Clinical Audit - Identifying patients who are not participating in regular cervical screening

Audit focus

The purpose of this audit is to initiate conversations about cervical screening with patients who are not regularly participating in the cervical screening programme, to identify the reason(s) why they are not and then, if possible, to try to resolve these issues.

Background

Cervical cancer is now largely preventable through HPV vaccination and cervical screening programmes; since the implementation of these programmes, fewer people are being diagnosed with and dying from cervical cancer. However, there are still an average of 171 new diagnoses (from 2015 – 2020) and 53 deaths (from 2015 – 2018)^* caused by cervical cancer each year. Cervical cancer is the third most common gynaecological cancer in New Zealand.

^*Mortality data are available for 2019, but are preliminary so have not been included. Mortality data for 2020 are not yet available.

Although the HPV immunisation programme has effectively reduced the prevalence of HPV infection and the incidence of cervical cancer, vaccination cannot eliminate cervical cancer entirely as people may:

• Not have been eligible for vaccination, did not opt to be vaccinated or did not complete the course (in rare cases, people may not develop immunity despite being vaccinated)
• Have been exposed to HPV prior to being vaccinated
• Have been infected with a high-risk type of HPV that was not covered by the vaccine (Gardasil 9 only covers seven of the 14 high-risk HPV types known to be associated with cervical cancer)
• Have been infected with a low-risk type of HPV that very rarely, can cause cervical cancer
• Have a non-HPV associated cervical malignancy

Therefore, all eligible people including those who have been vaccinated against HPV should undergo regular cervical screening to detect any pre-cancerous lesions and prevent progression to invasive cervical cancer.

HPV testing is now the primary cervical screening test in New Zealand, replacing the previous cytology-based test. Cytology will continue to be used in the follow-up of people in whom HPV is detected, and in some clinical scenarios as part of a co-test, e.g. people with symptoms or needing a test of cure. The HPV test can be performed on a vaginal swab sample (with the option of self-testing) or a liquid-based cytology (LBC) sample. The option of self-testing may change the views of some people who have previously declined cervical screening because they did not want to have a speculum examination (although a speculum examination will be required if HPV Type Other is detected from a vaginal swab).

The National Cervical Screening Programme (NCSP) recommends cervical screening every five years (or every three years if immune deficient – see below) following a “HPV Not detected” test result for people with a cervix or vagina aged 25^* – 69 years who have ever been sexually active. Screening is extended to people aged 70 – 74 years who are unscreened or under-screened. The target is for at least 80% of all eligible people to have had cervical screening. Management initially depends on the HPV test results; if HPV is detected, the patient is either referred directly for colposcopy or management depends on cytology results (if HPV Type Other is detected on a vaginal swab, a return visit for a LBC sample to be taken is needed, as cytology cannot be performed from a vaginal swab sample).

^†Prior to 2019, the start age was 20 years; people aged < 25 years who have already started cervical screening should continue to be recalled and managed in the same way as those aged 25 – 69 years

Females who are immune deficient require more frequent cervical screening, i.e. every three years after a “HPV Not detected” result, due to an increased risk and prevalence of HPV infection, cervical lesions and cervical cancer. Consider a single HPV test for people aged between 20 and 24 years if they have been immune deficient for more than five years and have been sexually active.

The responsibility for notifying patients that they are due for cervical screening, providing results and placing a recall on the PMS belongs to the primary care team. The NCSP provides an important “backstop” to ensure that people who have an abnormal cervical screening result are informed and that appropriate follow-up is planned.

If a patient is not undergoing regular cervical screening, it is important to discuss the reason(s) why (see below) and the benefits of being screened for cervical cancer if appropriate. Try to resolve the reason(s) if possible and book an appointment.

Some patients have appropriate reasons for not participating in cervical screening, e.g. they have had a hysterectomy (unless they had a recent history of abnormal cervical cytology), do not have a cervix, have been treated with radiotherapy for a gynaecological cancer (can cause abnormal changes to cells and therefore false positive cytology results), have never been sexually active^**.

Other patients may not be participating because they have missed appointments (e.g. due to COVID-19), were not recalled or had previously declined; regular discussion about participation is important as circumstances may change (e.g. becoming sexually active) and barriers or concerns may be able to be addressed (e.g. self-testing option); also see: “Reducing barriers to cervical screening".

^**Ensure patients are aware that being sexually active involves any form of sexual contact, i.e. it is not restricted to sexual intercourse, and includes those who are not currently sexually active but have been in the past

For further information, see: “Cervical cancer – early detection and referral”

Audit Plan

Summary

Ultimately the decision to participate in cervical screening is made by the patient and not the general practitioner, therefore it is difficult to audit practice in the usual way; hence this audit slightly differs from traditional ones. You will not need to search for and access the patient’s clinical notes to complete this audit. Instead, it can be completed over time opportunistically during consultations for other reasons with eligible patients until the required number of patients has been reached.

When an eligible patient presents for any reason during the period of the audit, check their cervical screening status. If they are up to date, indicate this in the audit data sheet; no further action is required. If they are not up to date with cervical screening, note the general reason(s) why in the data sheet (avoid any identifiable information) and ensure that this is also more comprehensively documented in their clinical record. If appropriate, reinforce the importance of being screened for cervical cancer and put a plan in place to resolve the reason(s) why the patient is not up to date. Indicate in the data sheet whether an appointment has been booked.

Recommended audit standards

All females aged 25 – 69 years who are sexually active are recommended to undergo regular cervical screening. Ideally those who do not participate in regular screening should periodically be encouraged to do so and asked if their circumstances or views have changed. The purpose of this audit is to initiate conversations about cervical screening with patients who are not regularly participating in the cervical screening programme, to identify the reason(s) why they are not and then, if possible, to try to resolve these issues.

Audit Data

Eligible patients

All females aged 25 – 69 years are eligible for this audit. This includes people who are biologically female but have a different identifier in their clinical record.

Identifying patients

This is a “working audit” where the data sheet is filled in over time when you have a consultation for any reason with an eligible patient until the required number of patients has been reached.

Sample Size

For the purposes of this audit, continue until 30 eligible patients have been identified and included.

Criteria for a positive result

A positive result is achieved by discussing cervical screening with a patient who is not regularly participating in the cervical screening programme to identify their reason(s) why, and then if possible, trying to resolve the reason(s). Ideally, the outcome is a booked appointment.

Data analysis

Use the sheet provided to record your data. Aim to resolve reasons for not participating in regular cervical screening for as many patients as possible.

Identifying opportunities for Audit of Medical Practice

The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual performance and then to decide how to change practice.

Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.

Taking action

It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).

Problem solving process

• What is the problem or underlying problem(s)?
• Change it to an aim
• What are the solutions or options?
• What are the barriers?
• How can you overcome them?

Overcoming barriers to promote change

• Identifying barriers can provide a basis for change
• What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them in the practice setting
• Identify the barriers
• Develop a priority list
• Choose one or two achievable goals

Effective interventions

• No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed to bring about lasting change
• Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance and behaviour

Review

Monitoring change and progress

It is important to review the action plan developed previously at regular intervals. It may be helpful to review the following questions:

• Is the process working?
• Are the goals for improvement being achieved?
• Are the goals still appropriate?
• Do you need to develop new tools to achieve the goals you have set?

Following completion of the first cycle, it is recommended that practitioners complete the first part of the Audit of Medical Practice (CQI Activity) summary sheet (Appendix 1).

Undertaking a second cycle

In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order to quantify progress on closing the gaps in performance.

It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle should begin at the data collection stage. Following the completion of the second cycle it is recommended that the remainder of the Audit of Medical Practice (CQI Activity) summary sheet is completed.

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