Our work provides insight into the quality of care being provided to women with abnormal cervical cytology. 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,11–13
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.
A majority of the patients with less than optimal care fell within the poor care category and not suboptimal care, pointing to the lack of provider adherence to practice guidelines as a prominent feature of care. Patient and clinic factors could account for delays in the timeliness of care received (suboptimal care); however, lack of provider knowledge of practice guidelines would account for incorrect procedures being performed during follow-up (poor care). Our findings point to a need for increased provider education regarding the appropriate evidence-based follow-up for women with abnormal cervical cytology.
In our study, women with high-grade Pap test abnormalities had better follow-up care then women with low-grade abnormalities with the exception of AGUS. This is consistent with findings from another study conducted within a largely suburban patient population where only 36% of women with an AGUS cytology result received appropriate and thorough evaluation.20
AGUS has often been misunderstood to represent a low-grade cervical abnormality with uncertain significance similar to ASCUS21,22
; however, invasive cancers are found in more than 5%, and high-grade pre-invasive disease is found in 14% of women with AGUS,23
which puts these patients at a significantly higher risk if they do not receive a timely and thorough evaluation.
Furthermore, it is worth noting that in our study, unsatisfactory smears received, with the exception of cancer, the highest rate of appropriate follow-up at almost 92%, identifying another opportunity for provider education. While assessment of adequacy is an integral part of the overall evaluation of a cervical cytology smear, data show that there are often no significant differences in the incidence of squamous abnormalities following an unsatisfactory smear compared to a negative smear.24,25
There was a large discrepancy in the appropriateness of care for low-grade cytological abnormalities (LSIL and ASCUS) that were managed through accelerated cytological evaluation rather than immediate colposcopy with histological evaluation. Although more than 70% of LSIL cases spontaneously revert to normal, about 30% of these patients will have CIN II/III or invasive cancer diagnosed at initial evaluation or during surveillance.26,27
Recent management guidelines (2001) recommend a more aggressive evaluation of women with LSIL diagnosis, with immediate colposcopy rather than serial cytology.16
Also, the addition of the category ASC-H in the 2001 Bethesda System serves to differentiate those cases of ASC that have a higher positive predictive value for histological abnormalities, triaging them to immediate colposcopy. Lastly, the introduction of HPV testing in the triage of women with ASCUS should serve as a significant factor in improving management of low-grade cytological abnormalities.
Although liquid-based cytology, reflex HPV testing for ASCUS, and combined HPV/cytology screening were not used during this study period, the results of this study remain valid. While these new screening and management modalities may shift patients between immediate colposcopy and accelerated or routine cytologic follow-up, the fundamental issue identified in this study remains unaltered: a deficiency in adherence to practice guidelines.
In our study, cases originating at larger medical centers received more optimal care than cases originating at small clinics. A study performed in this same population in 1990 also found that patients from PHCs were less likely to complete their follow-up care compared with patients from CHCs.28
Potential explanations include that women with abnormal cervical cytology at a PHC must navigate several additional medical facilities to receive complete evaluation for their abnormal Pap test. Both clinic and patient factors such as discrepancies in referral systems, delays in making appointments, and large travel distances would affect the success of these women receiving appropriate follow-up.
Regional variations, also apparent within this county healthcare system, could be explained by the geographic size of the cluster, availability or lack of a public transportation network, the socioeconomic and ethnic makeup of the patient population in that specific region, as well as the size, availability, and specialization of the medical teaching programs at specific facilities. Further studies are needed to determine which of these factors influence the quality of care being provided to women with abnormal cervical cytology.
As this study was conducted within a single healthcare system in Los Angeles County, the results may not be generalizable to healthcare systems in other regions or non-county healthcare systems within Los Angeles. In addition, the study results do not account for patient migration. As patients in the county healthcare system gain and lose health insurance, they may move in and out of the system, giving the appearance of incomplete care. However, if this were the sole reason, one would expect lack of follow-up to be randomly distributed across cytological abnormalities and not strongly inversely influenced by the degree of cytological abnormality.
Given that our study was conducted before the 2002 release of the updated management guidelines for abnormal cervical cytology, the criteria used in determining appropriateness of care were based on guidelines published in 1994. These guidelines provided instructions only on the procedures recommended during the management of abnormal Pap tests. The optimal time interval within which follow-up studies should have been done was determined by expert opinion. The validity of such criteria could be questioned; however, the experts enlisted strongly agreed that the criteria closely represented the standards of care at the time.
In conclusion, our study suggests that the overall quality of follow-up care being provided to women with abnormal Pap tests needs to be addressed. This need is not unique to this county’s healthcare system, as attested by several other recent studies, which highlighted under-management of AGUS20
or the lack of guideline adherence in women with ASCUS or LSIL.29
Deficiencies identified in practice guideline adherence in our study serve as a basis to further define factors influencing the quality of care for women with abnormal Pap tests and for developing targeted interventions of specific healthcare delivery practices. In addition, studies examining appropriateness of treatment of cervical dysplasia and early cancer are warranted. Ultimately, improving the quality of care in a healthcare system serving a high-risk population will help decrease disparities in cervical cancer mortality.