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Comparison of the effectiveness of General Practice cervical screening systems

Student: Meagan McLeod
Supervisors: Dee Mangin, Dept Public Health & General Practice, Co-Supervisor Vivian Daley, Pegasus Health
Sponsor: Pegasus Health IPA

What is Cervical Screening?
Cervical screening is the use of the Papanicolaou or ‘Pap.’ smear test to try and prevent cervical cancer developing in women within at-risk populations. In 1991 a national cervical screening programme was set up in New Zealand to keep a register of women receiving pap smears. This programme has been quite successful, within its first ten years the number of women getting cervical cancer dropped by nearly half and the number of women who died of cervical cancer was decreased by 60%! However, there is still plenty of room for improvement so the national cervical screening programme has set national goals for the percentage of women in the eligible age group that are having smears. To help achieve these goals the national programme requires that qualified smear takers give women plenty of opportunities to become involved in the programme and that after having a Pap. smear, women are followed up according to the result of the test.

General Practice and Cervical Screening
Most Pap. smears in New Zealand are provided by general practices, because of this general practices play an important role in reaching the national cervical screening goals. Both doctors (GPs) and nurses are an important influence on a woman’s decision to participate in the screening programme. This can be through providing information, encouragement and support, making an effort to remind women when they are due or overdue for their next smear or through creating an environment in which a woman feels comfortable enough to have the test done. There a number of ways that a general practice can record screening information as well as the system used to recall women for their next smear.

The Pegasus General Practice Survey and Audit of cervical screening rates
Pegasus Health, an independent practitioner association, recently funded a study looking into how the screening rates in general practices may be affected by the systems they used to record screening information and recall women for smears. The screening rate of a practice was calculated from the practice records, this was based on the percentage of the total number of women eligible for screening that had been screened in the last five years. Current general practice cervical screening systems were investigated by a questionnaire survey. From the questionnaire it was obvious that there is a lot of variation in cervical screening systems between practices although certain parts of the screening process were done the same way by almost all the practices. For example, in most practices it was one or more practice nurses who were responsible for processing the recalls, although, the person taking the smear was often the GP. Of all the practices surveyed 20% had a high screening rate (>75%). A few processes described in the questionnaire responses were found to be associated with a high rate of screening, such as, making more attempts to contact women overdue for a smear. Practices that use the cervical screening programme (CSP) laboratory form were more likely to have a higher recorded screening rate. Also, it was much more common in practices with high screening rates for both nurses and doctors to take smears than in practices with low screening rate (<50%). In these practices with low screening rates it was common for only GPs to be qualified to take the pap. smear. When women that are eligible for cervical screening first enrol in a general practice they need to be accurately entered into the recall system. The practice software will automatically put these women onto recall in 1 month unless the appropriate recall date is entered. Practices that did not access the national cervical screening register for the date of next smear or screening history for new patients but relied on the auto-recall and patient notes were more likely to have low screening rates. Low cervical screening rates were also related to uncertainty whether the screening codes had been updated to the recommended standards.

How can cervical screening rates in general practice be improved?
The differences between high and low screening rates may be explained by less women being dropped off or missed by recall processes, reduced barriers to women to have a smear (e.g. time, cost and male smear taker) and greater accuracy of information on the practice record system. This study has found strong associations between high screening rates and some cervical screening systems. Other practice systems were related to low rates of screening. From this it can be concluded that there is room for improvement in the way general practices manage their cervical screening systems. Screening rates recorded in general practices could potentially be increased through improving a number of aspects of the cervical screening systems.
These areas include the confidence and ability of staff members with the cervical screening system, national screening services and software functions. Also the investment of additional resources into following up non-responders to recall and provision of both GP and Nurse smear takers. Improving cervical screening rates in general practice is a step toward reaching the goals set by the national cervical screening programme. Ultimately it is hoped this will lead to fewer New Zealand women developing cervical cancer.