O02 Biopsy-to-excision ratios in dermatological surgery across a region: insights into clinical pathways and workforce models

Abstract

Following regional GIRFT recommendations to audit biopsy-to-excision ratios as a marker of service quality, we quantified biopsy-to-excision and nondefinitive-to-definitive treatment ratios across a multicentre regional network. We aimed to establish regional benchmarks for these ratios across a multicentre dermatology network. We explored variation by centre and teledermatology pathway to provide the data necessary for individual departments to audit their performance against regional averages. We audited consecutive dermatology surgery episodes (excluding Mohs) across seven NHS trusts. Primary outcomes were (i) biopsy-to-excision ratio (punch or incisional biopsies vs. excision or shave excision) and (ii) nondefinitive-to-definitive ratio (diagnostic intent vs. treatment intent). The data captured were procedure type, sex, age and pathway variables. Differences were tested with the χ2-test or Fisher’s exact test. Data from 902 cases showed an overall biopsy-to-excision ratio of 0.49 (267 to 541) and a nondefinitive-to-definitive treatment ratio of 0.51 (303 to 599). Both showed significant centre variation (both P < 0.001), with ratios in the range of 0.19–0.91 and 0.23–1.08, respectively. Among pigmented excisions, the melanoma yield was 27.0% (95% confidence interval 21.9–32.9), demonstrating marked variation (P < 0.001). Teledermatology cases (13.3%) showed a significantly higher skin cancer rate (68.1% vs. 40.6%; odds ratio 3.12, P < 0.001) and lower biopsy propensity (biopsy-to-excision odds ratio 0.49, P = 0.004) than nonteledermatology cases. In conclusion, the data from this large regional cohort provide a valuable benchmark for departments to inform quality improvement initiatives. Significant variation in ratios and yields supports their use as pragmatic indicators of unwarranted variation, allowing clinicians to audit practice against regional averages. Teledermatology pathways demonstrated higher malignancy yields and lower biopsy propensity, consistent with effective triage and confidence in proceeding to definitive treatment – possibly due to dual-clinician review improving diagnostic confidence. Further work is warranted to explore drivers of high biopsy or low definitive treatment ratios within units to optimize clinical pathways and outcomes