Evaluating the Uptake of Cotesting and Guideline Adherent Cervical Cancer Screening and Reported Barriers to Guideline Adherence in Academic and Community Practice Settings: A Mixed Methods Study

Background: Clinical practice screening guidelines recommend cotesting, a test that combines DNA Human Papillomavirus (HPV) testing with cervical cytology (also known as Pap testing) every 5-years, as a highly effective and preferred method for cervical cancer prevention among average-risk women aged 30-65. Up to date empirical data on the current uptake of this evidence-based intervention is sparse and does not allow for a complete understanding of the actual use of cotesting at the extended screening interval in practice among patients and providers in different types of practice settings. The 2012 national cervical cancer screening guidelines have further expanded in 2018 to include a third option for screening which includes primary HPV testing (testing without the use of cytology) for average-risk women 30-65 years of age, and its adoption by providers is unclear. Purpose: The goal of this research study was to evaluate the uptake of the 2012 cervical screening guideline recommendations and obtain a comprehensive understanding of the determinants that influence cotesting uptake and guideline adherence, and explore the provider reported barriers to conducting cervical cancer screening in accordance with the guidelines. In addition, this study explored the early adoption of primary HPV testing as a third cervical screening strategy option recommended in the 2018 update of cervical cancer screening guidelines. Methods: This explanatory sequential mixed methods study utilized a retrospective cohort design as part of the quantitative phase to analyze patient cervical cancer screening data retrieved from the George Washington (GW) Medical Faculty Associates (MFA) electronic health record (EHR) system. Using multivariable logistic regression analysis, variables including patient age, race and ethnicity, insurance type, provider gender, specialty, degree and practice type were analyzed to determine their association with guideline adherent screening and cotesting use. Patient cervical cancer screening test type and date(s) of screening test(s) were extracted for each patient from the EHR. The interval between two negative screening tests was measured to determine if the testing had been conducted in accordance with the guideline specified screening interval defined for this study. Next, in the qualitative phase, these results were further examined with providers who conduct cervical cancer screening. Using convenience sampling methods, 7 Ob/Gyn and Primary Care providers were recruited from academic and community clinical practice sites for open-ended, semi-structured interviews to explore barriers to guideline adherence in practice and to further explicate the determinants identified in the quantitative phase of the study. Interviews were transcribed verbatim and coded using NVivo V.12 (Pro) using a deductive framework informed by The Knowledge, Behaviors, and Attitude Framework and the Consolidated Framework for Implementation Research (CFIR). Results: One thousand patient records in the EHR were reviewed for retrospective analysis. 709 were eligible for study inclusion and 373 out of 709 were eligible for evaluation of the screening interval (i.e., guideline adherence). The overall uptake of cotesting between 2012 to 2020 was 86.3.6%. The median screening interval between two negative cotests was 36-months. 85.8% of patients were not screened in accordance with the guideline specified screening interval, with 75.1% overscreened and 10.7% underscreened. The final regression model showed that male providers had a lower odds (OR=0.31, 95%CI 0.13-0.78) of conducting cervical cancer screening within guideline specified intervals compared to females, and community practice sites had a lower odds (OR=0.15, 95%CI 0.08-0.31) of conducting screening within guideline specified intervals compared to academic sites. For cotesting, the final model showed that patients seeing male providers for screening had a lower odds (OR=0.45, 95%CI 0.20-0.99) of receiving cotesting compared to patients seen by female providers. Patients seen by Primary Care providers or Other providers also had a lower odds (OR=0.24, 95%CI 0.12-0.50) and (OR=0.04, 95%CI 0.0003-0.39), respectively of receiving cotesting compared to patients seen by Ob/Gyn & Midwifery providers. Patients seen at community practice sites had a lower odds (OR=0.25, 95%CI 0.10-0.63) of receiving cotesting compared to patients seen at academic sites. Further exploration of these findings and barriers to guideline adherent screening were discussed in semi-structured interviews with 7 Ob/Gyn and Primary Care providers. Knowledge of current guidelines varied among different types of providers and practice settings. Provider attitude toward guidelines were driven by their past training and experience and habits. Difficulties in articulating guideline information to patients were reported as a hindrance to guideline adherence. External barriers related to patient preferences and insurance policies were reported as barriers outside the control of the provider. Provider demographic characteristics such as age and number of years in practice were discussed by the participants as potential explanations for male providers having a lower odd of conducting guideline adherent screening and cotesting when compared to females. Further, the interviewees did not prioritize following an extended 5-year screening interval per the guideline recommendations as an important piece to implementing cervical screening guidelines. The integrated results from both phases of the study demonstrated expansion and confirmation of the quantitative findings by the interviewees and provided further explication for the differences observed between gender of providers, provider specialty and the practice setting in which they reside. Conclusion: There have been advancements in the adoption of cotesting since the issuance of the 2012 guidelines as evident by the high uptake of cotesting found in this study. Though providers mostly abide by cervical cancer screening recommendations and select the appropriate screening test, they fall short of adhering to the 5-year screening interval for cotesting and most women are overscreened. Provider characteristics such as gender, specialty, and practice setting are determinants found to influence guideline adherence and cotesting, but these are not sufficient to explain the discordant use of guidelines in practice. Barriers at the level of the health system, particularly the role of insurance and payor policies and their misalignment with current cervical screening guidelines are potential contributors to non-guideline adherent screening which result in driving up costs to the healthcare system resulting from overscreening and unnecessary testing. Multiple guidelines developed and issued on the same topic by stakeholders with different interests lends to confusion for the end-users on the recommended screening intervention to implement in practice. Finally, screening guidelines for cervical cancer prevention in the U.S. are designed to be population-based to reduce mortality and morbidity at the level of the population rather than the individual. However, delivery of population-based screening through a lack of an organized screening program or system makes screening reliant upon individual patient and provider encounters that introduce variability in the delivery of evidence-based screening interventions. To disrupt the cycle of less-than-optimal translation of cervical cancer screening guidelines in practice, changes to the current system of guideline development and delivery of cancer screening programs should be considered