Trends in over- and under-screening for cervical cancer after EMR implementation in rural China

Inappropriate cervical cancer screening practices, including over- and under-screening, pose significant healthcare burdens in low-resource settings. This study analyzed screening behaviors and determinants among 33,362 women aged 35-64 in Wuxiang County, China, using longitudinal cohort data. Screening events were classified as guideline-adherent, over-screened, under-screened, or unscreened based on prior methods (HPV, cytology, or co-testing) and results, using cause-specific frailty models for analysis. Overall, only 19.9% of events were guideline-adherent, while 29.5% were over-screened and 50.6% were under- or unscreened. Notably, the implementation of a county-wide Electronic Medical Record (EMR) platform in 2022 coincided with a sharp decline in over-screening from 36.7% to 15.7%. Compared with primary HPV testing, prior co-testing increased the hazard of both over- and under-screening, whereas prior cytology was strongly associated with under-screening. Women with low-grade abnormalities (≤CIN1) showed a substantially higher risk of under-screening compared to those with negative results. Additionally, community residents were more prone to over-screening, while village residents faced higher under-screening risks. These findings suggest that transitioning to HPV-based screening and integrating EMR systems effectively reduces unnecessary testing, though enhanced reminder systems are crucial to address persistent under-screening in resource-constrained regions.