Implementing Best Practices in Cervical Cancer Screening Ann Evensen, MD UW Health Verona

1. Implementing Best Practices in Cervical Cancer Screening Ann Evensen, MD UW Health Verona November 6, 2008

2. The Opportunity • A variety of pap smear techniques were being followed at UW Verona • This caused concern: • Some techniques did not reflect best practices • Potential for missing cervical disease • Lack of standardization increased work of nurses and wasted supplies

3. Team leaders: Ann Evensen, MD and Adrian Tabares, Med 2 Team Members: John Beasley, MD Kathleen Carr, MD Janice Cooney, PA-C Marguerite Elliott, DO William Scheibel, MD Mark Shapleigh, Clinic Manager Susan Skochelak, MD Sandy Skrede, LPN Doug Smith, MD Heidi Stokes, PA-C Our Team

4. Our Goal 90% of pap smears at UW Verona clinic for low-risk women will be done using a single method that reflects “best practices” as described in current literature.

5. Current Situation • We examined three variables in pap smear screening: 1) collection instrument 2) glass slide versus liquid-based cytology (LBC) 3) frequency

6. Current Situation, Part 1: The Ayre’s spatula and Cytobrush used together is the most sensitive method of collecting a pap smear. Martin-Hirsch PPL, Jarvis GG, Kitchener HC, Lilford R. Collection devices for obtaining cervical cytology samples. Cochrane Database of Systematic Reviews 2000, Issue 3.

7. Current Situation, Part 1: • Clinicians used • 62% Cervex broom • 31% Ayre’s spatula plus Cytobrush • 6% Cervex broom plus Cytobrush

8. Current Situation, Part 2: Liquid-based cervical cytology is neither more sensitive nor more specific for detection of high grade cervical intraepithelial neoplasia compared with the conventional Pap test. Arbyn M, Bergeron C, Klinkhamer P, Martin-Hirsch P, Siebers AG, Bulten J. Liquid compared with conventional cervical cytology: a systematic review and meta-analysis. Obstet Gynecol 2008;111:167–77.

9. Current Situation, Part 2: 37% 63%

10. Current Situation, Part 3: National guidelines recommend screening low risk women every 1-3 years based on age and type of pap Example: low risk women over 30 should be screened every three years with liquid based cytology

11. Current Situation, Part 3:

12. Root Cause Analysis We examined patient, clinician, and systems factors that may be contributing to the variety of cervical cancer screening practices at our clinic. Examples: • physician habit • patient preference • lack of knowledge of best practices

13. Intervention Faculty agreed on single method for screening low-risk women based on data from our clinic and literature review of best practices.

14. Liquid versus glass slide debate • Liquid $75, glass $25 • Fewer exams = fewer lab, physician labor, and supply costs • Fewer repeat exams due to need for HPV sample or “insufficient cells” • Screening required less often with liquid method

15. Implementation Protocol implemented at UW Verona Clinic: • Clinicians were trained to use plastic Ayre’s spatula plus Cytobrush with liquid-based cytology done every 2-3 years based on age. • Exam rooms restocked.

16. Assessment Six months after protocol implementation, feedback was gathered via: • Written survey of clinicians • Team meetings and individual staff interviews Pap smear audit was repeated

17. Results

18. Screening frequency issues • Data collection • Systems-based solution

19. Future Plans Plan QI project to develop a systems-based approach to improve screening frequency. Balance costs with need for resident education. Orient every new class of resident physicians to pap protocol to sustain improvements that we have realized.

20. Conclusions • Simplifying exam room set-up for pap smears is possible and can improve adherence to best practices for cervical cancer screening. • Despite some clinicians having to abandon personal preferences for screening, support for the protocol was wide-spread. • This project was successful because we changed the system rather than each clinician. However, we were not able to systematically change physician/patient expectations of annual screening.