Adherence to Conservative Management Recommendations for Abnormal Pap Test Results in Adolescents

Abstract

Objective To investigate whether the 2006 American Society for Colposcopy and Cervical Pathology guidelines for conservative management of minimally abnormal Pap tests (atypical squamous cells of undetermined significance human papillomavirus positive and low-grade squamous intraepithelial lesions) and moderate dysplasia (cervical intraepithelial neoplasia 2) in adolescents: 1) resulted in fewer colposcopies and loop electrosurgical excision procedures (LEEP) in adolescents; or 2) resulted in unintended management changes in older age groups. Methods We analyzed data from 1,806 women aged 18 and older attending one of six community health centers who were diagnosed with abnormal Pap tests between 1/1/2004–12/31/2008. We used multivariable logistic regression to examine management differences in women with minimally abnormal Pap tests prior to and after guideline changes. Variables included date of abnormality, site of care, race or ethnicity, language, and insurance type. We used Fisher exact tests to examine rates of LEEP in patients with moderate dysplasia prior to and after guideline publication. Results Among 206 women aged 18–20, rates of colposcopy after a minimally abnormal Pap test decreased from 78% (n=102) to 45% (n=34) after guideline changes (p<0.001). Colposcopy among women over age 21 (n=1542) remained unchanged (greater than 90%). Multivariable logistic regression indicated that both date of abnormality and site of care were associated with colposcopy referral. After guideline changes, management of moderate dysplasia with LEEP in women aged 18–23 decreased from 55% to 18% (p=0.04); rates remained stable in women ages 24 and over (70% vs. 74%) (p=0.72). Conclusion Health care providers quickly adopted new conservative management guidelines for low-income, minority adolescents which may reduce preterm deliveries in these high-risk populations.

Use of Pathology Data to Improve High-Value Treatment of Cervical Neoplasia

“…The 2013 guidelines for the prevention of cervical cancer are more conservative in the recommendations for screening and management than the 2006 guidelines. [18][19][20] Our findings appear to support this more conservative approach. The critical parts of the intervention were the collaborative, interdisciplinary, and interprofessional review and presentation of the preintervention data and the continuing collaborative postintervention review.…”

“…The 2013 guidelines for the prevention of cervical cancer are more conservative in the recommendations for screening and management than the 2006 guidelines. 18 - 20 Our findings appear to support this more conservative approach.…”

Cervical Cancer Screening

“…Clinician surveys monitoring adherence to cervical cancer screening guidelines have been discouraging. In the past, clinicians have had low guidelines adherence, 32–34 including beginning screening too early 35 ; repeating screening more often than indicated 35–38 ; and not ending screening in low-risk women, either at age 65 years 32,39,40 or after hysterectomy for benign disease. 41,42 Recent studies show a more optimistic picture, suggesting that the age of screening initiation is increasing, 43 and screening visits for women aged 65 years and older are decreasing.…”

Quality Improvement Intervention for Reduction of Redundant Testing

“…"Low-value" services are described as services that fail to improve care, that waste resources, and may instigate harm. 1,2 Persistence of lowvalue clinical orders can descend from unfamiliarity with best practice such as established clinical guidelines, 3 from complexity of implementing change, 3 from perceived patient preferences, 4 and from awareness of guideline limitations or their local applicability. 5,6 In seeking to eliminate low-value laboratory services, pathologists should recognize clinician perceptions of change can be affected by several human cognitive biases in addition to their expressed concerns about patient well-being.…”