Improving follow-up to abnormal cervical cytology

resultsTom Garvey, BS, M2

Ann Evensen, MDHelen Luce, DO

Two main types◦ Adenocarcinoma◦ Squamous cell carcinoma

Asymptomatic Develop slowly Risk factors

Cervical Cancer

Cytology◦ High sensitivity◦ Conventional glass slide◦ Liquid-based cytology◦ ASCUS, ASC-H, LGSIL, HGSIL, AIS, AGUS

HPV Testing

Cervical Cancer Screening

Normal vs. Abnormal Cervical Cells

Histology: Colposcopy◦ Visual examination◦ Biopsy◦ High specificity◦ CIN-1, 2, or 3; Cancer

Excisional Procedures◦ Loop Electrosurgical Excision

Procedure (LEEP)◦ Cold cone excision

Next Steps

LEEP

ASCCP – algorithms for cytological and histological results4

Clinical Best Practices

Barriers to screening Imperfect tests Loss of follow-up to abnormal results

◦ Patient factors◦ Provider error

Special challenges at residency clinics

Current Limitations

Intervention Results

Telephone counseling on psychological concerns/barriers Improves initial and long-term adherence

Educational brochure/pamphlet Improves adherence

Electronic tracking system Improves adherence

Family physician involvement in follow-up Improves adherence

Result reminder letters from cytologist to physician Improves adherence, especially with older patients

Framing of result messages to patient Not shown to be effective

Economic Reimbursement Improves adherence in disadvantaged patients

Interventions to Improve Adherence

HypothesisUsing an electronic tracking system to manage patients with abnormal cervical cytology will improve both communication of next steps to the patient and patient adherence with these

steps at two family medicine residency clinics

Data sources: ◦ UW-Verona Family Medicine Clinic◦ UW-Wausau Family Medicine Clinic

Timeframes:◦ Index Pap◦ Pre-intervention: 11/2005 - 11/2007◦ Post-intervention: 11/2008 - 11/2010

Intervention◦ Spreadsheet

Scoring care:◦ Follow ASCCP guidelines (3 month window)◦ Early testing appropriate◦ Extra vigilant care appropriate

Methods

If appropriate care took place, assumed communication was appropriate

Inappropriate steps◦ Review communication◦ Attribute loss of follow-up (patient or provider)

Scoring stopped after an inappropriate step Referrals appropriate Transfer of care Adolescents excluded from post-

intervention results

Methods

Patient Recruitment Flowchart – Pre-Intervention - Verona

72 Patients

5 Patients Excluded4 History Questions1 Chart Incomplete

67 Patients

Patient Recruitment Flowchart – Pre-Intervention - Wausau

62 Patients

9 Patients Excluded 6 Care Transferred2 Index Pap not at

Clinic1 Chart Incomplete

53 Patients

Las

Patient Recruitment Flowchart – Post-Intervention - Verona

127 Patients

23 Patient Excluded13 Adolescents

9 Care Transferred1 Superceding Provider

Judgment

104 Patients

Las

Patient Recruitment Flowchart – Post-Intervention - Wausau

77 Patients

8 Patients Excluded5 Care Transferred

3 Adolescents

69 Patients

Patient Care: ◦ Percentage of follow-up steps that were

appropriate Provider Communication:

◦ Percentage of follow-up steps that had correct provider communication

Significance of Results: ◦ analyzed with Fisher’s test

Data Analysis

Results: Appropriate Care By ClinicKey: V – VeronaW - Wausau

# of Steps with Appropriate

Care

# of Steps with Delayed or Absent

Care

Percent of Steps with

Appropriate Care

Clinic V W V W V W

Pre-intervention

82 76 27 24 75.2% 76.0%

Post-intervention

133 76 31 23 81.1% 76.8%

Improvement: 5.9%P=0.29

0.8%P=1

Results: Provider Communication By Clinic

Key: V – VeronaW - Wausau

# of Steps where Patient Received

Adequate Communication

# of Steps where Patients

Received Either No or Erroneous Communication

Percent of Steps with Adequate Communication

Clinic V W V W V W

Pre-intervention

93 87 16 13 85.3% 87.0%

Post-intervention

153 89 8 10 95.0% 89.9%

Improvement: 9.7%P=0.0082

2.9%P=0.66

Study not complete Challenges:

◦ Change in ASCCP guidelines◦ Implementation of EMR◦ Difficulty in judging communication of next steps◦ Clinicians not interpreting algorithms correctly, especially

post-colposcopy follow-up Next Steps

◦ Continue spreadsheet use◦ Track remaining patients◦ Provider Education◦ Intervention Tailoring: Initiating incentives, paying for

care or transportation, informational brochures

Discussion:

Ann Evensen, MD - project advisor Anna Hendrickson, RN – project member Laura Kutzke – program coordinator Helen Luce, DO – project advisor Clarissa Renken, DO – project member Mark Shapleigh – clinic manager Jon Temte, MD,PhD – program director

Acknowledgements

1. American Cancer Society - Cancer Facts & Figures 2009. At: http://www.cancer.org/acs/groups/content/@nho/documents/document/500809webpdf.pdf (Accessed July 13th 2010).

2. Parkin, DM, Pisani, P, Ferlay, J. Global cancer statistics. CA Cancer J Clin 1999; 49:33.

3. National Cancer Institute – Current Research: Health Disparities: Cervical Cancer. At: http://dceg.cancer.gov/research/healthdisparities/cervical (Accessed July 13th 2010).

4. American Society for Colposcopy and Cervical Pathology – Consensus Guidelines: 2006. At: http://www.asccp.org/pdfs/consensus/algorithms_cyto_07.pdf (Accessed July 13th 2010).

References