Association between physician specialty and uptake of new medical technologies: HPV tests in Florida Medicaid

Incorporating Stakeholder Feedback in Guidelines Development for the Management of Abnormal Cervical Cancer Screening Tests

OBJECTIVE

The 2019 ASCCP Risk-Based Management Consensus Guidelines present a paradigm shift from results- to risk-based management. Patient and provider factors can affect guideline adoption. We sought feedback from stakeholders to inform guideline development.

MATERIALS AND METHODS

To solicit provider feedback, we surveyed attendees at the 2019 ASCCP annual meeting regarding readiness to adopt proposed changes and used a web-based public comment period to gauge agreement/disagreement with preliminary guidelines. We elicited patient feedback via a brief survey on preferences around proposed recommendations for treatment without biopsy. Surveys and public comment included both closed-ended and free-text items. Quantitative results were analyzed using descriptive statistics; qualitative results were analyzed using content analysis. Results were incorporated into guideline development in real time.

RESULTS

Surveys indicated that 98% of providers currently evaluate their patients' past results to determine management; 88% felt formally incorporating history into management would represent an improvement in care. Most providers supported expedited treatment without biopsy: 22% currently perform expedited treatment and 60% were willing to do so. Among patients, 41% preferred expedited treatment, 32% preferred biopsy before treatment, and the remainder were undecided. Responses from the public comment period included agreement/disagreement with preliminary guidelines, reasons for disagreement, and suggestions for improvement.

CONCLUSIONS

Stakeholder feedback was incorporated into the development of the 2019 ASCCP Risk-Based Management Consensus Guidelines. Proposed recommendations with less than two-thirds agreement in the public comment period were considered for revision. Findings underscore the importance of stakeholder feedback in developing guidelines that meet the needs of patients and providers.

Factors associated with high-risk human papillomavirus test utilization and infection: a population-based study of uninsured and underinsured women

Background

Current cervical cancer screening guidelines recommend a Pap test every 3 years for women age 21–65 years, or for women 30–65 years who want to lengthen the screening interval, a combination of Pap test and high-risk human papilloma virus testing (co-testing) every 5 years. Little population-based data are available on human papilloma virus test utilization and human papilloma virus infection rates. The objective of this study was to examine the patient-level, cervical cancer screening, and area-level factors associated with human papilloma virus testing and infection among a diverse sample of uninsured and underinsured women enrolled in the New Jersey Cancer Early Education and Detection (NJCEED) Program.

Methods

We used data for a sample of 50,510 uninsured/underinsured women, age ≥ 29 years, who screened for cervical cancer through NJCEED between January 1, 2009 and December 31, 2015. Multivariable logistic regression models were used to estimate associations between ever having a human papilloma virus test or a positive test result, and individual- (age, race/ethnicity, birthplace) and area-level covariates (% below federal poverty level, % minority, % uninsured), and number of screening visits.

Results

Only 26.6% (13,440) of the sample had at least one human papilloma virus test. Among women who underwent testing, 13.3% (1792) tested positive for human papilloma virus. Most women who were positive for human papilloma virus (99.4%) had their first test as a co-test. Human papilloma virus test utilization and infection were significantly associated with age, race/ethnicity, birthplace (country), and residential area-level poverty. Rates of human papilloma virus testing and infection also differed significantly across counties in the state of New Jersey.

Conclusions

These findings suggest that despite access to no-cost cervical cancer screening for eligible women, human papilloma virus test utilization was relatively low among diverse, uninsured and underinsured women in New Jersey, and test utilization and infection were associated with individual-level and area-level factors.

Behavioral economic insights into physician tobacco treatment decision-making

RATIONALE

Physicians self-report high adherence rates for Ask and Advise behaviors of tobacco dependence treatment but are much less likely to engage in "next steps" consistent with sophisticated management of chronic illness. A variety of potential explanations have been offered, yet each lacks face validity in light of experience with other challenging medical conditions.

OBJECTIVE

Conduct a preliminary exploration of the behavioral economics of tobacco treatment decision-making in the face of uncertain outcomes, seeking evidence that behaviors may be explained within the framework of Prospect Theory.

METHODS

Four physician cohorts were polled regarding their impressions of the utility of tobacco use treatment and their estimations of "success" probabilities. Contingent valuation was estimated by asking respondents to make monetary tradeoffs relative to three common chronic conditions.

MEASUREMENTS AND MAIN RESULTS

Responses from all four cohorts showed a similar pattern of high utility of tobacco use treatment but low success probability when compared with the other chronic medical conditions. Following instructional methods aimed at controverting cognitive biases related to tobacco, this pattern was reversed, with success probabilities attaining higher valuation than for diabetes.

CONCLUSIONS

Important presuppositions regarding the potential "success" of tobacco-related patient interactions are likely limiting physician engagement by favoring the most secure visit outcome despite the limited potential for health gains. Under these conditions, low engagement rates would be consistent with Prospect Theory predictions. Interventions aimed at counteracting the cognitive biases limiting estimations of success probabilities seem to effectively reverse this pattern and provide clues to improving the adoption of target clinical behaviors.

The Possible Effects on Socio-Economic Inequalities of Introducing HPV Testing as Primary Test in Cervical Cancer Screening Programs

Background: Screening with HPV is more effective than Pap test in preventing cervical cancer. HPV as primary test will imply longer intervals and a triage test for HPV positive women. It will also permit the development of self-sampling devices. These innovations may affect population coverage, participation, and compliance to protocols, and likely in a different way for less educated, poorer, and disadvantaged women.

Aim: To describe the impact on inequalities, actual or presumed, of the introduction of HPV-based screening.

Methods: The putative HPV-based screening algorithm has been analyzed to identify critical points for inequalities. A systematic review of the literature has been conducted searching PubMed on HPV screening coverage, participation, and compliance. Results were summarized in a narrative synthesis.

Results: Knowledge about HPV and cervical cancer was lower in women with low socio-economic status and in disadvantaged groups. A correct communication can reduce differences. Longer intervals will make it easier to achieve high-population coverage, but higher cost of the test in private providers could reduce the use of opportunistic screening by disadvantaged women. There are some evidences that inviting for HPV test instead of Pap increases participation, but there are no data on social differences. Self-sampling devices are effective in increasing participation and coverage. Some studies showed that the acceptability of self-sampling is higher in more educated women, but there is also an effect on hard-to-reach women. Communication of HPV positivity may increase anxiety and impact on sexual behaviors, the effect is stronger in low educated and disadvantaged women. Finally, many studies found indirect evidence that unvaccinated women are or will be more probably under-screened.

Conclusion: The introduction of HPV test may increase population coverage, but non-compliance to protocols and interaction with opportunistic screening can increase the existing inequalities.

Human papillomavirus (HPV) testing for normal cervical cytology in low-risk women aged 30-65 years by family physicians

PURPOSE

The purpose of this study was to assess ordering of human papillomavirus (HPV) testing for normal cervical cytology among low-risk women aged 30 to 65 years.

METHODS

Audits of 833 cytology request forms for low-risk women completing a Papanicolaou smear, from January 2008 to April 2011, from 5 Michigan family medicine clinics determined HPV orders completed by the clinician performing the Papanicolaou smear. Multivariate logistic regression models examined differences in HPV test ordering by patient age at Papanicolaou test, provider status and sex, and clinic across sites. A Poisson regression model analyzed the annual number of HPV test orders over time.

RESULTS

Cytology requests were completed by 622 faculty (75%), 169 residents/fellows (20%), and 42 nurse practitioner/physician assistants (NP/PAs) (5%). HPV testing for any cytology result was ordered on 324 request forms (39%) by residents/fellows (48%), faculty (38%), and NP/PAs (10%). Female providers were twice as likely as men to order HPV testing for any cytology result across all clinics and provider statuses (P < .001). There were significant differences in HPV test ordering among clinics. Between 2008 and 2011 annual cytology requests increased 46%, including HPV testing for any cytology result after adjusting for faculty provider sex.

CONCLUSION

HPV test ordering when cytology is collected varied by clinic and provider status and sex. HPV co-testing for any cytology result remains modest, but is increasing over time in these clinics.

Trends of human papillomavirus testing in cervical cancer screening at a large academic cytology laboratory

OBJECTIVE

To estimate time trends of actual provider use of human papillomavirus (HPV) testing in cervical cancer screening by using laboratory and administrative data from the Johns Hopkins Hospital Division of Cytopathology in Baltimore, Maryland.

METHODS

In this ecologic trend study, we analyzed 178,510 Pap specimen records and 12,221 HPV tests among 85,048 patients from 2001 to 2007. Monthly frequencies and proportions of HPV reflex testing and HPV cotesting with Pap (stratified by patient ages 30 and older and 18-29 years) were calculated. Time trends of monthly HPV testing proportions were analyzed using joinpoint regression methods.

RESULTS

From April 2002, when the American Society for Colposcopy and Cervical Pathology added HPV reflex testing to its guidelines, to December 2007, the monthly the proportion of reflex testing was 95.8%. From February 2004, when the society added HPV cotesting with Pap among women aged 30 years or older to its guidelines, to December 2007, the overall proportion HPV cotesting with Pap among patients aged 30 years or older was 7.8% (compared with 4.9% among patients 18-29 years [P<.01]). The highest proportion of HPV cotesting among women aged 30 years or older, 15%, was observed in September 2006, and the trend later plateaued around 13%. The monthly proportions of HPV reflex testing and cotesting with Pap changed significantly over time.

CONCLUSION

These data reveal that a small percentage of women aged 30 years or older received HPV cotesting with Pap, thus identifying a significant opportunity for providers to improve patient care in cervical cancer prevention.

LEVEL OF EVIDENCE

III.