0
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 50.19.47.197. Please contact the publisher to request reinstatement.
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letter |

Biopsy Use in Skin Cancer Diagnosis Comparing Dermatology Physicians and Advanced Practice Professionals FREE

Ashley Nault, BS1; Chong Zhang, MS2,3; KyungMann Kim, PhD2; Sandeep Saha, MS2; Daniel D. Bennett, MD1; Yaohui G. Xu, MD, PhD1
[+] Author Affiliations
1Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison
2Department of Biostatistics and Medical Informatics, University of Wisconsin–Madison
3Division of Epidemiology, University of Utah School of Medicine, Salt Lake City
JAMA Dermatol. 2015;151(8):899-902. doi:10.1001/jamadermatol.2015.0173.
Text Size: A A A
Published online

Histopathologic evaluation is the criterion standard for diagnosis of skin cancer. Underuse of biopsies may promote misdiagnosis, and overuse will increase cost and morbidity. There is no benchmark with which to quantitatively compare health care professionals’ diagnostic accuracy and biopsy use. Prior studies suggest wide variability in biopsy use among practice settings and health care professionals.15 We conducted a retrospective review on the number of skin biopsies needed per malignant neoplasm in our department. The recent article by Coldiron and Ratnarathorn6 documents that, in 2012, mid-level health care professionals independently billed approximately 2.6 million dermatologic procedures, most of which required clinical distinction between benign and malignant lesions. To our knowledge, our study is the first to compare the number needed to biopsy (NNB) per malignant neoplasm between dermatology physicians and advanced practice professionals (APPs).

We performed a retrospective study of all biopsies submitted to our laboratory by 13 dermatology physicians (5 men and 8 women) and 5 APPs (1 physician assistant and 4 nurse practitioners, all women) between January 1 and February 15, 2010. The study was approved by the University of Wisconsin Institutional Review Board. We reviewed requisition forms and clinical notes, and only biopsy procedures that were performed with the intention to exclude skin cancer were included. Biopsies performed for inflammatory conditions, removal of lesions for cosmetic or functional reasons, and re-excisions, as well as biopsies with insufficient documentation, were excluded. Patient demographics and information on lesion appearance, type of health care professional, and final diagnoses were collected. The NNB for nonmelanoma skin cancer (NMSC) was calculated by dividing the total number of nonpigmented lesions by the number of histologically proven NMSCs. The NNB for melanoma was calculated by dividing the total number of pigmented lesions by the number of histologically proven melanomas. Uncommonly, NMSCs were diagnosed from the pigmented lesions, while melanomas were diagnosed from nonpigmented lesions. The NNB for any skin cancer was calculated by dividing the total number of all lesions by the total number of histologically proven malignant lesions.

A total of 1102 biopsy procedures from 743 patients met the inclusion criteria (Table 1). Nonpigmented lesions made up 55.4% of the total biopsies and pigmented lesions, 44.6% of all biopsies; 26.9% were histologically diagnosed as NMSC and 2.2% as melanoma. The NNB for any skin cancer, NMSC, and melanoma was 3.4, 2.1, and 21.4, respectively. There was a significant difference in NNB between physicians and APPs for any skin cancer (2.9 vs 5.9, P < .001), NMSC (1.9 vs 3.1, P < .001), and melanoma (17.4 vs 32.8, P = .04). The NNB was significantly lower for patients older than 65 years, male patients, and patients with a history of NMSC prior to biopsy. When patients were stratified by age, sex, and history of skin cancer, APPs performed significantly more biopsy procedures than did physicians to diagnose a malignant neoplasm in patients younger than 65 years and in patients without a history of skin cancer (Table 2).

Table Graphic Jump LocationTable 1.  Patient Demographics by Type of Health Care Professional

Our NNB differed from those in previous studies.15 We made an effort to recapitulate practice by including only biopsies for which physicians and APPs had intention to exclude malignant neoplasm. Wilson et al5 performed a similar study; their NNB for any cancer, NMSC, and melanoma was 2.2, 1.6, and 15, respectively. Variability between studies may result from differences in patient population, geographic location, and practice settings.

To our knowledge, our study is the first to compare NNB between types of health care professionals. At our institution, APPs see new and established patients, most of whom are not evaluated by a physician; however, a physician is available in the clinic. The mean length of practice for our physicians was 11.9 years (range, 0.5-25.5 years) compared with 6.8 years (range, 0.5-20 years) for APPs. In our study, the NNB of any skin cancer for APPs was double that of physicians, and that difference is most pronounced in younger patients and those without a history of skin cancer. The use of dermoscopy was not consistently recorded in the clinical notes, but we speculate that dermatologists’ training in dermoscopy may play a role in their lower NNB. Future studies may evaluate the use of dermoscopy in relation to NNB and type of health care professional.

At the time of this publication, we are reviewing additional cases submitted by dermatologists, other specialty physicians, and APPs from multiple departments to provide a more robust analysis of NNB by type of health care professional and specialty. Similar studies performed elsewhere may allow comparison of NNB across broader practice settings and may provide benchmarks with which physicians can compare their own practices. Most important, our findings suggest that increased use of biopsies may increase the morbidity and cost of care provided by APPs when compared with that provided by dermatologists.

Accepted for Publication: January 23, 2015.

Corresponding Author: Yaohui G. Xu, MD, PhD, Department of Dermatology, University of Wisconsin School of Medicine and Public Health, 1 S Park St, Seventh Floor, Madison, WI 53715 (yxu@dermatology.wisc.edu).

Published Online: March 25, 2015. doi:10.1001/jamadermatol.2015.0173.

Author Contributions: Drs Bennett and Xu had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Bennett and Xu contributed equally to this article.

Study concept and design: Saha, Bennett, Xu.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Nault, Saha, Bennett, Xu.

Critical revision of the manuscript for important intellectual content: Zhang, Kim, Saha, Bennett, Xu.

Statistical analysis: Zhang, Kim, Saha.

Obtained funding: Xu.

Administrative, technical, or material support: Saha, Bennett, Xu.

Study supervision: Bennett, Xu.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported in part by the Department of Dermatology, University of Wisconsin School of Medicine and Public Health, and Shapiro Research Program at University of Wisconsin School of Medicine and Public Health.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Justin Endo, MD, and Joanna McGetrick, MD, Department of Dermatology, University of Wisconsin School of Medicine and Public Health, assisted with the study design; Joshua Tarpley, BA, University of Wisconsin School of Medicine and Public Health, Farinoosh Dadrass, BS, Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Lauren Van Loon, BS, Department of Dermatology, University of Wisconsin School of Medicine and Public Health, and Loren Krueger, BS, University of Wisconsin School of Medicine and Public Health, assisted with data entry; and Diane Bock, BS, Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Tisha Kawahara, MS, CRCC, Department of Biostatistics and Medical Informatics, University of Wisconsin–Madison, and Sandra Olson, MS, Department of Dermatology, University of Wisconsin School of Medicine and Public Health, provided administrative assistance. None of the contributors were compensated for their assistance.

Argenziano  G, Cerroni  L, Zalaudek  I,  et al.  Accuracy in melanoma detection: a 10-year multicenter survey. J Am Acad Dermatol. 2012;67(1):54-59.
PubMed   |  Link to Article
Green  AR, Elgart  GW, Ma  F, Federman  DG, Kirsner  RS.  Documenting dermatology practice: ratio of cutaneous tumors biopsied that are malignant. Dermatol Surg. 2004;30(9):1208-1209.
PubMed
Hansen  C, Wilkinson  D, Hansen  M, Argenziano  G.  How good are skin cancer clinics at melanoma detection? number needed to treat variability across a national clinic group in Australia. J Am Acad Dermatol. 2009;61(4):599-604.
PubMed   |  Link to Article
Soares  TF, Laman  SD, Yiannias  JA,  et al.  Factors leading to the biopsy of 1547 pigmented lesions at Mayo Clinic, Scottsdale, Arizona, in 2005. Int J Dermatol. 2009;48(10):1053-1056.
PubMed   |  Link to Article
Wilson  RL, Yentzer  BA, Isom  SP, Feldman  SR, Fleischer  AB  Jr.  How good are US dermatologists at discriminating skin cancers? a number-needed-to-treat analysis. J Dermatolog Treat. 2012;23(1):65-69.
PubMed   |  Link to Article
Coldiron  B, Ratnarathorn  M.  Scope of physician procedures independently billed by mid-level providers in the office setting. JAMA Dermatol. 2014;150(11):1153-1159.
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1.  Patient Demographics by Type of Health Care Professional

References

Argenziano  G, Cerroni  L, Zalaudek  I,  et al.  Accuracy in melanoma detection: a 10-year multicenter survey. J Am Acad Dermatol. 2012;67(1):54-59.
PubMed   |  Link to Article
Green  AR, Elgart  GW, Ma  F, Federman  DG, Kirsner  RS.  Documenting dermatology practice: ratio of cutaneous tumors biopsied that are malignant. Dermatol Surg. 2004;30(9):1208-1209.
PubMed
Hansen  C, Wilkinson  D, Hansen  M, Argenziano  G.  How good are skin cancer clinics at melanoma detection? number needed to treat variability across a national clinic group in Australia. J Am Acad Dermatol. 2009;61(4):599-604.
PubMed   |  Link to Article
Soares  TF, Laman  SD, Yiannias  JA,  et al.  Factors leading to the biopsy of 1547 pigmented lesions at Mayo Clinic, Scottsdale, Arizona, in 2005. Int J Dermatol. 2009;48(10):1053-1056.
PubMed   |  Link to Article
Wilson  RL, Yentzer  BA, Isom  SP, Feldman  SR, Fleischer  AB  Jr.  How good are US dermatologists at discriminating skin cancers? a number-needed-to-treat analysis. J Dermatolog Treat. 2012;23(1):65-69.
PubMed   |  Link to Article
Coldiron  B, Ratnarathorn  M.  Scope of physician procedures independently billed by mid-level providers in the office setting. JAMA Dermatol. 2014;150(11):1153-1159.
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

864 Views
2 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles
Jobs
JAMAevidence.com

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Original Article: Does This Patient Have Temporal Arteritis?

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Results