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AJMC: Better Targeting of Pap Smear Interventions Can Come From Identifying Patient, Provider Reasons for Incorrect Usage



June 27, 2013

AJMC: Better Targeting of Pap Smear Interventions Can Come From Identifying Patient, Provider Reasons for Incorrect Usage

PLAINSBORO, NJ — Better targeting of patients who are not using Pap smears at correct intervals would come through more precise identification of factors that lead to incorrect use in the first place, both on the part of the patient and the provider, according to a study published in this month’s issue of The American Journal of Managed Care.

In a survey of 8018 women aged 30 or older, 34% received Papanicolaou (Pap) smears based on current US medical professional organization and US Preventative Services Task Force (USPSTF) guidelines. Another 45% were screened too often, and 21% were screened too infrequently. The share screened too often rose to 47% if unsatisfactory Pap tests were not considered, and shrank to 35% if the observation interval was reduced from 36 to 30 months.

For women with a low risk of cervical cancer who are 30 years or older, US medical professional organization and US Preventative Services Task Force (USPSTF) guidelines recommend cervical cancer screenings be administered every 3 years. Yet, annual screenings remain common. While some pay-for-performance initiatives encourage triennial cervical cancer screenings, rather than annual screenings, there are concerns that discouraging annual screenings might lead to some women missing a screening when they need one.

Factors that influenced overuse of screenings included being younger, having more frequent medical visits (including contraceptive management visits), and seeing a doctor who is a gynecologist. Underuse of screenings, by contrast, was associated with older age, fewer medical visits, and increased comorbidity. It is important, therefore, to examine both overuse and underuse in clinical evaluation.

While several studies have examined the use of cervical cancer screening from either the patient or provider perspective, the analysis in the June issue of AJMC presents a unique link between both the patient and provider factors that contribute to underuse or overuse of cervical cancer screening. The study also found that modifying the way the screening intervals are measured—and accounting for bad tests–alters the data on whether tests are “overused.”

For instance, the analysis showed that accounting for unsatisfactory Pap smears and narrowing the 3-year screening interval by 6 months reduces the share of testing classified as too frequent from 47% to 37%. This data suggest that if an intervention were targeted at all patients fitting the conventional definition of being tested too frequently, 10% to 15% of the women receiving the message would not need to hear it.

Cristina M Almeida, MD, MPH, et al say that it can take time for patterns of medical care to adjust to guideline changes, even if it means less frequent administration of invasive medical procedures like Pap smears. Nevertheless, there are multiple variables in patient characteristics that can guide interventions to target women for appropriate cervical cancer screening. For example, most young women need to be better educated about being tested too frequently, while most older women need to be targeted for underuse of Pap smears. The study findings encourage gynecologists to understand how they can better improve care.

“Variation in clinical practice has led to interest in defining appropriate use of common clinical procedures. However, there remains tension between patient-centered and evidence-based medicine,” the authors state, “Guidelines aimed at changing clinical behavior must account for clinical and structural variability in care, and when feasible, both underuse and overuse should be addressed. We studied cervical cancer screening here; however, the general principle applies to many diagnostic and treatment modalities.”

The study data may assist providers in identifying necessary areas of improvement in guidelines for cervical cancer screening, in addition to better targeting interventions. Making informed decisions is crucial, as the authors say improperly targeted interventions “reduce the effectiveness of efforts to improve care.” In cervical cancer screening, it is imperative that both patient and provider factors in underuse and overuse are evaluated.

View the article here


The American Journal of Managed Care, founded in 1995, is an independent, peer-reviewed publication dedicated to disseminating clinical information to managed care physicians, clinical decision makers, and other healthcare professionals. Its aim is to stimulate scientific communication in the ever-evolving field of managed care. Based in Plainsboro, N.J., AJMC addresses a broad range of issues relevant to clinical decision making in a cost-constrained environment and examines the impact of clinical, management, and policy interventions and programs on healthcare and economic outcomes. The Journal is mailed to nearly 49,000 clinical decision makers in managed care, including physicians, hospital directors, and medical / pharmacy / formulary directors at managed care organizations.

CONTACT: Nicole Beagin

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