Improving Follow-Up after an Abnormal Pap Smear: Results from a Quasi-Experimental Intervention Study

Abstract

The success of cervical cancer control programs depends on regular screening with the Pap smear test and prompt and appropriate treatment of early neoplastic lesions. Recognizing the potentially grave consequences of lack of follow-up for abnormal Pap smears, numerous intervention studies have tested the impact of a variety of strategies to increase return for follow-up. The majority of these studies were evaluated under controlled experimental conditions. Despite the encouraging findings of these trials, the next step in the research continuum requires that the effectiveness of these interventions be demonstrated in real world settings before full implementation is initiated. We report the results of an evaluation study assessing the combined effectiveness of three intervention modalities found effective in prior randomized studies: a tracking follow-up protocol, transportation incentives, and financial incentives. This study used a before-after, nonequivalent control group design to assess the impact of a multifaceted intervention that included a computerized tracking protocol with transportation and financial incentives. The study was implemented at two major hospitals, two comprehensive health centers (CHC), and nine public health centers (PHC) under the jurisdiction of the Los Angeles County Department of Health Services. One hospital, one CHC, and the four PHC located in the catchment area of the CHC were selected as experimental sites. The control sites - one hospital, one CHC, and five PHC - provided usual care. All women with an abnormal Pap smear at the intervention and control sites were included in the study. The study consisted of a 1-year period of baseline data collection (September 1989-August 1990), followed by a 2(1/2)-year intervention period (September 1990-February 1993). During the intervention period, the intervention protocol was implemented at the experimental sites, and the control sites provided usual care. Overall, we found that the rates of receipt of follow-up care were consistent with those found in similar studies. In contrast to results obtained in these prior randomized trials, we did not find strong and consistent evidence for intervention effects. Significant findings emerged only at the CHC and hospital levels and only for selected years. Results underscore the importance of testing interventions in real world conditions before large-scale implementation is initiated. In addition, this study highlights the challenge of detecting intervention effects in large-scale studies because of the greater measurement difficulties in field studies as compared with controlled experiments.

Variations in Practice Guideline Adherence for Abnormal Cervical Cytology in a County Healthcare System

“…Although screening rates for cervical cancer remain high, 19 appropriate diagnostic evaluation of abnormal screening tests and therapeutic intervention for pre-invasive neoplasia is necessary to reduce cervical cancer incidence and mortality. Our study suggests that compared to historical controls, [11][12][13] lost to follow-up rates have declined in this county healthcare system. However, for those that did return for follow-up care, a substantial proportion of women are receiving less than optimal follow-up care as defined by practice guidelines.…”

“…10 Other studies have shown that lost to follow-up rates in women seen at inner-city, public healthcare facilities vary from 20 to 50%. [11][12][13][14][15] Several interventional studies have been performed in the LACHS directed at reducing lost to follow-up rates; however, they did not address the quality of care that women received. [11][12][13] Of approximately 50 million women undergoing Pap testing each year, 3.5 million (7%) of the women will require additional follow-up and evaluation.…”

“…[11][12][13][14][15] Several interventional studies have been performed in the LACHS directed at reducing lost to follow-up rates; however, they did not address the quality of care that women received. [11][12][13] Of approximately 50 million women undergoing Pap testing each year, 3.5 million (7%) of the women will require additional follow-up and evaluation. 16 Determining which of these women are at increased risk for cervical neoplasia, performing appropriate diagnostic evaluations, and providing definitive treatment for discovered disease remains an important aspect of cervical cancer prevention and early detection.…”

Low-Income Women with Abnormal Breast Findings: Results of a Randomized Trial to Increase Rates of Diagnostic Resolution

“…Based on prior work in these settings (20)(21)(22)(23)(24)(25) and on the judgments and preferences of county clinicians and administrators, the major aim of the study was to improve diagnostic resolution (malignant or benign) versus to increase attendance at first diagnostic appointment. This was based on the observation that despite a fairly high rate of attendance at first diagnostic appointment (e.g., 84% in this study in treatment and control groups, and both hospitals as indicated in Table 1), the rate of diagnostic resolution was unacceptably low (56% in this study, as indicated in Table 1).…”

Impact of Patient Navigation Interventions on Timely Diagnostic Follow Up for Abnormal Cervical Screening

“…[1][2][3] Women from groups of racial/ethnic minorities and low education and income have limited access to healthcare and are less likely to seek care after an abnormal result. [4][5][6][7][8] In 1990, Freeman introduced the model of patient navigation as a way to support screening for, timely diagnosis of, and then treatment of cancer among vulnerable women.…”