Table of Contents
ABSTRACT
The governing entities for cervical cancer screening joined forces and released unified guidelines for screening in 2012. However, insurance companies did not base their payment for service on these guidelines until January 2017. It has been well documented through previous studies that providers did not adhere to these new guidelines for multiple reasons. The purpose of this study is to prove that insurance payment or payment for service influences the physician’s compliance to recommendations.
The Awareness to Adherence Model suggests that adherence to guidelines only occurs when physicians are aware of, agree with, adopt and adhere to the recommendations. By complying with evidence based guidelines, providers enhance their patients care and provide continuity of care across the patients’ health care experience. A pilot study is proposed using a sample size of 30-40 retrospective chart reviews from a private OBGYN facility. A quantitative methodology would allow descriptive statistics to be utilized and describe the data.
INTRODUCTION
Women around the world dread going to their wellness visit with their OBGYN, but it is important to their overall health. This visit provides beneficial preventative screenings, including cervical cancer screenings, that have saved women’s lives.
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The Centers for Disease Control and Prevention (CDC) suggests that the Papanicolaou (Pap) smear test initiated over 50 years ago has drastically decreased the number of deaths due to cervical cancer. However, the American Cancer Society (ACS) (2018) states that in 2018 over 13,000 new cases of invasive cervical cancer will be diagnosed and over 4,000 of those women will die. In the past, recommendations for cervical cancer screenings came from multiple agencies making it difficult for clinicians to follow one agencies guidelines without violating another (Baker, E. 2013, p. 28).
The American College of Obstetrics and Gynecology (ACOG), American Cancer Society (ACS), the United States Preventative Services Task Force (USPSTF), and American Society of Colposcopy and Cervical Pathology (ASCCP) released new joint guidelines for cervical cancer screening in May of 2012 (Carter, J.S. 2016). These guidelines changed the frequency of pap smears and HPV testing. According to the Centers for Disease Control and Prevention (CDC), cervical cancer is the easiest gynecologic cancer to prevent, with regular screening tests and follow-up (Centers for Disease Control and Prevention, 2017).
Prior to 2012, it was common practice for women to receive Pap screenings at each annual health screening per guideline recommendations at that time. The new guidelines recommend initiating screening no earlier than age 21, regardless of sexual behavior, and beginning Pap testing by cytology alone every 3 years until age 30. At age 30, it is the patient and physician’s choice to continue cytology only testing every 3 years until age 65 (if previously screened with normal results) or to add human papillomavirus (HPV) co-testing to the Pap test every 5 years until age 65.
The problem with the new recommendations is provider adherence. The guidelines are evidence based and provide cost-efficient, best practice recommendations, yet providers are still failing to comply. Insurance mandates changed in January 2017 requiring pap tests to be performed based on the new guidelines for payment. This research proposal would determine if payer participation has an impact on private OBGYN providers’ adherence to guidelines. OBGYN providers were chosen based on the fact they perform more pap tests per day than other provider types and are specialized in Women’s Health. There is a known gap in research results being implemented into practice, sometimes over a decade (Kirstensen, Nymann, & Konradsen, 2016).
Knowing the barriers, such as insurance payment policy, to implementing evidence-based practice into clinical practice will assist in narrowing the gap and make sure the best care and treatment actually reach the patient. This study is essential to ensure patients are receiving the most up to date quality care and the lowest cost for them and the health care provider. Providing cost efficient care allows insurance premiums to remain affordable.
LITERATURE REVIEW
Cervical cancer screening guidelines have evolved over the years, leading to frequent guideline changes. OB/GYN providers have relied on multiple entities recommendations to guide their treatment and care of their patients. However, these guidelines were often unclear and contradictory which allowed the physicians to interpret the guidelines in different ways.
Insurance companies were paying for cervical screenings and thus the physicians continued to practice according to previous guidelines instead of following current recommendations by the USPSTF and ACOG. In other words, there were no monetary consequences to providers not following guidelines and it was not perceived to cause any physical harm to the patients. Boone, Lewis, & Karp (2015) found that adherence to new guidelines is suboptimal and over-screening is a common phenomenon (256).
The purpose of their study was to understand the various issues that may limit the adherence to the new screening policies released in 2012 by the USPSTF (Boone, et al., 2015). The survey study revealed that OB/GYN providers were less likely to find any organizations guidelines authoritative and reliable, fifty-percent of them believe the currently guidelines are not clinically appropriate, and others that find the guidelines authoritative and reliable but simply disregard them (Boone, et al., 2015). This is an important finding because this study was performed prior to the insurance payment change in 2017 that is based on current guidelines.
In a study by Haas et al. (2015), 41% of providers reported cervical cancer screening in excess of the USPSTF guidelines in at least one age group and 20.7% admitted to screening sexually active women under age 21. This study concluded that “primary care providers do not consistently follow recent USPSTF breast and cervical cancer screening recommendations, despite noting that these guidelines are influential” (Haas, et al. 2015, p.52). Insurance companies now only pay for cervical screenings if the test was performed following USPSTF recommendations, and this affects the physician’s payment. So, now that these regulations are in place regarding payment, will the providers adhere to guidelines more accurately?
The Healthy People 2020 objective is that 93% of eligible women from age 21-65 receive cervical cancer screening in accordance with current recommendations (Watson, Benard, & Flagg, 2018). The National Health Interview Survey (NHIS) data from 2015 revealed that no group of women in the United States had met this goal and that screening was particularly low in uninsured women (Watson et al., 2018). Because these guidelines are still considered relatively new, there is a gap in the research regarding current practice by OB/GYNs and adherence to guidelines following the insurance mandate to pay for screenings based on recommendations.
PURPOSE STATEMENT
The purpose of this study is to evaluate private OBGYN providers, including physicians and advanced practice nurses, adherence to USPSTF guidelines on cervical cancer screenings in women age 21-65 with low risk since the insurance companies enforced following guidelines for payment in January 2017.
THEORETICAL FRAMEWORK
The Awareness to Adherence Model suggests that adherence to guidelines only occurs when physicians are aware of, agree with, adopt and adhere to the recommendations (Pathman, Konrad, Freed, Freeman & Koch, 2016). As in the findings of Boone, et al., (2015), this theory suggests that a physician must know the guidelines and have confidence in them in order to incorporate them in their daily practice. Guidelines are in place to increase continuity of care and assure that care is top quality. Unification of guidelines provides a way for patients to be seen by different providers in their lifetime and receive the same quality of care.
However, if the physicians do not accept these guidelines and adhere to them, it leaves confusion for the patient and can lead to poor decisions regarding care. The gap from research findings to incorporation into practice remains wide (Kristensen, et al., 2016) and if researchers are aware of which step physicians begin to deter from the guidelines (awareness, agreement, adoption, or adherence), steps can be taken to fix the problem.
Multiple studies have been done regarding provider’s compliance to current recommendation and their rationale/reasons for being non-compliant. Boone, et al. (2016) suggests that if any confusion exists regarding the guidelines, providers will default care to over treatment for safety.
However, that over treatment can be harmful to the patient and the budget. The USPSTF clinical guideline points out that abnormal test results obtained from an unnecessary screening can lead to increased testing and invasive procedures that may not be necessary, causing side effects such as pain, bleeding, and infection, as well as increased anxiety and concern for the patient (Moyer, V.A. 2012). The Awareness of Adherence model encourages an evaluation of the provider’s beliefs and attitudes towards new recommendations and can help identify where the problem lies.
RESEARCH/HYPOTHESIS
For the purpose of this study, the following question will be addressed:
Have women age 21-65 with no personal history of abnormal pap smear(s) been being screened in private OBGYN practice according to USPSTF guidelines from January 2017 to present?
For the purpose of this study, investigation will include one research hypothesis:
Private OBGYN providers have been more compliant with USPSTF guidelines for cervical cancer screening since the insurance mandate of January 2017, requiring pap smears to be performed in accordance with current recommendations.
METHODOLOGY
A pilot study would most beneficial for this study because there has been little to no research done to evaluate cervical cancer screenings specifically.
In a pilot study, a small sample size of 30-40 subjects to determine the study’s strengths, weaknesses, validity and reliability (Melnyk & Fineout-Overholt, 2015). The sample would be random and descriptive statistics would be used to describe the data. This research study would require a quantitative approach using a non-experimental study utilizing retrospective chart reviews to gather data.
This would involve receiving permission from the facility in which charts are to be reviewed, approval from the International Review Board, and reviewing charts of women who are age 21-65 with no history of abnormal pap smears and comparing what screening was actually performed in or after January 2017 the age specific guidelines set by the USPSTF.
The question is valid and free from bias and can only be answered with numeric data from chart reviews. The results will be reliable because it is based on lab results and documented actions of providers. The patient’s confidentiality will remain intact due to the HIPAA law that covers the clinic and all medical personnel involved in that patient’s care. Consent would not need to be obtained because the study is based on information already in existence (lab results). The study is feasible and can be conducted in a reasonable amount of time.
CONCLUSION
The goal of providers should be the safety and quality of care they provide to their patient’s. By complying with evidence based guidelines, providers enhance their patients care and provide continuity of care across the patients’ health care experience. Science is ever changing with new medical discoveries daily. With these discoveries comes change. The implementation of the Human
Papillomavirus (HPV) testing is one example of an advancement in care that created change. This virus has been found to be the cause of cervical cancer in what is known as HPV (16) and HPV (18). Therefore, along with the HPV test came the Gardasil vaccine that is said to prevent HPV if taken at the appropriate age. These medical advances have led to the implementation of new guidelines, however, because of the slow growing nature of cervical cancer, there remains a gap in the knowledge of exactly how effective these treatments are against cervical cancer. It is this uncertainty that leads the providers to continue practicing what they know to be effective. Providers beliefs and attitudes must change in order to comply with guidelines, regardless of payment.
In future research, it would be interesting to evaluate the adherence to guidelines in a public health care setting, such as health departments. A comparison study would also be beneficial to explore the theory that provider’s compliance to guidelines is reliant on the payment they receive for services.
References
- Title: Cervical Cancer Screening Guideline Adherence Before and After Implementing a Shared Payment Model: A Single Institution Experience
- Title: Cervical Cancer Screening and Prevention
- Title: Awareness of Cervical Cancer Screening Guidelines Among Obstetricians and Gynecologists
- Title: The barriers of implementing evidence-based cervical cancer screening: a nationwide survey among German gynecologists
- Title: Assessment of Knowledge, Awareness, Attitude, Barriers, and Interest Toward Hepatitis B Vaccination Among Medical Students in Nepal
- Title: Tests to Detect Cervical Cancer and Precancerous Cervical Cell Changes
- Title: Physician knowledge, awareness, and adherence to the 2017 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) guidelines for severe community-acquired pneumonia
- Title: Multicenter Study of HPV Testing in Management of Precancerous Cervical Lesions Among Women Living with HIV Infection
