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Consensus Statement |

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

Murad Alam, MD, MSCI1,2,3; Andy Lee, BS1; Omar A. Ibrahimi, MD, PhD4; Natalie Kim, MD1; Jeremy Bordeaux, MD, MPH5; Karen Chen, MD6; Scott Dinehart, MD7; David J. Goldberg, MD, JD8; C. William Hanke, MD9; George J. Hruza, MD, MBA10; Kishwer S. Nehal, MD11; Suzanne M. Olbricht, MD12; Jeffrey Orringer, MD13; Thomas E. Rohrer, MD14; Noah S. Scheinfeld, MD, JD15; Chrysalyne D. Schmults, MD, MSCE16; John M. Strasswimmer, MD, PhD17; James S. Taylor, MD18; Simon Yoo, MD1; Michael Nodzenski, BA1; Emily Poon, PhD1; Todd Cartee, MD19 ; for the Cutaneous Surgery Consensus Group
[+] 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.
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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.

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Figure.
Day of Definitive Surgery Decision Tree for Biopsy Site Identification

This decision tree conveys recommendations based on surgeon and patient surety regarding the biopsy site on the day of definitive surgery.

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