The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire.
Norris Cotton Cancer Center, Lebanon, New Hampshire.
JAMA Dermatol. 2021 Sep 1;157(9):1102-1106. doi: 10.1001/jamadermatol.2021.1779.
Diagnostic variation among pathologists interpreting cutaneous melanocytic lesions could lead to suboptimal care.
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.
Various second-opinion strategies for interpretation of melanocytic cutaneous lesions.
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.
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.
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.
病理学家对皮肤黑素细胞病变的解读存在差异,可能导致治疗效果不佳。
评估美国皮肤黑素细胞病变的组织病理学诊断中,第二意见策略与诊断准确性和 1 年人群水平成本之间的潜在关联。
设计、设置和参与者:决策分析,时间范围为 1 年,包括美国病理学家参与黑素瘤病理学研究(M-Path)和参考病理学家小组进行的黑素瘤病理诊断(MPATH-Dx 分类工具)。M-Path 数据收集时间为 2013 年 7 月至 2015 年 3 月;本研究的分析于 2015 年 4 月至 2021 年 1 月进行。
各种解读皮肤黑素细胞病变的第二意见策略。
评估病理学家诊断的准确性,定义为与参考小组诊断的一致性,以及各种第二意见策略下 1 年后活检后的医疗成本。预计的一致性诊断百分比,包括过度解读和解读不足的百分比,以及美国每 10 万人的医疗保健成本。
决策分析模型参数基于 187 名病理学家对 240 例病例的诊断解读,与参考小组的诊断进行比较。如果没有第二意见,美国估计有 83.2%的诊断是准确的,即与参考诊断一致;有 8.0%的过度解读和 8.8%的解读不足,每 10 万次活检中会出现 16850 次错误诊断。所有第二意见策略都提高了准确性。准确性(87.4%的一致性,3.6%的过度解读和 9.1%的解读不足)和成本(每年每 10 万次活检增加超过 1000 万美元)在所有第二意见策略中都是最高的,与没有第二意见相比。基于病理学家对第二意见的需求或机构要求的选择性第二意见策略是最准确的(86.5%的一致性;4.4%的过度解读;9.1%的解读不足),与没有第二意见相比,每年每 10 万次皮肤活检可节省超过 190 万美元的成本。所有第二意见策略都提高了诊断准确性,同时减少了过度解读,但没有减少解读不足。
在这个决策分析模型中,皮肤黑素细胞病变的选择性第二意见策略与没有第二意见或普遍的第二意见相比,有可能提高诊断准确性并降低成本。