Sarah Feldman

Association Between Clinician Confidence and Making Guideline-Recommended Decisions in the Management of Abnormal Cervical Cancer Screening Results

Guidelines for managing abnormal cervical cancer screening results are complex and adherence is challenging for clinicians. Previous studies have identified gaps in knowledge as a possible cause; few have explored the confidence clinicians have in their management decisions. Confidence in decision-making may influence management practices, particularly when guidelines are complex and evolving. Assess whether confidence in decision-making is associated with making guideline-concordant recommendations for abnormal cervical cancer screening results. A clinician survey used vignettes to ask clinicians to make a management recommendation for different abnormal results and rate their level of confidence in their response. Physicians and advanced practice providers (APPs) at three diverse health systems in Washington, Texas, and Massachusetts. Correct response to each vignette based on either the 2012 or 2019 American Colposcopy and Cervical Pathology (ASCCP) management guidelines. In total, 501 clinicians completed the survey between October and December 2020 (response rate 53.7%). Overall, most clinicians made guideline-recommended management decisions for two vignettes (73.2 and 73.7%), but fewer were confident in their selection (48.3% and 46.6%, respectively). Clinicians who reported high levels of confidence were more often correct than those who reported lower levels of confidence (85.8% vs. 62.2% and 87.5% vs. 60.7%, both p<0.001). After adjusting for clinician and practice characteristics, confidence remained significantly associated with selecting the correct answer. Clinician confidence in management decisions for abnormal cervical cancer screening results was significantly associated with knowing guideline-concordant recommendations. Given the complexity of cervical cancer management guidelines, solutions to improve clinician confidence in decision-making are needed.

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.

Current and prior human papillomavirus (HPV) type and cytology results enable risk assessment for triage to colposcopy

Linked article: This is a mini commentary on Gustafson et al., pp. 2132–2141. in this issue. To view this article visit https://doi.org/10.1111/1471‐0528.17200

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.