Objective
The purpose of this study is to describe current health care provider cervical cancer screening practice patterns for average-risk women in the state of Indiana in comparison to the 2012 guidelines as well as earlier guidelines. We also aim to describe what factors are associated with increased adherence to guidelines, and what factors may impede adherence.
Study Design
We conducted a vignette-based survey among a convenience sample of obstetricians, gynecologists, midwives, nurse practitioners, and physician assistants attending the Indiana American Congress of Obstetricians and Gynecologists Section meeting in January 2013.
Results
Questionnaires were returned by 51% (112/218) of attendants. Of the 111 providers with completed surveys, 42 (38%) follow current guidelines. Of providers, 86% start screening at age 21 years. Of providers, 33% screen women aged 21-29 years every 3 years. Of providers, 33% follow recommendations for cotesting every 5 years for patients 30-65 years of age. The majority of providers follow guidelines to stop screening after a benign hysterectomy or age 65 years (75% and 51%, respectively).
Conclusion
The majority of providers follow the 2012 guidelines for the initiation and cessation of cervical screening; however, most providers screen more frequently than currently recommended for patients between ages 21-65 years.
Cervical cancer screening with Pap tests has led to a remarkable decrease in new diagnoses and cervical cancer death over the last 40 years. However, with an estimated 12,340 new cases and 4030 deaths in 2013 in the Unites States, it remains an important health concern. In 2012, the American Congress of Obstetricians and Gynecologists (ACOG), the American Cancer Society (ACS), the American Society for Colposcopy and Cervical Pathology (ASCCP), the American Society for Clinical Pathology, and the US Preventive Services Task Forces (USPSTF) all released updated guidelines to provide consistent recommendations for cervical cancer screening.
The new guidelines have made changes due to increased available evidence. The guidelines clearly state the importance of adherence to the recommendations due to the balance of preventing morbidity and mortality from cervical cancer while avoiding the detection and unnecessary treatment of transient human papillomavirus (HPV) infection and associated benign lesions. As with any cancer screening test, the frequency should maximize the benefit while minimizing the harm. With the continually changing nature of evidence-based medicine, guidelines have changed many times over the years. We have reviewed the guidelines of the past 25 years in Table 1 . It is important that providers continue to change their practice as new evidence and guidelines are defined in all areas of medicine.
| Population | Recommendation | |||||||
|---|---|---|---|---|---|---|---|---|
| 1988 Consensus | ACS 2002 | ACOG 2003 | USPSTF 2003 | ACOG 2009 | 2012 ACOG, USPSTF, ACS/ASCCP/ASCP | USPSTF 2012 | ACOG 2012 | |
| When to start screening | Age 18 y or onset of sexual intercourse | Age 21 y or about 3 y after intercourse | Age 21 y or about 3 y after intercourse | Age 21 y or about 3 y after intercourse | Age 21 y | Age 21 y | Age 21 y | Age 21 y |
| Screening age 21-29 y | Annually until 3 negatives, then interval can be extended | Annual screening | Annual screening | Every 3 y | Every 2 y | Every 3 y | Every 3 y | Every 3 y |
| Screening age 30-65 y | Annually until 3 negatives, then interval can be extended | After 3 negatives, may screen every 2-3 y | After 3 negatives, may screen every 2-3 y | Every 3 y | After 3 negatives, every 3 y | Cytology every 3 y a or cotesting every 5 y b | Cytology every 3 y or cotesting every 5 y | Cytology every 3 y a or cotesting every 5 y b |
| Screening after hysterectomy | No recommendations | Pap not recommended if hysterectomy was for benign reasons with no history of CIN II or III | Screening may be discontinued if hysterectomy was for benign reasons with no history of CIN II or III | Discontinue screening after hysterectomy if good screening and no evidence of neoplasia or cancer | Discontinue screening if cervix removed and hysterectomy was for benign reasons with no history of CIN II or III | Discontinue screening if cervix removed and hysterectomy was for benign reasons with no history of CIN II or III | Discontinue screening if cervix removed and hysterectomy was for benign reasons with no history of CIN II or III | Discontinue screening if cervix removed and hysterectomy was for benign reasons with no history of CIN II or III |
| When to stop screening | No upper limit given | Age 70 y in well-screened, low-risk women | Evidence inconclusive | Age 65 y in well-screened, low-risk women | Age 65 or 70 y after ≥3 negative Pap smears | Age 65 y, if low risk with adequate screening | Age 65 y, if low risk with adequate screening | Age 65 y, if low risk with adequate screening |
Little evidence is available that determines if and how providers have changed their practice patterns with the new guidelines of 2012. To date, very few studies have compared practice patterns with current vs past guidelines. Additionally, it is not fully understood what leads providers to be more or less likely to follow new guidelines as they become available. This study aims to determine what percentage of Indiana’s Pap smear providers follow the most current screening guidelines, vs previous guidelines, for low-risk patients; and under what clinical circumstances providers are most likely to deviate from the current guidelines. Our secondary aim is to describe demographic and practice-setting characteristics associated with providers who adhere to the current guidelines. Finally, we describe factors that facilitate or impede changes in provider practice patterns.
Materials and Methods
We conducted a vignette-based survey among a convenience sample of practicing obstetricians, gynecologists, midwives, nurse practitioners, and physician assistants (PA) attending the Indiana ACOG Section meeting in January 2013. The study was approved by the Institutional Review Board of Indiana University, with exempt status. Questionnaires were placed in each of the information packets given to the conference attendants. Providers attending the meeting who perform Pap smears were included, which was obtained from the instructions given on the questionnaires. Providers still in training, including residents and students, were excluded. The providers who were excluded did not have questionnaires included in their packets. Questionnaires were returned throughout the meeting as participants turned in their CME materials.
Each questionnaire consisted of 5 case vignettes covering key patient populations addressed in the 2012 guidelines. The questionnaires were designed for this study and were not cognitively tested. Because this study focuses on screening examinations among a healthy population, the vignettes did not include high-risk populations with alternative screening strategies such as human immunodeficiency virus–positive patients, immune-compromised patients, patients with diethylstilbestrol exposure in utero, or women previously treated for cervical intraepithelial neoplasia (CIN) II, CIN III, or cancer. To establish when providers initiate screening, our first patient was a 17-year-old girl with recent initiation of intercourse. To differentiate what providers do for patients aged 21-29 years old, our second patient was a 25-year-old healthy woman with no history of abnormal Pap smears and her last Pap smear 1 year prior. To assess providers’ practice for patients aged 30-65 years, our third patient was a 40-year-old healthy woman with no history of abnormal Pap smears who had received cotesting 1 year prior. To determine providers’ practice after hysterectomy, our fourth patient was a 45-year-old healthy woman with a hysterectomy 8 months prior for menorrhagia, no history of abnormal Pap smears, and her last Pap smear 1 year prior. Finally, to determine providers’ practice for cessation of screening, our last patient was a 66-year-old healthy woman, with no history of abnormal Pap smears and her last Pap smear 1 year prior.
For each patient described in the clinical vignettes above, providers were asked to select 1 of 4 screening strategies based on what they would do in their typical practice. Each screening strategy corresponded to a screening guideline published between 1988 and 2012. Providers also completed 10 multiple choice demographic and practice-setting questions as well as 2 open-ended multiple selection questions regarding what factors influence their practice or lead them to deviate from current guidelines. Study participation was voluntary and anonymous. A raffle ticket was provided with each survey with the option to return the ticket separately from the questionnaire for a chance to win 1 of 10 $20 gift cards.
For each provider, the number of questions answered correctly with respect to each guideline was first calculated to obtain a score (0-5) for each guideline. We then determined which guideline was being followed by each provider by using a hierarchy that selected the most recent guidelines with the highest score. For a provider to be considered as following a guideline, the score had to be a 3, 4, or 5, meaning the provider followed that guideline for the majority of case scenarios. Therefore, if the current guidelines and the 2009 guidelines both received a score of 4, the most recent guidelines–or current guidelines–were selected as the guidelines being followed. As these were survey questions, all variables were analyzed as categorical. Demographic factors including age (categorized), sex, and years out of training, were compared between those who followed current guidelines and those who did not follow guidelines using Fisher exact test. Logistic regression was also used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for following current guidelines comparing providers who teach students or residents with those that do not teach; providers who are physicians–doctor of medicine (MD) and doctor of osteopathy (DO)–with other health care providers–advanced registered nurse practitioner (ARNP), certified nurse midwife (CNM), and PA; and providers who practice in university-based or university-affiliated settings with private practice or other settings. Finally, based on our sample size, we allowed up to 4 explanatory variables to be entered into a multivariate logistic regression model. Because residents and students teaching was highly associated (Fisher exact test P value < .0001), we ultimately allowed only the most significant (any resident teaching) of these 2 indicators to be entered into the final model. Statistical analysis of the data was performed using software (SAS V9.3; SAS Institute Inc, Cary, NC).
Results
Questionnaires were returned by 51% (112/218) of attendants. One questionnaire, returned without any case scenarios answered, was excluded. The demographic data for the attendants who did not return questionnaires is unknown, due to the anonymous nature of the survey. Of the 111 providers with completed surveys, 42 (38%) of the providers were determined to follow current guidelines according to the hierarchy above, with only 18 (16.2%) following current guidelines for all vignettes presented. The Figure displays the most commonly followed guidelines and their percentages.
Baseline characteristics and the percentage of providers following guidelines are displayed in Table 2 . Gender, age, years out of practice, and number of Pap smears performed per week were not significantly associated with following current guidelines. The characteristics that were significantly associated with following current guidelines included: provider type (MD and DO vs other) ( P = .002); any resident teaching per week ( P < .0001); any student teaching per week ( P = .006); and practice setting (university based or university affiliated vs other) ( P = .031). Thus for these variables, OR and 95% CI were also calculated.
| Baseline characteristics | Following current guidelines, n/total (%) | P value |
|---|---|---|
| Sex | ||
| Female | 27/73 (37.0) | .838 |
| Male | 15/38 (39.5) | |
| Age, y | ||
| <30 | 1/2 (50.0) | .626 |
| 31-40 | 11/22 (50.0) | |
| 41-50 | 9/30 (30.0) | |
| 51-60 | 12/34 (35.3) | |
| >60 | 9/23 (39.1) | |
| Title | ||
| ARNP | 1/14 (7.1) | .002 a |
| CNM | 0/2 (0.0) | |
| DO | 2/5 (40.0) | |
| MD | 39/89 (43.8) | |
| PA | 0/1 (0.0) | |
| Years out of training | ||
| <5 | 9/18 (50.0) | .272 |
| 5-9 | 3/13 (23.1) | |
| 10-20 | 10/34 (29.4) | |
| >20 | 20/46 (43.5) | |
| Average resident teaching, h/wk | ||
| None | 14/61 (22.9) | < .0001 a |
| 1-5 | 12/25 (48.0) | |
| 6-10 | 3/6 (50.0) | |
| 11-20 | 3/6 (50.0) | |
| >20 | 10/13 (76.9) | |
| Average student teaching, h/wk | ||
| None | 16/61 (26.2) | .006 a |
| 1-5 | 18/36 (50.0) | |
| 6-10 | 2/5 (40.0) | |
| 11-20 | 2/5 (40.0) | |
| 20 | 4/4 (100.0) | |
| Average Pap smears performed per week | ||
| None | 1/4 (25.0) | .188 |
| 1-5 | 6/11 (54.5) | |
| 6-10 | 11/19 (57.9) | |
| 11-20 | 5/19 (26.3) | |
| >20 | 19/56 (33.9) | |
| Practice setting | ||
| University based or affiliated | 14/24 (58.3) | .031 a |
| Private practice | 27/83 (32.5) | |
| Other | 1/4 (25.0) |
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