Association Between Clinician Confidence and Making Guideline-Recommended Decisions in the Management of Abnormal Cervical Cancer Screening Results.

BACKGROUND: Guidelines for managing abnormal cervical cancer screening results are complex and adherence is challenging for clinicians. Previous studies have identified gaps in knowledge as a possible cause; few have explored the confidence clinicians have in their management decisions. Confidence in decision-making may influence management practices, particularly when guidelines are complex and evolving. OBJECTIVE: Assess whether confidence in decision-making is associated with making guideline-concordant recommendations for abnormal cervical cancer screening results. DESIGN: A clinician survey used vignettes to ask clinicians to make a management recommendation for different abnormal results and rate their level of confidence in their response. PARTICIPANTS: Physicians and advanced practice providers (APPs) at three diverse health systems in Washington, Texas, and Massachusetts. MAIN MEASURES: Correct response to each vignette based on either the 2012 or 2019 American Colposcopy and Cervical Pathology (ASCCP) management guidelines. KEY RESULTS: In total, 501 clinicians completed the survey between October and December 2020 (response rate 53.7%). Overall, most clinicians made guideline-recommended management decisions for two vignettes (73.2 and 73.7%), but fewer were confident in their selection (48.3% and 46.6%, respectively). Clinicians who reported high levels of confidence were more often correct than those who reported lower levels of confidence (85.8% vs. 62.2% and 87.5% vs. 60.7%, both p<0.001). After adjusting for clinician and practice characteristics, confidence remained significantly associated with selecting the correct answer. CONCLUSIONS: Clinician confidence in management decisions for abnormal cervical cancer screening results was significantly associated with knowing guideline-concordant recommendations. Given the complexity of cervical cancer management guidelines, solutions to improve clinician confidence in decision-making are needed.

Evaluation of Human Papillomavirus Vaccination and Cancer Prevention Behaviors among LGBTQI + Individuals: A Cross-Sectional Study.

Human Papillomavirus (HPV) vaccination and cervical cancer screening rates are suboptimal in the US, particularly among historically underserved groups like Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex (LGBTQI+)-identifying women and transgender men. Therefore, our cross-sectional study assessed factors associated with these rates among LGBTQI+-identifying women and transgender men.HPV-related cancer knowledge, HPV vaccination and cervical cancer screening status, and the acceptability of self-collection for screening of 1983 LGBTQI+-identifying women and transgender men was assessed via an online survey available to members of the HER mobile app from March to May 2022. Associations between sociodemographic factors, vaccination, and screening were assessed using multivariable logistic regressions from November 2022 to December 2023.Most participants aged 18-26 (77.0%) and 6.3% of participants aged ≥46 (P < 0.001) had received at least one dose of the HPV vaccine. Cervical cancer screening rates were positively associated with age: 70.5% of those aged 21-26 and 96.1% aged ≥46 (P < 0.001). Screening was negatively associated with male gender identity (OR, 0.13; 95% CI, 0.04-0.42; P < 0.001), being uninsured (OR, 0.40; 95% CI, 0.24-0.67; P < 0.001), and being unvaccinated against HPV (OR, 0.28; 95% CI, 0.18-0.43; P < 0.001). 29.6% of those unscreened believed screening was not needed, and 22.1% were uncomfortable with pelvic exams. 40.4% of all participants would prefer self-collection for screening. Our findings indicate opportunities to increase screening and vaccination. Among under-screened individuals, lack of knowledge about screening necessity and discomfort with pelvic exams were important barriers. Targeted interventions addressing patient knowledge, practitioner communication, and exploring self-screening strategies are warranted.

Vaccine Coverage Associated With Ending a Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Wave: A Retrospective Longitudinal Analysis.

BACKGROUND: Two SARS-CoV-2 waves in Israel ended while a substantial number of individuals remained unvaccinated or partially vaccinated. The indirect protective effect of the first BNT162b2 vaccination campaign in Israel was evaluated between 22 December 2020 and 18 May 2021. METHODS: The daily percentage of new polymerase chain reaction (PCR)-confirmed SARS-CoV-2 cases among unvaccinated individuals was analyzed for trends. Major shifts were identified using piecewise linear regression analysis. At these shifts, the percentage of naturally vaccinated (past SARS-CoV-2 cases) and the percentage of actively vaccinated (by inoculation) individuals were weighted and summed to determine the percentage of natural and active vaccination (NAV). RESULTS: A first decline among unvaccinated individuals occurred during a lockdown period, when the percentage of NAV was 8.16%. The major decline occurred after the end of the lockdown when the percentage of NAV reached 52.05%. SARS-CoV-2 cases ultimately declined among unvaccinated individuals when the percentage of NAV reached 63.55%. During the study period, the Alpha variant was prevalent and the use of nonpharmaceutical interventions, including social distancing, existed to varying degrees. CONCLUSIONS: The vaccination campaign played a major role in the decline of SARS-CoV-2 infection among unvaccinated individuals, leading to the end of the first 2021 SARS-CoV-2 wave (Alpha variant) in Israel. Infection in unvaccinated individuals stopped when two-thirds of the population were naturally or actively vaccinated. Any change in characteristics of the virus or the population can lead to a new outbreak.

Comparison of Enhanced Recovery After Surgery (ERAS) metrics by race among gynecologic oncology patients: Ensuring equitable outcomes.

OBJECTIVES: Race and ethnicity are not routinely audited in Enhanced Recovery After Surgery (ERAS) pathways. Given known racial disparities in outcomes in gynecologic oncology, the purpose of this study was to compare differences in ERAS implementation and outcomes by race. METHODS: A cohort study was performed among gynecologic oncology patients enrolled in an ERAS pathway at one academic institution from March 2017 to December 2021. Compliance with ERAS metrics, postoperative complications, 30-day survival, reoperations, intensive care unit (ICU) transfers, and readmissions within 30 days were compared by race. RESULTS: Of 1083 patients (17.0% non-white), non-white women were younger (54.2 years ±13.1 vs. 60.7 years ±13.6, p < 0.001) and proportionally fewer spoke English (75.0% vs. 97.8%, p < 0.001). Fewer non-white women received preadmission ERAS education (73.4% vs. 79.9%, p = 0.05). There were no differences in ERAS implementation by race, including similar rates of preoperative nutritional assessment, carbohydrate loading, antibiotic and thrombosis prophylaxis, and unplanned surgeries by race. There were no differences in complications, reoperations, ICU transfers, or readmissions by race on univariate and multivariate analysis. Four non-white (2.2%) and two white women (0.2%, p = 0.009) died within 30 days of surgery. CONCLUSIONS: Fewer non-white women received preadmission education, possibly due to language barriers. ERAS compliance, postoperative complications, readmissions, reoperations, and ICU transfers did not differ by race. There were two additional deaths within 30 days postoperatively among non-white women compared to white women - which is difficult to interpret given the rarity of perioperative mortality - but appeared unlikely to be related to differences in ERAS protocol implementation. ERAS programs should ensure educational materials are translated into various languages and audit metrics by race to ensure equitable outcomes.

Provider- and Facility-Level Variation in Precancerous Cervical Biopsy Diagnoses.

OBJECTIVES: Reproducibility of cervical biopsy diagnoses is low and may vary based on where the diagnostic test is performed and by whom. Our objective was to measure multilevel variation in diagnoses across colposcopists, pathologists, and laboratory facilities. METHODS: We cross-sectionally examined variation in cervical biopsy diagnoses within the 5 sites of the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR I) consortium within levels defined by colposcopists, pathologists, and laboratory facilities. Patients aged 18 to 65 years with a colposcopy with biopsy performed were included, with diagnoses categorized as normal, cervical intraepithelial neoplasia grade 1 (CIN1), grade 2 (CIN2), and grade 3 (CIN3). Using Markov Chain Monte-Carlo methods, we fit mixed-effects logistic regression models for biopsy diagnoses and presented median odds ratios (MORs), which reflect the variability within each level. Median odds ratios can be interpreted as the average increased odds a patient would have for a given outcome (e.g., CIN2 or CIN3 vs normal or CIN1) when switching to a provider with higher odds of diagnosing that outcome. The MOR is always 1 or greater, and a value of 1 indicates no variation in outcome for that level, with higher values indicating greater variation. RESULTS: A total of 130,110 patients were included who received care across 82 laboratory facilities, 2,620 colposcopists, and 489 pathologists. Substantial variation in biopsy diagnoses was found at each level, with the most occurring between laboratory facilities, followed by pathologists and colposcopists. Substantial variation in biopsy diagnoses of CIN2 or CIN3 (vs normal or CIN1) was present between laboratory facilities (MOR: 1.26; 95% credible interval = 1.19-1.36). CONCLUSIONS: Improving consistency in cervical biopsy diagnoses is needed to reduce underdiagnosis, overdiagnosis, and unnecessary treatment resulting from variation in cervical biopsy diagnoses.

An Interactive Educational Tool to Improve Human Papillomavirus Vaccine Knowledge and Recommendation Among Nurses.

In United States, only 57% of  women and 53% of men in the recommended age groups have received all recommended doses of the human papillomavirus (HPV) vaccine. Healthcare provider education has been associated with strong vaccine recommendation and vaccination uptake. Our objective was to create a 7-min interactive online educational tool to improve knowledge and willingness to recommend the HPV vaccine among nurses. This is a prospective pre-test/post-test study to evaluate the effectiveness of the educational tool consisting of 10 flashcards in a question-answer format. Oncology nurses at our cancer center were invited to participate by email, which led them to the educational tool (i.e., intervention) along with pre- and post-test questions on HPV-associated cancers, vaccine-eligible age groups, dosing schedules, adverse events, and willingness to recommend. Of the 110 participants (mean age of 41.2 ± 11.4, 98% female, 64% >10 years of practice), there was improvement in knowledge after intervention in HPV-associated cancers (81% to 97%; p = 0.02), percentage of cervical caused by HPV (33% to 64%; p < 0.05), and dosing schedule (47% to 93%; p < 0.05). All participants correctly stated that continued screening is needed after vaccination both pre- and post-intervention. Eighty-five percent strongly agreed that the intervention improved their HPV knowledge, and 77% stated they were more likely to recommend the HPV vaccine after the intervention. While nurses are willing to recommend the vaccine, there remains persistent knowledge gaps. A brief 7-min self-administered online interactive flashcard educational intervention is effective in improving the HPV vaccine knowledge among nurses.

Human Papillomavirus (HPV) Education and Knowledge Among Medical and Dental Trainees.

Persistent human papillomavirus (HPV) infection is responsible for the majority of oropharyngeal and cervical cancers in the USA. Currently, HPV curricula within medical and dental schools are not standardized. As such, we implemented a brief online educational intervention to increase medical and dental trainees' knowledge of the HPV vaccine and the association between HPV and cancer. The objectives of this study were to (1) assess medical and dental trainees' baseline knowledge regarding HPV and HPV vaccine, (2) determine the willingness to recommend the HPV vaccine to patients, and (3) evaluate the impact of an online intervention on HPV-related knowledge. Medical and dental trainees from two large academic centers in the USA were asked to fill out an online pre-intervention questionnaire, followed by a 10-min HPV educational intervention based on the Center of Disease Control and Prevention (CDC) resources, and then a post-intervention questionnaire. There were 75 participants (67.4% females; median age 18-30 years). When asked about HPV-related cancer types, the correct response increased from 28.4% (pre-intervention) to 51.9% (post-intervention; p < 0.01). When asked about the prevalence of HPV infections, the correct response improved from 36 to 72% (p < 0.01). There was also a 25.2% improvement in identifying the correct HPV vaccination dosing schedule (p < 0.01). Eighty-seven percent of the participants mentioned that the online education improved their HPV knowledge, and 68.5% reported that they were more likely to recommend HPV vaccine after the online intervention. The proposed online educational intervention was effective at improving HPV-related cancer and HPV vaccine knowledge as well as attitudes towards vaccine recommendation among dental and medical trainees and could be implemented in medical and dental school curricula in the future.

Factors associated with timely colposcopy following an abnormal cervical cancer test result.

Successful cervical cancer prevention requires screening and appropriate management of abnormal test results. Management includes diagnostic evaluation and treatment, if indicated, based on cervical cancer risk after most abnormal test results. There is little guidance on the optimal timing of diagnostic evaluation, and few data exist on factors associated with timely management. We quantified time-to-colposcopy within 12 months of an abnormal cervical cancer screening or surveillance test result from 2010 to 2018 across three diverse healthcare systems and described factors associated with timely colposcopy. Among 21-65 year-old patients with an abnormal test result for which colposcopy was indicated (n = 28,706), we calculated the proportion who received a colposcopy within 12 months of the abnormal test and used Kaplan-Meier methods to estimate the probability of colposcopy within 12 months. Across all systems, 75.3% of patients received a colposcopy within 12 months, with site-specific estimates ranging from 70.0 to 83.0%. We fit mixed-effects multivariable logistic regression models to identify factors associated with receipt of colposcopy within 12 months. The healthcare system and cytology result severity were the most important factors associated with of timely colposcopy. We observed that sites with more centralized processes had higher proportions of colposcopy completion, and patients with high-grade results were more consistently evaluated earlier than patients with low-grade results. Patient age also affected receipt of timely colposcopy, though this association differed by healthcare system and result severity. These data suggest opportunities for system-level interventions to improve management of abnormal cervical cancer test results.

Variation in the receipt of human papilloma virus co-testing for cervical screening: Individual, provider, facility and healthcare system characteristics.

Since 2012, cervical cancer screening guidelines allow for choice of screening test for women age 30-65 years (i.e., Pap every 3 years or Pap with human papillomavirus co-testing every 5 years). Intended to give patients and providers options, this flexibility reflects a trend in the growing complexity of screening guidelines. Our objective was to characterize variation in cervical screening at the individual, provider, clinic/facility, and healthcare system levels. The analysis included 296,924 individuals receiving screening from 3626 providers at 136 clinics/facilities in three healthcare systems, 2010 to 2017. Main outcome was receipt of co-testing vs. Pap alone. Co-testing was more common in one healthcare system before the 2012 guidelines (adjusted odds ratio (AOR) of co-testing at the other systems relative to this system 0.00 and 0.50) but was increasingly implemented over time in a second with declining uptake in the third (2017: AORs shifted to 7.32 and 0.01). Despite system-level differences, there was greater heterogeneity in receipt of co-testing associated with providers than clinics/facilities. In the three healthcare systems, providers in the highest quartile of co-testing use had an 8.35, 8.81, and 25.05-times greater odds of providing a co-test to women with the same characteristics relative to the lowest quartile. Similarly, clinics/ facilities in the highest quartile of co-testing use had a 4.20, 3.14, and 6.56-times greater odds of providing a co-test relative to the lowest quartile. Variation in screening test use is associated with health system, provider, and clinic/facility levels even after accounting for patient characteristics.

Hepatitis B Core-Related Antigen to Indicate High Viral Load: Systematic Review and Meta-Analysis of 10,397 Individual Participants.

BACKGROUND & AIMS: To eliminate hepatitis B virus (HBV) infection, scale-up of testing and treatment in resource-limited countries is crucial. However, access to nucleic acid testing to quantify HBV DNA, an essential test to examine treatment eligibility, remains severely limited. We assessed the performance of a novel immunoassay, HBV core-related antigen (HBcrAg), as a low-cost (less than US $15/assay) alternative to nucleic acid testing to indicate clinically important high viremia in chronic HBV patients infected with different genotypes. METHODS: We searched Medline, Embase, Scopus, and Web of Science databases through June 27, 2018. Three reviewers independently selected studies measuring HBV DNA and HBcrAg in the same blood samples. We contacted authors to provide individual participant data (IPD). We randomly allocated each IPD to a derivation or validation cohort. We applied optimal HBcrAg cut-off values derived from the derivation set to the validation set to estimate sensitivity/specificity. RESULTS: Of 74 eligible studies, IPD were obtained successfully for 60 studies (81%). Meta-analysis included 5591 IPD without antiviral therapy and 4806 treated with antivirals. In untreated patients, the pooled area under the receiver operating characteristic curve and optimal cut-off values were as follows: 0.88 (95% CI, 0.83-0.94) and 3.6 log U/mL to diagnose HBV DNA level of 2000 IU/mL or greater; and 0.96 (95% CI, 0.94-0.98) and 5.3 log U/mL for 200,000 IU/mL or greater, respectively. In the validation set, the sensitivity and specificity were 85.2% and 84.7% to diagnose HBV DNA level of 2000 IU/mL or greater, and 91.8% and 90.5% for 200,000 IU/mL or greater, respectively. The performance did not vary by HBV genotypes. In patients treated with anti-HBV therapy the correlation between HBcrAg and HBV DNA was poor. CONCLUSIONS: HBcrAg might be a useful serologic marker to indicate clinically important high viremia in treatment-naïve, HBV-infected patients.