Computable Guidelines and Clinical Decision Support for Cervical Cancer Screening and Management to Improve Outcomes and Health Equity

Saraiya, Mona; Colbert, Jean; Bhat, Geeta L.; Almonte, Rose; Winters, D.W.; Sebastian, Sharon; O’Hanlon, Michael; Meadows, Ginny; Nosal, M.; Richards, Thomas B.; Michaels, Maria; Townsend, Julie S.; Miller, Jacqueline W.; Perkins, Rebecca B.; Sawaya, George F.; Wentzensen, Nicolas; White, Mary C.; Richardson, Lisa C.

doi:10.1089/jwh.2022.0100

Cited by 16 publications

(13 citation statements)

References 22 publications

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“…Fourth, defining appropriate follow-up for abnormal cancer screening test results for cervical cancer is particularly complex, and our algorithms did not reflect the most recent changes in the consensus guidelines for cervical and colorectal cancer . Fifth, given these limitations, health care systems may be reluctant to adapt such data systems; our findings suggest the need for national organizations to develop and maintain computable algorithms that are broadly interoperable among EHRs …”

Section: Discussionmentioning

confidence: 99%

A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results

Atlas,

Tosteson,

Wright

et al. 2023

JAMA

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ImportanceRealizing the benefits of cancer screening requires testing of eligible individuals and processes to ensure follow-up of abnormal results.ObjectiveTo test interventions to improve timely follow-up of overdue abnormal breast, cervical, colorectal, and lung cancer screening results.Design, Setting, and ParticipantsPragmatic, cluster randomized clinical trial conducted at 44 primary care practices within 3 health networks in the US enrolling patients with at least 1 abnormal cancer screening test result not yet followed up between August 24, 2020, and December 13, 2021.InterventionAutomated algorithms developed using data from electronic health records (EHRs) recommended follow-up actions and times for abnormal screening results. Primary care practices were randomized in a 1:1:1:1 ratio to (1) usual care, (2) EHR reminders, (3) EHR reminders and outreach (a patient letter was sent at week 2 and a phone call at week 4), or (4) EHR reminders, outreach, and navigation (a patient letter was sent at week 2 and a navigator outreach phone call at week 4). Patients, physicians, and practices were unblinded to treatment assignment.Main Outcomes and MeasuresThe primary outcome was completion of recommended follow-up within 120 days of study enrollment. The secondary outcomes included completion of recommended follow-up within 240 days of enrollment and completion of recommended follow-up within 120 days and 240 days for specific cancer types and levels of risk.ResultsAmong 11 980 patients (median age, 60 years [IQR, 52-69 years]; 64.8% were women; 83.3% were White; and 15.4% were insured through Medicaid) with an abnormal cancer screening test result for colorectal cancer (8245 patients [69%]), cervical cancer (2596 patients [22%]), breast cancer (1005 patients [8%]), or lung cancer (134 patients [1%]) and abnormal test results categorized as low risk (6082 patients [51%]), medium risk (3712 patients [31%]), or high risk (2186 patients [18%]), the adjusted proportion who completed recommended follow-up within 120 days was 31.4% in the EHR reminders, outreach, and navigation group (n = 3455), 31.0% in the EHR reminders and outreach group (n = 2569), 22.7% in the EHR reminders group (n = 3254), and 22.9% in the usual care group (n = 2702) (adjusted absolute difference for comparison of EHR reminders, outreach, and navigation group vs usual care, 8.5% [95% CI, 4.8%-12.0%], P &lt; .001). The secondary outcomes showed similar results for completion of recommended follow-up within 240 days and by subgroups for cancer type and level of risk for the abnormal screening result.Conclusions and RelevanceA multilevel primary care intervention that included EHR reminders and patient outreach with or without patient navigation improved timely follow-up of overdue abnormal cancer screening test results for breast, cervical, colorectal, and lung cancer.Trial RegistrationClinicalTrials.gov Identifier: NCT03979495

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Section: Discussionmentioning

confidence: 99%

A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results

Atlas,

Tosteson,

Wright

et al. 2023

JAMA

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“…Participants indicated interest in receiving clinical decision support via EMR or laboratory reports. The Centers for Disease Control and Prevention is leading efforts to provide clinical decision tools via the EMR 30 …”

Section: Discussionmentioning

confidence: 99%

A cross‐sectional survey examining clinician characteristics, practices, and attitudes associated with adoption of the 2019 American Society for Colposcopy and Cervical Pathology risk‐based management consensus guidelines

Vadaparampil

Fuzzell

Brownstein

et al. 2023

Cancer

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BackgroundThe 2019 American Society for Colposcopy and Cervical Pathology (ASCCP) risk‐based management consensus guidelines are the most recent national guidelines for the management of abnormal cervical cancer screening tests. These guidelines benefit patients by concentrating testing and treatment in those at highest cervical cancer risk. Adoption of guidelines often occurs slowly, with few studies examining the factors associated with guideline‐adherent management of abnormal results.MethodsTo elucidate the factors associated with the use of the 2019 ASCCP guidelines among clinicians who perform cervical cancer screening, physicians and advanced practice professionals who perform cervical cancer screening were cross‐sectionally surveyed. Clinicians responded to screening vignettes with differing recommendations for management between the 2019 and prior management guidelines. Screening vignette 1 involved reduction of invasive testing on a low‐risk patient; screening vignette 2 involved increased surveillance testing on a high‐risk patient. Binomial logistic regression models determined the factors associated with the use of the 2019 guidelines.ResultsA total of 1251 clinicians participated from across the United States. For screening vignettes 1 and 2, guideline‐adherent responses were given by 28% and 36% of participants, respectively. Management recommendations differed by specialty and were incorrect in different situations: there was inappropriate invasive testing by obstetrics and gynecology physicians (vignette 1) and inappropriate discontinuation of screening by family and internal medicine physicians (vignette 2). Regardless of their chosen response, over half erroneously believed they were guideline adherent.ConclusionsMany clinicians who believe they are following appropriate guidelines may not realize their management strategy is inconsistent with the 2019 guidelines. Education initiatives tailored to clinician specialty could address the understanding of current guidelines, encourage the use of updated guidelines, maximize patient benefits, and minimize harms.Plain Language Summary The 2019 American Society for Colposcopy and Cervical Pathology risk‐based management consensus guidelines are the most recent national guidelines for abnormal cervical cancer screening test management. We surveyed over 1200 obstetrics and gynecology (OB/GYN), family medicine, and internal medicine physicians and advanced practice providers about their screening and abnormal results follow‐up practices in relation to guidelines. Few clinicians are following the 2019 guidelines. Management recommendations differed by clinician specialty and were incorrect in different situations: there was inappropriate invasive testing by OB/GYN physicians and inappropriate screening discontinuation by family and internal medicine physicians. Education tailored by clinician specialty could address the understanding of current guidelines, encourage the use of updated guidelines, maximize patient benefits, and minimize harms.

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“…These studies were not cited by guidelines to support the use of the quality metric. The lack of subsequent studies may be because cervical cancer screening is a simple, relatively noninvasive, and well-established practice; although screening indications and intervals have changed frequently, test performance has remained fairly stable ( 18 ). With the widespread adoption of commercially available human papillomavirus tests, some of the work of monitoring cervical cancer screening test performance has been assumed by commercial entities and the Food and Drug Administration.…”

Section: Discussionmentioning

confidence: 99%

Test performance metrics for breast, cervical, colon, and lung cancer screening: a systematic review

Selby

Sedki

Levine³

et al. 2023

JNCI: Journal of the National Cancer Institute

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Background Multiple quality metrics have been recommended to ensure consistent, high-quality execution of screening tests for breast, cervical, colorectal and lung cancers. However, minimal data exist evaluating the evidence base supporting these recommendations and the consistency of definitions and concepts included within and between cancer types. Methods We performed a systematic review for each cancer type using MEDLINE, Embase and CINAHL from 2010 to April 2020, to identify guidelines from screening programs or professional organizations containing quality metrics for tests used in breast, cervical, colorectal and lung cancer screening. We abstracted metrics’ definitions, target performance levels, and related supporting evidence for test completeness, adequacy (sufficient visualization or collection), accuracy, and safety. Results We identified 11 relevant guidelines with 20 suggested quality metrics for breast cancer, 5 guidelines with 9 metrics for cervical cancer, 13 guidelines with 18 metrics for colorectal cancer, and 3 guidelines with 7 metrics for lung cancer. These included 54 metrics related to adequacy (6), test completeness (3), accuracy (33), and safety (12). Target performance levels were defined for 30 metrics (56%). Ten (19%) were supported by evidence, all from breast and colorectal cancer, with no evidence cited to support metrics from cervical and lung cancer screening. Conclusions Considerably more guideline-recommended test performance metrics exist for breast and colorectal cancer screening than cervical or lung cancer. The domains covered are inconsistent among cancers and few targets are supported by evidence. Clearer evidence-based domains and targets are needed for test performance metrics. Registration PROSPERO 2020 CRD42020179139

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Computable Guidelines and Clinical Decision Support for Cervical Cancer Screening and Management to Improve Outcomes and Health Equity

Cited by 16 publications

References 22 publications

A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results

A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results

A cross‐sectional survey examining clinician characteristics, practices, and attitudes associated with adoption of the 2019 American Society for Colposcopy and Cervical Pathology risk‐based management consensus guidelines

Test performance metrics for breast, cervical, colon, and lung cancer screening: a systematic review

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