The study found that 17% of Pap tests ordered in their resident clinic were inappropriate based on USPSTF guidelines. They created an intervention called the "Pap Clinic" which used an EMR template to guide decision making and patient discussions about cervical cancer screening guidelines. After implementing this clinic, they found a statistically significant decrease in inappropriate Pap tests, from 17% pre-intervention to 1.7% post-intervention. While the results were promising, the study had limitations including a small sample size and potential for selection bias. The intervention showed that templates in EMRs have potential to improve adherence to screening guidelines.

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, MSc
Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
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83%
14%
2%
1%
17%
Inappropriate
Appropriate
17% Inappropriate
(229 Patients)
1.7% Inappropriate
(119 Patients)
Background
High-quality clinical care follows cancer
screening guidelines.
Non-adherence to US Preventive
Services Task Force (USPSTF)
guidelines for cervical cancer screening
was prevalent in our clinic.
Goal to design and implement an
intervention to improve
-Understanding of guidelines
-Adherence to guidelines
AIM: 95% adherence to USPSTF
guidelines
Methods
Pilot chart review (n=229) for
appropriate Pap testing and adherence
to USPSTF guidelines
Implemented a “Pap Clinic” for focused
women’s health visits
-Used an electronic medical record
(EMR) template to guide decisions
-Focused gynecologic history
-Patient-centered discussion of
cervical cancer screening guidelines
Retrospective chart review (n=119)
from the “Pap Clinic”
Statistical Analysis
-Univariate and bivariate analyses
using Fischer exact, and ANOVA tests
-SAS 9.2 statistical software
-p<0.05 for statistical significance
Statistically Significant Decrease
in Inappropriate Pap Smears
Fischer Exact Test (p<0.0001)
Conclusions
Inappropriate Pap testing was prevalent in our
resident clinic, especially post-hysterectomy for
benign reasons.
Creating a clinic for focused women’s health visits
using an EMR template was effective at reducing
inappropriate Pap testing.
Educational intervention at the intern level is likely
to enhance compliance with USPSTF guidelines
throughout the trainee’s future career.
Discussion
Confusion exists about conflicting sources of
guidelines (ACOG, USPSTF, and ACS) and varied
medical school training with different specialties.
EMR templates may prove effective at improving
compliance with Pap testing guidelines in primary
care by highlighting pertinent history and guiding
decision-making in the context of cervical cancer
screening.
Results
Pilot Study
Post-Intervention with the “Pap Clinic”
Similar baseline demographic characteristics
(age, race, and insurance status).
Twenty patients deemed inappropriate referrals to
the “Pap Clinic” and did NOT undergo Pap testing.
Limitations
May lack generalizability
-Interns receptive to educational intervention
-Unique factors to underserved urban population
Results may reflect selection bias to those referred
to “Pap clinic” and over or under-estimate effect size
Small sample size
Too early to assess long-term efficacy
-Not all residents have participated in “Pap Clinic”
-Still 16.8% inappropriate referrals (close to
17% inappropriate Pap smears done initially)
Pre-Intervention Post-Intervention
Appropriate
Inappropriate
Post-hysterectomy
>age 65
Post-hyst and >65