Selective second opinions may lead to better accuracy, less cost in melanocytic lesions

For patients undergoing skin biopsies of melanocytic lesions, selective second opinions may lead to better diagnostic accuracy and less cost compared with no second opinions or universal second opinions, according to a study.

“Increased awareness of diagnostic variation among pathologists interpreting melanocytic lesions has raised concerns of diagnostic inaccuracy, which could lead to suboptimal care,” Anna N.A. Tosteson, ScD, of the Dartmouth Institute for Health Policy and Clinical Practice, and colleagues wrote. “The number of skin biopsies has increased over time, and approximately one-fourth of these are melanocytic lesions. Diagnostic misclassification directs patients to clinical care pathways that may result in overtreatment or undertreatment with the attendant adverse consequences.”

A decision-analytic model was developed to estimate the effects of second-opinion strategies, including no second opinion, second opinion for all, selective second opinion based on one of three types of initial case interpretations and second opinion based on pathologist’s desire or lab requirement. The study included 240 case interpretations by 187 pathologists in 10 states.

Diagnoses were estimated to be accurate in 83.2% of cases that did not receive second opinions, with 8% overinterpretation and 8.8% underinterpretation.

In all second opinion cases, accuracy was 87.4%, with 3.6% overinterpretation and 9.1% underinterpretation; however, this strategy also increased costs by more than $10 million per 100,000 biopsies per year compared with no second opinions.

Selective second opinions resulted in 86.5% concordance, with 4.4% overinterpretation and 9.1% underinterpretation; this strategy was estimated to reduce costs by more than $1.9 million per 100,000 biopsies compared with no second opinions.

“We conclude that selective second-opinion strategies for interpretation of melanocytic skin lesions may be associated with improved diagnostic accuracy and decreased costs relative to no second opinions or universal second opinions,” the authors wrote. “Implementation of second-opinion strategies should be studied in clinical settings to evaluate effective best practices for improving histopathologic interpretation of these challenging melanocytic skin lesions.”