Predictors of Follow-up of Atypical and ASCUS Papanicolaou Test Results in a High-Risk Population
Overall, many subjects remained in care in the health centers for a relatively short time. Almost one fourth of the subjects (23.7%) had a final visit to the health center less than 6 months from the index Pap test. Complete data including 2 full years of follow-up from the date of the index Pap test were available for 41% of subjects. Subjects with new atypia had a small chance of SIL on subsequent tests (6.5%, increasing to 10.9% for those subjects with persistent atypia). Results of biopsies for women with new and persistent atypia are presented in Table 1. The majority of subjects had normal or low-grade findings on histology, and no cancer was diagnosed.
Management of atypical results is depicted in the Figure 1. Providers were credited with a “correct” plan if they recommended either a repeat test in 6 months or less, or colposcopy. “Incorrect” management included any other recommendation or failure to document any plan (18.9%). Providers were most likely to recommend a repeat test in 3 months (31.8%) or 6 months (46.1%). We considered communication to subjects “complete” if the notes reflected discussion of the result at a visit (58.3%) or if a completed telephone call was documented (3.9%). Communication was considered attempted if a letter was sent (47.2%) or a call attempted (8.8%) and documented. In 8.3% of charts no documentation of attempted or completed communication was present. There were no significant associations of provider plan or communication of results with demographic variables, pregnancy, or abnormality type. Family physicians were more likely than midlevel providers or other physicians to generate a correct plan (87.3%, 80.8%, 69.8%, respectively; P=.002). Family physicians documented completed communication of results in 77.8% of cases, compared with 70.1% for other physicians and 57.4% for midlevel providers.
Providers were more likely to recommend colposcopy when the index Pap test result was reported as ASCUS rather than atypia (22.1% vs 11.4%, P=.016). Providers were much more likely to choose colposcopy if the pathologist made a recommendation for colposcopy rather than a repeat test (85.2% vs 8.9%, P=.001) and if the report included “favored SIL” in the result (75.0% vs 11.5%, P=.001.) When colposcopy was recommended, 70.8% completed the procedure. After a first atypical Pap test, 36% had no follow-up test; 27% had 1 follow-up test; 20% had 2 tests; and 17% had 3 subsequent tests. Subjects were found to have complete, moderate, and low adherence levels as follows: 26.9%, 27.6%, and 45.5%.
Univariate associations with levels of adherence are shown in Table 2. Complete adherence was more likely when the result was discussed at a visit, when the provider’s plan was documented, when the provider was other than a family physician, and if the plan was colposcopy as opposed to repeat cytology. Complete adherence was associated with remaining in care at the centers after 1997. It was more likely for results reported as ASCUS as opposed to atypia. Large differences are seen in the number of women with complete adherence by site, with the percentage ranging from 7% to 57%.
In the ordered logistic regression analysis, 4 factors were found to be predictive of the quality of adherence: the description of the abnormality (atypia vs ASCUS), availability of colposcopy on-site, discussion of the plan at a visit, and site. The detailed results are shown in Table 3. The adjusted odds ratio for complete versus moderate and low adherence (or equivalently moderate and complete vs low) associated with having an ASCUS lesion versus atypia is 1.56; for attending a clinic where colposcopy is referred off-site, 0.39; and for having discussed the follow-up plan, 3.44. The effects of ethnicity, type of health insurance, provider training, and pregnancy were not statistically significant.
Discussion
The introduction of the ASCUS label in the early 1990s created controversy and led to guidelines from the NCI7 and others8,9 based primarily on expert opinion. Data from a large randomized clinical trial25 currently underway may resolve some of the questions about the effectiveness of repeat cytology versus immediate colposcopy in the management of low-grade dysplasia. Importantly, lack of evidence for the guideline may adversely affect compliance. Implementation of either strategy is difficult, especially in communities with many risk factors for poor follow-up. Our results indicate low adherence to the NCI interim guideline in an urban primary care setting serving predominately low-income minority women. Of concern is that almost half our sample, compared with 30% of subjects in a Canadian study,26 had no follow-up cytology or histology. Our findings highlight some of the difficulties encountered in managing low-grade abnormalities in a setting challenged by high provider turnover, staffing difficulties, incorrect phone and address information, and financial and language barriers. Long-term repeated cytology is difficult to accomplish where loss to follow-up is common and competing demands of managing multiple chronic illnesses may interfere. Our findings are similar to those of other investigators27,28 in that colposcopy, when recommended, was not completed by approximately one third of the women.
