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Brief Report
June 2, 2021

Association of Second-Opinion Strategies in the Histopathologic Diagnosis of Cutaneous Melanocytic Lesions With Diagnostic Accuracy and Population-Level Costs

Author Affiliations
  • 1The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
  • 2Norris Cotton Cancer Center, Lebanon, New Hampshire
  • 3Oregon Health & Science University, Portland
  • 4Program in Biostatistics, Fred Hutchinson Cancer Research Center, Seattle, Washington
  • 5Department of Population Health Sciences, University of Utah, Salt Lake City
  • 6Division of Dermatology, University of Washington School of Medicine, Seattle
  • 7Dermatopathology Northwest, Bellevue, Washington
  • 8Pathology Associates, Clovis, California
  • 9Departments of Pathology and Translational Research, Institut Curie, Paris, France
  • 10Paris Sciences and Letters Research University, Paris, France
  • 11Department of Dermatology, Brown University, Providence, Rhode Island
  • 12Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
  • 13David Geffen School of Medicine, Department of Medicine, University of California, Los Angeles
JAMA Dermatol. Published online June 2, 2021. doi:10.1001/jamadermatol.2021.1779
Key Points

Question  What is the expected population impact of second opinions for histopathologic interpretation of cutaneous melanocytic lesions on diagnostic accuracy and direct medical costs in the year following biopsy?

Findings  This decision analysis, based on diagnostic interpretations for 240 cases by 187 pathologists, estimated that expected diagnostic accuracy increased with all second-opinion strategies considered and that costs decreased under selective second-opinion strategies compared with no second opinions.

Meaning  Second opinions may be associated with increased diagnostic accuracy and lower costs among patients undergoing skin biopsy.


Importance  Diagnostic variation among pathologists interpreting cutaneous melanocytic lesions could lead to suboptimal care.

Objective  To estimate the potential association of second-opinion strategies in the histopathologic diagnosis of cutaneous melanocytic lesions with diagnostic accuracy and 1-year population-level costs in the US.

Design, Setting, and Participants  Decision analysis with 1-year time horizon including melanocytic lesion diagnoses available from US pathologists participating in the Melanoma Pathology Study (M-Path) and from the study panel of reference pathologists who classified cases using the MPATH-Dx classification tool. M-Path data collection occurred from July 2013 through March 2015; analyses for the present study were performed between April 2015 and January 2021.

Exposures  Various second-opinion strategies for interpretation of melanocytic cutaneous lesions.

Main Outcomes and Measures  Estimated accuracy of pathologists’ diagnoses, defined as concordance with the reference panel diagnoses, and 1-year postbiopsy medical costs under various second-opinion strategies. Expected percentage of concordant diagnoses, including percentages of overinterpretation and underinterpretation, and 1-year costs of medical care per 100 000 in the US population.

Results  Decision-analytic model parameters were based on diagnostic interpretations for 240 cases by 187 pathologists compared with reference panel diagnoses. Without second opinions, 83.2% of diagnoses in the US were estimated to be accurate—ie, concordant with the reference diagnosis; with overinterpretation (8.0%) or underinterpretation (8.8%), and 16 850 misclassified diagnoses per 100 000 biopsies. Accuracy increased under all second-opinion strategies. Accuracy (87.4% concordance with 3.6% overinterpretation and 9.1% underinterpretation) and cost (an increase of more than $10 million per 100 000 biopsies per year) were highest when second opinions were universal (eg, performed on all biopsies), relative to no second opinions. A selective second-opinion strategy based on pathologists’ desire or institutional requirements for a second opinion was most accurate (86.5% concordance; 4.4% overinterpretation; 9.1% underinterpretation) and would reduce costs by more than $1.9 million per 100 000 skin biopsies relative to no second opinions. Improvements in diagnostic accuracy with all second-opinion strategies were associated with reductions in overinterpretation but not underinterpretation.

Conclusions and Relevance  In this decision-analytic model, selective second-opinion strategies for interpretation of melanocytic skin lesions showed the potential to improve diagnostic accuracy and decrease costs relative to no second opinions or universal second opinions.

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