Last fall, the 1,400-member American Society of Dermatopathology (ASDP) became one of the newest specialty society to join the Choosing Wisely campaign. ASDP’s list of “Five Things Physicians and Patients Should Question” focuses on diagnostic testing of skin lesions, skin cancers and other disorders. Claudia Vidal, MD, PhD, Chair of ASDP’s Appropriate Use Criteria Committee, and M. Yadira Hurley, MD, Past Chair of the committee, shared background on how the recommendations were developed.
What prompted the ASDP to become involved with the Choosing Wisely campaign?
With the increase in the number of diagnostic tests available to physicians and calls from policymakers and patients for more cost-conscious care, the ASDP recognized the importance of developing appropriate use criteria (AUC) that can serve as guidelines for physicians practicing dermatopathology and inform their clinical colleagues and patients in their use of tests performed in dermatopathology.
The criteria were developed using the RAND/ UCLA methodology that combines scientific evidence with expert judgment. The resulting AUC can be utilized to explore both overuse and underuse. Converting some of the AUC into recommendations for the Choosing Wisely campaign seemed like a logical next step to help bring all parties involved (pathologists, clinicians and patients) to the table.
What is the focus of your first five recommendations?
Our first list focuses on not using additional testing in situations where there are testing limitations, where a diagnosis can be reached on histological grounds alone, and when testing is already completed by another testing modality.
Why do these areas of focus have the potential for overuse?
Diagnostic testing has the potential for overuse because physicians order them out of fear of uncertainty. The recommendations and developed AUC hopefully decrease this uncertainty by providing physicians with guidelines.
Some of the drivers of overuse include pressure from patients and other providers to order tests, the ordering of tests by physicians because of fear of malpractice or uncertainty, and unfortunately the benefit from financial incentives. Not understanding the cost of tests can be another driver of overuse. It is important that all stakeholders work together in a multidisciplinary team to make sure value is added in healthcare.
What has been the response of your membership to the recommendations?
The ASDP’s membership has been overall accepting of the developed AUC and Choosing Wisely recommendations. In addition to being on our website, they were recently discussed at our annual meeting.
How can clinicians share these recommendations with patients?
The Choosing Wisely recommendations have been distributed to dermatopathologists utilizing these tests. We encourage the dermatopathologists to engage in a dialogue with clinicians so that this information can be disseminated to patients. The developed AUC as well as the Choosing Wisely recommendations were also recently featured in a soon to be released article in Dermatology World, where it is our hope they can be further brought into light with our clinical colleagues.
What are the next steps for ASDP with regard to Choosing Wisely?
The ASDP is currently working on adding new tests that are slated for AUC development. We anticipate that additional appropriateness recommendations will come out in late 2020. As with the prior AUC development, the ASDP plans to include not only dermatopathologists but also dermatologists and pathologists in the process. We will then look at these new appropriateness recommendations to see if any fit into the Choosing Wisely model.
Vidal is Associate Professor of Dermatology and Pathology at Saint Louis University School of Medicine. Hurley is Professor of Dermatology and Pathology, Director of Dermatopathology, and Interim Associate Chairman of the Department of Dermatology at Saint Louis University School of Medicine.