxs7WwJICw9BLZINYAqohZ/HAMQirMXg2uFnjwsK7sizMfN8fnWjxoKHgf3w0Q14tdxOMzeeYfDMsI2Zd5t1zjGgw3jS0m7g15JgJs1jcJgRpMU4hw2oRYLHDK8W+9vp30Ba7NuYeZ4Z5/wjQovB7RywLYlALcyPc9uI01IG0pLcxsxmxpzbJ8HDRtgv6dukef4ctu3nP/z4c863Ojl+9sPH8GpBBmwSYJJY5SDA/IEU1aNgFIyCUTByAADmbEIKKph32gAAAABJRU5ErkJggg==","orcid":"","institution":"University of Alabama – Birmingham","correspondingAuthor":true,"prefix":"","firstName":"Aman","middleName":"","lastName":"Nihal","suffix":""},{"id":509260189,"identity":"bc13144f-3053-400f-a54e-31620a1480ca","order_by":1,"name":"Kevin Yang","email":"","orcid":"","institution":"University of Alabama – Birmingham","correspondingAuthor":false,"prefix":"","firstName":"Kevin","middleName":"","lastName":"Yang","suffix":""},{"id":509260190,"identity":"d1128ac8-083a-4be2-bf63-3c3546a4cd01","order_by":2,"name":"Eric C. 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Figure 3b (right): Medicare Mohs first-layer coding per capita in 2022\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7104611/v1/b2233604030eeaaf7869b187.png"},{"id":90805226,"identity":"d923d734-38da-4dfb-90bc-7a64aceda7ef","added_by":"auto","created_at":"2025-09-08 10:45:56","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":71265,"visible":true,"origin":"","legend":"\u003cp\u003eMohs Relative Demand (MoRD) by state\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7104611/v1/5597742fc324af2521c7bdea.png"},{"id":90805231,"identity":"7bd14446-60e5-4b19-9129-5d75328c4907","added_by":"auto","created_at":"2025-09-08 10:46:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":523835,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7104611/v1/307fc6f6-83f7-4747-a148-e0d0aac02369.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Leveraging Google Trends to Analyze Spatiotemporal Disparities in Public Interest and Demand for Mohs Surgery","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSince its introduction in the 1930s and its refinement into its modern form in the 1950s, MMS has gained widespread adoption and is now considered first-line treatment of nonmelanoma skin cancers (NMSC). Medicare billing data indicate that MMS procedures per 1,000 Medicare beneficiaries increased from 5 to 15 between 2000 and 2015 [1]. Similar trends have been observed globally, with countries like Australia reporting significant growth in MMS cases [2].\u003c/p\u003e\u003cp\u003eDemographic studies have identified factors associated with higher rates of MMS utilization. Nationally, 74% of counties where MMS cases are performed are urban, reflecting higher procedure volume in metropolitan areas [3]. Higher household income and education levels have also been associated with increased MMS use [3]. While these data highlight where and on whom MMS is performed, they do not reveal areas with unmet demand, underscoring the need for additional methods to assess Mohs surgery accessibility.\u003c/p\u003e\u003cp\u003eThis study aims to leverage Google Trends (GT) to identify spatiotemporal disparities in public interest in Mohs surgery and explore factors contributing to these differences. Additionally, it seeks to introduce a metric for MMS “demand” to determine regions where an increased presence of Mohs surgeons may be warranted.\u003c/p\u003e\u003cp\u003eGT is a powerful, publicly accessible tool that analyzes Google search queries to track trends over time and across regions for specific search terms [4]. It accounts for variations in spelling, acronyms, and language translations, ensuring comprehensive search analysis. GT quantifies search interest using “Relative Search Volume” (RSV), which represents the proportion of searches for a given term relative to all Google search activity within specified parameters. By reporting RSV as a proportion, GT normalized for differences in gross search volume across regions and time periods, creating a per capita metric.\u003c/p\u003e\u003cp\u003eRSV is presented on a scale from 0 to 100, with 100 representing the peak search volume for the term within the selected parameters. For example, when analyzing search trends for “COVID-19” from 2018–2024, an RSV of 100 corresponds to the period with the highest relative search interest - March 2020 in this case. In comparison, an RSV of 19 in July of 2020, indicates that searches for “COVID-19” at that time were 19% of the peak volume recorded in March 2020.\u003c/p\u003e\u003cp\u003eWhen comparing RSV across geographic regions, a value of 100 represents the area the specified term has the highest relative search interest. For instance, when analyzing searches for “college football” from 2004 to 2024, Alabama has an RSV of 100, indicating the highest concentration of searches, whereas Maine has an RSV of 14, reflecting significantly lower interest in the topic.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA Google Trends query was conducted on January 1, 2025, to analyze search interest in “Mohs surgery”. Data were collected for searches from January 1, 2004, to December 31, 2024, with the start date chosen as the earliest available in GT records. Three RSV datasets were obtained: one tracking U.S. search interest over time, another comparing RSV between states over the full study period, and a third comparing RSV across countries.\u003c/p\u003e\u003cp\u003eState-level RSV data were analyzed in relation to various demographic factors, including percentage of population uninsured, healthcare expenditure per capita, median household income, poverty rate, and education level (categorized as the percentage of population with high school, college, or advanced degrees). Additional factors included the percentage living in an urban environment, aged 65 and older, identifying as non-Hispanic white, median UV index, and average daily UV irradiance. Whenever possible, these data were sourced from the U.S. Census Bureau. Healthcare expenditure per capita was obtained from Centers for Medicare and Medicaid Services (CMS) data and data on UV index and average daily UV irradiance was obtained from the Centers for Disease Control’s National Environmental Public Health Tracking Network.\u003c/p\u003e\u003cp\u003eMohs surgery volume per capita was estimated at the state-level using CMS data for Current Procedural Terminology (CPT) codes 17311 and 17313 (Mohs first-layers) from 2022, normalized by state population. A novel metric, the Mohs Relative Demand (MoRD), was introduced to contextualize search interest relative to surgical volume, defined as the RSV for a given state divided by CMS coding for first-layers per capita. Statistical analyses were conducted using R, version 4.3.0. Comprehensive demographic data and sources are available in Supplemental File 1.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eSearch interest for the term \u0026ldquo;Mohs surgery\u0026rdquo; in the United States steadily increased over the study period (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The highest RSV was recorded in October 2024 (100), while the lowest occurred in December 2005 (19). Similar trends were observed globally.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAmong countries, the United States had the highest search interest (100), followed by the U.S. Virgin Islands (77), Cayman Islands (67), Bermuda (59), and Bahamas (35). When limited to countries with high Google search volumes, the United States is followed by New Zealand (31), Australia (25), Canada (23), Ireland (17) and the United Kingdom (16).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAt the state level, RSV was highest in Florida (100), Rhode Island (100), and Pennsylvania (98), and lowest in Alaska (40), Nevada (44), and Mississippi (44). First-layer Mohs coding per capita was highest in South Dakota (0.0058), Florida (0.0057), and Arizona (0.0050), and lowest in Alaska (0.0008), Hawaii (0.0010), and Washington D.C. (0.0012).\u003c/p\u003e\u003cp\u003eRSV correlated significantly with the percentage of the state populations living in urban areas (p\u0026thinsp;=\u0026thinsp;0.046), identifying as non-Hispanic white (p\u0026thinsp;=\u0026thinsp;0.005), aged over 65 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), average daily ultraviolet (UV) irradiance (p\u0026thinsp;=\u0026thinsp;0.048) and Mohs first-layer coding per capita (p\u0026thinsp;=\u0026thinsp;0.0026). Results neared significance for healthcare expenditure per capita (p\u0026thinsp;=\u0026thinsp;0.074). No significant correlation was found between RSV and education level (p\u0026thinsp;=\u0026thinsp;0.136 for high school, p\u0026thinsp;=\u0026thinsp;0.138 for college, and p\u0026thinsp;=\u0026thinsp;0.809 for an advanced degree), median household income (p\u0026thinsp;=\u0026thinsp;0.59), poverty rate (p\u0026thinsp;=\u0026thinsp;0.77), percentage of the population uninsured (p\u0026thinsp;=\u0026thinsp;0.31), or median UV index (p\u0026thinsp;=\u0026thinsp;0.11).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe states with the highest Mohs Relative Demand (MoRD), in order, were Maine, Hawaii, Alaska, Michigan, Vermont, Washington D.C., Connecticut, Illinois, and Minnesota. The ten states with the lowest MoRD were Arkansas, South Dakota, Kansas, Nevada, Arizona, Florida, Georgia, California, Mississippi, and North Dakota. Geographically, MoRD was noted to be higher in the Midwest and Northeast, and lower in the Southeast, South Central, and Southwest.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eGT has been proven to be a valuable tool in medicine. Among other things, GT has aided in the prediction of influenza outbreaks, identification of previously unknown Lyme disease risk areas, and tracking of trends in substance use disorder [5,6,7]. In dermatology, GT data have been linked to cancer incidence and mortality rates for NMSC [8]. This study adds to the growing body of GT research by applying it to MMS.\u003c/p\u003e\u003cp\u003eOur findings align with previous studies reporting a steady rise in public interest in Mohs surgery over time [9]. A notable decline in RSV occurred starting in March of 2020, coinciding with the onset of the COVID-19 pandemic. This likely represents a combination of decreased procedural volume during this time (i.e. fewer patients researching their procedure) and a surge in overall volume of Google searches related to COVID-19. Prior research has also noted seasonal trends, with RSV for dermatologic topics peaking in summer and declining in winter [10,11]. This pattern was found to hold true for MMS, except for January and February 2023, when a surge in interest was likely driven by increased media attention following First Lady Jill Biden's MMS procedure [12].\u003c/p\u003e\u003cp\u003eGlobally, search interest in MMS was highest in the United States and tended to be higher in North American countries. The United States had far higher search interest than other large, developed, English-speaking countries, with the next highest country, New Zealand, recording only 31% of the U.S. search interest. This discrepancy is notable given the higher incidence of NMSC in Australia and New Zealand and the geographical and cultural proximity of the U.S. and Canada [13]. A limiting factor of this analysis is the usage of alternative search engines in some countries (e.g. Baidu in China). These findings suggest that the U.S. has a higher interest in MMS and potentially a greater overall utilization of MMS than comparable countries.\u003c/p\u003e\u003cp\u003eAt the state level, RSV was noted to have an east-coast predominance and was found to correlate with several demographic factors. Search interest was significantly higher in states with larger proportions of elderly and non-Hispanic white populations, and those with higher average daily UV irradiance. These factors are well established to correlate with risk of NMSC and therefore MMS, indicating that RSV may reflect MMS volume [14]. This claim is strengthened by the significant correlation between RSV and the percentage of state population living in urban areas, another factor known to correlate with MMS volume [3]. Lastly, RSV was found to correlate with procedural volume per capita itself. Together, these factors suggest that search interest is largely driven by individuals considering or preparing for MMS. This highlights the potential of RSV as a proxy for procedural demand, offering a more accessible alternative to traditional measures such as claims data analysis and surgeon surveys.\u003c/p\u003e\u003cp\u003eTo further contextualize the relationship between RSV and MMS volume, we developed MoRD as a metric to highlight potential unmet needs. To reiterate, MoRD is the RSV divided by the surgical volume per capita. A high MoRD indicates a higher search volume than expected compared to procedural volume performed, indicating a potential unmet demand for MMS (i.e. more people searching for the procedure than having the procedure). Conversely, a low MoRD suggests a well-matched supply-and-demand balance. This metric may be valuable for individual surgeons evaluating practice locations and for professional organizations involved in workforce planning and resource allocation.\u003c/p\u003e\u003cp\u003eIn contrast to previous studies, RSV did not correlate with common economic indicators such as median household income, percentage uninsured, education level, or poverty rate, though it did have near significance for healthcare expenditure per capita [3]. The lack of correlation with these factors may be a positive sign for the field, as a significant correlation would suggest that MMS is primarily accessible to wealthier populations.\u003c/p\u003e\u003cp\u003eA limitation of this study is the reliance on Medicare CPT data to estimate procedural volume. Since only an estimated 16.7% of the U.S. population is covered by Medicare and this population skews older, the generalizability of these findings to younger populations is limited [15]. However, studies have estimated that around 40% of NMSCs occur in Medicare patients, somewhat mitigating this shortcoming [16].\u003c/p\u003e\u003cp\u003eIn conclusion, this study reinforces the utility of Google Trends in medical research and demonstrates that RSV can serve as a proxy for procedural volume. Additionally, the MoRD metric provides insights into potential unmet demand for Mohs surgery at the state level. While our analysis focuses on national and state trends, GT also enables search analysis at the metropolitan and local levels, offering valuable applications for demand forecasting, workforce planning, and resource distribution, both for the individual surgeon and for professional organizations. Future studies leveraging GT data may help refine strategies for optimizing Mohs surgery access and addressing regional disparities in dermatologic care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDisclosures:\u003c/strong\u003e The authors have no relevant conflicts of interest to disclose\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eAN conceived the study and was the primary author of the manuscript. AN and KY conducted all data analysis. All authors contributed to the interpretation of results, critical revision of the manuscript, and approved the final version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWang DM, Morgan FC, Besaw RJ, Schmults CD. An ecological study of skin biopsies and skin cancer treatment procedures in the United States Medicare population, 2000 to 2015. J Am Acad Dermatol. 2018 Jan;78(1):47-53. doi: 10.1016/j.jaad.2017.09.031. Epub 2017 Sep 22. PMID: 28947293.\u003c/li\u003e\n\u003cli\u003eStewart TJ, Moreno Bonilla G, Venning VL, Lee S, Fernandez-Pe\u0026ntilde;as P. Mohs Micrographic Surgery at the Skin and Cancer Foundation Australia, 20 Years Later (1997-2017). Dermatol Surg. 2020 Feb;46(2):165-168. doi: 10.1097/DSS.0000000000002010. PMID: 31274529.\u003c/li\u003e\n\u003cli\u003eSharma AN, Peterman N, Juhasz M, Shive M. MMS hotspots: a cross-sectional comparison of U.S. counties with and without Mohs micrographic surgery. Arch Dermatol Res. 2023 Dec 7;316(1):21. doi: 10.1007/s00403-023-02751-x. PMID: 38060044; PMCID: PMC10703960.\u003c/li\u003e\n\u003cli\u003eGoogle Trends [Internet]. Mountain View (CA): Google Inc.; [cited 2025 Apr 20]. Available from: https://trends.google.com\u003c/li\u003e\n\u003cli\u003eWychgram C, Aucott JN, Rebman AW, Curriero FC. Identifying the geographic leading edge of Lyme disease in the United States with internet searches: A spatiotemporal analysis of Google Health Trends data. PLoS One. 2024 Nov 13;19(11):e0312277. doi: 10.1371/journal.pone.0312277. PMID: 39535983; PMCID: PMC11560046.\u003c/li\u003e\n\u003cli\u003ePatton T, Abramovitz D, Johnson D, Leas E, Nobles A, Caputi T, Ayers J, Strathdee S, B\u0026oacute;rquez A. Characterizing Help-Seeking Searches for Substance Use Treatment From Google Trends and Assessing Their Use for Infoveillance: Longitudinal Descriptive and Validation Statistical Analysis. J Med Internet Res. 2022 Dec 1;24(12):e41527. doi: 10.2196/41527. PMID: 36454620; PMCID: PMC9756118.\u003c/li\u003e\n\u003cli\u003eZhang Y, Bambrick H, Mengersen K, Tong S, Hu W. Using Google Trends and ambient temperature to predict seasonal influenza outbreaks. Environ Int. 2018 Aug;117:284-291. doi: 10.1016/j.envint.2018.05.016. Epub 2018 May 16. PMID: 29778013.\u003c/li\u003e\n\u003cli\u003eWehner MR, Nead KT, Linos E. Correlation Among Cancer Incidence and Mortality Rates and Internet Searches in the United States. JAMA Dermatol. 2017 Sep 1;153(9):911-914. doi: 10.1001/jamadermatol.2017.1870. PMID: 28658470; PMCID: PMC5817428.\u003c/li\u003e\n\u003cli\u003eCallaghan DJ 3rd. Use of Google Trends to Examine Interest in Mohs Micrographic Surgery: 2004 to 2016. Dermatol Surg. 2018 Feb;44(2):186-192. doi: 10.1097/DSS.0000000000001270. PMID: 28930787.\u003c/li\u003e\n\u003cli\u003eSeth D, Gittleman H, Barnholtz-Sloan J, Bordeaux JS. Association of Socioeconomic and Geographic Factors With Google Trends for Tanning and Sunscreen. Dermatol Surg. 2018 Feb;44(2):236-240. doi: 10.1097/DSS.0000000000001324. PMID: 28902024.\u003c/li\u003e\n\u003cli\u003eKamiński M, Tizek L, Zink A. \u0026apos;Dr. Google, What Is That on My Skin?\u0026apos;-Internet Searches Related to Skin Problems: Google Trends Data from 2004 to 2019. Int J Environ Res Public Health. 2021 Mar 4;18(5):2541. doi: 10.3390/ijerph18052541. PMID: 33806391; PMCID: PMC7967401.\u003c/li\u003e\n\u003cli\u003eOrdo\u0026ntilde;ez F, Archie A. Jill Biden had three skin lesions removed [Internet]. NPR; 2023 Jan 11 [cited 2025 Apr 20]. Available from: https://www.npr.org/2023/01/11/1148332417/jill-biden-skin-cancer-surgery\u003c/li\u003e\n\u003cli\u003eLomas A, Leonardi-Bee J, Bath-Hextall F. A systematic review of worldwide incidence of nonmelanoma skin cancer. Br J Dermatol. 2012 May;166(5):1069-80. doi: 10.1111/j.1365-2133.2012.10830.x. PMID: 22251204.\u003c/li\u003e\n\u003cli\u003eNehal KS, Bichakjian CK. Update on Keratinocyte Carcinomas. N Engl J Med. 2018 Jul 26;379(4):363-374. doi: 10.1056/NEJMra1708701. PMID: 30044931.\u003c/li\u003e\n\u003cli\u003eVangsness CT Jr, Adamson TC 3rd, Daley MJ. Consequences on Private Insurance Coverage: The AAOS Clinical Practice Guidelines and Hyaluronic Acid Injections. J Bone Joint Surg Am. 2020 May 20;102(10):920-926. doi: 10.2106/JBJS.19.00272. PMID: 32079873; PMCID: PMC7508284.\u003c/li\u003e\n\u003cli\u003eRogers HW, Weinstock MA, Feldman SR, Coldiron BM. Incidence Estimate of Nonmelanoma Skin Cancer (Keratinocyte Carcinomas) in the U.S. Population, 2012. JAMA Dermatol. 2015 Oct;151(10):1081-6. doi: 10.1001/jamadermatol.2015.1187. PMID: 25928283.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-dermatological-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Archives of Dermatological Research](https://www.springer.com/journal/403)","snPcode":"403","submissionUrl":"https://submission.nature.com/new-submission/403/3","title":"Archives of Dermatological Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7104611/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7104611/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e– Google Trends (GT) assesses public interest in search terms using “Relative Search Volume” (RSV), which represents the proportion of searches for a term relative to total search activity.\u003c/p\u003e\n\u003cp\u003eObjective– To analyze GT data for “Mohs surgery” to identify spatiotemporal trends and evaluate RSV as a potential proxy marker for Mohs surgery demand.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods and Materials\u003c/strong\u003e– GT was queried for data on “Mohs surgery” (2004-2024). RSV was correlated against demographic factors from the U.S. Census and Centers for Medicare and Medicaid Services (CMS) data for Mohs first-layers (codes 17311 and 17313). A novel metric for Mohs demand, the Mohs Relative Demand (MoRD), was created.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e- Interest in “Mohs surgery” increased over time. RSV correlated with urban population (p=0.046), white population (p=0.006), age over 65 (p\u0026lt;0.001), daily ultraviolet irradiance (p=0.048) and CMS coding for Mohs first-layers (p=0.0026). MoRD was lowest in Arkansas, South Dakota, and Kansas, and highest in Maine, Hawaii, and Alaska.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e- RSV serves as a valuable proxy for Mohs surgery interest, offering an alternative to traditional methods such as claims data analysis. MoRD provides insights on demand for surgery, highlighting potential unmet needs.\u003c/p\u003e","manuscriptTitle":"Leveraging Google Trends to Analyze Spatiotemporal Disparities in Public Interest and Demand for Mohs Surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-08 10:37:51","doi":"10.21203/rs.3.rs-7104611/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-13T22:41:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"320870198462045793796376300327774343698","date":"2026-01-13T22:30:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317647320178314711108405903925342731705","date":"2026-01-11T02:31:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-28T17:40:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-12T07:00:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-12T06:58:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Dermatological Research","date":"2025-07-11T21:37:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-dermatological-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Archives of Dermatological Research](https://www.springer.com/journal/403)","snPcode":"403","submissionUrl":"https://submission.nature.com/new-submission/403/3","title":"Archives of Dermatological Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2e1b423f-e025-4492-aa9f-ba24776c232d","owner":[],"postedDate":"September 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-08T10:37:51+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-08 10:37:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7104611","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7104611","identity":"rs-7104611","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}