The recommended screening interval when using the Papanicolaou (Pap) and human papillomavirus (HPV) test (co-testing) is 5 years. However because providers are reluctant to extend the screening interval, we launched a study to identify barriers to appropriate use of the co-test and to implement an educational intervention to promote evidence-based screening practices. This article provides an overview of the study including the multi-component intervention and participant demographics.
The study was conducted in 15 clinics associated with 6 Federally Qualified Health Centers (FQHCs) in Illinois. Each clinic received HPV tests to administer with routine Pap tests among enrolled patients (n=2,246) and was assigned to a study arm: intervention arm (n=7) received a multi-component educational intervention (small media, academic detailing, and website) for providers and printed educational materials for patients, and control arm (n=8) received printed copies of general guidelines. Clinic coordinators (n=15), providers (n=98), and patients (n=984) completed baseline surveys to assess screening practices.
Providers reported an average age of 41.3 years and were predominately female, non-Hispanic, and white. Patients reported an average age of 45.0 years and nearly two-thirds were Hispanic or black. Of the 2,246 patients, 89% had a normal co-test. Lessons learned from the study included the importance of buy-in at a high level in the organization, a champion provider, and a clinical coordinator devoted to the study.
Materials from this study can be adapted to educate providers and patients on appropriate use of the co-test and encourage extended screening intervals as a safe and effective practice.
[Show abstract][Hide abstract] ABSTRACT: Introduction:
In the United States, Federally Qualified Health Centers (FQHCs) are safety-net clinics that provide cervical cancer screening and human papillomavirus (HPV) vaccination to medically underserved women, some of whom may be at risk for developing cervical cancer. National guidelines recommend against using screening test results or sexual history to determine vaccine eligibility. Documenting HPV vaccine recommendations and beliefs of primary care providers in FQHCs may aid in promoting evidence-based practices and prioritizing health interventions for vulnerable populations.
Between 2009 and 2010, we collected data from 98 primary care providers in 15 FQHC clinics in IL, USA using a cross-sectional survey. Questions assessed provider and practice characteristics, HPV vaccine recommendations, and provider's belief about whether their screening and management procedures would change for women who were vaccinated.
93% of providers recommended the HPV vaccine, most frequently for females aged 13-26 years (98%). Some providers reported sometimes to always using HPV test results (12%), Pap test results (7%), and number of sexual partners (33%) to determine vaccine eligibility. More than half of providers (55%) reported they will not change their screening and management practices for vaccinated females, yet believe vaccination will yield fewer abnormal Pap tests (71%) and referrals for colposcopy (74%).
Study providers routinely recommended the HPV vaccine for their patients. However, providers made fewer recommendations to vaccinate females ages 9-12 years (which includes the target age for vaccination) compared to older females, and used pre-vaccination assessments not recommended by U.S. guidelines, such as screening test results and number of sexual partners. In order to maximize the public health benefit of the HPV vaccine to prevent cervical cancer, adherence to guidelines is necessary, especially in settings that provide care to medically underserved women.
[Show abstract][Hide abstract] ABSTRACT: The primary cervical cancer screening strategy for women over age 30 is high-risk human papillomavirus (HPV) testing combined with Pap testing (co-testing) every 5 years. This combination strategy is a preventive service that is required by the Affordable Care Act to be covered with no cost-sharing by most health insurance plans. The co-testing recommendation was made based entirely on prospective data from an insured population that may have a lower proportion of women with HPV positive and Pap negative results (i.e., discordant results). The discordant group represents a very difficult group to manage. If the frequency of discordant results among underserved women is higher, health care providers may perceive the co-testing strategy to be a less favorable screening strategy than traditional Pap testing every 3 years.
The Centers for Disease Control and Prevention's Cervical Cancer Study was conducted at 15 clinics in 6 Federally Qualified Health Centers across Illinois. Providers at these clinics were given the option of co-testing for routine cervical cancer screening. Type-specific HPV detection was performed on residual extracts using Linear Array.
Pap test results were abnormal in 6.0% and HPV was positive in 7.2% of the underserved women screened in this study (mean age 45.1 years). HPV prevalence decreased with age, from 10.3% among 30- to 39-year-olds to 4.5% among 50- to 60-year-olds. About 5% of the women had a combination of a positive HPV test and normal Pap test results; HPV 16/18 was identified in 14% of discordant women.
The rate of discordant results among underserved women was similar to those reported throughout the U.S. in a variety of populations. Typing for HPV 16/18 appears to assist in the management in a small proportion of women with discordant results.
American journal of obstetrics and gynecology 05/2014; 211(4). DOI:10.1016/j.ajog.2014.05.001 · 4.70 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
Little is known about the information providers share with patients when ordering a co-test, or combined human papillomavirus (HPV) and Papanicolaou (Pap) test, for cervical cancer screening. We assessed provider perceptions of such communication practices with female patients aged 30-60 years.
We analyzed data from 98 providers in 15 Federally Qualified Health Center clinics across Illinois (2009-2010).
About 70% of the providers reported that when ordering a co-test, they would usually or always communicate information about the HPV test to their patients, explain the test detects a sexually transmitted infection, and discuss how the test results may determine their next screening interval. Most (>85%) reported that they were comfortable discussing co-test results. Compared with concordant positive results (HPV positive/Pap positive), providers were more likely to perceive that discordant results (HPV positive/Pap negative) would be too complex for patients to understand (25% vs. 15%, p = 0.006), and make patients feel less assured that they were getting the best standard of care (67% vs. 88%, p < 0.001).
As HPV testing plays a more prominent role in cervical cancer screening, more attention should be given to communications between providers and patients about the benefits and harms of different screening options.
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