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Increasing Adherence to Pap Screening Guidelines

Am Fam Physician. 2004 Jan 15;69(2):409.

Despite the positive impact of Papanicolaou smears on the morbidity and mortality of cervical cancer, some women still do not receive screening as recommended. Current goals set by Healthy People 2010 are intended to increase Pap smear counseling by primary care physicians. Multiple studies have found that a physician's recommendation for Pap smear screening is one of the strongest predictors for its use, but many women report that their physician has never recommended Pap smears. Women at risk for not receiving Pap smears are more likely to be older, uninsured, or underinsured; to not have a regular physician or source of health care; and to have lower educational attainment or household income. Several studies have evaluated different interventions to increase physician recommendations concerning Pap smear screening or to reduce some of the barriers that women face concerning this screening. Yabroff and associates assessed the published reports about the various interventions for physicians and patients aimed at increasing the use of Pap smears.

The authors performed a MEDLINE search for articles published between 1980 and 2001 concerning interventions to increase Pap smear use. The abstracts were reviewed to determine which studies met the following inclusion criteria: random or concurrent assignment to an intervention or control group, prospective design, and outcomes of Pap smear use or recommendation. Interventions were divided into four groups, with the first directed at patients, the second at physicians, the third at patients and physicians, and the fourth at health care systems. The groups were further divided based on the expected action of the intervention being behavior-oriented, cognitive, sociologic, or a combination. In addition, the authors calculated the effect size and 95 percent confidence intervals for each intervention.

The review included 46 studies that met the inclusion criteria. Most of the studies showed that interventions increased the use of Pap smears, but the increase usually was not statistically significant. Behavior interventions for patients, such as mailed or telephone reminders, increased the use of Pap smears by up to 18.8 percent. Most cognitive and sociologic interventions for patients were only marginally effective, with the exception of a single culturally specific intervention that used a lay health care worker. In the studies that evaluated behavior interventions for physicians, changes ranged from a decrease in Pap smear use of 18 percent to an increase in use of 44 percent. Cognitive and sociologic interventions for physicians provided minimal or no increase in Pap smear screening. Only one intervention directed at health care systems had a positive impact on screening; the intervention integrated a nurse practitioner into the clinic system to perform same-day Pap smears. Interventions that were aimed at physicians and patients did not appear to provide any greater benefit than those directed at one group or the other.

The authors conclude that most interventions increase the use of Pap smears to screen for cervical disease. They note that intervention strategies should be based on physician and patient population characteristics, as well as the feasibility of implementing the intervention. In addition, combining physician and patient interventions appears to be no more effective than intervening in only one group.

Yabroff KR, et al. Effectiveness of interventions to increase Papanicolaou smear use. J Am Board Fam Pract. May-June 2003;16:188–203.


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