Performance of implementing guideline-driven cervical cancer screening measures in an inner-city hospital system

Abstract

Objective: : In 2006, the American Society for Colposcopy and Cervical Pathology updated evidence-based guidelines recommending screening intervals for women with abnormal cervical cytology diagnosis. In our low-income inner-city population, we sought to improve performance by uniformly applying the guidelines to all patients. We report the prospective performance of a comprehensive tracking, evidence-based algorithmically driven call back, and appointment scheduling system for cervical cancer screening in a resource-limited inner-city population.

Materials and methods: : Outreach efforts were formalized with algorithm-based protocols for triage to colposcopy, with universal adherence to evidence-based guidelines. During implementation from August 2006 to July 2008, we prospectively tracked performance using the electronic medical record with administrative and pathology reports to determine performance variables such as the total number of Pap tests, colposcopy visits, and the distribution of abnormal cytology and histology results, including all cervical intraepithelial neoplasia 2, 3 diagnoses.

Results: : A total of 86,257 gynecologic visits and 41,527 Pap tests were performed system-wide during this period of widespread and uniform implementation of standard cervical cancer screening guidelines. The number of Pap tests performed per month varied little. The incidence of CIN 1 significantly decreased from 117 (68.4%) of 171 during the first tracked month to 52 (54.7%) of 95 during the last tracked month (p = 0.04). The monthly incidence rate of CIN 2, 3, including incident cervical cancers, did not change. The total number of colposcopy visits declined, resulting in a 50% decrease in costs related to colposcopy services and approximately a 12% decrease in costs related to excisional biopsies.

Conclusions: : Adherence to cervical cancer screening guidelines reduced the number of unnecessary colposcopies without increasing numbers of potentially missed CIN 2, 3 lesions, including cervical cancer. Uniform implementation of administrative-based performance initiatives for cervical cancer screening minimizes differences in provider practices and maximizes performance of screening while containing cervical cancer screening costs.

Figure 1

Algorithm used by the administrative staff in the follow up office to guide outreach efforts and timing of subsequent visit. All outreach was initially by phone and followed with a letter. When an appointment was missed, additional outreach was by phone followed by a letter. In cases where a certified letter was sent, a routine letter was also sent as some patients did not pick up certified letters.

Figure 2

The overall number of gynecology visits varied little over this time period. However, the number of abnormal Pap tests with equivocal results such as LSIL and ASCUS decreased significantly over the 24 month study period. The number of HSIL and clinically significant lesions did not vary during this time period.

Figure 3

There was a trending decrease in the number of colposcopy and biopsy procedures. The number of LEEP/Cone procedures did not vary during this time period.

Figure 4

Over time, the number of histologic findings of CIN 1 significantly decreased. There was little variation with regards to the other histologic categories of dysplasia.