HMO Learns From Coscreening Initiative


VANCOUVER, B.C. — Incorporating testing for human papillomavirus into cervical screening practices for women older than 30 years may take more effort than one would think, Walter Kinney, M.D., said at the 22nd International Papillomavirus Conference.

He described the first 123,909 HPV tests performed within the Kaiser Permanente system on women over age 30 who also had satisfactory results from cytology performed at the same time. Kaiser said its “cotesting” policy of Pap smears plus HPV tests for women over age 30 in 2002.

“We told the lab to anticipate a tidal wave of specimens. That didn't happen,” said Dr. Kinney of the Permanente Medical Group, Sacramento. “You can't just buy the reagent, announce the guidelines, turn on the machine, and expect this to happen.”

Kaiser officials set out to get clinicians and patients to accept HPV testing. “This was a humbling process that went on for a couple of years” but led to strong acceptance rates for doctors and patients, Dr. Kinney said at the meeting held by the University of California, San Francisco.

Between May 2003 and August 2004 85%–93% of appropriate patients underwent cotesting at Kaiser facilities, with the exception of one facility that posted a 70% cotesting rate.

This compares with results of a 2005 survey of 185 ob.gyns. randomly selected from the American Medical Association database in which only 33% said they would offer cotesting, despite recommendations by the American College of Obstetricians and Gynecologists and the American Cancer Society (Am. J. Obstet. Gynecol. 2005;192:414–21).

Kaiser gained wider acceptance of cotesting by addressing issues related to staff, patients, and clinicians. For staff, training on how and why to do HPV testing is critical. “They have to think it's something they would choose for themselves,” and they need to know how to talk with patients about it, Dr. Kinney said.

Kaiser created a specimen handling policy and flow charts for cotesting, posted summary sheets, obtained new color-coded order forms and color-coded specimen bins, and redesigned its “Pap books” to track results and patient responses.

Patients should be informed about cotesting before the clinician arrives in the exam room, he said. One way to do this is to have a medical assistant give the patient written materials after taking her blood pressure. Have information sheets hand. For patients with abnormal test results, have available brochures explaining their condition.

What the clinician says to the patient about cotesting is important too. A poll of 350 Kaiser patients and 37 physicians asking why the patient did or did not have cotesting found physicians believed their words and printed materials were important. Patients, on the other hand, felt that what mattered most was whether physicians said cotesting is a good idea and that they would choose testing themselves.

Give clinicians the education and tools they need to know what to say to patients about cotesting. Steps include guidelines, sample messages or scripts, and handouts on frequently asked questions.

In the Kaiser study, only 5.3% of the first 123,909 cotests were HPV positive. Of these, 3.7% had negative Pap tests.

The rate of HPV positivity dropped by half after age 39, from 9% in 30- to 39-year-olds to 5% of 40- to 49-year-olds. HPV positivity rates decreased with age to a low of 3% in women in their 60s, then crept up a bit over time, he said.

The lead investigator in studying the HPV data was Barbara Fetterman, Ph.D., of the Permanente Medical Group, Oakland, Calif.

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