Predictors of Follow-up of Atypical and ASCUS Papanicolaou Test Results in a High-Risk Population

Our findings highlight the importance of strict use of Bethesda terminology by cytopathologists, since the older terminology may be misunderstood and less aggressively followed by primary care clinicians. We chose to include women with either atypical or ASCUS results, because they are different labels for the same spectrum of abnormalities. We found that providers were slightly more likely to recommend colposcopy for ASCUS and ultimately that women with atypical results were more likely to have low adherence to the CPG. This probably reflects that many primary care providers do not view the guideline as applicable to results reported as atypia or communicate with patients about atypical results differently.

There were substantial differences in rates of follow-up by site that are likely related to several factors. Although tracking of abnormal Pap test results was required at all sites the intensity varied, with the most successful site staffed by registered nurses who worked closely with the colposcopy providers in maintaining a manual card file. Sites where colposcopy was recommended more often had overall higher proportions of women with complete adherence to the CPG than those sites where serial cytology was the follow-up strategy of choice. Family physicians were more likely to generate a correct plan yet had worse overall adherence. This is likely due to a preference to follow up women by serial cytology, which proves difficult in settings where patients often stay in care for less than 2 years. However, the finding persists even after controlling for the provider plan, suggesting that other factors are also contributing to account for the differences between sites. Importantly, providers were more likely to opt for colposcopy, and women were more likely to complete it if the service was available in the subject’s health center.

We are unable to determine all of the causes of inadequate follow-up. Systemic factors, however, are clearly implicated by the present data, as indicated by the substantial variation by site and the number of charts in which a clear provider plan was not indicated or where no indication that the subject had been informed of the result was documented. When documentation was present that results were discussed with patients during visits patients were much more likely to have good follow-up, again suggesting that good communication of results is imperative. Our results also suggest that reducing barriers to colposcopy, by such means as providing the service on-site, may be effective in achieving optimal follow-up when colposcopy is recommended. Recommending colposcopy for all women with an initial ASCUS or atypical Pap test result will result in significant stress on available colposcopic resources and expose large numbers of women to an expensive, uncomfortable, and distressing procedure unnecessarily. However, providers need to carefully consider the risk of loss to follow-up in making a recommendation, take extra effort to insure that women are informed of and understand their Pap test result, and establish clinical tracking efforts to meet the challenge of serial cytology in high-risk settings.

Limitations

Our findings are limited in that the standard of care to which we compared practice is based on a guideline that is not evidence based. Other limitations of the project are largely due to constraints imposed by the abstraction of retrospective data from primary care charts. Information about how women were informed of results is sketchy, and failure to document may result in underestimation of actual patient contact. The extent to which women had follow-up if they no longer received care in the health centers cannot be estimated. Some women may have had follow-up with other providers outside our system. Demographic information was obtained from site registration databases rather than self-report and may include some misclassification. Some important information is not captured consistently in the site’s computers, including changes in insurance and primary care providers. Provider turnover was extremely high in these health centers during the interval studied, though lists of providers are not available to create a precise measure to include in our model.

Acknowledgments

This work was supported by a clinical research training grant from the American Cancer Society.