Specialty Differences in Primary Care Physician Reports of Papanicolaou Test Screening Practices: A National Survey, 2006 to 2007 — Ann Intern Med

Article
http://www.ncbi.nlm.nih.gov/pubmed
Specialty Differences in Primary Care Physician Reports of Papanicolaou Test Screening Practices: A National Survey, 2006 to 2007
K. Robin Yabroff, PhD; Mona Saraiya, MD; Helen I. Meissner, PhD; David A. Haggstrom, MD, MAS; Louise Wideroff, PhD; Gigi Yuan, MS; Zahava Berkowitz, MSc, MSPH; William W. Davis, PhD; Vicki B. Benard, PhD; and Steven S. Coughlin, PhD
+ Author Affiliations

From the National Cancer Institute and the National Institutes of Health, Bethesda, and Information Management Services, Silver Spring, Maryland; Centers for Disease Control and Prevention, Atlanta, Georgia; Veterans Affairs Medical Center, Regenstrief Institute, and Indiana University School of Medicine, Indianapolis, Indiana; and Department of Veterans Affairs, Washington, DC.

Abstract
Background: Cervical cancer screening guidelines were substantially revised in 2002 and 2003. Little information is available about primary care physicians' current Papanicolaou (Pap) test screening practices, including initiation, frequency, and stopping.

Objective: To assess current Pap test screening practices in the United States.

Design: Cross-sectional survey.

Setting: Nationally representative sample of physicians during 2006 to 2007.

Participants: 1212 primary care physicians.

Measurements: The survey included questions about physician and practice characteristics and recommendations for Pap screening presented as clinical vignettes describing women by age and by sexual and screening histories. A composite measure—guideline-consistent recommendations—was created by using responses to vignettes in which major guidelines were uniform.

Results: Most physicians reported providing Pap tests to their eligible patients (91.0% [95% CI, 89.0% to 92.6%]). Among Pap test providers (n = 1114), screening practices, including number of tests ordered or performed, use of patient reminder systems, and cytology method used, varied by physician specialty (P < 0.001). Although most Pap test providers reported that screening guidelines were very influential in their clinical practice, few had guideline-consistent recommendations for starting and stopping Pap screening across multiple vignettes (22.3% [CI, 19.9% to 25.0%]). Guideline-consistent recommendations varied by specialty (obstetrics/gynecology, 16.4%; internal medicine, 27.5%; and family or general practice, 21.1%). Compared with obstetricians/gynecologists, internal medicine specialists and family or general practice specialists were more likely to have guideline-consistent screening recommendations (odds ratio, 1.98 [CI, 1.22 to 3.23] and 1.45 [CI, 0.99 to 2.13], respectively) in multivariate analysis.

Limitation: Physician self-report may reflect idealized rather than actual practice.

Conclusion: Primary care physicians' recommendations for Pap test screening are not consistent with screening guidelines, reflecting overuse of screening. Implementation of effective interventions that focus on potentially modifiable physician and practice factors is needed to improve screening practice.

Primary Funding Source: National Cancer Institute, Centers for Disease Control and Prevention, and Agency for Healthcare Research and Quality.

Editors' Notes
Context•The American College of Obstetrics and Gynecology, American Cancer Society, and U.S. Preventive Services Task Force modified their cervical cancer screening guidelines in the early 2000s to reflect new information about human papillomavirus and decreased the advised frequency of screening in some risk groups.

Contribution
•In 2006 to 2007, physician responses to clinical vignettes for which all guidelines agreed suggest that fewer than 25% reported guideline-consistent care. Most variations indicated overuse of screening. Guideline-consistent responses were most frequent among internists, followed by family physicians and then gynecologists.

Caution
•Results are not based on actual practice behaviors.

Implication
•Physicians need to better understand cervical cancer screening recommendations.

—The Editors

In 2008, approximately 11 000 women in the United States received a diagnosis of invasive cervical cancer, and nearly 4000 women died of the disease (1). Although Papanicolaou (Pap) test screening, an evaluation of cervical cells for abnormalities for early detection of cervical cancer, is widely used (2–4), some women have never or rarely been screened (5). Others continue to be screened even after they are no longer at risk for cervical cancer (for example, those who had hysterectomy for benign disease) (6, 7). Although many patient factors are associated with screening (2, 8, 9), physician recommendation is one of the strongest predictors of cervical cancer screening (10, 11). By recommending such preventive services as Pap test screening to their patients, primary care physicians play a central role in implementing the screening guidelines of major professional organizations.

During 2002 and 2003, cervical cancer screening guidelines for prevention and early detection of cervical cancer were substantially revised to reflect increased understanding of the natural history of human papillomavirus (HPV) infection and its role in the development of cervical cancer, as well as to reflect the introduction of new screening methods, including liquid-based cytology (12–14). Revised guidelines addressed the ideal age for starting routine Pap test screening and appropriate intervals between screening tests and identified situations when routine Pap testing should be stopped (Table 1). To assess the effect of these revisions, the National Cancer Institute, in collaboration with the Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality, conducted a national cross-sectional survey of primary care physicians about current cervical cancer screening recommendations and practices.


full-text:
Specialty Differences in Primary Care Physician Reports of Papanicolaou Test Screening Practices: A National Survey, 2006 to 2007 — Ann Intern Med