Jennifer S Haas

Gaps in care across the cancer screening continuum for cervical, colorectal, and lung cancers

Abstract Background Screening for cervical, colorectal, and lung cancers reduces cancer-specific mortality, but the full benefits of screening are realized only when they are coupled with timely care across the subsequent “screening continuum” steps, including surveillance (results warranting frequent monitoring), diagnostic evaluation (results that require additional testing), and treatment (detected cancers). Our goal was to describe the proportion of individuals receiving timely cervical, colorectal, and lung cancer care at each step in the screening continuum. Methods This retrospective cohort study used data from the 10 health-care settings that participate in the Population-based Research to Optimize the Screening Process, 2018 to present, consortium and included individuals who were eligible for a step along the cancer screening continuum in 2018. Proportions of individuals who received timely testing were calculated for screening, surveillance, and diagnostic tests for each of the 3 cancers and treatment (colorectal cancer only), and we evaluated the association of these outcomes with patient characteristics using multivariate logistic regression. Results The overall proportions of timely screening, surveillance, and diagnostic testing were 41.8%, 37.3%, and 61.2% for cervical cancer; 82.4%, 45.5%, and 73.5% for colorectal cancer (94.1% for timely treatment); and 73.8%, 80.5%, and 80.7% for lung cancer. Across all 3 cancers, there were differences across the screening continuum by insurance status, race and ethnicity, and socioeconomic status. Conclusions There are important gaps in care across the screening continuum beyond common metrics for screening uptake. Comparison across organ types may facilitate the identification of interventions and policies that could broadly improve cancer prevention and promote health equity.

Assessing Management of Abnormal Cervical Cancer Screening Results and Concordance with Guideline Recommendations in Three US Healthcare Settings

Abstract Background: Follow-up of abnormal results is essential to cervical cancer screening, but data on adherence to follow-up are limited. We describe patterns of follow-up after screening abnormalities and identify predictors of guideline-concordant follow-up. Methods: We identified the index screening abnormality (positive human papillomavirus test or atypical squamous cells of undetermined significance or more severe cytology) among women of ages 25 to 65 years at three US healthcare systems during 2010 to 2019. We estimated the cumulative incidence of surveillance testing, colposcopy, or treatment after the index abnormality and initial colposcopy. Logistic regressions were fit to identify predictors of guideline-concordant follow-up according to contemporaneous guidelines. Results: Among 43,007 patients with an index abnormality, the cumulative incidence of any follow-up was 49.6% by 4 years for those with atypical squamous cells of undetermined significance/human papillomavirus–negative and higher for abnormalities warranting immediate colposcopy. The 1-year cumulative incidence of any follow-up after colposcopy was 70% for patients with normal results or cervical intraepithelial neoplasia I and 90% for patients with cervical intraepithelial neoplasia II+. Rates of concordant follow-up after screening and colposcopy were 52% and 47%, respectively. Discordant follow-up was associated with factors including age, race/ethnicity, overweight/obese body mass index, and specific types of public payor coverage or being uninsured. Conclusions: Adherence to the recommended follow-up of cytologic and histopathologic abnormalities is inconsistent in clinical practice. Concordance was poor for mild abnormalities and improved, although suboptimal, for more severe abnormalities. Impact: There remain gaps in the cervical cancer screening process in clinical practice. Further study is needed to understand the barriers to the appropriate management of cervical abnormalities.

Process Mapping to Compare and Improve Management of Abnormal Cervical Cancer Screening Results in Two US Healthcare Systems within the PROSPR Consortium

Abstract Background: Guidelines for management of abnormal cervical cancer screening results have increased in complexity over the past two decades. Little is known about how patient-, clinician-, and organization-level factors influence implementation when guidelines change. Process mapping may offer insights into organizational processes and facilitate visualization for potential intervention opportunities. Methods: We conducted an iterative multimodal qualitative assessment to compare abnormal cervical cancer screening management between two health systems: a safety-net institution and an integrated health system. We interviewed clinicians and staff to generate (phase I, May 2019–March 2021) and validate (phase II, July–Oct 2022) process maps at both systems. We conducted a rapid and thematic content analysis and engaged clinical and nonclinical stakeholders during interpretation. Results: At both health systems, process maps informed by phase I participants (n = 31) identified a gap in care during patients’ transition back to primary care following resolution of abnormal tests by gynecologists. In phase II, participants (n = 21) validated and revised maps, noting guideline updates and quality improvement initiatives. Although each system deployed unique strategies to address gaps in care, strategies in common included creating electronic health record–based clinical decision support tools, enabling gynecologists to provide real-time e-consults to primary care clinicians, and engaging patients via the portal. Conclusions: The complexity of cervical cancer screening management guidelines elevates the importance of identifying system-level tools to support clinician decision-making and coordinate between primary and specialty care teams. Impact: Process maps are valuable in generating cross-system comparisons by documenting clinical workflows, identifying care gaps, and engaging participants in formulating potential interventions.