Follow-up of abnormal pap smears in a hospital based adolescent clinic

Abstract

Background An increasing number of adolescents have abnormal Pap smears, and little is know about factors which influence compliance with recommendations for repeat Pap smears and referrals for colposcopy. Methods Data was collected on all patients who were receiving health care in a hospital based comprehensive adolescent clinic and who had an abnormal Pap smear between July 1, 1994 and June 30, 1995. Demographic and clinical data included age, race, ethnicity, insurance status, prior abnormal Pap smears and colposcopy (between 1992 and July 1. 1994), Pap smears at follow-up, results of colposcopy, number of scheduled and kept appointments, and number of reminders (telephone calls, letters). Follow-up data was then collected through December 1, 1995. Data was analyzed using SPSS statistical software. Results 107 adolescents (mean age 18.2 ± 2.4 Years; range 11–23 years) had an abnormal Pap during the year. The adolescents were of mixed ethnicity and payor status: 29% were white, 61% black, 5% other, 6% unknown; 14% were Hispanic. 27% had Medicaid, 37% private insurance, 16% self-pay, 8% free care, 6% other, 6% missing data. The results of the index Pap smear was: 90 (84%) Atypia, 17 (16%) SIL LG. Of the 64 (60%) who had a second Pap smear, 32 (50%) were normal, 18 (28%) Atypia and 12(22) SIL LG. Of the initial 108 patients, the index Pap was the first abnormal Pap for 85 (79%) of the patients; 22 had had a previous abnormal Pap (15 atypias, 5 SIL LG, 2 SIL HG) and 11 had had a previous colposcopy. 80 patients had no prior colposcopy and atypia on the index Pap smear. Of these, 50 had a second Pap smear. The second Pap revealed 27 (54%) normal, 13 (26%) atypia, and 10 (20%) SIL LG. In all 52 (49%) patients were referred to the hospital's colposcopy clinic but only 28 actually had colposcopy despite outreach. Among those with no prior colposcopy and atypia on the index Pap, 32 patients were ultimately referred and only 17 kept the appointment. Following colposcopy patients kept an average of 2.1 visits and missed 1.1 visits. For both follow-up for repeat Pap smears and colposcopy, there are no difference by race, insurance status, age, Pap smear result, prior referral for colposcopy, or number of letters. The only significant factor for keeping a referral to colposcopy clinic was a visit to the adolescent clinic after notification of the abnormal Pap result and prior to the colposcopy appointment (77% v 38%)(p = .006). Conclusions Adolescents with abnormal Pap smears have high rates of failing to keep appointments for follow-up Pap smears and colposcopy. Because demographics factors did not define a group of adolescents at particular risk of noncompliance, interventions that target all adolescents with abnormal Paps need to be designed and tested. A visit to an Adolescent Program to explain the abnormal Pap smear and the reason for referral aided compliance. To improve surveillance more information needs to be gathered from the adolescents’ perspectives on reasons that follow-up appointments are not kept.