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

Anna N.A. Tosteson, Stephanie Tapp, Linda J. Titus, Heidi D. Nelson, Gary M. Longton, MacKenzie Bronson, Margaret Pepe, Patricia A. Carney, Tracy Onega, Michael W. Piepkorn, Stevan R. Knezevich, Raymond Barnhill, Martin A. Weinstock, David E. Elder, Joann G. Elmore

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


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 100000 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 16850 misclassified diagnoses per 100000 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 100000 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 100000 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..

Original languageEnglish (US)
Pages (from-to)1102-1106
Number of pages5
JournalJAMA Dermatology
Issue number9
StatePublished - Sep 2021

ASJC Scopus subject areas

  • Dermatology


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