Objective
In December 2009, the American Congress of Obstetricians and Gynecologists (ACOG) recommended that women under 21 years old should not receive cervical cancer screening (Papanicolaou tests) or human papillomavirus (HPV) tests. This study examined whether clinicians stopped administering Papanicolaou and HPV tests among women younger than 21 years of age after new ACOG guidelines were issued.
Study Design
This study was a retrospective secondary data analysis of administrative claims data that included insurance enrollees from across the United States that examined the frequency of Papanicolaou tests and HPV tests among 178,898 nonimmunocompromised females 12-20 years old who had a paid claim for a well-woman visit in 2008, 2009, or 2010. Young women with well-woman examinations in each observed year were examined longitudinally to determine whether past diagnoses of cervical cell abnormalities accounted for Papanicolaou testing in 2010.
Results
The proportion of women younger than 21 years old that received a Papanicolaou test as part of her well-woman exam dropped from 77% in 2008 and 2009 to 57% by December of 2010, whereas HPV testing remained stable across time. A diagnosis of cervical cell abnormalities in 2009 was associated with Papanicolaou testing in 2010. However, a previous Papanicolaou test was more strongly associated with a Papanicolaou test in 2010.
Conclusion
These data show that some physicians are adjusting their practices among young women according to ACOG guidelines, but Papanicolaou and HPV testing among insured women younger than 21 years of age still remains unnecessarily high.
In 2009, the American Congress of Obstetricians and Gynecologists (ACOG) recommended that Papanicolaou and human papillomavirus (HPV) testing not be performed in young women before they reach 21 years of age. Previous guidelines recommended that young women should receive a Papanicolaou test 3 years after sexual initiation or at age 21 years, whichever came first.
New recommendations in 2009 were made because precancerous cervical cells have been found to regress more often among adolescents compared with adult women with low-grade squamous intraepithelial lesions (LSILs), cervical intraepithelial neoplasia (CIN) I, and CIN II regressing among young women in most cases within 6 months to 3 years. Thus, the use of Papanicolaou tests in this population may lead to unnecessary treatment of conditions that would spontaneously resolve if left untreated. Furthermore, there is evidence that some procedures used to treat precancerous lesions may lead to long-term problems such as low birthweight infants, preterm premature rupture of the membranes, and difficulties with carrying a pregnancy fully to term. The diagnosis of a precancerous lesion or sexually transmitted infection, such as HPV, may also cause unnecessary psychological distress and increased concern among teenage patients.
ACOG also recommends that if a Papanicolaou test has previously been done and low-grade abnormalities have been detected, conservative observational management should be the course of action among young women, with annual Papanicolaou tests to monitor possible progression. For adolescents with high-grade squamous intraepithelial lesions (HSILs), colposcopic evaluation with endocervical assessment is recommended every 6 months if they have not been diagnosed with CIN II or III by biopsy. An excisional diagnostic procedure should be performed only for HSIL that persists for at least 24 months. In addition, guidelines state that HPV tests should not be administered in women younger than 21 years old. However, if HPV tests are inadvertently performed in this group, the results should not affect management because HPV infections are common in young women and may not cause the development of HSIL.
Although the recommendations regarding the initiation of Papanicolaou testing were published almost 3 years ago, it is unknown to what extent physicians are adhering to these new guidelines. The purpose of this study was to determine whether physicians adopted ACOG Papanicolaou testing and HPV testing guidelines in females younger than 21 years of age. We also examined whether inappropriate Papanicolaou testing in 2010 resulted from previous diagnoses of cervical cell abnormalities among females (younger than 21 years in 2010) who had well-woman examinations during each of the 3 years of the study.
Materials and Methods
For this study, we used administrative claims records from a private health insurance provider with plans available across the United States. The dataset that was used represents more than 45 million individuals who were enrolled between 2000 and 2010 and who had at least 1 medical claim. Records were obtained from a claims dataset called Clinformatics for DataMart affiliated with OptumInsight (Eden Prairie, MN). Demographic and socioeconomic information were not available for individual enrollees in this dataset.
These records were examined for females that had well-woman examinations between 2008 and 2010. A total of 179,684 individual cases who had a well-woman examination using the International Classification of Diseases, ninth edition (ICD-9) code V72.31 and who were between 12 and 20 years old during the year their examination occurred were identified. Of these females, 786 had an ICD-9 code indicating they were immunocompromised or had conditions that are associated with a compromised immune system, including the following: HIV positive, immune deficiencies, leukocytopenia, hemophagocytic syndrome, and neutropenia (ICD-9 codes 042, 043, 044, V08, 795.71, 279.3, 279.0, 279.1, 279.2, 288.50, 288.4, 288.00, 288.5, and 288.09).
Immunocompromised cases were excluded from further analyses because ACOG recommends that these individuals should be screened for cervical cancer at a younger age because of their increased risk of developing malignancies. The remaining 178,898 females had a total of 221,580 well-woman encounters between 2008 and 2010. The University of Texas Institutional Review Board exempted this study from full review.
ICD-9, Healthcare Common Procedure Coding System, and Current Procedural Terminology (CPT) codes for Papanicolaou smears (V72.32, V76.2, V76.47, P3000, G0123, G0124, G0141, G0143, G0144, G0145, 88141-88143, 88147, 88148, 88155, 88164, 88165, and 88174) indicated the receipt of a Papanicolaou smear among females who had a record of a well-woman examination. HPV testing was identified using an ICD-9 code (V73.81) and CPT codes (87620-87622). Colposcopies (CPT codes 56820, 56821, 57420, 57421, 57452, 47454, 57455, 57456, 57460, and 57461) and conizations (CPT code 57520) or loop electrosurgical excision procedures (LEEP; CPT codes 57460, 57522, and 57461) were also examined.
To determine the occurrence of cervical dysplasia and other related conditions among the subjects in this study, ICD-9 codes indicating that they had the following conditions were examined: high-grade HPV DNA (795.05), atypical glandular cells (795.00), cervical dysplasia (633.10), atypical squamous cells of undetermined significance (ASCUS; 795.01), and atypical squamous cells of undetermined significance cannot exclude high-grade (ASCH; 795.02), LSIL (795.03), HSIL (795.04), CIN I-III (622.11, 622.12, and 233.1), and malignant neoplasm of the cervix (180.1 and 180.8).
Statistical analyses
The proportion of young females who received a Papanicolaou smear, HPV DNA test, colposcopy, or conization/LEEP as part of their well-woman examination was examined for 2008, 2009, and 2010. Fisher exact tests were used for 1-way comparisons of reductions in Papanicolaou tests, HPV tests, colposcopy procedures, conizations/LEEPs, and diagnoses of cervical cell abnormalities between 2008 and 2009 as well as between 2009 and 2010. These tests were used to determine whether proportions in subsequent years were significantly lower than in the previous year.
The proportion of females who had an ICD-9 diagnosis for the following conditions as part of their well-woman examination and as a result of a Papanicolaou test during the respective year was also determined: high-risk HPV DNA, those with any diagnosis of abnormal cervical cells, atypical glandular cells, cervical dysplasia, ASCUS, ASCH, LSIL, HSIL, CIN I-CIN III, and malignant neoplasm of the cervix. The proportion of females who received a Papanicolaou smear as part of their well-woman examination was plotted across time by month.
The proportion of young women who received an HPV test, an HPV test and a Papanicolaou test, and an HPV test without a Papanicolaou test were plotted by month for the 3 years included in the study. A multivariate binary logistic regression was used to examine the association between a previous diagnosis of cervical cell abnormalities and a Papanicolaou test in 2010 among young females who had a well-woman examination in 2008, 2009, and 2010 (n = 5294). This model controlled for age in 2010, having a Papanicolaou test in 2008 or 2009, an HPV test given in 2008 or 2009, and the presence of high-risk HPV DNA in 2008 or 2009.
Results
The mean age of young women in the 2008 sample was 18.4 years and was 18.5 years old in both 2009 and 2010. Age distribution was the same for each year of observation, in which 5% of the sample was 12-15 years old, 25% were younger than 18 years, and 50% were 19-20 years old. These young women lived in the United States, with a higher proportion living in the South, followed by the Midwest, Southwest, and Mid-Atlantic states ( Table 1 ). Providers working at a facility, such as a hospital or clinic, provided the majority of the well-woman examinations that were included in the dataset.
| Variable | n (%) | ||||
|---|---|---|---|---|---|
| Region of participants who had a well-woman examination (n = 178,898) a | |||||
| Northeast | 6815 (3.8) | ||||
| Mid-Atlantic | 18,622 (10.4) | ||||
| Midwest | 45,798 (25.6) | ||||
| South | 61,318 (34.3) | ||||
| Southwest | 30,619 (17.1) | ||||
| West | 15,726 (8.8) | ||||
| Provider type for well-woman examinations that were recorded (n = 221,580) | |||||
| Obstetrician-gynecologist | 10,560 (7.6) | ||||
| Family practitioner | 7891 (4.9) | ||||
| Nurse practitioner | 727 (0.4) | ||||
| Specialist | 26,286 (16.4) | ||||
| Facility | 113,967 (71.3) | ||||
| Other | 464 (0.3) | ||||
| Unknown | 61,685 | ||||
| Year procedure performed | 2008 | 2009 | 2010 | ||
| Procedure | P value b | P value c | |||
| Well-woman examination | 79,776 | 76,885 | 64,919 | ||
| Papanicolaou test, n (%) | 61,922 (77.6) | 57,927 (75.3) | < .001 | 40,018 (61.6) | < .001 |
| HPV test, n (%) | 9930 (12.4) | 9879 (12.8) | .98 | 7719 (11.9) | < .001 |
| Colposcopies, (%) | 1631 (2.0) | 1480 (1.9) | .05 | 1037 (1.6) | < .001 |
| Conization/LEEP, (%) | 390 (0.5) | 260 (0.3) | < .001 | 118 (0.2) | < .001 |
a Northeast included Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island, Vermont; Mid-Atlantic included the District of Columbia, Delaware, Maryland, New Jersey, New York, and Pennsylvania; Midwest included Iowa, Illinois, Indiana, Kansas, Michigan, Minnesota, Missouri, North Dakota, Nebraska, Ohio, South Dakota, and Wisconsin; South included Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia; Southwest included Arizona, New Mexico, Oklahoma, and Texas; and West included Alaska, California, Colorado, Hawaii, Idaho, Montana, Nevada, Oregon, Utah, Washington, and Wyoming
b Comparison made using Fisher exact 1-way comparison to determine the decrease in each procedure between 2008 and 2009
c Comparison made using Fisher exact 1-way comparison to determine the decrease in each procedure between 2009 and 2010.
The proportion of young women who received Papanicolaou tests, colposcopies, or conization/LEEPs decreased between 2008 and 2009 and again between 2009 and 2010. An increase in the number of HPV tests performed was observed between 2008 and 2009 ( P < .01). However, after the ACOG guidelines were issued at the end of 2009, a decrease in HPV tests between 2009 and 2010 as a proportion of women who received well-woman examinations was observed.
Analyses also tested whether HPV tests, colposcopies, and conization/LEEPs decreased as a proportion of women who also received Papanicolaou tests. χ 2 analyses revealed that there were no significant differences in the proportion of colposcopies that were received among women who also had a Papanicolaou test ( P > .05). A decrease in conizations/LEEPs between 2008 and 2009 ( P < .001) and between 2009 and 2010 ( P < .001) among those who also received Papanicolaou tests was observed.
Two percent of young females who had well-woman examinations received a diagnosis of high-risk HPV DNA during each year of the study ( Table 2 ). Of females who had a HPV test during the current or previous year, 12% were diagnosed with high-risk HPV DNA in 2009 and 11% were diagnosed in 2010. Among the entire sample, the proportion of young women with a diagnosis of any type of cervical cell abnormalities decreased between 2008 and 2010 ( P < .001). However, among young women who received a Papanicolaou test, the proportion who received a diagnosis of any type of cervical cell abnormalities remained stable between 2008 and 2009 ( P > .05) and increased between 2009 and 2010 ( P < .01).
| Variable | Any diagnosed with well-woman examination in 2008, n (%) | Diagnosed with Papanicolaou tests during 2008, n (%) | Any diagnosed with well-woman examination in 2009, n (%) | Diagnosed with Papanicolaou tests during 2009, n (%) | Any diagnosed with well-woman examination in 2010, n (%) | Diagnosed with Papanicolaou tests during 2010, n (%) |
|---|---|---|---|---|---|---|
| High-risk HPV DNA | 1584 (2.0) | 1509 (2.0) | 1181 (1.8) | |||
| Abnormal cervical cells | 10,701 (13.4) | 10,157 (16.4) | 9704 (12.6) | 9257 (16.0) | 7038 (10.8) | 6689 (16.7) |
| Atypical glandular cells, endocervicals, endometrials (excludes CIN, SIL, CIS, ASCH) | 2499 (3.1) | 2347 (3.8) | 1939 (2.5) | 1825 (3.2) | 1368 (2.1) | 1288 (3.2) |
| Cervical dysplasia | 1167 (1.5) | 1100 (1.8) | 823 (1.1) | 777 (1.3) | 540 (0.8) | 504 (1.3) |
| ASCUS | 5339 (6.7) | 5177 (8.4) | 4832 (6.3) | 4687 (8.1) | 3590 (5.5) | 3475 (8.7) |
| ASCH | 661 (0.8) | 625 (1.0) | 573 (0.8) | 539 (0.9) | 374 (0.6) | 351 (0.9) |
| LSIL | 4347 (5.4) | 4141 (6.7) | 4031 (5.2) | 3880 (6.7) | 2879 (4.4) | 2751 (6.9) |
| HSIL | 373 (0.5) | 354 (0.6) | 281 (0.4) | 264 (0.5) | 181 (0.3) | 169 (0.4) |
| CIN I | 2432 (3.0) | 2313 (3.7) | 1898 (2.5) | 1806 (3.1) | 1270 (2.0) | 1202 (3.0) |
| CIN II | 633 (0.8) | 608 (1.0) | 452 (0.6) | 425 (0.7) | 240 (0.4) | 229 (0.6) |
| CIN III | 207 (0.3) | 198 (0.3) | 158 (0.2) | 144 (0.3) | 81 (0.1) | 79 (0.2) |
| Malignant neoplasm of cervix | 1 | 1 | 0 | 0 | 0 | 0 |
Of those who received a Papanicolaou test, a small proportion was diagnosed with CIN III in the observation period. In these data, there was 1 diagnosis code for a malignant neoplasm between 2008 and 2010, but upon further investigation of that case, the diagnosis could not be confirmed because there were no follow-up codes that would indicate treatment of a malignancy.
The proportion of females who received a Papanicolaou smear as part of their well-woman examination remained stable between January 2008 and October 2009, when the proportion began to decrease ( Figure 1 ). In December 2010, the proportion of the sample who received a Papanicolaou smear had dropped to 57%, compared with an average of 76.8% who received a Papanicolaou smear as part of their well-woman visit between January of 2008 and October of 2009.
