Author Affiliations: Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia (Ms Berkowitz and Dr Saraiya); and Departments of Obstetrics, Gynecology, and Reproductive Sciences and Epidemiology and Biostatistics, University of California, San Francisco (Dr Sawaya).
Clinical guidelines recommend that women 30 years and older with a negative test result for oncogenic human papillomavirus (HPV) and with a concurrent normal Papanicolaou test result (co-testing) not be tested again for at least 3 years.1 Previous studies, however, indicate that primary care providers continue to perform annual testing regardless of prior test results.2,3 Our objective was to examine clinicians' reported behaviors regarding cervical cancer screening intervals over a 4-year period after the endorsement of co-testing.
We used nationally representative sample of primary care providers from the 2006, 2007, 2008, and 2009 Cervical Cancer Screening Supplement (CCSS) to the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS).4 The overall response rates for the NAMCS and NHAMCS surveys were 61.1% and 84.7% in 2006; 33.6% and 73.0% in 2007; 61.8% and 73.3% in 2008; and 60.5% and 50.4% in 2009, respectively.
We combined NAMCS and NHAMCS providers to assess their recommendations for the next Papanicolaou test for women aged 30 to 60 years using 5 clinical vignettes. Primary care providers were asked “When would your practice recommend that a woman between 30 and 60 years of age return for her next Pap test?” Possible answers included the following: no follow-up needed, less than 6 months, 6 to less than 12 months, 1 year, 2 years, 3 years or more, or have no experience with this type of patient or test. Each vignette included Papanicolaou test results in the prior 5 years and current HPV and Papanicolaou test results. Using the screening recommendations applicable at the time of the surveys,1 we defined responses for timing of the next Papanicolaou test as consistent with guidelines; sooner than recommended; and later than recommended (Table 1 and Table 2).
The analysis included 2087 primary care providers after excluding practitioners who were not aware of the HPV DNA test in their practice, unknown, or missing (n = 84). Potential differences in guideline-consistent recommendations between years were compared with t test statistic. Data were analyzed with SUDAAN 10.1 (RTI International) to account for the sampling design and nonresponse.
During the study period, 26% of NAMCS and NHAMCS providers were obstetrician-gynecologists and the remainder practiced general medicine. Nearly 60% of NAMCS providers were male, 64% were 45 years and older, 84% worked in metropolitan areas, and 69% worked in practices with fewer than 6 practitioners. Guideline adherence was low overall, especially in vignettes portraying women with normal test results (vignettes 1, 2, and 3). After normal co-testing results (vignettes 2 and 3), most respondents (67.1% to 93.8%) recommended Papanicolaou tests sooner than recommended by guidelines. Adherence was particularly low for a woman without prior Papanicolaou tests and normal co-testing results (vignette 3), with more than 86% recommending the next Papanicolaou test sooner than recommended by guidelines. Adherence improved when the recommendation was to repeat screening in 1 year because of abnormal results (vignettes 4 and 5). In vignette 4, percentages increased from 36.7% in 2006 to 48.5% in 2008 (P < .05), but decreased slightly in 2009 (43.8%). However, without a known Papanicolaou test history (vignette 5), guideline adherence was low, ranging from 21.1% in 2006 to 32.7% in 2009 (P < .05).
From 2006 to 2009, primary care providers consistently reported that they would recommend Papanicolaou testing sooner than recommended by guidelines, especially after normal co-testing results. A novel benefit of co-testing is the ability to extend screening intervals immediately among women who have no prior screening or whose screening history is unavailable if both test results are normal, yet the lowest adherence to guidelines was for the vignette of a woman with unknown Papanicolaou test history and negative co-test results (3.1%, all years combined). The finding of exceedingly low adherence in this scenario is troubling because reports from a large US cohort5 demonstrate that more than 90% of women will have normal co-testing results. The highest adherence to guidelines occurred when the recommended interval was less than 3 years, suggesting that clinicians are willing to adhere to guidelines if more vigilant testing is recommended. The ability to obtain prior screening results and the use of electronic medical records or systems changes, such as office reminders or reimbursement packages, may help achieve adherence to recommended intervals.
The low response rate in 2007 (NAMCS) was a limitation of our study. However, estimates were weighted to physician population and accounted for survey nonresponse. Uncertain concordance of practitioner response to hypothetical vignette with actual practice might also be of concern. Vignettes, however, have been shown to be inexpensive and useful tools for measuring quality of care by physicians.6 Important strengths are the inclusion of the latest NAMCS and NHAMCS data available and the consistent methodology, which make the survey a useful tool to gauge changes in clinicians' recommendations over time. Future analyses will monitor adherence to newer guidelines that recommend extending screening intervals to 5 years among women with normal co-testing results, a strategy designed to achieve a reasonable balance between benefits and harms.7- 9
Correspondence: Ms Berkowitz, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Mail Stop K-55, Atlanta, GA 30341 (Zab3@cdc.gov).
Published Online: April 8, 2013. doi:10.1001/jamainternmed.2013.368
Author Contributions:Study concept and design: Berkowitz, Saraiya, and Sawaya. Acquisition of data: Berkowitz. Analysis and interpretation of data: Berkowitz, Saraiya, and Sawaya. Drafting of the manuscript: Berkowitz, Saraiya, and Sawaya. Critical revision of the manuscript for important intellectual content: Berkowitz, Saraiya, and Sawaya. Statistical analysis: Berkowitz. Obtained funding: Saraiya.
Conflict of Interest Disclosures: None reported.
Disclaimer: The finding and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
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