In the Journals

Current cervical cancer guidelines foster overscreening

Adhering to strict time interval requirements for cervical cancer screening may lead to overscreening, according to data published in Annals of Internal Medicine.

“Health care systems use performance measures based on guidelines from such organizations as the American College of Obstetricians and Gynecologists (ACOG) to monitor the appropriateness of cervical cancer screening,” Natasha K. Parekh, MD, MS, from the University of Pittsburgh, and colleagues wrote. “According to the performance measure currently in the Healthcare Effectiveness Data and Information Set, satisfactory cervical cancer screening involves at least one Pap test every 3 years for average-risk women aged 21 to 64 years or at least one Pap and HPV test every 5 years for average-risk women aged 30 to 64 years.”

These measures do not allow for brief and clinically nonsignificant delays in cervical cancer screening and fail to recognize overscreening, according to Parekh and colleagues. The researchers evaluated how changes to these measures can address these flaws. They used the existing categories of underscreening and appropriate screening and added overscreening, which they defined as having intervals between screening shorter than the guideline-recommended intervals. Furthermore, the researchers replaced the single interval for adherence with ± 3 months and ± 6 months ranges.They used Pennsylvania Medicaid administrative data of 14,786 women aged 18 to 64 years from 2007 to 2013 to calculate how frequently screening practices were adherent to traditional performance measures.

The researchers evaluated the 2009 ACOG guidelines, which recommended that at age 21 years women should initiate Pap testing and be screened at 2-year intervals until 30 years, at which time they should start being screened at 3-year intervals. Women were eligible if they were younger than 30 years and continuously enrolled in Medicaid for at least 3 years, aged 30 years or older and continuously enrolled for at least 4 years and had an initial Pap test during the 6 months after November 2009. Women who were additionally enrolled in Medicare, did not have at least one office visit and had preexisting conditions that required different screening frequencies were excluded.

Parekh and colleagues identified 27,076 screening intervals. Traditional measures revealed that underscreening was apparent in 29% of intervals among women younger than 30 years and 35% of intervals among women aged 30 years or older. A majority of intervals that were classified as appropriate under traditional measures were classified as overscreening under alternative measures, according to the researchers. Incorporating ranges of 3 or more months and 6 or more months resulted in a slight decline in underscreening, but most intervals remained representative of overscreening.

Creating a separate overscreening category helped reduced appropriate screening by up to 70%, but adding 6-month ranges instead of a single interval increased appropriate screening by up to 11%, according to the researchers. In addition, after including ranges to adherence intervals, the researchers observed that a majority of Pap screening that was identified as appropriate was actually representative of overscreening.

“Current performance measures that classify overscreening as appropriate may incentivize providers to overscreen, to the detriment of patients and the health care system,” Parekh and colleagues concluded. “We believe that changing cervical cancer screening performance measures to align better with clinical guidelines will help reduce the frequency of unnecessary procedures and more accurately measure the quality of women's health care.” – by Alaina Tedesco

Disclosure: The authors report no relevant financial disclosures.

Adhering to strict time interval requirements for cervical cancer screening may lead to overscreening, according to data published in Annals of Internal Medicine.

“Health care systems use performance measures based on guidelines from such organizations as the American College of Obstetricians and Gynecologists (ACOG) to monitor the appropriateness of cervical cancer screening,” Natasha K. Parekh, MD, MS, from the University of Pittsburgh, and colleagues wrote. “According to the performance measure currently in the Healthcare Effectiveness Data and Information Set, satisfactory cervical cancer screening involves at least one Pap test every 3 years for average-risk women aged 21 to 64 years or at least one Pap and HPV test every 5 years for average-risk women aged 30 to 64 years.”

These measures do not allow for brief and clinically nonsignificant delays in cervical cancer screening and fail to recognize overscreening, according to Parekh and colleagues. The researchers evaluated how changes to these measures can address these flaws. They used the existing categories of underscreening and appropriate screening and added overscreening, which they defined as having intervals between screening shorter than the guideline-recommended intervals. Furthermore, the researchers replaced the single interval for adherence with ± 3 months and ± 6 months ranges.They used Pennsylvania Medicaid administrative data of 14,786 women aged 18 to 64 years from 2007 to 2013 to calculate how frequently screening practices were adherent to traditional performance measures.

The researchers evaluated the 2009 ACOG guidelines, which recommended that at age 21 years women should initiate Pap testing and be screened at 2-year intervals until 30 years, at which time they should start being screened at 3-year intervals. Women were eligible if they were younger than 30 years and continuously enrolled in Medicaid for at least 3 years, aged 30 years or older and continuously enrolled for at least 4 years and had an initial Pap test during the 6 months after November 2009. Women who were additionally enrolled in Medicare, did not have at least one office visit and had preexisting conditions that required different screening frequencies were excluded.

Parekh and colleagues identified 27,076 screening intervals. Traditional measures revealed that underscreening was apparent in 29% of intervals among women younger than 30 years and 35% of intervals among women aged 30 years or older. A majority of intervals that were classified as appropriate under traditional measures were classified as overscreening under alternative measures, according to the researchers. Incorporating ranges of 3 or more months and 6 or more months resulted in a slight decline in underscreening, but most intervals remained representative of overscreening.

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Creating a separate overscreening category helped reduced appropriate screening by up to 70%, but adding 6-month ranges instead of a single interval increased appropriate screening by up to 11%, according to the researchers. In addition, after including ranges to adherence intervals, the researchers observed that a majority of Pap screening that was identified as appropriate was actually representative of overscreening.

“Current performance measures that classify overscreening as appropriate may incentivize providers to overscreen, to the detriment of patients and the health care system,” Parekh and colleagues concluded. “We believe that changing cervical cancer screening performance measures to align better with clinical guidelines will help reduce the frequency of unnecessary procedures and more accurately measure the quality of women's health care.” – by Alaina Tedesco

Disclosure: The authors report no relevant financial disclosures.