Download Improving Follow-up to abnormal cervical pathology results at

Tom Garvey, BS, M2
Ann Evensen, MD
Helen Luce, DO
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Two main types
◦ Adenocarcinoma
◦ Squamous cell carcinoma
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Asymptomatic
Develop slowly
Risk factors
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Cytology
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High sensitivity
Conventional glass slide
Liquid-based cytology
ASCUS, ASC-H, LGSIL, HGSIL, AIS, AGUS
HPV Testing
Normal vs. Abnormal Cervical Cells
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Histology: Colposcopy
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Visual examination
Biopsy
High specificity
CIN-1, 2, or 3; Cancer
Excisional Procedures
◦ Loop Electrosurgical Excision
Procedure (LEEP)
◦ Cold cone excision
LEEP
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ASCCP – algorithms for cytological and
histological results4
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Barriers to screening
Imperfect tests
Loss of follow-up to abnormal results
◦ Patient factors
◦ Provider error
 Special challenges at residency clinics
Intervention
Results
Telephone counseling on psychological concerns/barriers
Improves initial and long-term adherence
Educational brochure/pamphlet
Improves adherence
Electronic tracking system
Improves adherence
Family physician involvement in follow-up
Improves adherence
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
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
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Data sources:
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Timeframes:
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Intervention
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Scoring care:
◦ UW-Verona Family Medicine Clinic
◦ UW-Wausau Family Medicine Clinic
◦ Index Pap
◦ Pre-intervention: 11/2005 - 11/2007
◦ Post-intervention: 11/2008 - 11/2010
◦ Spreadsheet
◦ Follow ASCCP guidelines (3 month window)
◦ Early testing appropriate
◦ Extra vigilant care appropriate
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If appropriate care took place, assumed
communication was appropriate
Inappropriate steps
◦ Review communication
◦ Attribute loss of follow-up (patient or provider)
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Scoring stopped after an inappropriate step
Referrals appropriate
Transfer of care
Adolescents excluded from post-intervention
results
72 Patients
5 Patients Excluded
4 History Questions
1 Chart Incomplete
67 Patients
62 Patients
9 Patients Excluded
6 Care Transferred
2 Index Pap not at Clinic
1 Chart Incomplete
53 Patients
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127 Patients
Las
23 Patient Excluded
13 Adolescents
9 Care Transferred
1 Superceding Provider Judgment
104 Patients
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77 Patients
Las
8 Patients Excluded
5 Care Transferred
3 Adolescents
69 Patients
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Patient Care:
◦ Percentage of follow-up steps that were
appropriate
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Provider Communication:
◦ Percentage of follow-up steps that had correct
provider communication
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Significance of Results:
◦ analyzed with Fisher’s test
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
V
W
V
W
Preintervention
82
76
27
24
75.2%
76.0%
Postintervention
133
76
31
23
81.1%
76.8%
5.9%
0.8%
Improvement:
P=0.29
P=1
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
V
W
V
W
Preintervention
93
87
16
13
85.3%
87.0%
Postintervention
153
89
8
10
95.0%
89.9%
9.7%
2.9%
Improvement:
P=0.0082
P=0.66
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Study not complete
Challenges:
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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
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Continue spreadsheet use
Track remaining patients
Provider Education
Intervention Tailoring: Initiating incentives, paying for
care or transportation, informational brochures
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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
1.
2.
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4.
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).