Article Text
Abstract
Background The incidence of cervical cancer has decreased by 70% since the 1950s. Preventative measures include vaccination against HPV strains and Papanicolaou tests. Early identification of cervical cancer through routine screening can significantly improve patient outcomes.
Materials and methods At our academic institution, Community Internal Medicine (CIM) Clinic, 63% of female patients aged 21–65 were compliant with cervical cancer screening. The opening of the ‘Saturday Pap Smear Clinic’ sought to address barriers by offering non-traditional appointment times on Saturday mornings with an all female staff. Our aim was to increase the cervical cancer screening rate by 1% within 12 weeks. Our team compared CIM (intervention) and family medicine (FM) (control) compliance rates from September 2021 to January 2022. Messages were sent to the patient indicating non-compliance and offering options to complete screening.
Results At the start of this study, 5239 CIM patients were cervical cancer screening non-compliant. Postintervention, cervical screening rates among non-compliant women within CIM improved by 1.2%. The intervention cohort, CIM patients, had a significant improvement in compliance compared with the control group, FM patients. White women between the ages of 50 and 65 comprised the majority of patients who used the ‘Saturday Pap Smear Clinic’.
Conclusions The availability of Saturday appointments for cervical cancer screening completion can enhance cervical cancer screening compliance among eligible women. Eliminating barriers for women can improve health outcomes.
- Women's health
- PRIMARY CARE
- General practice
- Health Promotion
- Obstetrics and gynecology
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
WHAT IS ALREADY KNOWN ON THIS TOPIC
There are critical barriers for women for a basic health screening that can be addressed simply by modifying the times available for cervical cancer screening.
WHAT THIS STUDY ADDS
This study offered non-traditional appointment times on Saturday mornings to address this barrier in cervical cancer compliance. Through this, our intervention resulted in a statistically significant increase in cervical cancer screening compliance.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This intervention gives practical ways to change practice, reduce barriers and could be adapted to other clinics and healthcare systems.
Introduction
Cervical cancer is the fourth most prevalent diagnosed cancer in females worldwide.1 The principal cause of cervical cancer is an infection with HPV.2 The incidence of cervical cancer in the USA has significantly decreased by 70% since 1955 due to preventative measures such as primary prevention by vaccination against cancer-causing Human papillomavirus (HPV) strains and secondary prevention through Papanicolaou tests, also known as Pap smears and HPV screening.3 The Pap smear allows for microscopic visualisation of harvested cervical cells; observation of atypical cells are indicative of infection induced inflammation. HPV screening refers to sensitive molecular tests using DNA to identify HPV type and distinguish oncogenic infection from no, or low-risk infection. While the sensitivity of individual Pap smears is low, around 70%–80%, routine examinations are effective at the early detection of precancerous cells.3 Cervical cancer screening recommendations vary internationally. For our project, routine Pap smears and HPV screening are indicated in the USA for women aged 21–65.4 5 Our institution follows guidelines based on the United States Preventive Services Task Force, American College of Obstetricians and Gynecologists, American Cancer Society, and American Society for Colposcopy and Cervical Pathology recommendations (table 1). Early identification of cervical cancer through routine screening can significantly improve patient outcomes.3
Barriers to and the general reluctance of women to complete routine Pap smears are common.3 From a survey sent before the pilot study, lack of awareness, fear, embarrassment, constrained appointment availability and limited access to preferred provider type contributed to cervical cancer screening non-compliance. Local resources, including Planned Parenthood and primary care practices, generally operate during usual business hours. Weekend medical resources are available for acute and urgent care but not for routine medical examinations, including cervical cancer screening. Cervical cancer can be prevented if diagnosed early through routine cervical cancer screening exams. Ensuring barriers are eliminated that prevent women from getting routine examinations is a crucial effort to improve the health outcomes of females.
Materials and methods
Study design
A ‘Saturday Pap Smear Clinic’ was made available to mitigate barriers to cervical cancer screening. The ‘Saturday Pap Smear Clinic’ worked to eliminate the need for women to take time off of work, locate child care and attend routine appointment times available Monday to Friday between 8:00 and 17:00 hours.
Target population
Within our academic medical centre intervention group, patients empanelled in CIM identified as ‘non-compliant’ in cervical cancer screening prior to implementation were selected. The control group were patients identified as ‘non-compliant’ in family medicine (FM) at the same academic medical centre. The intervention and control groups had similar patient populations of race, ethnicity and age. Additionally, the intervention and control groups had similar provider demographics. Patients were all empanelled to providers in Southeast Minnesota.
Intervention
Cervical cancer screening non-compliant patients empanelled in CIM were identified using electronic medical records (EMRs) based on current guidelines. Messages were sent to their patient portals indicating that they were overdue for cervical cancer screening.
Patient message
Content of the patient message:
Dear Patient,
After review of your chart, it appears you are due for cervical cancer screening and need an updated pap smear. We are currently offering a Saturday morning pap smear clinic with appointments from 8am to 12pm on Saturdays. This is running from September 2021 to November 2021 along with our normal Monday to Friday appointments to help meet this screening need. Please let us know if we can help set up an appointment to arrange this. You can contact my office via Patient Online Services or by calling (***) ***-****.
Sincerely, your Primary Care Provider
Through this, patients were offered additional appointment times on Saturdays from 8:00 to 12:00 hours to complete their cervical cancer screening. To schedule appointments, patients in both the intervention and control groups had to call the clinic. Patients in the control and intervention group continued to receive regularly scheduled outreach for cervical cancer screening if non-compliant. Advertisements for the Saturday Clinic included primary care news, E-boards, posters, social media, practice-related information newsletters for clinical staff, academic medical centre news and provider education.
Our aim was to improve the cervical cancer screening non-compliance rate by 1% within 12 weeks through the intervention of offering Saturday cervical cancer screening appointments staffed by female providers to reduce barriers experienced by patients. Our intervention consisted of offering non-traditional appointments to accommodate the identified barriers to compliance, including women who work standard business hours or who otherwise cannot make weekday appointments. Specifically, our cervical cancer screening specific clinic was innovatively made available on Saturdays. An additional barrier to obtaining cervical cancer screening, identified in the patient survey, was fear/anxiety surrounding the procedure. The Saturday Pap Clinic was unique, as it is entirely staffed by female providers with hopes of providing relief from some of the fear.
Study timeline
The intervention was implemented and tested from September 2021 to November 2021. Due to delays in pathology results, the study was prolonged through January 2022 as patients who attended the clinic in November had results that were not yet available and counting towards compliance.
Data analysis
Demographic characteristics of Saturday cervical cancer screening patients were obtained retrospectively via electronic health record analysis. Race, ethnicity, age and HPV prevalence/type were recorded and depicted. Overall cervical cancer compliance rates within CIM from September 2021 to January 2022 were extrapolated from the EMR and compared with compliance rates within FM during this same time period. Compliance rates during this time frame included women who were seen in the Saturday pap clinic and women who became compliant with their cervical cancer screening through traditional appointment times. A two-tailed χ2 analysis with Yates correction was used to compare CIM and FM compliance rates from September 2021 to January 2022.
Results
At our academic institution, the intervention group consisted of 14 195 eligible patients; of these, 5239 patients were found to be pap-smear non-compliant at the start of the intervention. As compared with the control group that had 26 828 eligible patients; of these 8723 patients were found to be pap-smear non-compliant at the beginning of the intervention (table 2).
Our intervention department had a 63.09% Pap-smear compliance rate in female patients aged 21–65. This academic medical centre and the Minnesota Community Measures have an 82% cervical cancer screen rate goal and healthy people 2030 has a 84.3% cervical cancer screening goal.6 7
Demographic data of the intervention group revealed the highest non-compliance rates within the intervention group were those requiring an interpreter (41.86%). Overall, in the intervention group, the percentage of non-compliant patients was as follows: 45.31% of black/African descent, 50.00% of American Native descent, 60.5% of Asian/Asian descent and 66.29% of white race.
During our 12-week Saturday cervical cancer screening clinic intervention, 62 female patients were seen for cervical cancer screening. There were a total of 72 available appointment slots. Appointments that were filled and subsequently cancelled were filled with acute appointments. Through this intervention, cervical screening rates among non-compliant women within CIM improved by 1.2%. The intervention cohort (CIM patients) had a significant improvement in compliance compared with the control group (FM patients). Two-tailed χ2 analysis with Yates correction p value was determined to be less than 0.0001 (figure 1).
Demographics of women who attended the Saturday Pap Clinic were retrieved from the EMR. It was found that a majority of women who used the non-traditional appointment times in the Saturday Pap Clinic during the months of September to January were primarily white women, ages 51–65. Overall, 77.4% of the patients who attended were Caucasian, 9.7% were African American, 8.1% were of Asian descent and 4.9% did not disclose their race. Additionally, 48.4% of patients were aged 51–65, 25.8% were 41–50, 11.3% were 31–40 and 14.5% were 21–30 years old (figure 2).
In addition to demographic analysis, we compiled results of the pap screening among women who attended the Saturday Pap Clinic. Of the 62 tests that were completed, 3.2% came back as high-risk HPV. There are 14 HPV types defined as high risk, and they can lead to several types of cancer including cervical, oropharyngeal and others.8 This was compared with the national average (figure 3), which was 39.9%.9
Additionally, the intervention group saw a 15% increase in cervical cancer compliance in women during the months of September to January, compared with the control group, which had an 11% increase through traditional and non-traditional appointment times (table 2). This increase among the intervention group includes patients who were seen in the Saturday Pap Clinic, and patients who completed screening during traditional appointment times as well. The combination of non-traditional appointment times and increased direct advertising resulted in a significant increase in compliance as compared with the control group.
Discussion
The Saturday Pap Clinic enhanced patient care in multiple ways, including offering non-traditional appointment times for women busy during the week, sending additional reminders to prompt women to get screened, and addressing other best care practices such as scheduling mammograms, colonoscopies and immunisations.
Our intervention resulted in a statistically significant increase in cervical cancer screening compliance for patients within the intervention group who were overdue for cervical cancer screening compared with the control group. Through the ‘Saturday Pap Smear Clinic’ intervention, we were able to improve the non-compliance rate by 1.2%. Patient reminders for routine cervical cancer screening have previously been proven effective in increasing patient compliance.10 11 Our intervention group’s overall compliance rate continued to remain below the Minnesota Community Measures target. Through the ‘Saturday Pap Smear Clinic’ intervention, we were able to improve the non-compliance rate by 1.2%. However, this improvement in non-compliance rates was not due to the availability of Saturday appointment times alone.
Rather, a combination of non-traditional appointment slots and increased advertising during these months encouraged women to complete the appointment and helped compliance. When comparing overall compliance rates during these months to the control group, it was found that the intervention group had a 15% increase in compliance, while the control group only had 11%. Thus, the combination of non-traditional appointment times and increased direct advertising and reminders significantly increased compliance rates within the intervention group compared with the control group.
Limitations of this study include determining which patients completed cervical cancer screening because of our advertisement reminder and those who became compliant as a result of their own free will. Additionally, the study population was homogeneous, primarily white, insured and educated. Following compliance rates in a longitudinal study may help trend out compliance rates as compared with the control. We acknowledge that the lack of assessment of cost-effectiveness makes it harder to judge the sustainability of the intervention. Future research is needed in the identification of enhanced communication methodologies to reach more patients and encourage cervical cancer screening compliance.
Conclusions
Barriers to obtaining cervical cancer screenings and other crucial health maintenance items remain prevalent and are often multifactorial. The ‘Saturday Pap Smear Clinic’ provides additional opportunities for cervical cancer screening compliance. This intervention group was most frequently attended by educated and insured patients, supporting the notion that traditional appointment hours are a barrier to routine cervical cancer screening compliance. Additional interventions are needed to target women that we did not reach through our ‘Saturday Pap Smear Clinic’. Early detection and patient compliance are crucial factors in reducing associated cervical cancer-related morbidity and mortality. Due to the improvements made by this quality improvement project, the ‘Saturday Pap Smear Clinic’ was implemented permanently every Saturday with expansion to other primary care clinics.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Ethics statements
Patient consent for publication
Ethics approval
This was a Quality Improvement project carried out by Community Internal Medicine, which was approved by the institution’s leadership. This study involves human participants. This study was a pilot for a quality improvement project; therefore, the ethics committee exempted our study.
Acknowledgments
The authors would like to recognise a key member of the Saturday Pap Clinic, Brent Helgren, who significantly contributed to the success of this project.
Footnotes
Contributors BS is guarantor. BS, DO'L, NF, SF, JS, SP, AS and JT conceived of the presented idea and implementation of the research. BS, DO'L, MF, GG, RO, KA, DA and JA analysed the results and wrote the manuscript with support from NF, SF, JS, SP, AS and JT.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.