1. Intervention to Reduce Inappropriate Papanicolaou Testing in a Resident Clinic
L. Kyle Horton MD, MBA; Samantha H. H. Hudson MD, MEng; Denise L. Borden MD; Arpita Aggarwal MD, MSc
Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
#
83%
14%
2%
1%
17%
Inappropriate
Appropriate
17% Inappropriate
(229 Patients)
1.7% Inappropriate
(119 Patients)
Background
High-quality clinical care follows cancer
screening guidelines.
Non-adherence to US Preventive
Services Task Force (USPSTF)
guidelines for cervical cancer screening
was prevalent in our clinic.
Goal to design and implement an
intervention to improve
-Understanding of guidelines
-Adherence to guidelines
AIM: 95% adherence to USPSTF
guidelines
Methods
Pilot chart review (n=229) for
appropriate Pap testing and adherence
to USPSTF guidelines
Implemented a “Pap Clinic” for focused
women’s health visits
-Used an electronic medical record
(EMR) template to guide decisions
-Focused gynecologic history
-Patient-centered discussion of
cervical cancer screening guidelines
Retrospective chart review (n=119)
from the “Pap Clinic”
Statistical Analysis
-Univariate and bivariate analyses
using Fischer exact, and ANOVA tests
-SAS 9.2 statistical software
-p<0.05 for statistical significance
Statistically Significant Decrease
in Inappropriate Pap Smears
Fischer Exact Test (p<0.0001)
Conclusions
Inappropriate Pap testing was prevalent in our
resident clinic, especially post-hysterectomy for
benign reasons.
Creating a clinic for focused women’s health visits
using an EMR template was effective at reducing
inappropriate Pap testing.
Educational intervention at the intern level is likely
to enhance compliance with USPSTF guidelines
throughout the trainee’s future career.
Discussion
Confusion exists about conflicting sources of
guidelines (ACOG, USPSTF, and ACS) and varied
medical school training with different specialties.
EMR templates may prove effective at improving
compliance with Pap testing guidelines in primary
care by highlighting pertinent history and guiding
decision-making in the context of cervical cancer
screening.
Results
Pilot Study
Post-Intervention with the “Pap Clinic”
Similar baseline demographic characteristics
(age, race, and insurance status).
Twenty patients deemed inappropriate referrals to
the “Pap Clinic” and did NOT undergo Pap testing.
Limitations
May lack generalizability
-Interns receptive to educational intervention
-Unique factors to underserved urban population
Results may reflect selection bias to those referred
to “Pap clinic” and over or under-estimate effect size
Small sample size
Too early to assess long-term efficacy
-Not all residents have participated in “Pap Clinic”
-Still 16.8% inappropriate referrals (close to
17% inappropriate Pap smears done initially)
Pre-Intervention Post-Intervention
Appropriate
Inappropriate
Post-hysterectomy
>age 65
Post-hyst and >65