1. Improving follow-up to abnormal cervical cytology results Tom Garvey, BS, M2 Ann Evensen, MD Helen Luce, DO

2. Cervical Cancer • Two main types • Adenocarcinoma • Squamous cell carcinoma • Asymptomatic • Develop slowly • Risk factors

3. Cervical Cancer Screening • Cytology • High sensitivity • Conventional glass slide • Liquid-based cytology • ASCUS, ASC-H, LGSIL, HGSIL, AIS, AGUS • HPV Testing Normal vs. Abnormal Cervical Cells

4. Next Steps • Histology: Colposcopy • Visual examination • Biopsy • High specificity • CIN-1, 2, or 3; Cancer • Excisional Procedures • Loop Electrosurgical Excision Procedure (LEEP) • Cold cone excision LEEP

5. Clinical Best Practices • ASCCP – algorithms for cytological and histological results4

6. Current Limitations • Barriers to screening • Imperfect tests • Loss of follow-up to abnormal results • Patient factors • Provider error • Special challenges at residency clinics

7. Interventions to Improve Adherence

8. Hypothesis Using an electronic tracking system to manage patients with abnormal cervical cytology will improve both communication of next steps to the patient and patient adherence with these steps at two family medicine residency clinics

9. Methods • Data sources: • UW-Verona Family Medicine Clinic • UW-Wausau Family Medicine Clinic • Timeframes: • Index Pap • Pre-intervention: 11/2005 - 11/2007 • Post-intervention: 11/2008 - 11/2010 • Intervention • Spreadsheet • Scoring care: • Follow ASCCP guidelines (3 month window) • Early testing appropriate • Extra vigilant care appropriate

10. Methods • If appropriate care took place, assumed communication was appropriate • Inappropriate steps • Review communication • Attribute loss of follow-up (patient or provider) • Scoring stopped after an inappropriate step • Referrals appropriate • Transfer of care • Adolescents excluded from post-intervention results

11. Patient Recruitment Flowchart – Pre-Intervention - Verona 72 Patients 5 Patients Excluded 4 History Questions 1 Chart Incomplete 67 Patients

12. Patient Recruitment Flowchart – Pre-Intervention - Wausau 53 Patients 62 Patients 9 Patients Excluded 6 Care Transferred 2 Index Pap not at Clinic 1 Chart Incomplete

13. Patient Recruitment Flowchart – Post-Intervention - Verona • Las 127 Patients 23 Patient Excluded 13 Adolescents 9 Care Transferred 1 Superceding Provider Judgment 104 Patients

14. Patient Recruitment Flowchart – Post-Intervention - Wausau • Las 77 Patients 8 Patients Excluded 5 Care Transferred 3 Adolescents 69 Patients

15. Data Analysis • Patient Care: • Percentage of follow-up steps that were appropriate • Provider Communication: • Percentage of follow-up steps that had correct provider communication • Significance of Results: • analyzed with Fisher’s test

16. Results: Appropriate Care By Clinic

17. Results: Provider Communication By Clinic

18. Discussion: • Study not complete • Challenges: • Change in ASCCP guidelines • Implementation of EMR • Difficulty in judging communication of next steps • Clinicians not interpreting algorithms correctly, especially post-colposcopy follow-up • Next Steps • Continue spreadsheet use • Track remaining patients • Provider Education • Intervention Tailoring: Initiating incentives, paying for care or transportation, informational brochures

19. Acknowledgements • Ann Evensen, MD - project advisor • Anna Hendrickson, RN – project member • Laura Kutzke – program coordinator • Helen Luce, DO – project advisor • Clarissa Renken, DO – project member • Mark Shapleigh – clinic manager • Jon Temte, MD,PhD – program director

20. References • American Cancer Society - Cancer Facts & Figures 2009. At: http://www.cancer.org/acs/groups/content/@nho/documents/document/500809webpdf.pdf (Accessed July 13th 2010). • Parkin, DM, Pisani, P, Ferlay, J. Global cancer statistics. CA Cancer J Clin 1999; 49:33. • National Cancer Institute – Current Research: Health Disparities: Cervical Cancer. At: http://dceg.cancer.gov/research/healthdisparities/cervical (Accessed July 13th 2010). • American Society for Colposcopy and Cervical Pathology – Consensus Guidelines: 2006. At: http://www.asccp.org/pdfs/consensus/algorithms_cyto_07.pdf (Accessed July 13th 2010).