Steven J. Atlas

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.

Patient Perceptions on the Follow-Up of Abnormal Cancer Screening Test Results

Timely follow-up after an abnormal cancer screening test result is needed to maximize the benefits of screening, but is frequently not achieved. Little is known about patient experiences with the process of following up abnormal screening results. Assess patient experiences and perceptions regarding the process of a diagnostic workup following abnormal breast, cervical, or colorectal cancer screening results. Survey of participating patients between April 2021 and June 2022 after reaching the primary outcome time point in a randomized controlled trial to improve follow-up of overdue abnormal screening results. Patients from 44 participating practices in three primary care practice networks. Self-reported ease of scheduling follow-up, perceived barriers or concerns, provider trust, and satisfaction with communication and care received for the follow-up of abnormal screening results. Overall, 241 (25.0%) patients completed the survey including 66 (32.8%) with breast, 79 (25.3%) with cervical, and 96 (21.3%) with colorectal screening test; median age 55 years, 79.7% women, 80.5% non-Hispanic white, and 51.0% did not complete recommended follow-up. Most patients were worried that the test would find cancer (63.1%), but fewer worried about discomfort or side effects (34.4%), and neither were associated with completing follow-up. However, 17% of patients did not think they needed follow-up tests or appointments and were less likely to complete follow-up (10.5% vs. 24.0%, respectively, p-value 0.009). Most patients were very satisfied with their overall care (71.0%), but only 50.2% strongly agreed that they trusted their provider to put their medical needs above all else when making recommendations. Patients with overdue abnormal breast, cervical, and colorectal cancer screening test results reported important deficiencies in the management of recommended follow-up. Addressing patient concerns about fear of cancer and effectively communicating the need for follow-up procedures may improve timely follow-up after an abnormal cancer screening result. ClinicalTrials.gov NCT03979495.

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.

Comparing clinical decision support systems for improving follow-up of abnormal cervical cancer screening test results

Many individuals with abnormal cervical cancer screening test results do not receive timely follow-up care. Clinical decision support systems (CDSS) to improve follow-up are challenged by difficulty identifying clinical elements and applying complex guideline recommendations. As part of a multisite trial, two CDSS models were implemented: one used natural language processes to evaluate extracted data outside of the electronic health record (EHR) (System A); the other used commercial EHR functionality using LOINC-defined result fields (System B). This secondary analysis compared the accuracy and trial outcomes among sites using these two CDSS models. Primary care clinics (32 in System A and 12 in System B) were randomly assigned to usual care, CDSS alone, or CDSS with patient outreach with or without navigation. CDSS identified individuals with overdue abnormal screening results and specified the recommended follow-up and time interval. CDSS accuracy was assessed by manual chart review. Patient outreach consisted of portal/mailed letters plus a single phone call. Navigation included one or more phone calls to address barriers to care. Completion of recommended follow-up at 120 days after enrollment was the primary outcome. Clinic was the unit of randomization, and the patient was the unit of analysis. Between October 2020 and December 2021, 2596 patients with abnormal results were identified by the CDSS. CDSS true positives were 61.3 % in System A and 70.4 % in System B. CDSS alone versus usual care did not improve outcomes in either system. CDSS with patient outreach with or without navigation versus usual care significantly increased follow-up rates in System A (38.2 % or 37.2 % vs 23.5 %, p < 0.001) and System B (25.4 % or 23 % vs. 19.7 %, p = 0.044). Two CDSS models developed to identify overdue abnormal cervical cancer screening test results had moderate accuracy. Both models with patient outreach with or without navigation - but not CDSS alone - increased recommended follow-up. Future CDSS for cervical cancer screening may be improved with open-source tools developed in public-private partnerships.