Tom Garvey BS M2 Ann Evensen MD Helen Luce DO Two main types Adenocarcinoma Squamous cell carcinoma Asymptomatic Develop slowly Risk factors Cervical Cancer Cytology High sensitivity ID: 514379
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Slide1
Improving follow-up to abnormal cervical cytology results
Tom Garvey, BS, M2
Ann
Evensen
, MD
Helen Luce, DOSlide2
Two main typesAdenocarcinoma
Squamous
cell carcinomaAsymptomaticDevelop slowlyRisk factors
Cervical CancerSlide3
CytologyHigh sensitivity
Conventional glass slide
Liquid-based cytologyASCUS, ASC-H, LGSIL, HGSIL, AIS, AGUSHPV Testing
Cervical Cancer Screening
Normal vs. Abnormal Cervical CellsSlide4
Histology: Colposcopy
Visual examination
BiopsyHigh specificityCIN-1, 2, or 3; CancerExcisional Procedures
Loop Electrosurgical Excision
Procedure (LEEP)
Cold cone excision
Next Steps
LEEPSlide5
ASCCP – algorithms for cytological and histological results
4
Clinical Best PracticesSlide6
Barriers to screening Imperfect tests
Loss of follow-up to abnormal results
Patient factors
Provider error
Special challenges at residency clinics
Current LimitationsSlide7
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 patientsFraming of result messages to patientNot shown to be effectiveEconomic ReimbursementImproves adherence in disadvantaged patients
Interventions to Improve AdherenceSlide8
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 Slide9
Data sources
:
UW-Verona Family Medicine ClinicUW-Wausau Family Medicine ClinicTimeframes:Index Pap
Pre-intervention: 11/2005 - 11/2007
Post-intervention: 11/2008 - 11/2010
Intervention
SpreadsheetScoring care:
Follow ASCCP guidelines (3 month window)
Early testing appropriate
Extra vigilant care appropriate
MethodsSlide10
If appropriate care took place, assumed communication was appropriateInappropriate steps
Review communication
Attribute loss of follow-up (patient or provider)Scoring stopped after an inappropriate stepReferrals appropriateTransfer of care
Adolescents excluded from post-intervention results
MethodsSlide11
Patient Recruitment Flowchart – Pre-Intervention - Verona
72 Patients
5 Patients Excluded
4 History Questions
1 Chart Incomplete
67 PatientsSlide12
Patient Recruitment Flowchart – Pre-Intervention - Wausau
62 Patients
9 Patients Excluded
6 Care Transferred
2 Index Pap not at Clinic
1 Chart Incomplete
53 PatientsSlide13
Las
Patient Recruitment Flowchart – Post-Intervention - Verona
127 Patients
23 Patient Excluded
13 Adolescents
9 Care Transferred
1
Superceding
Provider Judgment
104 PatientsSlide14
Las
Patient Recruitment Flowchart – Post-Intervention - Wausau
77 Patients
8 Patients Excluded
5 Care Transferred
3 Adolescents
69 PatientsSlide15
Patient Care:
Percentage of follow-up steps that were appropriate
Provider Communication: Percentage of follow-up steps that had correct provider communicationSignificance of Results:
analyzed with Fisher’s test
Data Analysis Slide16
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
V
W
V
W
Pre-intervention
82
76
27
24
75.2%
76.0%
Post-intervention
133
76
31
23
81.1%
76.8%
Improvement:
5.9%
P=0.29
0.8%
P=1Slide17
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
V
W
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=0.66Slide18
Study not completeChallenges:
Change in ASCCP guidelines
Implementation of EMRDifficulty in judging communication of next stepsClinicians not interpreting algorithms correctly, especially post-
colposcopy
follow-up
Next Steps
Continue spreadsheet useTrack remaining patientsProvider EducationIntervention Tailoring: Initiating incentives, paying for care or transportation, informational brochures
Discussion: Slide19
Ann Evensen, MD - project advisor
Anna Hendrickson, RN – project member
Laura Kutzke – program coordinatorHelen Luce, DO – project advisorClarissa
Renken
, DO – project member
Mark Shapleigh – clinic manager
Jon Temte, MD,PhD – program director
AcknowledgementsSlide20
American Cancer Society - Cancer Facts & Figures 2009. At: http://www.cancer.org/acs/groups/content/@nho/documents/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.pdf (Accessed July 13th 2010).
References