1. Implementing Best Practices in Cervical Cancer Screening
Ann Evensen, MD
UW Health Verona
November 6, 2008

2. The Opportunity
A variety of pap smear techniques were being followed at UW Verona
This caused concern:
Some techniques did not reflect best practices
Potential for missing cervical disease
Lack of standardization increased work of nurses and wasted supplies

3. Our Team Team leaders: Ann Evensen, MD and Adrian Tabares, Med 2
Team Members:
John Beasley, MD
Kathleen Carr, MD
Janice Cooney, PA-C
Marguerite Elliott, DO
William Scheibel, MD
Mark Shapleigh, Clinic Manager
Susan Skochelak, MD
Sandy Skrede, LPN
Doug Smith, MD
Heidi Stokes, PA-C

4. Our Goal
90% of pap smears at UW Verona clinic for low-risk women will be done using a single method that reflects “best practices” as described in current literature.

5. Current Situation We examined three variables in pap smear screening:
1) collection instrument
2) glass slide versus liquid-based cytology (LBC)
3) frequency

6. Current Situation, Part 1:
The Ayre’s spatula and Cytobrush used together is the most sensitive method of collecting a pap smear.
Martin-Hirsch PPL, Jarvis GG, Kitchener HC, Lilford R. Collection devices for obtaining cervical cytology samples. Cochrane Database of Systematic Reviews 2000, Issue 3.

7. Current Situation, Part 1:
Clinicians used
62% Cervex broom
31% Ayre’s spatula plus Cytobrush
6% Cervex broom plus Cytobrush

8. Current Situation, Part 2:
Liquid-based cervical cytology is neither more sensitive nor more specific for detection of high grade cervical intraepithelial neoplasia compared with the conventional Pap test.
Arbyn M, Bergeron C, Klinkhamer P, Martin-Hirsch P,
Siebers AG, Bulten J. Liquid compared with conventional
cervical cytology: a systematic review and meta-analysis.
Obstet Gynecol 2008;111:167–77.

9. Current Situation, Part 2:
37% %

10. Current Situation, Part 3:
National guidelines recommend screening low risk women every 1-3 years based on age and type of pap
Example: low risk women over 30 should be screened every three years with liquid based cytology

11. Current Situation, Part 3:

12. Root Cause Analysis
We examined patient, clinician, and systems factors that may be contributing to the variety of cervical cancer screening practices at our clinic.
Examples:
physician habit
patient preference
lack of knowledge of best practices

13. Intervention
Faculty agreed on single method for screening low-risk women based on data from our clinic and literature review of best practices.

14. Liquid versus glass slide debate
Liquid $75, glass $25
Fewer exams = fewer lab, physician labor, and supply costs
Fewer repeat exams due to need for HPV sample or “insufficient cells”
Screening required less often with liquid method

15. Implementation Protocol implemented at UW Verona Clinic:
Clinicians were trained to use plastic Ayre’s spatula plus Cytobrush with liquid-based cytology done every 2-3 years based on age.
Exam rooms restocked.

16. Assessment
Six months after protocol implementation, feedback was gathered via:
Written survey of clinicians
Team meetings and individual staff interviews
Pap smear audit was repeated

17. Results

18. Screening frequency issues
Data collection
Systems-based solution

19. Future Plans
Plan QI project to develop a systems-based approach to improve screening frequency. Balance costs with need for resident education.
Orient every new class of resident physicians to pap protocol to sustain improvements that we have realized.

20. Conclusions
Simplifying exam room set-up for pap smears is possible and can improve adherence to best practices for cervical cancer screening.
Despite some clinicians having to abandon personal preferences for screening, support for the protocol was wide-spread.
This project was successful because we changed the system rather than each clinician. However, we were not able to systematically change physician/patient expectations of annual screening.