Challenges in cervical cancer prevention: a survey of U.S. obstetrician-gynecologists

Why are U.S. girls getting meningococcal but not human papilloma virus vaccines? Comparison of factors associated with human papilloma virus and meningococcal vaccination among adolescent girls 2008 to 2012

BACKGROUND

Human papilloma virus (HPV) vaccination rates in the United States remain low, compared with other recommended adolescent vaccines. We compared factors associated with intention to receive and receipt of HPV and meningococcal vaccines and completion of the HPV vaccine series among U.S. adolescent girls.

METHODS

Secondary analysis of data from the National Immunization Survey-Teen for 2008 through 2012 was performed. Multivariable logistic modeling was used to determine factors associated with intent to receive and receipt of HPV and meningococcal vaccination, completion of the HPV vaccine series among girls who started the series, and receipt of HPV vaccination among girls who received meningococcal vaccination.

FINDINGS

Provider recommendation increased the odds of receipt and intention to receive both HPV and meningococcal vaccines. Provider recommendation was also associated with a three-fold increase in HPV vaccination among girls who received meningococcal vaccination (p<.001), indicating a relationship between provider recommendation and missed vaccine opportunities. However, White girls were 10% more likely to report provider recommendation than Black or Hispanic girls (p<.01), yet did not have higher vaccination rates, implying a role for parental refusal. No factors predicted consistently the completion of the HPV vaccine series among those who started.

CONCLUSION

Improving provider recommendation for co-administration of HPV and meningococcal vaccines would reduce missed opportunities for initiating the HPV vaccine series. However, different interventions may be necessary to improve series completion.

Cost effectiveness of human papillomavirus-16/18 genotyping in cervical cancer screening

BACKGROUND

There is limited understanding of the health economic implications of cervical screening with human papillomavirus (HPV)-16/18 genotyping.

OBJECTIVE

The aim of this study was to evaluate the cost effectiveness of cervical cancer primary screening with a HPV-16/18 genotyping test which simultaneously detects 12 other high-risk HPV types.

METHODS

A Markov cohort model compared four strategies: (1) cytology with reflex HPV testing for atypical squamous cells of undetermined significance (ASC-US); (2) co-testing with cytology and HPV testing; (3) HPV with reflex to cytology; and (4) HPV with 16/18 genotyping and reflex cytology (ASC-US threshold). Screening began at age 30 and was performed triennially over 40 years. Screening sensitivity and specificity values for cervical intraepithelial neoplasia (CIN) 3 were obtained from the Addressing THE Need for Advanced HPV Diagnostics (ATHENA) trial. Outcomes for a 1-year follow-up scenario wherein persistent disease was detected were estimated. Screening and cancer treatment costs were calculated from a US payer's perspective in 2013. Costs and quality-adjusted life-years (QALYs) were discounted at 3 % annually.

RESULTS

Applying a US$50,000/QALY threshold, strategy (4) dominated strategies (2) and (3) by reducing costs and cancer incidence and improving QALYs, and was cost effective versus strategy (1). Accounting for persistent ≥CIN 3 at 1 year, strategy (4) was cost effective versus all other strategies. Detecting HPV-16/18 resulted in earlier diagnosis of clinically relevant ≥CIN 3 at initial screening and efficient use of follow-up resources. Outcomes were most influenced by strategy performance.

CONCLUSIONS

Incorporating HPV-16/18 genotyping is cost effective and may improve detection of CIN, thereby preventing cervical cancer.

Provider beliefs associated with cervical cancer screening interval recommendations: A pilot study in Federally Qualified Health Centers

Background

Among providers who serve low-income and uninsured women, resistance to extending the cervical cancer screening interval following normal Pap and co-test results has been documented. Our objective was to examine provider characteristics and beliefs associated with guideline-consistent screening interval recommendations.

Method

We collected cross-sectional survey data between 2009 and 2010 from 82 primary care providers in six Federally Qualified Health Centers in Illinois, USA. The relationships between characteristics, beliefs, and screening interval recommendations (1 year vs. 3 years) were tested with Pearson chi-square, negative binomial and ordered logistic regression.

Results

Compared to providers who recommended annual intervals after a normal co-test, providers who recommended a guideline-consistent (i.e., 3 years) screening interval were significantly more likely to report the goodness, ease, and benefit of their recommendation and perceived encouragement for a 3-year interval from professional organizations and journals (p < .05). Providers who recommended a 3-year interval were also less likely to report that longer intervals increase patient risk for cervical cancer (p < .05). Interval recommendations were not associated with provider specialty, gender, or years in practice.

Conclusion

Messages that promote the benefits of longer screening intervals after a normal co-test, the natural history of human papillomavirus and cervical cancer, and low risk of developing cancer with a longer interval may be useful to promote evidence-based screening in this population of Federally Qualified Health Center providers. Dissemination of targeted messages through professional journals and specialty organizations should be considered.

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Annual cervical cancer screening is common, but not recommended by guidelines.

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Pilot study assessed provider factors associated with screening recommendations.

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Screening recommendations are associated with positive beliefs about screening tests.

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Perceived risk of the patient developing cancer between screenings is significant.

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Professional journals and organizations can disseminate screening interval messages.

Can automated alerts within computerized physician order entry improve compliance with laboratory practice guidelines for ordering Pap tests?

BACKGROUND

The electronic health record (EHR) provides opportunity to improve health and enhance appropriate test utilization through decision support. Electronic alerts in the order entry system can guide test use. Few published reports have assessed the impact of automated alerts on compliance of Pap ordering with published screening guidelines.

METHODS

Programming rules for Pap test ordering were developed within the EHR (Epic, Madison, WI) of the University of California, Davis Health System using American College of Obstetrics and Gynecology's 2009 guidelines and implemented in primary care clinics in 2010. Alerts discouraged Pap orders in women <21 and >71 years and displayed when an order was initiated. Providers were not prevented from placing an order. Results were measured during four calendar periods: (1) pre-alert (baseline) (July 2010 to June 2011), (2) post alert (alerts on) (July 2011 to December 2011), (3) inadvertent alert turn-off ("glitch") (January 2012 to December 2012), (5) post-glitch (alerts re-instated) (1/2013-7/2013). Metrics used to measure alert impact were between time and period seasonally adjusted relative frequency ratios.

RESULTS

Alerts were most effective in the <21 year old age group. During the baseline period 2.7 Pap tests were order in patients less than age 21 for every 100 Paps in those 21-71 years of age. This relative frequency decreased to 1.7 in the post-alert period and 1.4 during the glitch, with an even greater decline to 0.8 post-glitch when alerts were reinstated. Less impact was observed in the >70 year old group where the baseline relative frequency was 2.4 and declined to 2.1 post-alert, remained stable at 2.0 during the glitch period, and declined again to 1.7 post-glitch when alerts were reinstated. This likely reflects inclusion of women with a history of abnormal Pap tests for whom continued Pap testing is indicated, as well as reluctance by providers and patients to accept discontinuation of Pap testing for women with a history of normal Pap results. In both age groups, decreases in ordering were greatest when the alerts were functioning, indicating that the alerts had an effect beyond the influences of the environment.

CONCLUSIONS

Discouraging alerts can impact ordering of Pap tests and improve compliance with established guidelines, thus avoiding unnecessary follow-up tests that can create potential patient harm and unnecessary expense. Alerts represent a potential model to address utilization of other lab tests. Longer study intervals are necessary to determine if provider compliance is maintained.

Cervical cytology screening among low-income, minority adolescents in New York City following the 2009 ACOG guidelines

OBJECTIVES

In December 2009, the American College of Obstetricians and Gynecologists recommended that cervical cancer screening begin at age 21 for young women. In this study, we examine receipt of first lifetime Papanicolaou (Pap) test and predictors of over-screening among adolescents within a large urban ambulatory care network.

METHODS

We compared the proportion of first lifetime Pap test of adolescents aged 13-20years between June 2007 - November 2009 (n=7700) and December 2009-June 2012 (n=9637) using electronic health records. We employed multivariable regression models to identify demographic and health care factors associated with receiving a first lifetime Pap test at age <21years in the post-guideline period (over-screening).

RESULTS

The proportion of Pap tests declined from 19.3% to 4.2% (p<0.001) between the two periods. Multivariable logistic regression results showed receiving care from gynecologic/obstetric/family planning clinics compared to pediatric clinics, having more clinic encounters, and older age were associated with over-screening in the post-guideline period.

CONCLUSIONS

We found that guideline adherence differed by clinic type, insurance status, and health care encounters. In the quickly evolving field of cervical cancer control, it is important to monitor practice trends as they relate to shifts in population-based guidelines, especially in high-risk populations.

U.S. clinicians' perspectives on less frequent routine gynecologic examinations

OBJECTIVE

With newer recommendations for less frequent cervical cancer screening, longer intervals between routine gynecologic examinations might also be considered.

METHODS

A nationally representative mailed survey of U.S. obstetrician-gynecologists (n=521, response rate 62%) was conducted in 2010-11. Clinicians were asked their views on annual gynecologic examinations and on the consequences of extending the interval from annually to every 3 years for asymptomatic patients.

RESULTS

Over two-thirds considered annual gynecologic examination very important for women in their reproductive years (69%); fewer consider it very important for women in menopause (55%). Most anticipated that shifting examinations to every 3 years would result in lower patient satisfaction (78%), contraceptive provision (74%), and patient health and well-being (74%). Decreases in clinic volume (93%) and financial reimbursement (78%) were also expected. Anticipated effects of longer intervals varied by provider characteristics, geography, and practice setting.

CONCLUSION

Obstetrician-gynecologists in the U.S. believed that longer intervals between routine examinations would have negative repercussions for patients and medical practice, but there were differences by region, practice, and personal characteristics. Redefining annual gynecologic visits as contraceptive counseling and health maintenance visits could address financial and patient volume concerns, and perspectives from patients and other providers might reveal possible benefits of less frequent gynecologic examinations.

Smoking cessation during pregnancy and postpartum: practice patterns among obstetrician-gynecologists

OBJECTIVES

To assess current obstetrician-gynecologist (ob-gyn) practice patterns related to the management of and barriers to smoking cessation during pregnancy and postpartum.

METHODS

A smoking cessation questionnaire was mailed to 1024 American College of Obstetricians and Gynecologists Fellows in 2012. χ(2) analyses were used to assess for categorical differences between groups, Pearson r was used to conduct correlational analysis, and analysis of variance was used to assess for mean differences between groups.

RESULTS

The analyses included 252 practicing ob-gyns who see pregnant patients who returned a completed survey. Ob-gyns estimated that 23% of their patients smoke before pregnancy, 18% smoke during first trimester, 12% during second trimester, and 11% during third trimester. They approximated that 32% quit during pregnancy, but 50% return to smoking postpartum. A large majority of ob-gyns feel that it is important for pregnant and postpartum women to quit smoking, and report asking all pregnant patients about tobacco use at the initial prenatal visit. Fewer ob-gyns follow-up on tobacco use at subsequent visits when the patient has admitted to use at a prior visit. The primary barrier to intervention was reported as time limitations, though other barriers were noted that may be addressable through the provision of additional training and resources offered to physicians.

CONCLUSIONS

Compared with findings from a similar study conducted in 1998, physicians are less likely to adhere to the 5 As smoking cessation guideline at present. As we know that brief intervention is effective, it is imperative that we work toward addressing practice gaps and providing additional resources to address the important public health issue of smoking during pregnancy and postpartum.

Disseminating a cervical cancer screening program through primary physicians in Hong Kong: a qualitative study

BACKGROUND

Organized screening programs are more effective and equitable than opportunistic screening, yet governments face challenges to implement evidence-based programs. The objective of this study was to identify reasons for low levels of adoption among primary care physicians of a government sponsored Cervical Screening Program (CSP).

METHODS

We conducted in-depth interviews with a snowball sample of primary care private and public primary care physicians in Hong Kong. Rogers' theory of diffusion of innovation was used to understand the factors that influenced the physicians' practice decisions.

RESULTS

Our study found that Hong Kong physicians made the decision to encourage cervical screening and to participate in the CSP based primarily upon their clinical and business practice needs rather than upon the scientific evidence. The low rates of adoption of the CSP can be attributed to the physicians' perceptions that the program's complexity and incompatibility exceeded its relative advantages. Furthermore, women's knowledge, attitudes and practices, identified as barriers by physicians, were also barriers to physicians adopting the CSP.

CONCLUSIONS

In both private and public health care systems, screening programs that rely on physicians must align program incentives with the physicians' motivators or pursue additional demand creation policies to achieve objectives.

Promising alternative settings for HPV vaccination of US adolescents

Vaccination in alternative settings, defined here as being outside of traditional primary care, can help address the pressing public health problem of low human papillomavirus vaccine coverage among adolescents in the United States. Pharmacies are promising because they are highly accessible and have well established immunization practices. However, pharmacies currently face policy and reimbursement challenges. School-located mass vaccination programs are also promising because of their high reach and demonstrated success in providing other vaccines, but control by local policymakers and challenges in establishing community partnerships complicate widespread implementation. Health centers in schools are currently too few to greatly increase access to human papillomavirus vaccine. Specialty clinics have experience with vaccination, but the older age of their patient populations limits their reach. Future steps to making alternative settings a success include expanding their use of statewide vaccine registries and improving their coordination with primary care providers.

Awareness and understanding of cancer immunotherapy in Europe

The use of immunotherapy in the management of cancer is growing, and a range of new immunotherapeutic strategies is becoming available. It is important that people involved in the care of cancer understand how cancer immunotherapies differ from conventional chemotherapy and apply this knowledge to their clinical practice. Therefore, from August-September 2011 we undertook a survey of awareness, attitudes, and perceptions of cancer immunotherapy among 426 healthcare professionals (HCPs) in Europe with the aim of identifying and prioritizing educational needs. Nearly all (98%) HCPs were aware of cancer immunotherapy. While 68% of HCPs indicated a high level of interest in cancer immunotherapies, only 24% of the HCPs had direct experience with them. Overall perceptions of cancer immunotherapy among HCPs were largely positive (60%) and rarely negative (3%). The key advantages of cancer immunotherapy were perceived to be good safety and tolerability (75%), a targeted mechanism of action (61%) and good efficacy (48%). The leading barriers to use of immunotherapies were costs of treatment (58%), past clinical trial failures (45%), and access/formulary restrictions (44%). The results indicate that, among the respondents, awareness of cancer immunotherapy was high but that knowledge levels varied and direct experience with their use was limited. There appears to be a need for educational activities on cancer immunotherapy, as well as generation and communication of clinical data on long-term efficacy and safety.