K. Robin Yabroff, PhD; Mona Saraiya, MD; Helen I. Meissner, PhD; David A. Haggstrom, MD, MAS; Louise Wideroff, PhD; Gigi Yuan, MS; Zahava Berkowitz, MSc, MSPH; William W. Davis, PhD; Vicki B. Benard, PhD; Steven S. Coughlin, PhD
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the National Cancer Institute or the Centers for Disease Control and Prevention. Dr. Yabroff had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Acknowledgment: The authors thank the Principal Investigator, National Survey of Primary Care Physicians' Recommendations & Practice for Breast, Cervical, Colorectal, & Lung Cancer Screening; Dr. Carrie Klabunde, National Cancer Institute, for coordination and leadership of this effort and thoughtful comments on an earlier version of the manuscript; and Dr. Caroline McLeod, Westat, for survey research work.
Grant Support: By the National Cancer Institute (contract N02-PC-51308), Centers for Disease Control and Prevention (interagency agreement Y3-PC-6017-01), and Agency for Healthcare Research and Quality (interagency agreements Y3-PC-5019-01 and Y3-PC-5019-02).
Potential Conflicts of Interest: None disclosed.
Reproducible Research Statement:Study protocol: Available from Dr. Yabroff (e-mail, email@example.com). Statistical code: Not available. Data set: Certain portions of the analytic data set are available to approved individuals through written data use agreements with the research sponsor; contact Dr. Klabunde (e-mail, firstname.lastname@example.org).
Requests for Single Reprints: K. Robin Yabroff, PhD, MBA, Health Services and Economics Branch/Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Executive Plaza North, Room 4005, 6130 Executive Boulevard, Bethesda, MD 20892-7344; e-mail, email@example.com.
Current Author Addresses: Dr. Yabroff: Health Services and Economics Branch/Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Executive Plaza North, Room 4005, 6130 Executive Boulevard, MSC 7344, Bethesda, MD 20892-7344.
Drs. Saraiya and Benard and Ms. Berkowitz: Centers for Disease Control and Prevention, 4770 Buford Highway, Mailstop K-55, Atlanta, GA 30341.
Dr. Meissner: Office of Behavioral and Social Sciences Research, Office of the Director, National Institutes of Health, 31 Center Drive, Building 31/Room B1C19, Bethesda, MD 20892-2027.
Dr. Haggstrom: Veterans Affairs Health Services Research & Development Center for the Implementation of Evidence-Based Practice, 1481 West 10th Street, Indianapolis, IN 46202.
Dr. Wideroff: 6001 Executive Boulevard, National Institute on Drug Abuse, Bethesda, MD 20892.
Ms. Yuan: Information Management Services, 12501 Prosperity Drive, Suite 200, Silver Spring, MD 20904.
Dr. Davis: Social Security Administration, 6401 Security Boulevard, Baltimore, MD 21235.
Dr. Coughlin: Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420.
Author Contributions:Conception and design: K.R. Yabroff, M. Saraiya, H.I. Meissner, D.A. Haggstrom, L. Wideroff, Z. Berkowitz, S.S. Coughlin.
Analysis and interpretation of the data: K.R. Yabroff, M. Saraiya, H.I. Meissner, D.A. Haggstrom, L. Wideroff, G. Yuan, Z. Berkowitz, W.W. Davis, S.S. Coughlin.
Drafting of the article: K.R. Yabroff, M. Saraiya, H.I. Meissner, V.B. Bernard, S.S. Coughlin.
Critical revision of the article for important intellectual content: K.R. Yabroff, M. Saraiya, H.I. Meissner, D.A. Haggstrom, L. Wideroff, Z. Berkowitz, V.B. Bernard, S.S. Coughlin.
Final approval of the article: K.R. Yabroff, M. Saraiya, H.I. Meissner, D.A. Haggstrom, L. Wideroff, G. Yuan, W.W. Davis, V.B. Bernard, S.S. Coughlin.
Statistical expertise: K.R. Yabroff, W.W. Davis.
Administrative, technical, or logistic support: Z. Berkowitz.
Cervical cancer screening guidelines were substantially revised in 2002 and 2003. Little information is available about primary care physicians' current Papanicolaou (Pap) test screening practices, including initiation, frequency, and stopping.
To assess current Pap test screening practices in the United States.
Nationally representative sample of physicians during 2006 to 2007.
1212 primary care physicians.
The survey included questions about physician and practice characteristics and recommendations for Pap screening presented as clinical vignettes describing women by age and by sexual and screening histories. A composite measure—guideline-consistent recommendations—was created by using responses to vignettes in which major guidelines were uniform.
Most physicians reported providing Pap tests to their eligible patients (91.0% [95% CI, 89.0% to 92.6%]). Among Pap test providers (n = 1114), screening practices, including number of tests ordered or performed, use of patient reminder systems, and cytology method used, varied by physician specialty (P < 0.001). Although most Pap test providers reported that screening guidelines were very influential in their clinical practice, few had guideline-consistent recommendations for starting and stopping Pap screening across multiple vignettes (22.3% [CI, 19.9% to 25.0%]). Guideline-consistent recommendations varied by specialty (obstetrics/gynecology, 16.4%; internal medicine, 27.5%; and family or general practice, 21.1%). Compared with obstetricians/gynecologists, internal medicine specialists and family or general practice specialists were more likely to have guideline-consistent screening recommendations (odds ratio, 1.98 [CI, 1.22 to 3.23] and 1.45 [CI, 0.99 to 2.13], respectively) in multivariate analysis.
Physician self-report may reflect idealized rather than actual practice.
Primary care physicians' recommendations for Pap test screening are not consistent with screening guidelines, reflecting overuse of screening. Implementation of effective interventions that focus on potentially modifiable physician and practice factors is needed to improve screening practice.
National Cancer Institute, Centers for Disease Control and Prevention, and Agency for Healthcare Research and Quality.
The American College of Obstetrics and Gynecology, American Cancer Society, and U.S. Preventive Services Task Force modified their cervical cancer screening guidelines in the early 2000s to reflect new information about human papillomavirus and decreased the advised frequency of screening in some risk groups.
In 2006 to 2007, physician responses to clinical vignettes for which all guidelines agreed suggest that fewer than 25% reported guideline-consistent care. Most variations indicated overuse of screening. Guideline-consistent responses were most frequent among internists, followed by family physicians and then gynecologists.
Results are not based on actual practice behaviors.
Physicians need to better understand cervical cancer screening recommendations.
Table 1. Comparison of Guidelines in 2002 and 2003 for Pap Testing for Cervical Cancer
Identification of primary care physician sample.
AMA = American Medical Association.
Table 2. Pap Test Screening Practice and Beliefs, by Physician Specialty
Table 3. Responses to Vignettes About Pap Test Screening
Guideline-consistent recommendations for Papanicolaou test screening, by physician specialty.
* Guideline-consistent recommendations measured when guidelines are uniform for starting or stopping Papanicolaou testing.
Appendix Table. Associations Between Physician and Practice Characteristics and Guideline-Consistent Screening Recommendations
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Yabroff KR, Saraiya M, Meissner HI, Haggstrom DA, Wideroff L, Yuan G, et al. Specialty Differences in Primary Care Physician Reports of Papanicolaou Test Screening Practices: A National Survey, 2006 to 2007. Ann Intern Med. 2009;151:602–611. doi: 10.7326/0003-4819-151-9-200911030-00005
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Published: Ann Intern Med. 2009;151(9):602-611.
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