Quality Papanicolaou Smears
Arch Fam Med. 1999;8:413.
Due to the complexity of this study on the quality of Papanicolaou (Pap) smears, I have reread this article several times to ascertain its meaning. The authors make the presumption that the percentage of abnormalities discovered on Pap smears is a good quality criterion for Pap smears. The authors found that obstetrician-gynecologists perform more Pap smears than family physicians and have different types of patients. Here are some of the other findings:
- "Adequate" Pap smears by Bethesda criteria slightly revised by the authors do not relate to the percentage of reported abnormalities; thus, the percentage of adequate Pap smears may not be a good quality criterion.
- The presence of endocervical cells on Pap smears is associated with higher rates of detection of abnormalities.
- Use of the cytobrush is associated with higher rates of endocervical cell detection.
- There is a group of clearly underperforming providers found among all the specialty groups that should be targeted for improvement.
- Obstetrician-gynecologists are more likely to use the cytobrush and have a higher rate of endocervical cell detection. Obstetrician-gynecologists detect a higher rate of abnormalities, even when some typical factors (such as age and hysterectomy status) and the use of the cytobrush are accounted for statistically. However, socioeconomic status, referral status, and individual risk factors were unknown and could be confounding factors.
Lack of generalizability may also result from the low rate of voluntary participation (40.0%).
I continue to be uncertain that the higher rate of detection of abnormalities is the best quality criterion, although I do use the cytobrush. Why the uncertainty? Well, we do not know whether these additional abnormalities apparently discovered with the cytobrush are the ones that would truly progress to the clinically important outcomes, such as carcinoma, or whether they are the ones more likely to regress. For example, one study1 published in the ARCHIVES found that the results with the Ayre spatula alone correlated better with diagnosis than those with the Zelsmyr cytobrush alone after 2 years of follow-up. Therefore, reliance on the marker of endocervical cells as an indirect quality measure may be the best we have at this time, but I believe we need further work on identifying quality measures for Pap smears based on outcomes.
Marjorie A. Bowman, MD, MPA
1. Crouse BJ, Elliot BA, Nesin N. Clinical follow-up of cervical sAmpling with the Ayre spatula and Zelsmyr cytobrush. Arch Fam Med. 1993;2:145-148.
FREE FULL TEXT
Characteristics and Quality of Papanicolaou Smears Obtained by Primary Care Clinicians Using a Single Commercial Laboratory
Peter Curtis, Melanie Mintzer, Daphne Morrell, Jacqueline C. Resnick, Selinde Hendrix, and Bahjat F. Qaqish
Arch Fam Med. 1999;8(5):407-413.
| FULL TEXT