Objective
The goal of this pilot study was to evaluate adherence to the 2012 cervical cancer screening guidelines among health care providers in a large health maintenance organization.
Study Design
A cross-sectional survey evaluating knowledge, reported practices, and views of the 2012 cervical cancer screening guidelines was distributed to 325 health care providers within HealthPartners. The survey was divided into 3 sections: (1) provider demographics; (2) knowledge of the 2012 age-specific cancer screening guidelines; and (3) provider practice. Comparisons based on appropriate knowledge and practice of the guidelines were made using Fisher exact tests.
Results
The response rate was 42%. Of 124 respondents, 15 (12.1%) reported they were not aware of the 2012 guideline changes. Only 7 (5.7%) respondents answered all the knowledge questions correctly. A majority of respondents reported correct screening practices in the 21-29 year patient age group (65.8%) and in the >65 year patient age group (74.3%). Correct screening intervals in the 30-65 year patient age group varied by modality, with 89.3% correctly screening every 3 years with Pap smear alone, but only 57.4% correctly screening every 5 years with Pap smear + human papillomavirus cotesting. The most frequently cited reasons for not adhering were lack of knowledge of the guidelines and patient demand for a different screening interval.
Conclusion
Adherence to the 2012 cervical cancer screening guidelines is poor due, in part, to a lack of knowledge of the guidelines. Efforts should focus on improved provider and patient education, and methods that facilitate adherence to the guidelines such as electronic health record order sets.
Screening has significantly decreased cervical cancer morbidity and mortality through the detection and treatment of preinvasive lesions, and diagnosis of invasive cervical cancers at earlier stages when treatment is more effective. Pap smear screening was recommended annually for decades in an effort to maximize detection of precancerous lesions. The discovery that infection with the human papillomavirus (HPV) is a necessary cause of cervical cancer has led to the incorporation of HPV tests into routine screening since 2002. Previous cervical cancer screening guidelines focused on maximizing detection of precancerous lesions through frequent screening. However, more aggressive screening can result in colposcopy evaluation and biopsies of lesions that are unlikely to progress to invasive cancer, resulting in patient stress and increased health care costs. Unnecessary excisional procedures can also result in distorted cervical anatomy and an increased risk of preterm delivery in future pregnancies. The 2012 revised cervical cancer screening guidelines developed by the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology and by the US Preventive Service Task Force aimed to maximize detection of precancerous lesions while minimizing harms. Previous guidelines recommended Pap smear testing alone every 1-2 years or cotesting with Pap smear and HPV test every 3 years for women aged 30-65 years. In contrast, the 2012 guidelines recommend cotesting every 5 years or Pap smear alone every 3 years. For women aged 21-29 years, Pap smear screening alone every 3 years is currently recommended ( Table 1 ).
| Screening population age | Screening method |
|---|---|
| <21 y | No screening |
| 21-29 y | Cytology alone (no HPV testing) every 3 y |
| 30-65 y | Cytology and HPV cotesting every 5 y preferred; cytology alone every 3 y acceptable |
| >65 y | No screeningIf history of CIN2+, then screen for 20 y after diagnosis |
| Posthysterectomy | No screening provided following criteria are met: |
| 1) Cervix removed | |
| 2) No history of CIN2+ in past 20 y | |
| 3) No history of cervical cancer | |
| Post-HPV vaccination | Follow age-specific recommendations (same as unvaccinated women) |
The 2012 cervical cancer screening guidelines were developed based on extensive systematic evidence reviews, and sought to maintain disease detection while minimizing the overtreatment of lesions that are likely to resolve spontaneously. However, for the new guidelines to be effective, health care providers and patients must adhere to them. A national survey of health care providers administered annually from 2006 through 2009 showed that 67-94% of providers recommended Pap smear testing at a shorter interval than recommended by the guidelines. To date, there has not been a published study evaluating adherence of health care providers to the most recent (2012) guidelines, which lengthens the screening interval even further than previous guidelines. The goal of this pilot study was to evaluate the knowledge, reported practices, and views of the new (2012) cervical cancer screening guidelines among practitioners in a large health maintenance organization.
Materials and Methods
Survey
A cross-sectional survey was conducted to evaluate health care provider knowledge, reported practices, and views of the 2012 cervical cancer screening guidelines within HealthPartners, a large health maintenance organization in Minnesota that performs approximately 46,000 Pap smears per year. An electronic health record query identified all practitioners in the organization who had ordered screening Pap smears within the past year. An explanatory email with a link to an anonymous World Wide Web questionnaire was sent to the organizational email address of each of these providers. This study was exempt from the institutional review board since it met the criteria for a quality improvement study, and all information was collected anonymously.
The survey was divided into 3 sections: (1) provider demographics; (2) knowledge of the 2012 cervical cancer screening guidelines; and (3) provider practice. The demographic section collected information about provider age, provider gender, number of years in practice, medical specialty and degree, and information about the provider’s practice, including frequency with which the provider performs Pap smears and average number of Pap smears performed per year. We also collected information about how the provider learned of the 2012 cervical cancer screening guidelines (email, World Wide Web site, memo/letter, press release, social media, professional organization, other), and how the provider would like to receive guideline updates in the future. The knowledge section presented 6 questions that asked the provider to identify the screening recommendation for each scenario per the 2012 cervical cancer screening guidelines. The questions assumed all previous cervical cancer screening results were normal, and covered 4 patient age groups: <21 years; 21-29 years; 30-65 years; and >65 years. The provider practice section consisted of 15 questions. There were 3 groups of 4 questions, each of which addressed cervical cancer screening for the following age categories: 21-29 years; 30-65 years; >65 years. The questions addressed how providers are screening patients (Pap smear alone vs cotesting) and the frequency at which they are performing each screening modality (cotesting every 5 years vs Pap smear alone every 3 years, or either at another interval). The last 5 questions in this section addressed provider views of their practice in relation to the guidelines, including how often they adhere to the guidelines (always; sometimes; rarely; never; not aware of the 2012 guidelines) and reasons for not adhering to guidelines in each age group (I am following the guidelines; I do not know the current guidelines; I do not think the guidelines are based on good data; I feel I have a higher-risk patient population; my patients are demanding a different screening interval; I am worried about missing a high-grade dysplasia/cancer in the interim; other). All survey questions were in a multiple-choice format, with a free-write option under “other.”
Statistical analysis
Survey item frequencies were examined for errors, missing data, or inconsistencies. Respondent demographic and clinical practice were summarized and presented as number and percent of sample unless otherwise noted. A total knowledge score was calculated for each respondent using the 6 clinical scenario questions, with respondents receiving 1 point for each correct answer. Since HealthPartners recommends either cotesting every 5 years or Pap smear alone every 3 years as acceptable cervical cancer screening strategies for women aged 30-65 years, practitioners were given credit for selecting “cytology + HPV cotesting every 5 years, ” “cytology alone every 3 years,” or both answers.
Provider practice scores for each respondent for the screening age groups 21-29 years and >65 years were calculated using groups of 4 questions each. Participants with scores of 4 out of 4 in the 21-29 years or >65 years screening age groups were considered to appropriately follow the guidelines in their practice for a particular age group. A total score was not calculated for the 30-65 year screening age group since there are 2 correct screening strategies per the 2012 guidelines; proportion of respondents reporting correct screening practices for Pap smear alone and Pap smear + HPV cotesting are presented individually. Comparisons based on appropriate knowledge and practice of the guidelines for the 21-29 and >65 year screening age groups were conducted using Fisher exact tests. All analyses were performed using software (SAS, version 9.3; SAS Institute Inc, Cary, NC).
Results
From February through March 2013, 135 of 325 eligible providers responded to the survey for a total survey response rate of 41.5%. Eleven providers responded only to the demographic questions, resulting in 124 surveys available for analysis of the knowledge questions and practice patterns.
Table 2 presents the demographic results for the survey respondents. Physicians (MD/DO) represented the majority of respondents (63.7%), with physician assistants, nurse practitioners, and certified nurse midwives making up the remainder. Approximately half of respondents were >50 years of age, and only 15.6% of respondents were aged <35 years. Three quarters of respondents were female; male respondents tended to be older ( P = .131). Family practitioners represented the largest group of respondents (38.5%) followed by gynecologists (23.0%), internal medicine (20.0%), and midwives (14.1%). The majority of practitioners reported >10 years in practice (69.9%). The large majority of respondents performed cervical cancer screening at least weekly, with 61.5% performing screening daily.
| Variable | n | % |
|---|---|---|
| Degree | ||
| MD/DO | 86 | 63.7 |
| PA | 12 | 8.9 |
| NP | 19 | 14.1 |
| Other a | 18 | 13.3 |
| Age, y | ||
| <35 | 21 | 15.6 |
| 35-50 | 45 | 33.3 |
| >50 | 69 | 51.1 |
| Sex | ||
| Female | 99 | 73.3 |
| Male | 36 | 26.7 |
| Years in practice | ||
| <5 | 20 | 14.8 |
| 5-10 | 21 | 15.6 |
| >10 | 94 | 69.6 |
| Specialty | ||
| Gynecology | 31 | 23.0 |
| Internal medicine | 27 | 20.0 |
| Family practice | 52 | 38.5 |
| Midwifery | 19 | 14.1 |
| Other b | 6 | 4.4 |
| Frequency of Pap smear screening in practice | ||
| Daily | 83 | 61.5 |
| Weekly | 36 | 26.7 |
| Monthly | 13 | 9.6 |
| Yearly | 3 | 2.2 |
| Approximate no. of Pap smears/y | ||
| 0-5 | 3 | 2.2 |
| 5-20 | 14 | 10.4 |
| 20-50 | 20 | 14.8 |
| >50 | 98 | 72.6 |
a 17 Certified nurse midwives, 1 bachelor of medicine
b Primary care, medicine-pediatrics, geriatrics, and occupational medicine each represented <2% of practitioners.
Among respondents, 15 (12.1%) reported they were not aware that the screening guidelines changed in March 2012 ( Table 3 ). Of the 15 respondents who were not aware of the guideline changes, the breakdown by specialty was gynecology (n = 5; 33.3%), internal medicine (n = 3; 20.0%), family practice (n = 5; 33.3%), midwifery (n = 1; 6.7%), and geriatrics (n = 1; 6.7%). Of those who were aware of the guideline changes, the majority learned of the change through a professional organization, while one-third learned of the change through an email from the health care organization. In the future, the majority (87.9%) would like to learn of guideline changes via email, while 39% also indicated that they would like the electronic health record prompts to reflect new guidelines.
| Guideline awareness and compliance | n | % |
|---|---|---|
| Aware guidelines changed March 2012? | ||
| Yes | 109 | 87.9 |
| No | 15 | 12.1 |
| If aware, how did you learn about them? (Check all that apply) | ||
| HealthPartners email | 36 | 33.0 |
| HealthPartners World Wide Web site | 5 | 4.6 |
| HealthPartners memo/letter | 6 | 5.5 |
| Press release | 15 | 13.8 |
| Social media | 3 | 2.8 |
| Professional organization | 56 | 51.4 |
| Other a | 22 | 17.7 |
| How would you like HealthPartners to communicate new guidelines to you? (Check all that apply) | ||
| 109 | 87.9 | |
| Online newsletter | 12 | 9.7 |
| World Wide Web site | 11 | 8.9 |
| Epic (EHR) prompts | 48 | 38.7 |
| Paper letter/memo | 4 | 3.2 |
| Social media | 2 | 1.6 |
| Other b | 2 | 1.6 |
| What level of compliance have you achieved with new guidelines? | ||
| I always comply with new guidelines | 63 | 50.8 |
| I sometimes comply with new guidelines | 50 | 40.3 |
| I rarely comply with new guidelines | 4 | 3.2 |
| I never comply with new guidelines | 0 | 0.0 |
| I am not aware of new guidelines | 7 | 5.7 |
a Continuing medical education (5), colleague (5), publication in peer-reviewed medical journal (3), American Society for Colposcopy and Cervical Pathology and/or US Preventive Services Task Force (4); unknown (5)
b Employee Resource Information Center on HealthPartners Intranet (1) and source not identified (1).
Results from the 6 multiple-choice knowledge questions are detailed in Table 4 . Only 7 (5.7%) respondents answered all 6 knowledge questions correctly, however 99 (79.8%) answered 4 of the 6 questions correctly. The highest percentage of correct answers was for the question that addressed patients who had already undergone a hysterectomy including removal of cervix, with only 1 incorrect response. Most respondents also identified the age groups who do not require screening, including <21 years (92.7%) and >65 years with previous normal screening (87.1%). Most respondents (83.7%) answered questions about guidelines for patients aged 30-65 years correctly when cotesting every 5 years, Pap smear alone every 3 years or both were all counted as correct answers. The lowest proportion of correct responses was in the 21-29 year age group (62.9%).
| Screening group | Knowledge question (clinical scenario) | n | % |
|---|---|---|---|
| Age <21 y | Age 19 y, no abnormal history, presents for STD screening | ||
| Correct – no screening recommended | 115 | 92.7 | |
| Incorrect | 9 | 7.3 | |
| Age 21-29 y | Age 24 y, no abnormal history, presents for preconception counseling | ||
| Correct – Pap smear every 3 y | 78 | 62.9 | |
| Incorrect | 46 | 37.1 | |
| Age 30-65 y | Age 32 y, no abnormal history, presents for annual exam | ||
| Correct – Pap smear every 3 y and/or Pap smear + high-risk HPV cotesting every 5 y | 103 | 83.7 | |
| Incorrect | 20 | 16.3 | |
| Age >65 y | Age 67 y, received regular Pap screening for 20 y, no abnormal history, presents for annual exam | ||
| Correct – no screening recommended | 108 | 87.1 | |
| Incorrect | 16 | 12.9 | |
| Age >65 y | Age 69 y, not undergone Pap screening since 30s, presents for annual exam | ||
| Correct – Pap smear every 3 y and/or Pap smear + high-risk HPV cotesting every 5 y | 8 | 6.5 | |
| Incorrect | 116 | 93.6 | |
| Hysterectomy | Age 42 y, history of total hysterectomy (including removal of cervix), no abnormal history, presents for annual exam | ||
| Correct – no screening recommended | 123 | 99.2 | |
| Incorrect | 1 | 0.8 | |
| Summary | All 6 items correct | ||
| Yes | 7 | 5.7 | |
| No | 117 | 94.4 | |
| At least 5 items correct | |||
| Yes | 61 | 49.2 | |
| No | 63 | 50.8 | |
| At least 4 items correct | |||
| Yes | 99 | 79.8 | |
| No | 25 | 20.2 |
Results from the practice section of the survey are presented in Tables 5-7 . In the 21-29 year patient age group, three-quarters of respondents (78.1%) reported screening women in the 21-29 year age group correctly with Pap smear alone every 3 years, however, one-third (36.7%) report screening incorrectly with a Pap smear + HPV cotesting ( Table 5 ). In the 30-65 year age group, the proportion of correct responses varied by screening modality used. Similar numbers of respondents reported screening with Pap smear + HPV cotesting (58.1%) and Pap smear alone (64.1%) ( Table 6 ). When screening with Pap smear alone, 89.3% of respondents reported correctly screening every 3 years. However, only 57.4% reported cotesting at a correct interval of 5 years, with another 38.2% cotesting at an incorrect interval of every 3 years. In the >65 year patient age group with no history of abnormal cervical cancer screening tests, 74.3% of respondents do not screen, in concordance with the 2012 guidelines; however, 11.0% of respondents incorrectly screen if the woman has a new sexual partner ( Table 7 ). For those health care providers who reported not always adhering to the guidelines, the most frequently cited reasons for not complying were lack of knowledge of the guidelines and patient demand for a different screening interval.
| For women ages 21-29 y, no history of abnormal Pap | n | % |
|---|---|---|
| Are you screening with Pap smear alone? | ||
| Yes a | 82 | 68.3 |
| No | 38 | 31.7 |
| Missing | 4 | |
| At what interval are you screening with Pap smears alone? | ||
| Every year | 8 | 9.8 |
| Every 3 y a | 64 | 78.1 |
| Every 5 y | 0 | 0.0 |
| Every 10 y | 0 | 0.0 |
| Other | 10 | 12.2 |
| Missing – does not screen with Pap only | 42 | |
| Are you screening with Pap smear and HPV cotesting together? | ||
| Yes | 44 | 36.7 |
| No a | 76 | 63.3 |
| Missing | 4 | |
| At what interval are you performing Pap smears and HPV cotesting together? | ||
| Every year | 5 | 11.4 |
| Every 3 y | 30 | 68.2 |
| Every 5 y | 5 | 11.4 |
| Every 10 y | 0 | 9.1 |
| Other | 4 | 0.0 |
| Missing – does not screen with Pap + HPV cotesting | 80 | |
| If not following current screening guidelines, why? | ||
| I am following current guidelines | 73 | 60.8 |
| I do not know current guidelines | 12 | 10.0 |
| I do not think guidelines are based on good data | 0 | 0.0 |
| I feel I have a higher-risk patient population | 3 | 2.5 |
| My patients are demanding a different screening interval | 10 | 8.3 |
| I am worried about missing high-grade dysplasia or cancer in that interim | 0 | 0.0 |
| Other | 22 | 18.3 |
| Missing | 4 |
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