Do follow-up recommendations for abnormal Papanicolaou smears influence patient adherence?

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.

Detection of high-grade cervical dysplasia: impact of age and Bethesda system terminology.

Pap smear, colposcopy, and biopsy results were collected from 1988-1993 at a group of family planning clinics. Positive predictive values and likelihood ratios were calculated for diagnosis of high-grade lesions based on age and Pap smear results. One thousand and forty-seven colposcopies were logged; 771 had a biopsy or endocervical curettage. Seventy-nine (10%) were high-grade lesions. If only human papillomavirus (HPV) was reported on the Pap smear, the likelihood of a high-grade biopsy was lowest (positive predictive value, 4.5%; likelihood ratio, 0.4). Women under age 25 were less likely to have high-grade biopsies (positive predictive value, 7.3%; likelihood ratio 0.7). Repeat Pap smears for atypical cells of undetermined significance (ASCUS) and low grade squamous intra-epithelial lesion (LGSIL) showing only HPV in women under age 30 would have reduced the immediate colposcopy rate by 60% and delayed diagnosis by 23% of high-grade lesions. Consideration of patient age and whether HPV is the only Pap smear finding may reduce referral for immediate colposcopy.

Effect of a transportation incentive on compliance with the first prenatal appointment: a randomized trial.

OBJECTIVE: To evaluate the effectiveness of incentives for improving compliance with the first prenatal appointment. METHODS: One hundred four low-income women, intending to enroll for prenatal care in a system of Northern California family planning clinics, were recruited for a randomized trial. Study subjects were assigned randomly to one of three groups, receiving a taxicab voucher or a baby-blanket coupon or an appointment slip (controls). Intention-to-treat analysis was used to compare compliance with the first prenatal appointment between the three groups. RESULTS: Subjects receiving the taxi voucher had a compliance rate of 82% for the first prenatal appointment, 22% higher than mean appointment compliance in the other groups. The odds ratio for missing the first appointment was 0.32 (95% confidence interval 0.12, 0.88) in the taxi voucher group. This was not affected by controlling for possible confounders. Despite better appointment compliance, only one of 34 taxi vouchers distributed was actually used. CONCLUSION: A taxi voucher incentive was effective in improving compliance with the first prenatal appointment, despite the fact that only one subject actually used the voucher.

Female sterilization.

PIP: The number of female sterilization procedures performed in the US has remained relatively constant over the past 15 years, and there are an estimated 1-2 deaths per 100,000 procedures. Although there have been no important breakthroughs in female sterilization technique, research on the long-term physical and psychosocial effects of the procedure continues. In terms of menstrual disturbances, dysmenorrhea is more often recorded among women who undergo cauterization or the Pomeroy method than in Fallope ring patients. A recent study reported a regret rate of 7%; low age at time of sterilization, parity of 2 and under, and change in marital status were the factors most often linked to this finding. This finding underscores the need for through preoperative assessment and counseling and the provision of informed choice to all women. It has been suggested that a nonsurgical female sterilization method with a 5% failure rate would be preferable to the current surgical methods, especially in developing countries where the risk-benefit ratio is unacceptable. To date, the most researched such method has been the Zipper technique, which involves 2 transcervical applications of 250 mg of quinacrine pellets.^ieng

Planned Parenthood experience with triphasil.

Triphasil, a low-dose combination oral contraceptive containing levonorgestrel and ethinyl estradiol, was tested in four Planned Parenthood clinics on 317 women between 18 and 34 years of age (mean, 23) for a total of 4,692 cycles, or 361 woman-years of usage. Approximately half these volunteers (165) were nulligravidas, and 309 (97.5%) were white. Despite instructions on proper tablet usage, there were 416 cycles (8.9%) in which one or more tablets were missed. Only one pregnancy occurred, in a cycle in which a total of four tablets was missed, for an uncorrected Pearl index of 0.28 pregnancies per 100 woman-years of usage. No pregnancy resulted from method failure, indicating a 100% efficacy rate for Triphasil when taken properly. The mean length of the menstrual cycle with Triphasil was 27.9 days; the mean length of menses, 4.4 days; and the mean latency period, 2.1 days. Menstrual flow was average in 64.1% of the subjects, light in 34.1%, heavy in 1.3% and variable in 0.5%. Amenorrhea during the tablet-free interval occurred in only 0.6% of the 4,692 cycles in which Triphasil was used. Breakthrough bleeding occurred in 6.9% of first cycles and 3.2% of total cycles; spotting, in 10.7% of first cycles and 4.4% of total cycles. Other symptoms that occurred with an incidence of greater than or equal to 1% were acne (1.0%), appetite increase (1.2%), breast discomfort (2.8%), breast enlargement (1.3%), gastrointestinal symptoms (1.7%), simple headache (1.4%) and nausea (1.1%). A total of 44 women (13.9%) discontinued treatment for medical reasons.(ABSTRACT TRUNCATED AT 250 WORDS)

Therapeutic abortion in California. Effects of septic abortion and maternal mortality.

PIP: The impact of the reformed California abortion law, passed in November 1967, is investigated. The law allows interruption of pregnancy in the presence of substantial risk of grave impairment to the mental or physical health of the mother. Septic abortions (complete or incomplete abortion in a patient whose gestation is less than 20 weeks; duration and whose temperature is greater than 100.4 degrees F for more than 4 hours) per 1000 deliveries at San Francisco General Hospital fell from 69 in 1967 to 22 in 1969. The total number of abortions rose from less than 100 per 1000 births in 1968 to more than 250 in 1969. Maternal deaths due to abortion decreased in California per 100,000 live births from 8 to 5 to 3 in 1967, 1968, and 1969. Maternal deaths due to other causes remained relatively fixed in incidence. Maternal deaths have decreased much more markedly in the San Francisco Bay area, where many more therapeutic abortions have been performed, than in the Los Angeles Area, where relatively few therapeutic abortions have been performed. The decrease in septic abortion seems to represent a trend toward decrease in the number of illegal abortions.^ieng