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- 1. Intervention to Reduce Inappropriate Papanicolaou Testing in a Resident Clinic L. Kyle Horton MD, MBA Samantha H. H. Hudson MD, Meng Denise L. Borden MD Arpita Aggarwal MD, MS
- 2. Slide 2 Disclosure Statement Speaker: Kyle Horton MD, MBA Co-Investigators from VCU Internal Medicine: Samantha H. H. Hudson MD, Meng Denise L. Borden MD Arpita Aggarwal MD Contributors to Pilot Study Ajay Patil DO Amy Anderson DO, MPH Neither the speaker nor any co-investigators have any relevant disclosures to make.
- 3. Slide 3 Background • Guideline-inconsistent cancer screening is prevalent -Yabroff et al survey regarding Papanicolaou testing published in Annals 2006 to 2007 *Internists only guideline-consistent 27.5% of time -Yabroff et al regarding colorectal cancer screening *Only 19.1% of providers guideline-consistent Yabroff et al. Ann Int Med. 2009; 151: 602-611 Yabroff et al. J Gen Intern Med. 2010; 10.1007
- 4. Slide 4 VCU IM Resident Clinic • Internal Medicine and Med/Peds Residents -Continuity clinic 1/2 day per week • Diverse Population – Urban and Rural – Largely underserved – Often under- or non-insured
- 5. Slide 5 Over-screening for Cervical Cancer • Noted over-screening for cervical cancer in our resident clinic • Conflicting Guidelines -American College of Obstetrics and Gynecology (ACOG) -United States Preventive Services Task Force (USPSTF) -American Cancer Society (ACS) • Residents have varied training/backgrounds -Family Medicine, Internal Medicine, and OB/Gyn
- 6. Slide 6 Pilot Study # 83% 14% 2% 1% 17% Appropriate Post-Hyst > age 65 Post-Hyst and > age 65
- 7. Slide 7 Aim Aim: Design and implement an intervention to improve -Understanding of guidelines -Adherence to guidelines Goal: achieve 95% adherence to USPSTF cervical cancer screening guidelines
- 8. Slide 8 Intervention Plan • Created a “Pap Clinic” held 1/2 day per week -For focused Women’s Health Visits -Created an Electronic Medical Record Template Note *Highlights relevant Gyn history *Incorporates the USPSTF guidelines *Includes a follow-up plan for further screening
- 9. Slide 9 Methods • Pilot Study-229 charts assessed for appropriateness • Implemented the “Pap Clinic” • Retrospectively reviewed 119 charts from “Pap Clinic” • Univariate and bivariate analyses: means, Fisher exact, and ANOVA tests • SAS 9.2 statistical software • P-value <0.05 was considered statistically significant
- 10. Slide 10 Demographics Pilot Post-Intervention Age Average 51.4 50.8 Inappropriate 60.3 73.5 Race African-American 69.9% 68.9% Caucasian 28.4% 30.3% Other 1.7% 0.8% Insurance Medicare 32.3% 38.7% Private 22.7% 11.8% Indigent 26.2% 30.3% Self-Pay 15.3% 10.9% Other 3.5% 8.4%
- 11. Slide 11 Results Pre-Intervention vs. Post-Intervention 17.0% Inappropriate (229 Total Patients) 1.7% Inappropriate (119 Total Patients) Statistically significant decrease in inappropriate Paps (Fisher Exact Test p<0.0001) Inappropriate Appropriate
- 12. Slide 12 Limitations • Results may lack generalizability -Interns more easily molded by intervention • May reflect selection bias to referred patients • Small sample size post-intervention • Too early to assess for overall effect -Not all of current residents rotated through the “Pap Clinic” -Still 16.8% inappropriate referrals
- 13. Slide 13 Conclusions • Creating a clinic for focused women’s health visits using an electronic medical record template was effective at reducing inappropriate Pap testing • The Future: Data re-analysis for broader efficacy once all trainees have rotated through the clinic • Implication: creating electronic medical record templates and focusing women’s health visits may prove to be an effective way to improve compliance with Pap testing guidelines in primary care
- 14. Slide 14 Questions? THE WALL STREET JOURNAL 2/15/2011 “Questioning the Need For Routine Pelvic Exam” By Melinda Beck “Of all the indignities that women endure in their lives, one of the most dreaded is the routine pelvic exam.” -Based on commentary Journal of Women’s Health -Article makes reference to the new ACOG guidelines recommending Pap every 2 years for women age 21 to 30 and 3 years 30 for older
Editor's Notes
- As background, there has been much attention recently devoted to the fact that guideline-inconsistent cancer screening is prevalent. A survey published in Annals regarding Pap testing found that despite physician commitment to guidelines, a very low percentage of providers were guideline consistent in their recommendations across clinical vignettes. -Internists were only guideline consistent across all vignettes for Pap screening 27.5% of the time This problem was also evident in recent research regarding colorectal cancer screening -Investigators noted both overuse and underuse of screening with only 19.1% of providers guideline consistent recommendations across all colorectal cancer screening modalities
- With the recent research and attention to guidelines, we turned to our own internal medicine resident clinic at the VCU ambulatory care center pictured to the right. The VCU internal medicine resident clinic is staffed by both internal medicine and med/peds residents who maintain their own patient panel and see patients 1/2 day per week. Patients served come from both urban and rural settings throughout a broad distance in southern Virginia Patients are largely medically underserved and often under or non-insured
- With regard to our own clinic and adherence to cancer screening guidelines, we noted a tendency to over-screen patients for cervical cancer. Much of the confusion about cervical cancer screening stems from the multiple sources of often conflicting guidelines. The principle sources of Pap testing guidelines include the American College of Obstetrics and Gynecology as well as the U.S. Preventive Services Task Force and the American Cancer Society. The conflicting recommendations from these three sources often contribute to confusion among providers. Residents are likely aware of all three of the major sources of guidelines based on their medical school training. The fact that students are trained in pap testing on family medicine, internal medicine, and OB/gyn rotations renders them especially vulnerable
- Suspecting that our residents were vulnerable to confusion about cervical cancer screening and noting a tendency toward overscreening in our own clinic, we began a retrospective chart review including 229 patients who underwent Pap testing between February of 2004 and December of 2009. Appropriateness of Pap tests was based on USPSTF guidelines for cervical cancer screening On the left, you’ll note that we conducted inappropriate pap tests 17% of the time (n=39; mean age 60.3, SD +/- 10.3 years). On the right you’ll see that out of the inappropriate tests, 79.5% were performed on women post hysterectomy for a non-malignant cause, 12.9% on women &gt; age 65 without risk factors, and 7.7% on women &gt; age 65 who also had a hysterectomy for non-malignant cause.
- Our aim was to design and implement an intervention to improve residents understanding of guidelines and their adherence to guidelines with regard to the appropriate use of Pap testing. We hypothesized that we would achieve 95% adherence to USPSTF cervical cancer screening guidelines
- Our intervention plan created a “Pap Clinic” held 1/2 day per week, staffed by 2 interns, a women’s health resident, and an attending. Essential components to the plan for our clinic were to allow for focused women’s health visits and to design an appropriate electronic medical record template to help with these focused visits Key components to the electronic medical record template Highlights relevant GYN history to prompt the questions needed to ascertain appropriateness of a Pap smear (repetitively and methodically collect the necessary information to determine if pap testing is appropriate 2. Incorporates a brief version of the USPSTF guidelines themselves (visual reminder of guidelines repetitively) 3. Interns were advised to include in their plan why they did/did not perform Pap testing and a recommendation regarding the appropriate interval for screening to inform the referring providers
- In our pilot study, 229 charts were reviewed for appropriateness of Pap testing with a result of 17% inappropriate testing. Instituted the Pap Clinic Subsequently, we reviewed 119 charts from our “Pap Clinic” between February 2009 and July 2010 Criteria for appropriateness were the same pre and post-intervention We conducted univariate and bivariate analyses with means, Fisher exact, and ANOVA tests We used SAS 9.2 statistical software and a p-value &lt;0.05 was considered statistically significant
- Demographic information was collected during the pilot study and post-intervention to analyze for differences with regard to age, race, and insurance status. You’ll note that there were no significant differences between the initial study group and the post-intervention characteristics. Note that the average age was not substantially different between our pilot study patients and the post-intervention group. Similarly, the ethnic breakdown of patients was not significantly different with the majority of patients being African-American Finally, the percentage insured by either medicare or private insurance was not substantially different (55% vs. 50.5%)
- You’ll remember that in our pilot study, 17% of Pap tests performed in our clinic were inappropriate by USPSTF guidelines with the vast majority (79.5%) done on women who were post-hysterectomy for benign reasons. On the right hand side of the screen, you’ll see that post-intervention there was a statistically significant decrease in inappropriate Paps based on USPSTF guidelines. We were able to achieve our goal 95% adherence to USPSTF guidelines with only 1.7% inappropriate tests, both of which were performed on women. Both of the inappropriate tests in our post-intervention group were done on patients who were too old and post-hysterectomy for benign reasons.
- Results may lack generalizability both in terms of the demographics and complexity of our patient population (majority are african american and underinsured), as well results may be more robust in the setting of medical education because interns are more easily molded by intervention than experienced practitioners Both of these facts may mean that results are not generalizable to other clinics and practice settings Our post-intervention data is subject to selection bias in that only Pap smears performed in the Pap clinic were analyzed post-intervention We may be over-estimating our intervention effect size based on our small sample size post-intervention. Given the simplicity of our intervention, we were willing to over-estimate our treatment effect size and tolerate a large Type I error It is still too early to assess for the overall effect of our intervention. At present, the first interns to rotate through the Pap Clinic are still second years. -Note that we still have 16.8% inappropriate referral