Evidence based guidelines recommend against screening for cervical cancer (Pap testing) in average risk adolescents. Despite this, many still undergo unindicated screenings with detrimental reproductive health and economic consequences. Our aim was to evaluate the efficacy of using provider notifications to reduce Pap testing in women < 21 years old in a large healthcare system.

Starting in July of 2020, a Best Practice Advisory (BPA) appeared in the electronic medical record (EMR) if providers ordered Pap testing on individuals < 21 years old. This BPA reiterated that screening was not indicated for average risk adolescents and prompted users to choose an indication for screening. A retrospective analysis was performed comparing females < 21 years old with Pap testing performed January 2019 - June 2020 (pre-intervention) to those with testing performed July 2020 - June 2021 (post-intervention). This study was approved by the IRB. Patient characteristics including age, race/ethnicity, health insurance status, and medical history were extracted from the EMR and analyzed using Fisher's exact tests, Kruskal-Wallis tests, and logistic regression.

There were 140 subjects included: 106 in the pre- and 34 in the post-intervention group. There were no differences in patient characteristics between the two groups. Neither Pap nor human papillomavirus (HPV) testing results differed in the two groups, however 6.6% of cytology tests were indicated pre-intervention, compared to 20.6% post-intervention (p=0.042) (Table 1). The proportion of indicated HPV testing did not differ pre- and post-intervention at 65% and 45%, respectively (p=0.295). The overall reduction in unindicated cervical cancer screening post-intervention was 13.9% (95% CI 4.0-23.7). This reduction in unindicated cervical cancer screening occurred in academic (p=0.048) rather than community settings and in tests ordered by physicians (p< 0.01) rather than advanced practice providers (Figure 1). The mean reduction in number of Pap tests (indicated and unindicated) performed per quarter post-intervention was 17.5% (p< 0.01). This reduction occurred in community (p< 0.01) rather than academic settings and in tests ordered by physicians (p< 0.01) rather than advanced practice providers. There was no association between unindicated cervical cancer screening and age, race/ethnicity, insurance status, or medical history.

Unindicated cervical cancer screening impacts future reproductive and mental health and can lead to higher healthcare spending. We demonstrated that the incorporation of a BPA to the EMR is a successful approach to reduce unindicated cervical cancer screening, particularly in academic settings.

Supporting Figures or Tables

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