| | Abnormal Pap Smear Follow Up 1998-2003
Purpose
To assure patients who have abnormal cervical cancer screening receive notification of the results, appropriate treatment and follow-up.
Background
Research indicates that the rate of abnormal Pap smears in women undergoing testing will vary from 1-20%, depending on the population.(1,2) Patients need to be notified of the abnormal results so further testing and treatment and follow-up can be initiated. Usually patients are notified by mail or phone call. However, it is recognized that neither system is perfect in the ability to reach all patients. In addition, some patients may not understand the importance of further evaluation. The Gundersen Lutheran Colposcopy and Cervical Pathology Clinic was established in 1986 for the purpose of enhancing patient care and providing a database for future research related to cervical dysplasia and cervical cancer prevention. Verification that all patients receive proper evaluation and treatment and follow-up was considered to be of paramount importance. A review of the scientific literature demonstrates rates of follow-up ranging from 64 to 77% after extensive efforts were taken to improve follow-up. (3-8)
Aims
A goal of the Colposcopy and Cervical Pathology Clinic staff is to evaluate the rate of follow-up with further evaluation and treatment in patients who experience abnormal Pap smears at Gundersen Lutheran Medical Center outpatient clinics.
Changes
June 2002 – letter sent to medical and associate staff who perform Pap smears regarding the guideline for abnormal pap smear follow-up.
Methods/Measures
Over the six year study period, the number of patients who underwent cervical Pap smear evaluation at Gundersen Lutheran Medical Center main and Onalaska and LaCrescent campuses was pulled from billing data. The number of patients who had abnormal Paps reported was pulled from the abnormal pap database. Refer to the following table for numbers and percents.
Date | Total Paps | Abnormal Paps | % Abnormal Paps | Total patients followed-up | % patients followed-up |
1998 | 20,010 | 1163 | 5.81 | 1148 | 98.71 |
1999 | 22,629 | 1050 | 4.64 | 1037 | 98.76 |
2000 | 20,282 | 990 | 4.88 | 980 | 98.99 |
2001 | 21,594 | 782 | 3.62 | 770 | 98.47 |
2002 | 21,729 | 929 | 4.28 | 920 | 99.03 |
2003 | 21,257 | 885 | 4.16 | 873 | 98.64 |
Medical records (electronic and paper charts) are accessed for quality review. If no follow-up information is found, one or two letters requesting follow-up information are sent as necessary.
Benchmark
The best results in the literature suggest that 75% is an obtainable rate for follow-up of abnormal Pap smears. (8)
Results
Conclusions and Comments
Gundersen Lutheran’s results are significantly better than the best results in the scientific
literature. Gundersen Lutheran benefits from a very stable patient population. The ability to
identify and find patients significantly aids in the good follow-up rates. Many medical centers do
not establish cervical cancer screening follow-up as a high priority. We are fortunate to have
dedicated staff that make this part of their daily work.
Impact
Previous studies have demonstrated a high rate (17-30%) of cervical cancer in patients who are
lost to follow-up. (9,10) If progression to higher-grade abnormalities or cancer occurs, more
extensive and costly treatment is often required. Patient anxiety can also be greater.
Next Steps
Rates for abnormal pap smear follow-up will continue to be monitored and changes will be
made as the data and staff indicate are appropriate.
References
1. Benar VB, Lee NC, Piper M, Richardson L. Race-specific results of Papanicolaou testing and the rate of cervical neoplasia in the National Breast and Cervical Cancer Early Detection Program, 1991-1998. Cancer Causes and Control 2001;12:61-8.
2. Edelman M, Fox AS, Alderman EM, Neal W, Shapiro A, Silver EJ, Spigland I, Suhrland M. Cervical Papanicolaou smear abnormalities in inner city Bronx adolescents: prevalence, progression,a nd immune modifiers. Cancer 1999;87:184-9.
3. Khanna N, Phillips MD. Adherence to care plan in women with abnormal Papanicolaou smears: A review of barriers and interventions. J Am Board Fam Pract 2001;14:123-30.
4. Paskett ED, White E, Carter WB, Chu J. Improving follow-up after an abnormal Papanicalaou smear: a randomized controlled trial. Prev Med 1990;19:630-41.
5. Lerman C, Hanjani P, Capto C, et al. Telephone counseling improves adherence to colposcopy among lower-income minority women. J Clin Oncol 1992;10:330-3.
6. Stewart DE, Buchegger PM, Lickrish GM, Sierra S. The effect of educational brochures on follow-up compliance in women with abnormal Papanicolaou smears. Obstet Gynecol 1994;83:583-5.
7. Marcus AC, Kaplan CP, Crane LA, et al. Reducing loss-to-follow-up among women with abnormal Pap smears. Results from a randomized trial testing an intensive follow-up protocol and economic incentives. Med Care 1998;36:397-410.
8. Lauver D, Rubin M. Message framing, dispositional optimism, and follow-up for abnormal Papanicolaou tests. Res Nurs Health. 1990;13:199-207.
9. Kinlen LJ, Spriggs AI. Women with positive cervical smears but without surgical intervention: A follow-up study. Lancet 1978;2:463-5.
10. Lane DS. Compliance with referrals from a cancer-screening project. J Fam Pract 1983;17:811-7.
Activity Leader
Susan Bobenmoyer, Colposcopy and Cervical Pathology Clinic
Ken Merkitch, M.D., Chairman, Department of Obstetrics & Gynecology
Acknowledgments
Charles Schauberger, M.D.
Jane Robinson, RHIA |