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Consensus Statement
May 2014

A Multistep Approach to Improving Biopsy Site Identification in Dermatology: Physician, Staff, and Patient Roles Based on a Delphi Consensus

Author Affiliations
  • 1Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 2Department of Otolaryngology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 3Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 4currently in private practice, Stamford, Connecticut
  • 5Department of Dermatology, Case Western Reserve School of Medicine, Case Western Reserve University, Cleveland, Ohio
  • 6Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston
  • 7currently in private practice, Little Rock, Arkansas
  • 8currently in private practice, Hackensack, New Jersey
  • 9Department of Dermatology, Indiana University School of Medicine, Indianapolis
  • 10Department of Dermatology, St Louis University School of Medicine, St Louis, Missouri
  • 11Department of Dermatology, Memorial Sloan-Kettering Cancer Center, New York, New York
  • 12Department of Dermatology, Lahey Hospital and Medical Center, Burlington, Massachusetts
  • 13Department of Dermatology, University of Michigan Medical School, University of Michigan, Ann Arbor
  • 14Department of Dermatology, Brown University School of Medicine, Providence, Rhode Island
  • 15Department of Dermatology, Columbia University Medical Center, Columbia University, New York, New York
  • 16Mohs Micrographic Surgery Unit, Brigham & Women’s Faulkner Hospital, Boston, Massachusetts
  • 17currently in private practice, Delray Beach, Florida
  • 18Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio
  • 19Department of Dermatology, Penn State Hershey Medical Center, Penn State University, Hershey
JAMA Dermatol. 2014;150(5):550-558. doi:10.1001/jamadermatol.2013.9804

Importance  Excisional skin cancer surgery is a common procedure, with no formal consensus for mitigating the risk of wrong-site cutaneous surgery.

Objective  To systematically consider the usefulness and feasibility of proposed methods for correct biopsy site identification in dermatology.

Evidence Review  Survey study with a formal consensus process. Item development was via a literature review and expert interviews, followed by 2 stages of a Delphi process to develop consensus recommendations.

Findings  In total, 2323 articles were reviewed in the literature search, with data extraction from 14. Twenty-five experts underwent 30-minute structured interviews, which were transcribed and coded. The resulting survey was composed of 42 proposed interventions by multiple stakeholders (biopsying physicians, operating physicians, nurses, ancillary staff, patients, caregivers, and family members) at 3 time points (day of biopsy, delay and consultation period, and day of definitive surgery). Two rounds of a Delphi process with 59 experts (25 academic and 34 private practice) scored the survey. Strong consensus was obtained on 14 behaviors, and moderate consensus was obtained on 21 other behaviors. In addition, a 2-state simultaneous algorithm was developed to model surgeon behavior on the day of definitive surgery based on surgeon and patient perceptions.

Conclusions and Relevance  When definitive surgery is performed after the initial biopsy and by a different surgeon, procedures can be implemented at several time points to increase the likelihood of correct site identification. The specific circumstances of a case suggest which methods may be most appropriate and feasible, and some may be implemented. The risk of wrong-site cutaneous surgery can be reduced but not eliminated.