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Do Follow-up Recommendations for Abnormal Papanicolaou Smears Influence Patient Adherence?
Joy Melnikow, MD, MPH;
Benjamin K. S. Chan, MS;
Gary K. Stewart, MD, MPH
Arch Fam Med. 1999;8:510-514.
Objective To compare adherence to follow-up recommendations for colposcopy or repeated Papanicolaou (Pap) smears for women with previously abnormal Pap smear results.
Design Retrospective cohort study.
Setting Three northern California family planning clinics.
Patients All women with abnormal Pap smear results referred for initial colposcopy and a random sample of those referred for repeated Pap smear. Medical records were located and reviewed for 90 of 107 women referred for colposcopy and 153 of 225 women referred for repeated Pap smears.
Intervention Routine clinic protocols for follow-up—telephone call, letter, or certified letter—were applied without regard to the type of abnormality seen on a Pap smear or recommended examination.
Main Outcome Measures Documented adherence to follow-up within 8 months of an abnormal result. Attempts to contact the patients for follow-up, adherence to follow-up recommendations, and patient characteristics were abstracted from medical records. The probability of adherence to follow-up vs the number of follow-up attempts was modeled with survival analysis. Cox proportional hazards models were used to examine multivariate relationships related to adherence.
Results The rate of overall adherence to follow-up recommendations was 56.0% (136/243). Adherence to a second colposcopy was not significantly different from that to a repeated Pap smear (odds ratio, 1.40; 95% confidence interval, 0.80-2.46). The use of as many as 3 patient reminders substantially improved adherence to follow-up. Women without insurance and women attending 1 of the 3 clinics were less likely to adhere to any follow-up recommendation (hazard ratio for no insurance, 0.43 [95% confidence interval, 0.20-0.93], and for clinic, 0.35 [95% confidence interval, 0.15-0.73]).
Conclusions Adherence to follow-up was low in this family planning clinic population, no matter what type of follow-up was advised. Adherence was improved by the use of up to 3 reminders. Allocating resources to effective methods for improving adherence to follow-up of abnormal results may be more important than which follow-up procedure is recommended.
From the Departments of Family and Community Medicine (Dr Melnikow), Internal Medicine (Mr Chan), and Obstetrics and Gynecology (Dr Stewart), University of California–Davis School of Medicine, Sacramento. Mr Chan is now with the Division of Medical Informatics and Outcomes Research, Oregon Health Sciences University, Portland. Dr Stewart is deceased.
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