October 24, 2012
A simple, multidisciplinary quality improvement program dramatically increased cervical cancer screening rates among HIV-infected women at a St. Louis clinic, according to a study presented at IDWeek 2012. The findings suggest that low-cost interventions could help reduce morbidity and mortality among women living with HIV, despite structural barriers to routine checkups.
Because women with HIV have higher rates of cervical cancer than HIV-uninfected women, cervical cancer screening should be performed annually. However, many women never get screened. There are several reasons for this, according to Sara L. Cross, M.D., an infectious diseases clinical fellow at the Washington University School of Medicine in St. Louis, which operates an infectious diseases clinic. At Cross's clinic, only 53% of women were screened for cervical cancer in the year prior to July 2010.
"Patients frequently refused cervical cancer screening," Cross explained. "Also, providers weren't doing the screening because they were too busy and they didn't have time. Additionally, trainees often felt they had not received enough education on how to perform the cervical cancer screening. Finally, patients often don't come to their clinic appointment. To improve the care we deliver and improve the health of our patients, we decided to implement a quality and improvement intervention to try to increase screening."
The program was not only aimed at patients, but at medical staff as well. The interventions included:
The year after the program was implemented, the clinic's cervical cancer screening rate jumped from 53% to 75%, a statistically significant difference (P < .01).
The study included 545 women with a mean age of 38 years. About 78% were African American and 46% had a below-high-school-level education. Due to the lower socioeconomic status of many of the clinic patients, many didn't have reliable access to phone numbers where they could be reached, increasing the challenge of reliably screening them. About 45% of the patient population had a history of human papillomavirus infection, a history of sexually transmitted infection (STI) and a history of depression. The average CD4+ cell count was 475 cells/mL.
In terms of predictors or risk factors for lack of screening, more cancelled visits and fewer visits were both statistically significant (P < .01). None of the other generally accepted risk factors of not getting screened, including depression and substance abuse, were found to be predictors in this study.
Interestingly, having a history of STI actually increased likelihood of getting screened, which trended towards statistical significance but fell slightly short (P = .09).
"It works," Cross said of the intervention program. "We don't know which of these [specific methods] worked -- maybe a combination of all of them." Cross noted that, since the study's conclusion, her clinic has continued almost all of the interventions. "Our number has fallen a little bit, but we're at 69% [screening rate] for the year so far, but we are looking at additional ways to continually improve," she said.
Interventions such as the program Cross and her colleagues implemented are only becoming more important in the context of HIV care, Cross suggested. "The female HIV-positive population is growing. Several years ago we didn't have to worry about issues related to women and HPV or cervical cancers because there weren't that many HIV-positive women," she stated. "The percentage of women with HIV is growing since the '80s. In our clinic it's also growing; approximately 30% of the HIV-positive patients in our clinic are women. So these issues are being brought to light."
Cross believes these interventions can be applied to other clinics. "There are only a few necessary components needed to implement all of these tools," she said. "First, you need to be able to identify women needing screening through data queries or other means. You also need to engage your clinic support staff so that everyone is communicating the same message to patients about the importance of screening."
"I think anyone can do improve their cervical cancer screening rates, especially if they engage their staff and identify the barriers to care," Cross added. "In our clinic, the providers take it upon themselves to know who needs a Pap smear and perform the test. It's really all about education and awareness for the providers and the patients."
But the first step, Cross noted, is realizing that cervical cancer screening efforts need to be stepped up for patients in the first place. "As with all quality improvement interventions, if you don't know there's an issue, you don't know what to fix," she said.
Warren Tong is the research editor for TheBody.com and TheBodyPRO.com.
Follow Warren on Twitter: @WarrenAtTheBody.
Reporting for this article was contributed by Myles Helfand.