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Barriers to the Equitable Implementation of Risk-Based Cervical Cancer Management Guidelines
Cheryl R Clark1, Jacquelyn M Lykken2,3, Patricia M Chen2
1Division of General Internal Medicine & Primary Care, Brigham and Women's Hospital, Boston, MA, USA. crclark@bwh.harvard.edu.
Background:
The 2019 American Society for Colposcopy and Cervical Pathology provides risk-based management guidelines for abnormal cervical cancer screening test result management. It is not known whether populations facing inequities in primary care delivery have the prior screening history needed to take advantage of risk-based management of abnormal cervical cancer screening results.
Objective:
Determine the prevalence and associations of unknown screening history for people with an abnormal cervical cancer screening result.
Design:
Retrospective multi-center population-based study of three large, structurally diverse healthcare systems in Washington state, Massachusetts, and Dallas County, Texas.
Participants:
Females ages 25-65 at index abnormal Pap cytology or positive Human Papillomavirus (HPV) result from 2010 to 2019 (n = 63,739).
Main Measure(S):
Unknown cervical cancer screening history, assessed as missing or insufficient documentation of cervical screening, diagnostic tests, and procedures extracted from administrative data and electronic health records of health systems.
Key Results:
Over a third of patients had unknown cervical cancer screening history prior to the index abnormal test during the study period (38.3% overall, 27.6 to 52.3% across healthcare systems). Patients empaneled to a primary care provider at the time of their abnormal test had a lower prevalence of an unknown screening history than those who were not (prevalence ratio 0.74, 95% CL 0.72-0.75). Those who were uninsured or had multiple insurance transitions had a higher prevalence of unknown screening history than those who were commercially insured (PR 1.13, 95% CL 1.09-1.16). There were health system-specific associations with having an unknown screening history.
Conclusions:
In three large health systems, historical screening data needed to implement ASCCP risk-based guidelines were frequently missing. Our findings call for greater attention to potential management inequities for patients with missing data. Importantly, more attention is needed to address potential primary care access barriers to equitable delivery of risk-based cervical cancer surveillance and care.
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