1. Promoting Maternal Pap Testing during a Child Visit W B Jordan MD MPH1, Laura Wyatt MPH, S M Young2, E J Garland MD MS3, M D McKee MD MS4 1Montefiore Medical Center, 2University at Buffalo School of Medicine & Biomedical Sciences, 3Mount Sinai School of Medicine, 4Albert Einstein College of Medicine APHA 2009, November 8, Philadelphia
introduction
methods 2
figure 3: women reporting a Pap test in the past 3 years
Stage 4
The 76 female guardians who were unscreened at baseline were read a motivational paragraph by the provider, and given DOHMH Health Bulletin on Pap testing and a pamphlet on free or low-cost Pap testing options across NYC. These unscreened female guardians were enrolled for a 3-month follow-up survey by phone to detect any changes in Pap testing status after provider intervention.
Statistical analysis
Microsoft Excel was used for simple counts. SPSS was used for other calculations. Chi-square tests were used for proportions, with McNemar’s test used for pre- and post- comparisons of proportions. T-tests were used to compare means. Odds ratios were calculated with 95% confidence intervals.
While cervical cancer mortality in New York City is low, disparities in screening rates of 10 to 20% persist among some groups. The New York City Department of Health and Mental Hygiene (NYC DOHMH) conducted focus groups in 2007 with unscreened women, providing 3 main findings (Power et al):
many had never received a recommendation for screening from a health care provider
many would get screened if they received a recommendation from a provider
many bring children for care, even if they neglect themselves
Based on these findings, the DOHMH Cancer Prevention and Control Program devised a pilot to reach out to unscreened women via their children’s provider. The intervention built on the precedent of addressing maternal smoking and depression during pediatric visits, and hoped to capitalize on the existing push for HPV vaccination among girls.
The two central hypotheses were:
the child’s provider would be comfortable recommending maternal Pap testing
family medicine providers might be more comfortable than pediatric providers
after provider recommendation, unscreened female guardians would be more likely to get tested
results
Stage 1: Provider Survey
>50% rarely/never discussed guardian Pap status during a child HPV vaccination visit
77% willing to encourage guardian screening (p=0.083 for specialty)
62% willing to both ask screening status and refer for screening
family doctors more likely than pediatricians to
ask female guardian Pap status: OR=3.183, p=0.003
refer unscreened female guardians for Pap testing: OR=2.465, p=0.021
Stage 2: Provider Feedback (see figure 2)
individual providers completed the feedback survey multiple times
repeated 5-point Likert responses by an individual provider were aggregated in 2 ways and compared: median response and minimum (most negative) response
according to median response or most negative response, 60% or 40% of providers planned to adopt the intervention (no difference by specialty)
Stage 3: Female Guardian Baseline (see figure 3)
screening rates not significantly different from citywide rates (except for Asian women)
76 (13% of 565) were unscreened at baseline and received provider recommendation
Stage 4: Female Guardian Follow-up
47 women (62% of 76) reached were all comfortable with provider recommendation
20 women (26% of 76 or 43% of 47) scheduled (n=2) or obtained (n=18) a Pap test following provider recommendation
4 women (8.5% of 47) were uninsured
conclusions
This convenience sample of providers was positive about the intervention and the intercepted female guardians were receptive to the provider’s recommendation. The intervention may be effective for reaching unscreened women.
Limitations
selection bias: provider
response bias: women reached for follow-up
design complexity & execution
pilot without control group
Future Directions
more robust test of the intervention, followed by
possible incorporation in DOHMH-supported electronic medical record
possible incorporation into DOHMH public health detailing
possible application to other missed opportunities
figure 1: study flow
174 providers surveyed
68 providers intercepted guardians
489 guardians Pap test in last 3 yrs
76 guardians no Pap in last 3 yrs
47 guardians reached 3 mos later
20 had Pap test or appt
27 had no Pap test or appt
STAGE 1
STAGE 2
STAGE 3
STAGE 4
INTERVENTION
references
methods 1
NYC DOHMH. Cervical Cancer Screening in New York City. Community Health Survey, EpiQuery:
Power B. Hoffman D. Bragdon E. Pap Test Project – Report of findings from focus groups [unpublished data commissioned by NYC DOHMH]. Global Strategy Group. July 2007.
The pilot was conducted April 2008-February 2009 in 4 stages. Providers were enrolled to: (1) intercept female guardians of female patients aged 9-17; (2) motivate unscreened guardians to get Pap testing; and (3) enroll unscreened guardians for 3-month follow-up.
Stage 1
An initial online provider survey (n=174) assessed pediatrician and family physician attitudes about addressing guardian cervical cancer screening during a child visit. The survey also recruited 24 providers for Stage 2.
Stage 2
As providers conducted the brief intervention, they completed a 4-item provider feedback survey on the intervention. Sixty-eight providers at 35 clinics participated.
Stage 3
The 68 providers intercepted 565 female guardians. The providers completed an anonymous baseline survey of female guardians, including Pap testing status, age, and race/ethnicity.
acknowledgements
figure 2: provider feedback on pilot intervention
This evaluation was conducted in partnership with the NYC Department of Health and Mental Hygiene Cancer Prevention and Control Program. We owe deep gratitude to Marian Krauskopf, Ephraim Shapiro, Anafidelia Tavares, and the entire team for their work.
We gratefully acknowledge Andrea Cassells & Tzyy Jye Lin of Clinical Directors Network for their work. We also thank Linda Prine of the local chapter of the Academy of Family Physicians for recruiting providers.
The authors had no relevant outside sources of funding or conflicts of interest. We thank the American Cancer Society for an unrestricted grant supporting the general preventive medicine resident who led the project.
correspondence
W B Jordan, MD MPH
MMC, DFSM, 3544 Jerome Ave, Bronx, NY 10467