Improving and Sustaining
Cervical Cancer Screening Rates
Issues, Challenges, Successes
Moderator: Deborah Willis-Fillinger, MD, PO, HRSA/HAB/DCHAP
Co-Presenters/Facilitators:
Mississippi QM Group: Tonya Green, Stephanie Pettiet Hedgepeth,
Kawanis Collins
Eastern PA QM Group: Elizabeth Brown, Jim Bond, Christa Delong
Workshop Assumptions
We all have an interest in women’s health.
We all have experience; however we don’t have the
answers.
We’re here to learn about improving HIV+ women’s
health with a focus on annual Pap screens
Let’s reach a better understanding together.
Workshop Learning Outcomes
By the end of this workshop, participants will be able to:
• Engage in a dialogue with grantees about their
experiences with
• Improving cervical cancer screening rates,
• Facing challenges from multiple perspectives – organizational,
supportive services, and patient level, and
• Sustaining improvements.
• Identify successful approaches and interventions.
Agenda
3:00 Welcome.
Renewing Commitment
3:15 Tough Road To Sustained Improvement
Benchmarking data and results
Reasons for variable rates
3:30 Improvement Experiences in MS and E. PA
3:55 Small Group Exchange
4:15 Large group sharing and summation.
4:30 Adjourn. Thank you!
Renewing Commitment
Cervical Cancer Screening
The Clinical Case
Deborah Willis-Fillinger, MD
HRSA/HAB/DCHAP
AGM 2012
Shorter Survival For Women?
• Analysis of studies involving more than 4,500
people with HIV infection revealed women
were 33 percent more likely than men to die
within the study period.
1990- 1995
• New York City AIDS Surveillance data from
1990 to 1995, observed cervical cancer cases
in HIV-positive women were two to three
times higher than the expected number of
cases.6,7
2007- 2009
• By 2009, in the U.S., women accounted for
more than 25% of the new HIV infections.
• For women the most common methods of
transmission were high-risk heterosexual
contact and injection drug use.
What We Can Do….
• Cervical cancer can be prevented or detected
in its earliest stages through effective Pap
smear screening.
• Even HIV-infected women with invasive
cervical cancer tend to do well with surgery
and treatment and good immune function
• Accentuates the importance of routine Pap
smears for HIV-infected women.13
Human Papillomavirus (HPV)
• Common infection in the general population.
• Over 50% of sexually active adults have been
infected with one or more HPV types.
• Within 5 years of sexual debut—70% have
HPV
HPV 16-18 and Pap Co-Tests?
• 100 genotypes of HPV
– 15 cause cancer
• HPV 16 & 18 = 70% of cervical cancer
• Co-Testing for HPV with Pap Smears may
Increase predictive value of cervical cancer
screenings.. More to come..
• Current Guidelines….
Tough Road To Sustaining Improvement
Experience
National Benchmarking Data – 2007-09
HIVQUAL GYN Care Indicator
GYN Care in review period
3,640 women eligible in 2009
Eligible/denominator: at least one clinical
Visit in each 6-month period of the
review period.
Clinic mean for patients who had both a
pelvic exam and a Pap test: 69% to 62%
GYN Care
96%93%
100%
80%
69%
90%
85%
62%
60%
40%
Of 2,293 women with a pelvic and pap
smear, clinic mean of
–23% (556) abnormal
–With clinic mean of 90% (487) referred
for follow-up
20%
0%
Pap and Pelvic
(all females)
Pap test (among
those with a
Pelvic exam)
2007 C/D
Follow-up for
abnormal Pap
2009 C/D
13
What is Your Measure?
What are Your Rates?
How many of you are using HRSA/HAB
performance measure for Cervical Cancer
Screening?
Percentage of women with HIV infection who have a Pap screening in the
measurement year
• Numerator: Number of HIV-infected female clients who had Pap
screen results documented in the measurement year
• Denominator: Number of HIV-infected female clients who:
– were >18 years old1 in the measurement year or reported having a history of sexual
activity , and
– had a medical visit with a provider with prescribing privileges2 at least once in the
measurement year
What are your results?
Please raise your hands. How many have
results? How many have sustained their
results after improvement efforts?
< 50%
50% - 60%
60% - 70%
70% - 80%
80% - 90%
90% - 100%
Are we still facing the same reasons
for low rates or variable rates?
Program
Data from
2008
Mississippi Statewide Quality
Management HIVQUAL Group
Part C Grantee Representatives
Successful Interventions
Can they be sustained?
• Southeast Mississippi Rural Health, Inc.
(SeMRHI) – Tonya Green
• Crossroads Clinics North – Stephanie Pettiet
Hedgepeth
• Magnolia Medical Clinic – Kawanis Collins
Who do we serve in Mississippi?
• Percentage of HIV+ female patients
• Percentage of African American, White,
Hispanic, Other
• Percentage below the Federal Poverty level
• Percentage on ART
• Percentage with AIDS Diagnosis
Mississippi Grantees’ Experience
Part C
2010-2012 Pap Screening Results
Lost NP
90%
Staff Turnover;
New team hired.
80%
70%
60%
Provider Reminder in chart
“Pap Me”
50%
Program 1
40%
Hired new NP
30%
20%
10%
0%
Apr-10
Aug-10
Dec-10
Apr-11
Aug-11
Dec-11
Apr-12
Aug-12
Program 2
Program 3
Eastern Pennsylvania Quality
Management HIVQUAL Group
Part C Grantee Representatives
Successful Interventions
Can they be sustained?
Two Rivers Health and Wellness Foundation
• St. Luke’s University Hospital Network,
Community Health – Liz Brown
• ECHO Program, Easton Hospital – Christa
Delong
• Comprehensive Care Medicine, Lancaster
General Health – Jim Bond
Who do we serve in E. PA?
• Percentage of HIV+ female patients
• Percentage of African American, White,
Hispanic, Other
• Percentage below the Federal Poverty level
• Percentage on ART
• Percentage with AIDS Diagnosis
Eastern PA Grantees’ Experience
Part C
• 2010 – 2012 Pap screening results
90%
Lost PA
created monthly tracking log and outreach
phone protocol to contact pts nt meeting measure
and those in need of a Pap test in 3 mos
80%
70%
Hired PA,
60% Created pt need
List - placed in
50% visible location to
incr provider
40% awaress
patient education calls to
Schedule appt
Pap Squad
NP
30%
Program 1
Lost NP;
Adhere to different
Guidelines
Program 2
Program 3
New PA
Hired; Program1
20%
10%
0%
Oct-09
Feb-10
Jun-10
Oct-10
Feb-11
Jun-11
Oct-11
Feb-12
Jun-12
Sharing Experiences
Small Group Discussion
Instructions: Divide into groups of 5-6 participants. Each group
should have only one person from a program. Select a facilitator
and recorder. Discuss the following questions and, then, share
your recommendations for further action.
1. What interventions and approaches have you tried? Please share
your successes and challenges.
2. Have you been able to sustain your gains? If yes, why? If not, why
not?
3. What are your recommendations to guide future improvement
work for women’s health and annual cervical cancer screens?
Large Group Exchange and Summation
A volunteer from each group shares the
highlights of the group’s discussion.
Large Group Summation:
1. Are there recurrent ideas and themes related
to improving and sustaining annual pap tests?
If so, what are they?
2. Any additions? Comments?
Ask
Contact Information
Deborah Willis-Fillinger, MD, Project Officer, HRSA/HAB/DCHAP,
dwillis-fillinger@hrsa.gov
Comprehensive Care Medicine, Lancaster General Health – James T.
Bond, Data Manager/CQI Coordinator
jtbond@LancasterGeneral.org
Two Rivers Health and Wellness Foundation
• Elizabeth Brown, Community Health, St. Luke’s University
Hospital Network, HIV RN, Elizabeth.Brown@slunhn.org
• Christa , ECHO Program, Easton Hospital, christa_delong@chs.net
Contact Information
Crossroads Clinics North – Stephanie Pettiet Hedgepeth, Program
Coordinator, spettiet@deltaregional.com
Magnolia Medical Center – Kawanis Collins, BSW, Program
Coordinator, kcollins@glh.org
Southeast Mississippi Rural Health, Initiative (SeMRHI) – Tonya
Green, ACRN, MPH, Director of Social Services,
tgreen@semrhi.com
Contact Information
NQC/HIVQUAL – Nanette Brey Magnani, EdD, Quality Consultant
for Eastern PA Regional QM Group and Mississippi Statewide
QM Group, AGM Session Coordinator, breymagnan@aol.com