Impact of multimodal dermatoscopy training on skin biopsies by primary care providers

Abstract

Primary care providers (PCPs) play a pivotal role in skin cancer detection. With training, dermatoscopy improves skin cancer identification. Yet, access to dermatoscopy training remains a barrier for many PCPs.1Fee J.A. McGrady F.P. Rosendahl C. Hart N.D. Training primary care physicians in dermoscopy for skin cancer detection: a scoping review.J Cancer Educ. 2020; 35: 643-650https://doi.org/10.1007/s13187-019-01647-7Crossref PubMed Scopus (9) Google Scholar In this study, a multimodal dermatoscopy training intervention for novice dermatoscopist PCPs was implemented. We present the impact of the training intervention on the proportion of benign-to-malignant biopsies performed and on the number needed to biopsy (NNB) to detect a melanoma across the MaineHealth system. A needs assessment at our institution found that <10% of PCPs were trained to use dermatoscopy. To address this training gap, a multimodal dermatoscopy curriculum was created and implemented over a 1-year period. The curriculum provided foundational dermatoscopy training using a 90-minute dermatoscopy workshop, followed by monthly telementoring online review sessions.2Seiverling E.V. Li D. Stevens K. Cyr P. Dorr G. Ahrns H. Distance learning and spaced review to complement dermoscopy training for primary care.Dermatol Pract Concept. 2021; 11e2021030https://doi.org/10.5826/dpc.1102a30Crossref PubMed Scopus (5) Google Scholar A total of 267 PCPs participated in the training. A skin biopsy database was developed to analyze the impact of the intervention on the proportion of benign-to-malignant neoplasms being removed in the primary care setting. Here we present data comparing 5 years before the intervention (from November 5, 2013, to November 5, 2018) to almost 2 years after the intervention (from November 6, 2018, to October 1, 2020). Using the Current Procedural Terminology codes, skin biopsy data were extracted from electronic medical records using the Business Intelligence Portal (Epic). Pathology reports were manually reviewed by 2 reviewers (KS and MP) and entered into Research Electronic Data Capture. The inclusion criteria for PCPs were providers at MaineHealth in internal medicine, family medicine, internal medicine/pediatrics, and pediatrics. Skin biopsy reports were excluded in the following situations: rash, re-excision, pathology absent, and duplicate record. Biopsies were categorized by results (benign, malignant, and premalignant) and further into subtypes (benign: seborrheic keratosis, angioma, dermatofibroma, nevi, etc; malignant: basal cell carcinoma, squamous cell carcinoma, and melanoma). A total of 4565 biopsies were included in the preintervention group, whereas 2969 biopsies were included in the postintervention group. Two years following multimodal dermatoscopy training, significant shifts in biopsy percentages were demonstrated. There was a 10% shift from benign to malignant biopsy results found using binomial probability (P < .0001, Fig 1). The NNB for melanoma decreased from 119 before the intervention to 53 after the intervention (P < .001, Fig 2). Although there was a notable increase in the overall number of biopsies after the intervention, the NNB to detect melanoma was reduced by >50%. Our multimodal dermatoscopy curriculum included training on how to perform skin biopsies. The training may have led to increased confidence in performing skin biopsies and fewer external referrals for skin biopsies. As PCPs gain additional dermatoscopy skills, streamlined management and even “watchful waiting” of some skin cancers might be possible.3Wu X. Elkin E.B. Jason Chen C.S. Marghoob A. Traditional versus streamlined management of basal cell carcinoma (BCC): a cost analysis.J Am Acad Dermatol. 2015; 73: 791-798https://doi.org/10.1016/j.jaad.2015.07.021Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar,4van Winden M.E.C. Hetterschijt C.R.M. Bronkhorst E.M. van de Kerkhof P.C.M. de Jong E.M.G.J. Lubeek S.F.K. Evaluation of watchful waiting and tumor behavior in patients with basal cell carcinoma: an observational cohort study of 280 basal cell carcinomas in 89 patients.JAMA Dermatol. 2021; 157: 1174-1181https://doi.org/10.1001/jamadermatol.2021.3020Crossref PubMed Scopus (9) Google Scholar These strategies might help reduce health care costs and overdiagnosis. As we shift toward value-based care models, dermatoscopy has the potential to hit on all aspects of the quadruple aim.5Sikka R. Morath J.M. Leape L. The Quadruple Aim: care, health, cost and meaning in work.BMJ Qual Saf. 2015; 24: 608-610https://doi.org/10.1136/bmjqs-2015-004160Crossref PubMed Scopus (298) Google ScholarFig 2Impact of multimodal dermatoscopy training on number needed to biopsy to detect 1 melanoma by year. The training intervention duration is indicated by the time between the 2 vertical lines.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The limitations of this study are that the postintervention data were limited to 23 months and the sample size for melanomas was small. Without a control group, we were unable to determine how much of the improvement in biopsy ratios and NNB was due to additional clinical experience. We also have not accounted for changes in skin cancer incidence in our patient population. None disclosed.