Improving follow-up to abnormal cervical cytology results Tom Garvey, BS, M2 Ann Evensen, MD Helen Luce, DO

Cervical Cancer Two main types Asymptomatic Develop slowly Adenocarcinoma Squamous cell carcinoma Asymptomatic Develop slowly Risk factors Adenocarcinoma – glandular ; squamous cell carcinoma – squamous cells Lack of symptoms underscores need for screening. Slow development also provides a window of time for screening and detection United States (2009) - 11,270 estimated new cases, 4,070 expected deaths, 75% decrease in past 50 years1 Developing (2002) - 493,243 cases, 273,606 deaths, Second most common cause of cancer related morbidity and mortality2 Risk factors: HPV, Smoking, Immune Status, Youth, Low SES, Minority Status, Family Hx, inadequate screening/follow-up

Cervical Cancer Screening Cytology High sensitivity Conventional glass slide Liquid-based cytology ASCUS, ASC-H, LGSIL, HGSIL, AIS, AGUS HPV Testing Slides - Sample cells from cervix and vagina, plate on slides, set in fixative. Thin – sample cells, place in transport medium, spin down, plate. Equally effective. Thin costs more and allows HPV testing reflex testing. Thin less affected by blood/mucous. Pap smears – high sensitivity to have low false negatives Colposcopy – high specificity to have low false positives Normal vs. Abnormal Cervical Cells

Next Steps Histology: Colposcopy Excisional Procedures Visual examination Biopsy High specificity CIN-1, 2, or 3; Cancer Excisional Procedures Loop Electrosurgical Excision Procedure (LEEP) Cold cone excision CIN – Cervical Intraepithelial Neoplasia http://my.clevelandclinic.org/services/loop_electrosurgical_exision/hic_loop_electrosurgical_excision_procedure.aspx LEEP

Clinical Best Practices ASCCP – algorithms for cytological and histological results4

Current Limitations Barriers to screening Imperfect tests Loss of follow-up to abnormal results Patient factors Provider error Special challenges at residency clinics Barriers to screening – Low educational attainment, Lack of knowledge of cervical cancer screening, Inability to find transportation to clinic, Difficulty covering cost of screening, Lower lesion severity, Small social support structure, Low SES, Minority SES, Youth, Psychological factors Patient errors –missed appointments, failure to schedule appointments, discontinuation of communication, delays and refusal to continue screening Provider error includes – transition of care between providers, especially in academic settings where residents might only be involved within a small window of the patient’s treatment, misunderstanding algorithms, failure to communicate results or next steps to patient, cancelled appointments Residency challenges – provider turnover, time between steps, demands on time, relative inexperience

Interventions to Improve Adherence Results Telephone counseling on psychological concerns/barriers Improves initial and long-term adherence Educational brochure/pamphlet Improves adherence Electronic tracking system Family physician involvement in follow-up 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

Hypothesis Using 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

Methods Data sources: Timeframes: Intervention Scoring care: 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

Patient Recruitment Flowchart – Pre-Intervention - Verona 72 Patients 5 Patients Excluded 4 History Questions 1 Chart Incomplete 67 Patients Chart Incomplete – no record of initial pap History Questions – need to go back into paper charts for information on communication (steps missed)

Patient Recruitment Flowchart – Pre-Intervention - Wausau 62 Patients 9 Patients Excluded 6 Care Transferred 2 Index Pap not at Clinic 1 Chart Incomplete 53 Patients

Patient Recruitment Flowchart – Post-Intervention - Verona Las 127 Patients 23 Patient Excluded 13 Adolescents 9 Care Transferred 1 Superceding Provider Judgment 104 Patients

Patient Recruitment Flowchart – Post-Intervention - Wausau Las 77 Patients 8 Patients Excluded 5 Care Transferred 3 Adolescents 69 Patients

Data Analysis Patient Care: Provider Communication: 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

Results: Appropriate Care By Clinic Key: V – Verona W - Wausau # of Steps with Appropriate Care # of Steps with Delayed or Absent Care Percent of Steps with Appropriate Care Clinic V W Pre-intervention 82 76 27 24 75.2% 76.0% Post-intervention 133 31 23 81.1% 76.8% Improvement: 5.9% P=0.29 0.8% P=1

Results: Provider Communication By Clinic Key: V – Verona W - 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 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

Discussion: Study not complete Challenges: Next Steps 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 18 month window means that we have only just begun to get patients who have been tracked through the entire timeframe in our current data The ASCCP guidelines changed – 2001 to 2006, released in Oct 2007. This means that we also have a different set of guidelines, which also became less aggressive EMR came up at both UW and Dane County Cytology – documentation might be better – assumption of provider communication error if a step was inappropriate and no communication was specifically documented. Track remaining patients – talk about next 18 months of follow-up

Acknowledgements 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

References American Cancer Society - Cancer Facts & Figures 2009. At: http://www.cancer.org/acs/groups/content/@nho/document s/document/500809webpdf.pdf (Accessed July 13th 2010). Parkin, DM, Pisani, P, Ferlay, J. Global cancer statistics. CA Cancer J Clin 1999; 49:33. National Cancer Institute – Current Research: Health Disparities: Cervical Cancer. At: http://dceg.cancer.gov/research/healthdisparities/cervical (Accessed July 13th 2010). American Society for Colposcopy and Cervical Pathology – Consensus Guidelines: 2006. At: http://www.asccp.org/pdfs/consensus/algorithms_cyto_07.p df (Accessed July 13th 2010).