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

2. 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

3. 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

4. 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
LEEP

5. Clinical Best Practices
ASCCP – algorithms for cytological and histological results4

6. 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

7. 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

8. 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

9. Methods Data sources: Timeframes: Intervention Scoring care:
UW-Verona Family Medicine Clinic
UW-Wausau Family Medicine Clinic
Timeframes:
Index Pap
Pre-intervention: 11/ /2007
Post-intervention: 11/ /2010
Intervention
Spreadsheet
Scoring care:
Follow ASCCP guidelines (3 month window)
Early testing appropriate
Extra vigilant care appropriate

10. 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

11. 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)

12. 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

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

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

15. 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

16. 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

17. 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

18. 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 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

19. 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

20. References
American Cancer Society - Cancer Facts & Figures At: 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: (Accessed July 13th 2010).
American Society for Colposcopy and Cervical Pathology – Consensus Guidelines: At: df (Accessed July 13th 2010).