Collaborating with Choosing Wisely Alberta, the Alberta Cancer Screening Program, and the Health Quality Council of Alberta, this project aims to support efforts ensuring women at risk of cervical cancer receive adequate screening, and also to highlight when screening might be inappropriate.
Don't screen women with pap smears if under 21 years of age or over 69 years of age.
Begin screening at age 21 or 3 years after becoming sexually active (whichever occurs later).
3-year Cervical Screening Rate (2012-2014) in women where screening is not recommended
The College of Family Physicians of Canada and the Canadian Association of Pathologists have each identified Pap smear screening as one of their recommendations for the Choosing Wisely Canada (CWC) campaign: Don’t screen women with Pap smears if under 21 years of age or over 69 years of age.
To evaluate current Alberta Pap smear screening practices to see how frequently Alberta doctors are following the CWC recommendation, the Physician Learning Program analyzed administrative data to develop provincial and health zone population adjusted Pap smear screening baseline measures as well as individual physician screening dashboards for consenting physicians.
The discrete number of women who had one or more Pap smears in the three years from 2012 to 2014 was pulled from Alberta Health Claims database by AH Surveillance and Assessment Branch using the appropriate billing and lab codes. Provincial and health zone population three-year adjusted screening rates were calculated using number of discrete women screened and mid-year population of 2013 from Alberta Health Interactive Application (IHDA) to recommendations for three age groups: females aged 15-20 years, 70-79 years and 80 years and older. Alberta yearly screening rates are also calculated to reflect changes from 2011 to 2014.
The screening rate in Alberta for women between the ages of 15-20 years old was 14.6%. There were significant differences in the screening rate among different health zones, ranging as low as 11.8% and as high as 20.8% in the Calgary and North Zones respectively. For women over 69, the provincial screening rate was 16.9% and there were also differences in various regions within Alberta. The population used to calculate the rate was not corrected to account for women whom had received hysterectomies, which likely has little effect on the rate in youger women, however, this could mean the rate for older women is underestimated.
Large Majority of Pap Smears billed by Primary Care Practitioners
|Discipline||# of Pap smear tests (% of total)|
|Family or General Practice||331,893 (87.8%)|
|Obstetrics & Gynecology||45,702 (12.1%)|
Several initiatives have been implemented since 2011 that may led to the resulting decrease in pap smear tests performed in women from ages where testing may be more harmful than helpful. Several significant interventions have been implemented since 2011, guideline updates implemented by Toward Optimized Practice in 2011 and again in 2016 (1,2), Alberta Cervical Cancer Screening Program (ref), launch of the Choosing Wisely National Campaign in 2013 (ref), and new evidence-based recommendations developed by the Canadian Task Force for Preventative Health Care (2013, ref). These initiatives combined with commitment from Primary Care Practitioners to provide the best level of care for women in Alberta may partly explain the decrease in screening rates for women 15-20, and older than 69 years of age between 2011 and 2014.
Screening Rate of Discrete Recipients (per 100 women)
Cervical cancer screening with Pap smear testing is a valuable and potentially lifesaving tool. However, its broad application to women at very low risk for cervical cancer may result in both harm and unnecessary expenditure of valuable health care resources. Local data from Alberta demonstrates the ongoing screening of very low risk younger and older women. This analysis provides clear evidence for the related Choosing Wisely Canada recommendations and may provide the impetus for further evaluation of cervical cancer screening practices.
This project allowed the Physician Learning Program to help identify the rates at which groups of women where cervical cancer cancer is not recommended and the differences among health zones within Alberta. This information could be valuable to identify and inform physicians of an opportunity to reduce unnecessary testing while ensuring women have the best quality of care according to the latest scientific evidence.
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