Provider Adherence to the 2019 American Society for Colposcopy and Cervical Pathology Guidelines: A Retrospective Review

Provider Adherence to the 2019 American Society for Colposcopy and Cervical Pathology Guidelines: A Retrospective Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Provider Adherence to the 2019 American Society for Colposcopy and Cervical Pathology Guidelines: A Retrospective Review Asia Ayabe, Jeffrey Killeen, Arianna Antoku, Ayumi Sakamoto, Ann Lee Chang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6897373/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background: In 2019, the American Society for Colposcopy and Cervical Pathology (ASCCP) released updated guidelines for cervical cancer screening. While these guidelines are heavily evidence-based, we anticipated poor adherence as providers have been notoriously non-adherent to prior cervical cancer screening guidelines. The purpose of this study is to assess provider adherence to the 2019 ASCCP guidelines, within a single group of academic ObGyn providers. Methods: We collected all cytology and HPV requisition forms ordered by a group of ObGyn providers from November 2022 to February 2023. Each patient’s prior cervical cancer screening results were determined through a review of the laboratory electronic database and the patient’s electronic medical record. Screening results, type of test ordered, and the time interval between successive tests were compiled and compared against the 2019 ASCCP guidelines to determine whether a given order was adherent. Adherence rates were also analyzed by provider, by clinic, and by month, and reported as median adherence rates with interquartile ranges. Results: A total of 336 requisition forms from 14 clinics and 24 providers were included in the analysis. We found an overall adherence rate of 65.2%. The median adherence rate per provider was 74.0% (57.5% to 83.3%). The median adherence rate per clinic was 67.3% (53.6% to 82.3%). There was no significant trend in adherence per given month with adherence rates of 70.9% in November, 65.0% in December, 53.0% in January, and 74.2% in February. The most common reasons for non-adherence were 1) too long of an interval between successive screen/follow up (41%) 2) incorrect order (35%), and 3) too short of an interval between successive screen/follow-up (16.2%). From the last group, 41.7% were patients who did not show up for appointments. Conclusions: Within our group, the overall adherence to the 2019 ASSCP guidelines is suboptimal (65.2%). The most common reason for non-adherence was too long of an interval between successive screen/follow up results. This suggests that non-adherence may be influenced by factors outside of a provider’s control. However, the high rate of incorrect orders indicates a lack of knowledge, which may be improved with outreach and education. Cervical cancer screening practice guidelines clinician behavior Figures Figure 1 Figure 2 Figure 3 Figure 4 BACKGROUND Cervical cancer screening guidelines are frequently updated to incorporate growing knowledge of cervical cancer and the Human Papilloma Virus (HPV) as it relates to the development of cervical cancer. Since 2006, the American Society for Colposcopy and Cervical Pathology (ASCCP) has released three new guidelines on the screening and management of cervical lesions [( 1 ), ( 2 ), ( 3 )]. Each set of guidelines subsequently tailored management to more closely reflect a patient’s risk of developing cervical cancer. The current 2019 ASCCP Risk-Based Management Consensus Guidelines recommend treatment only if a patient’s 5-year risk of having CIN3 is 4%. Setting this cutoff point at 4% allows for the detection of a maximal number of cervical cancer and pre-cancerous lesions while balancing the risks of over-treatment [( 3 ), ( 4 )]. Unnecessary treatment exposes patients to increased costs, pain, psychological distress, and potential loss of fertility. Clinicians have been historically poor at adopting new cervical cancer screening guidelines. When the 2012 guidelines were released, numerous studies suggested that 18–59% of providers deviated from the ASCCP recommendations [( 5 ), ( 6 ), ( 7 ), ( 8 ), ( 9 )]. While the 2019 guidelines are heavily evidence based, emerging literature already suggests poor provider adherence to the recommendations. Two national clinician surveys have demonstrated poor provider adherence to simulated scenarios involving cervical cancer screening and management after colposcopic biopsy [( 10 ),( 11 )]. We anticipate that many providers in our cohort will have difficulty incorporating the new guidelines into their practices. The objective of this study was to assess provider adherence to the 2019 ASCCP Guidelines among a single group of ObGyn providers. We also aimed to evaluate factors associated with non-adherence, in hopes that we might identify potential areas for improvement. METHODS Cervical cancer screening requisition forms from a single group of ObGyn providers (Hawaii Pacific Health Medical Group) from November 2022 to February 2023 were selected from the Clinical Laboratories of Hawaii Pathology Database. From each requisition form, the specific clinic, patient medical record number, pathologic accession number, patient age, type of test ordered, and the ordering provider were all noted. Each patient’s prior cervical cancer screening results were determined through a review of the electronic pathology database system, CoPath, and the patient’s electronic medical record (EMR) on Epic Systems. If the given order followed the 2019 ASCCP guidelines, it was labeled as “adherent.” A given screening order was determined to be “non-adherent” if the screening did not follow ASCCP guidelines. All reasons for deviating from the guidelines were tabulated for all non-adherent orders (e.g. interval between surveillance too long or too short, etc.) Requisition forms were excluded if the indication for the test was for abnormal uterine bleeding or post-menopausal bleeding. All information was stored on an encrypted external hard drive stored in a secure location. The study was reviewed by the Hawaii Pacific Health Research Institute Scientific Review Committee and was deemed to be exempt from further Institutional Review Board review and informed consent as the study posed minimal to no increased risk to patients. A visual representation of our methods is presented in Fig. 1 . We determined that 162 requisition forms would be needed to achieve an at least 10% difference between the two groups (adherent and non-adherent) with a power of 80%. Cross tabulations were used to determine the incidence and percentage of provider non-adherence. A student’s t-test was used to determine if the overall result was statistically significant at a p value of 0.05. Median adherence rates and interquartile ranges were calculated by provider and clinic. Linear regression was used to determine if there was any change in adherence patterns over time. Statistical analyses were performed using StatPlus, version 8.0. RESULTS We reviewed 342 requisition forms from 14 clinics and 24 ObGyn providers. Six forms were excluded as providers had ordered tests for abnormal uterine bleeding and 336 forms were ultimately included. We found an overall adherence rate of 65.2% (n = 219; non-adherence rate of 34.8%). The median adherence rate per provider was 74.0% (57.5–83.3%), and the overall range was 23.1–100%. When stratified by clinic, the median adherence rate was 67.3% (53.6–82.3%) with a total range of 46 to 100% (Table 1 ). There was no significant trend in adherence per given month with adherence rates of 70.9% in November 2022, 65.0% in December 2022, 53.0% in January 2023, and 74.2% in February 2023 (R 2 = 0.0017, p = 0.96), (Fig. 2 ). Table 1 Adherence rates to the 2019 ASCCP guidelines. Adherence rate Interquartile range Total range Overall 65.2% N/A N/A Provider 74.0% 57.5–83.3% 23.1–100% Clinic 67.3% 53.6–82.3% 46–100% Of the 117 non-adherent orders, we identified three main reasons for non-adherence: 1) too long of a surveillance interval between subsequent tests (n = 48, 41%) 2) too short of a surveillance interval between subsequent tests (n = 19, 16.2%), and 3) incorrect order placed (n = 41, 35%). Several requisition forms had more than one reason for non-adherence, including too long of an interval/incorrect order (n = 5, 4.3%) and too short of an interval/incorrect order (n = 4, 3.4%) (Fig. 3 ). Of those cases with too long of an interval between successive screen/follow up, 41.7% (n = 20) involved patients who did not show up for appointments (with documentation of trying to contact the patient), and 29.1% (n = 14) involved patients who had transferred care from an outside provider. Cases in which an incorrect order was placed were further evaluated for type of incorrect order. These included ordering a co-test under age 30 without medical indication (n = 3), screening in a patient older than 65 with at least two documented normal prior results (n = 5), cytology with reflex to HPV if ASCUS in patients under 25 (n = 11), and cytology with reflex to HPV if ASCUS in patients older than 30 (n = 12). Ten forms were found to have other reasons or combinations of the above incorrect orders (Fig. 4 ). DISCUSSION Our retrospective analysis of assessing ObGyn adherence to the 2019 ASCCP guidelines demonstrated a total adherence rate of 65.2%. Stratification by provider and clinic revealed similarly poor adherence rates, suggesting that no singular provider or clinic had a disproportionate effect on the data. While we may have expected to see adherence rates improve over time, adherence rates per month were similar to one another, with no trend identified. When assessing reasons for non-adherence, the most common reason was too long of an interval between screening tests. When assessing each of these cases, nearly half (41.7%) were cases in which patients did not show up despite documented attempts at contact. Recent national studies published in 2023 and early 2025 suggest that healthcare providers have been in poor concordance with cervical cancer screening and management after colposcopy [( 10 ), ( 11 )]. The National Institute of Health estimates that, as recently as 2020, only 67.86% of females living in the United States are up to date with their cervical cancer screening, a percentage that has been on the decline since 2000 (88.95%) [( 12 )]. This is consistent with our current findings and adherence rate of 65.2%. Clinician adoption of cervical cancer screening guidelines has previously been met with mistrust [( 5 ), ( 6 ), ( 7 ), ( 8 ), ( 9 )]. Reasons for non-adherence often included fear of increase in cervical cancer incidence, lack of insurance coverage for patients, and inadequate time to explain the guideline changes to patients and staff [( 6 ), ( 9 ), ( 13 ), ( 14 ), ( 15 )]. Of note, many studies also indicated higher rates of non-adherence by family medicine, internal medicine, and private practice providers [( 5 ), ( 6 ), ( 7 ), ( 14 ), ( 15 )]. Improved adherence has been demonstrated with consistent continuity of care, with female providers, and in clinics more prepared for language translation [( 16 )]. In contrast, providers in the current study all specialized in ObGyn and were all part of the same academic organization. Future studies evaluating rates of adherence in the larger medical community may therefore be helpful in identifying additional areas for improvement. This is of particular interest as the United States Preventive Services Task Force recently released Draft Recommendations, which state that HPV primary screening alone every 5 years is adequate for cervical cancer screening [( 17 )], and the ASCCP has also endorsed the need to move towards primary HPV screening [( 18 )]. Numerous studies have also suggested patient mistrust of new cervical cancer screening guidelines, especially those aged 36 and above [( 19 ), ( 20 ), ( 21 )]. When the ASCCP 2012 guidelines were first released, 57% of patients surveyed at federally qualified health centers across Illinois indicated they did not want to wait 3 years to have their pap smear performed, even if recommended by their physician. These authors also found that patients with poor understanding of the purpose of the pap smear were significantly more likely to request yearly pap smears [( 21 )]. While this was not a phenomenon explicitly found in our study, it does highlight an ongoing need for patient education. When assessing cases that deviated from the guidelines, we found the most common occurrence was too long of a time interval between one screening result to the next. A review of the EMR revealed nearly half were related to patients not showing up for scheduled appointments or other factors beyond a provider’s control. In correcting for these patients during post-hoc analysis, we estimated that our total rate of provider adherence would improve to 69.8%. However, a patient’s decision to participate in their own healthcare is often based on numerous factors such as relationship with their provider, availability of transportation, cultural views of western medicine, and health literacy [( 22 )]. This study was also conducted towards the end of the COVID-19 pandemic, during which 41–59% of patients were estimated to have missed healthcare appointments [( 23 ), ( 24 )]. Additionally, Hawaii is a state with a unique population and contentious history with Western medicine and diseases [( 25 ), ( 26 ), ( 27 )]. In many Pacific Island cultures, there is no need to visit a doctor unless one is sick [( 28 ), ( 29 ), ( 30 )]. A likely combination of these factors may have contributed to the long cervical cancer screening intervals in this study. This highlights a further need for culturally grounded approaches to health care promotion. In the literature, additional reasons cited by providers for ASCCP guideline non-adherence include provider mistrust of current guidelines and screening intervals, patient request, lack of insurance coverage for co-testing, and inadequate time to explain guideline changes to patients [( 5 ), ( 6 )]. Our study assessed reasons why a specific order did not meet guideline criteria, but did not formally investigate reasons why this order may have been placed. On speaking with some of the providers evaluated in this study, it seems there were many issues with insurance coverage, particularly in rural clinics. This suggests a need for further evaluation and collaboration with lawmakers and insurance providers. While the providers in this study were from a single organization, this group uses at least five different EMR platforms. Using multiple EMR platforms, rather than a single-vendor system, has been shown to decrease the quality of clinical care [( 31 ), ( 32 )]. When a provider uses more than one EMR platforms, they risk missing patient data, errors in order placement, and poor communication with patients [( 31 ), ( 32 )]. We therefore hypothesize that at least some of the incorrect orders made in this study may have been due to this phenomenon. In 2019, our institution performed a similar quality improvement project evaluating rates of adherence to the 2012 ASCCP Guidelines for a group of ObGyn and primary care providers (different group from the current study). We found appropriate screening and management performed in only 26.7% cases. In further analysis, only 21% of ObGyn physicians were adherent to guidelines, 33% of primary care physicians were adherent to guidelines, and nurse practitioners (NP’s) were 5% adherent to guidelines. After a brief, voluntary educational intervention, 86–100% of ObGyn physicians were adherent to guidelines and 97% of NP’s were adherent to guidelines. The primary care physicians did not attend the educational session and their adherence remained at 33%. This suggests that adherence can be improved with education of the guidelines. During the educational session, many of the ObGyn providers reported that their orders were often placed by medical assistants after verbal confirmation, but the ObGyn providers themselves did not thoroughly check these orders before signing them. Having office-specific interventions for the entire medical team might therefore be beneficial in improving guideline adherence. Evaluating the responses of a singular group of ObGyn providers lent some insight into reasons for non-adherence. However, we suspect that there may be worsened adherence in the larger community and therefore, additional and more nuanced reasons for non-adherence. Based on prior quality improvement projects, educational interventions appear to improve adherence and would likely be very helpful in this organization. Comparing each requisition form against prior clinical data in EMR systems gave us the ability to follow a complex ordering process. However, we did not have access to every EMR system, limiting this utility. CONCLUSIONS This study initially intended to reassess provider adherence rates to the 2019 ASCCP guidelines after educational sessions were provided for all providers and ancillary staff at all offices. While we still intend to continue assessing adherence rates, our group has recently adopted a primary high risk HPV screening regimen for patients with cervixes aged 25 years and older. This is considering a wealth of literature suggesting the superiority of primary HPV screening over cytology only screening for preventing invasive cervical cancer. [( 33 ), ( 34 ), ( 35 ), ( 36 )] Like the guidelines before it, the 2019 ASCCP Guidelines were created with the intent of improving pathologic detection while minimizing the harms of over-intervention. It is groundbreaking in that it tailors screening and intervention to an individual’s unique risk of developing cervical cancer based on prior results. Adherence rates in this group of are moderate, but we suspect they may lower in the overall community. Additional evaluation of the larger community and efforts at education interventions should be performed to improve adherence to the 2019 ASCCP Guidelines. Abbreviations ASCCP American Society for Colposcopy and Cervical Pathology ObGyn Obstetrics and Gynecology HPV Human Papilloma Virus ASCUS Atypical squamous cells of undetermined significance EMR Electronic medical record Co-test Cytology and HPV screening together COVID-19 Corona virus disease of 2019 NP Nurse practitioner Declarations ETHICS APPROVAL AND CONSENT TO PARTICIPATE This study determined to be exempt from the Hawaii Pacific Health Institutional Review Board by a designee of the Institutional Official of Hawaii Pacific Health using the guidelines set by the U.S. Department of Health and Human Services Office of Human Research Protection (45 CFR 46.104(d)(4)). HPHRI Study Number: 2021-089. A waiver of authorization was granted by the Hawaii Pacific Health Privacy Board for the use and disclosure of protected health information for the above research. Our study adhered to the Declaration of Helinski – Ethical Principles for Medical Research Involving Human Participants, including research using identifiable human material or data. CONSENT FOR PUBLICATION Not applicable AVAILABILITY OF DATA AND MATERIALS The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. COMPETING INTERESTS The authors declare no competing interests FUNDING This research was supported by funding from the Myra W and Jean Kent Angus Foundation. AUTHORS’ CONSTRIBUTIONS Dr. Asia Ayabe was responsible for writing the manuscript and creating the figures and tables. Ariana Antoku was responsible for formatting the references. All authors were responsible for proofreading and reviewing the entire manuscript. 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Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 18 Aug, 2025 Reviewers agreed at journal 18 Aug, 2025 Reviews received at journal 05 Aug, 2025 Reviewers agreed at journal 05 Aug, 2025 Reviewers invited by journal 31 Jul, 2025 Editor assigned by journal 23 Jul, 2025 Editor invited by journal 01 Jul, 2025 Submission checks completed at journal 30 Jun, 2025 First submitted to journal 30 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6897373","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":495631224,"identity":"5e882982-5be8-4c20-a97c-863c5201ef7d","order_by":0,"name":"Asia Ayabe","email":"","orcid":"","institution":"Hawaii Pacific Health","correspondingAuthor":false,"prefix":"","firstName":"Asia","middleName":"","lastName":"Ayabe","suffix":""},{"id":495631226,"identity":"c8761ebf-9dd6-4725-b0d2-b9f0d502bfa6","order_by":1,"name":"Jeffrey Killeen","email":"","orcid":"","institution":"University of Hawaii School of 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Chang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYJACZhDBLwEiDUBkApFaJGeQrMXgBpxPQAv/7N6Dnwtq7thtvt38TOJHgQUDP3uOAV4tEnfOJUvPOPYsedudY2aSPUCHSfa8wa+F4UaOGTMP2+FksxsJZjd4gFoMbhCwRR6s5d/hZOMZ6d9u/gFqsSekxQCkhbftsJ2BRI7ZbbAtEgS0GN7IMZbm7TucIHEjp/y3jIEEj8SZZwV4tcjdyDH8zPPtsD3/jPTNhm/+1MnxtydvwKsFBhIboAweopSDgD3RKkfBKBgFo2DkAQD0iEQI3Pu9HwAAAABJRU5ErkJggg==","orcid":"","institution":"University of Hawaii School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Ann","middleName":"Lee","lastName":"Chang","suffix":""}],"badges":[],"createdAt":"2025-06-15 09:08:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6897373/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6897373/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88422387,"identity":"89f77f87-0b44-490b-9d9a-6da31da1e91b","added_by":"auto","created_at":"2025-08-06 09:36:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":23336,"visible":true,"origin":"","legend":"\u003cp\u003eVisual representation of the study design.\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6897373/v1/0f958f162faedb0264d35b35.png"},{"id":88424072,"identity":"dddc33d9-5b83-4bcb-8b82-4b90fd81ff80","added_by":"auto","created_at":"2025-08-06 09:44:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":30722,"visible":true,"origin":"","legend":"\u003cp\u003eAdherence rates by month.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6897373/v1/1bf0d49c6ed8cfacf04890ba.png"},{"id":88422393,"identity":"dc6edb1b-9dd3-4e84-84f4-b712d4e5fda9","added_by":"auto","created_at":"2025-08-06 09:36:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":41551,"visible":true,"origin":"","legend":"\u003cp\u003eReasons for non-adherent orders.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6897373/v1/2e5a379ef9fdba789424aca6.png"},{"id":88422389,"identity":"0decab69-2808-4d6b-ade7-c24aabc40025","added_by":"auto","created_at":"2025-08-06 09:36:05","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":25903,"visible":true,"origin":"","legend":"\u003cp\u003eBreakdown of incorrect orders.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-6897373/v1/70ca1fefe295ce171ec0fcc5.png"},{"id":88424076,"identity":"a3f76097-da87-4857-bd91-034345292b0e","added_by":"auto","created_at":"2025-08-06 09:44:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":506775,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6897373/v1/5d13722e-6a7d-4c6f-85b1-30a54fb70693.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Provider Adherence to the 2019 American Society for Colposcopy and Cervical Pathology Guidelines: A Retrospective Review","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003e Cervical cancer screening guidelines are frequently updated to incorporate growing knowledge of cervical cancer and the Human Papilloma Virus (HPV) as it relates to the development of cervical cancer. Since 2006, the American Society for Colposcopy and Cervical Pathology (ASCCP) has released three new guidelines on the screening and management of cervical lesions [(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)]. Each set of guidelines subsequently tailored management to more closely reflect a patient\u0026rsquo;s risk of developing cervical cancer. The current 2019 ASCCP Risk-Based Management Consensus Guidelines recommend treatment only if a patient\u0026rsquo;s 5-year risk of having CIN3 is 4%. Setting this cutoff point at 4% allows for the detection of a maximal number of cervical cancer and pre-cancerous lesions while balancing the risks of over-treatment [(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)]. Unnecessary treatment exposes patients to increased costs, pain, psychological distress, and potential loss of fertility.\u003c/p\u003e\u003cp\u003e Clinicians have been historically poor at adopting new cervical cancer screening guidelines. When the 2012 guidelines were released, numerous studies suggested that 18\u0026ndash;59% of providers deviated from the ASCCP recommendations [(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)]. While the 2019 guidelines are heavily evidence based, emerging literature already suggests poor provider adherence to the recommendations. Two national clinician surveys have demonstrated poor provider adherence to simulated scenarios involving cervical cancer screening and management after colposcopic biopsy [(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e),(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)].\u003c/p\u003e\u003cp\u003e We anticipate that many providers in our cohort will have difficulty incorporating the new guidelines into their practices. The objective of this study was to assess provider adherence to the 2019 ASCCP Guidelines among a single group of ObGyn providers. We also aimed to evaluate factors associated with non-adherence, in hopes that we might identify potential areas for improvement.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eCervical cancer screening requisition forms from a single group of ObGyn providers (Hawaii Pacific Health Medical Group) from November 2022 to February 2023 were selected from the Clinical Laboratories of Hawaii Pathology Database. From each requisition form, the specific clinic, patient medical record number, pathologic accession number, patient age, type of test ordered, and the ordering provider were all noted. Each patient\u0026rsquo;s prior cervical cancer screening results were determined through a review of the electronic pathology database system, CoPath, and the patient\u0026rsquo;s electronic medical record (EMR) on Epic Systems. If the given order followed the 2019 ASCCP guidelines, it was labeled as \u0026ldquo;adherent.\u0026rdquo; A given screening order was determined to be \u0026ldquo;non-adherent\u0026rdquo; if the screening did not follow ASCCP guidelines. All reasons for deviating from the guidelines were tabulated for all non-adherent orders (e.g. interval between surveillance too long or too short, etc.) Requisition forms were excluded if the indication for the test was for abnormal uterine bleeding or post-menopausal bleeding. All information was stored on an encrypted external hard drive stored in a secure location. The study was reviewed by the Hawaii Pacific Health Research Institute Scientific Review Committee and was deemed to be exempt from further Institutional Review Board review and informed consent as the study posed minimal to no increased risk to patients. A visual representation of our methods is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eWe determined that 162 requisition forms would be needed to achieve an at least 10% difference between the two groups (adherent and non-adherent) with a power of 80%. Cross tabulations were used to determine the incidence and percentage of provider non-adherence. A student\u0026rsquo;s t-test was used to determine if the overall result was statistically significant at a p value of 0.05. Median adherence rates and interquartile ranges were calculated by provider and clinic. Linear regression was used to determine if there was any change in adherence patterns over time. Statistical analyses were performed using StatPlus, version 8.0.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eWe reviewed 342 requisition forms from 14 clinics and 24 ObGyn providers. Six forms were excluded as providers had ordered tests for abnormal uterine bleeding and 336 forms were ultimately included. We found an overall adherence rate of 65.2% (n\u0026thinsp;=\u0026thinsp;219; non-adherence rate of 34.8%). The median adherence rate per provider was 74.0% (57.5\u0026ndash;83.3%), and the overall range was 23.1\u0026ndash;100%. When stratified by clinic, the median adherence rate was 67.3% (53.6\u0026ndash;82.3%) with a total range of 46 to 100% (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). There was no significant trend in adherence per given month with adherence rates of 70.9% in November 2022, 65.0% in December 2022, 53.0% in January 2023, and 74.2% in February 2023 (R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.0017, p\u0026thinsp;=\u0026thinsp;0.96), (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAdherence rates to the 2019 ASCCP guidelines.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdherence rate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInterquartile range\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal range\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e65.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProvider\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e74.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.5\u0026ndash;83.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23.1\u0026ndash;100%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e67.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53.6\u0026ndash;82.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46\u0026ndash;100%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eOf the 117 non-adherent orders, we identified three main reasons for non-adherence: 1) too long of a surveillance interval between subsequent tests (n\u0026thinsp;=\u0026thinsp;48, 41%) 2) too short of a surveillance interval between subsequent tests (n\u0026thinsp;=\u0026thinsp;19, 16.2%), and 3) incorrect order placed (n\u0026thinsp;=\u0026thinsp;41, 35%). Several requisition forms had more than one reason for non-adherence, including too long of an interval/incorrect order (n\u0026thinsp;=\u0026thinsp;5, 4.3%) and too short of an interval/incorrect order (n\u0026thinsp;=\u0026thinsp;4, 3.4%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Of those cases with too long of an interval between successive screen/follow up, 41.7% (n\u0026thinsp;=\u0026thinsp;20) involved patients who did not show up for appointments (with documentation of trying to contact the patient), and 29.1% (n\u0026thinsp;=\u0026thinsp;14) involved patients who had transferred care from an outside provider. Cases in which an incorrect order was placed were further evaluated for type of incorrect order. These included ordering a co-test under age 30 without medical indication (n\u0026thinsp;=\u0026thinsp;3), screening in a patient older than 65 with at least two documented normal prior results (n\u0026thinsp;=\u0026thinsp;5), cytology with reflex to HPV if ASCUS in patients under 25 (n\u0026thinsp;=\u0026thinsp;11), and cytology with reflex to HPV if ASCUS in patients older than 30 (n\u0026thinsp;=\u0026thinsp;12). Ten forms were found to have other reasons or combinations of the above incorrect orders (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e Our retrospective analysis of assessing ObGyn adherence to the 2019 ASCCP guidelines demonstrated a total adherence rate of 65.2%. Stratification by provider and clinic revealed similarly poor adherence rates, suggesting that no singular provider or clinic had a disproportionate effect on the data. While we may have expected to see adherence rates improve over time, adherence rates per month were similar to one another, with no trend identified. When assessing reasons for non-adherence, the most common reason was too long of an interval between screening tests. When assessing each of these cases, nearly half (41.7%) were cases in which patients did not show up despite documented attempts at contact.\u003c/p\u003e\u003cp\u003eRecent national studies published in 2023 and early 2025 suggest that healthcare providers have been in poor concordance with cervical cancer screening and management after colposcopy [(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)]. The National Institute of Health estimates that, as recently as 2020, only 67.86% of females living in the United States are up to date with their cervical cancer screening, a percentage that has been on the decline since 2000 (88.95%) [(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)]. This is consistent with our current findings and adherence rate of 65.2%.\u003c/p\u003e\u003cp\u003eClinician adoption of cervical cancer screening guidelines has previously been met with mistrust [(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)]. Reasons for non-adherence often included fear of increase in cervical cancer incidence, lack of insurance coverage for patients, and inadequate time to explain the guideline changes to patients and staff [(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)]. Of note, many studies also indicated higher rates of non-adherence by family medicine, internal medicine, and private practice providers [(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)]. Improved adherence has been demonstrated with consistent continuity of care, with female providers, and in clinics more prepared for language translation [(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)]. In contrast, providers in the current study all specialized in ObGyn and were all part of the same academic organization. Future studies evaluating rates of adherence in the larger medical community may therefore be helpful in identifying additional areas for improvement. This is of particular interest as the United States Preventive Services Task Force recently released Draft Recommendations, which state that HPV primary screening alone every 5 years is adequate for cervical cancer screening [(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)], and the ASCCP has also endorsed the need to move towards primary HPV screening [(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)].\u003c/p\u003e\u003cp\u003eNumerous studies have also suggested patient mistrust of new cervical cancer screening guidelines, especially those aged 36 and above [(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)]. When the ASCCP 2012 guidelines were first released, 57% of patients surveyed at federally qualified health centers across Illinois indicated they did not want to wait 3 years to have their pap smear performed, even if recommended by their physician. These authors also found that patients with poor understanding of the purpose of the pap smear were significantly more likely to request yearly pap smears [(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)]. While this was not a phenomenon explicitly found in our study, it does highlight an ongoing need for patient education.\u003c/p\u003e\u003cp\u003e When assessing cases that deviated from the guidelines, we found the most common occurrence was too long of a time interval between one screening result to the next. A review of the EMR revealed nearly half were related to patients not showing up for scheduled appointments or other factors beyond a provider\u0026rsquo;s control. In correcting for these patients during post-hoc analysis, we estimated that our total rate of provider adherence would improve to 69.8%. However, a patient\u0026rsquo;s decision to participate in their own healthcare is often based on numerous factors such as relationship with their provider, availability of transportation, cultural views of western medicine, and health literacy [(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)]. This study was also conducted towards the end of the COVID-19 pandemic, during which 41\u0026ndash;59% of patients were estimated to have missed healthcare appointments [(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)]. Additionally, Hawaii is a state with a unique population and contentious history with Western medicine and diseases [(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)]. In many Pacific Island cultures, there is no need to visit a doctor unless one is sick [(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)]. A likely combination of these factors may have contributed to the long cervical cancer screening intervals in this study. This highlights a further need for culturally grounded approaches to health care promotion.\u003c/p\u003e\u003cp\u003eIn the literature, additional reasons cited by providers for ASCCP guideline non-adherence include provider mistrust of current guidelines and screening intervals, patient request, lack of insurance coverage for co-testing, and inadequate time to explain guideline changes to patients [(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)]. Our study assessed reasons why a specific order did not meet guideline criteria, but did not formally investigate reasons why this order may have been placed. On speaking with some of the providers evaluated in this study, it seems there were many issues with insurance coverage, particularly in rural clinics. This suggests a need for further evaluation and collaboration with lawmakers and insurance providers.\u003c/p\u003e\u003cp\u003eWhile the providers in this study were from a single organization, this group uses at least five different EMR platforms. Using multiple EMR platforms, rather than a single-vendor system, has been shown to decrease the quality of clinical care [(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)]. When a provider uses more than one EMR platforms, they risk missing patient data, errors in order placement, and poor communication with patients [(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)]. We therefore hypothesize that at least some of the incorrect orders made in this study may have been due to this phenomenon.\u003c/p\u003e\u003cp\u003e In 2019, our institution performed a similar quality improvement project evaluating rates of adherence to the 2012 ASCCP Guidelines for a group of ObGyn and primary care providers (different group from the current study). We found appropriate screening and management performed in only 26.7% cases. In further analysis, only 21% of ObGyn physicians were adherent to guidelines, 33% of primary care physicians were adherent to guidelines, and nurse practitioners (NP\u0026rsquo;s) were 5% adherent to guidelines. After a brief, voluntary educational intervention, 86\u0026ndash;100% of ObGyn physicians were adherent to guidelines and 97% of NP\u0026rsquo;s were adherent to guidelines. The primary care physicians did not attend the educational session and their adherence remained at 33%. This suggests that adherence can be improved with education of the guidelines. During the educational session, many of the ObGyn providers reported that their orders were often placed by medical assistants after verbal confirmation, but the ObGyn providers themselves did not thoroughly check these orders before signing them. Having office-specific interventions for the entire medical team might therefore be beneficial in improving guideline adherence.\u003c/p\u003e\u003cp\u003eEvaluating the responses of a singular group of ObGyn providers lent some insight into reasons for non-adherence. However, we suspect that there may be worsened adherence in the larger community and therefore, additional and more nuanced reasons for non-adherence. Based on prior quality improvement projects, educational interventions appear to improve adherence and would likely be very helpful in this organization. Comparing each requisition form against prior clinical data in EMR systems gave us the ability to follow a complex ordering process. However, we did not have access to every EMR system, limiting this utility.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003e This study initially intended to reassess provider adherence rates to the 2019 ASCCP guidelines after educational sessions were provided for all providers and ancillary staff at all offices. While we still intend to continue assessing adherence rates, our group has recently adopted a primary high risk HPV screening regimen for patients with cervixes aged 25 years and older. This is considering a wealth of literature suggesting the superiority of primary HPV screening over cytology only screening for preventing invasive cervical cancer. [(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)]\u003c/p\u003e\u003cp\u003e Like the guidelines before it, the 2019 ASCCP Guidelines were created with the intent of improving pathologic detection while minimizing the harms of over-intervention. It is groundbreaking in that it tailors screening and intervention to an individual\u0026rsquo;s unique risk of developing cervical cancer based on prior results. Adherence rates in this group of are moderate, but we suspect they may lower in the overall community. Additional evaluation of the larger community and efforts at education interventions should be performed to improve adherence to the 2019 ASCCP Guidelines.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eASCCP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAmerican Society for Colposcopy and Cervical Pathology\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eObGyn\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eObstetrics and Gynecology\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHPV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHuman Papilloma Virus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eASCUS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAtypical squamous cells of undetermined significance\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEMR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eElectronic medical record\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCo-test\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCytology and HPV screening together\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCOVID-19\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCorona virus disease of 2019\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNurse practitioner\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eETHICS APPROVAL AND CONSENT TO PARTICIPATE\u003c/p\u003e\n\u003cp\u003eThis study determined to be exempt from the Hawaii Pacific Health Institutional Review Board by a designee of the Institutional Official of Hawaii Pacific Health using the guidelines set by the U.S. Department of Health and Human Services Office of Human Research Protection (45 CFR 46.104(d)(4)). HPHRI Study Number: 2021-089. A waiver of authorization was granted by the Hawaii Pacific Health Privacy Board for the use and disclosure of protected health information for the above research. Our study adhered to the Declaration of Helinski – Ethical Principles for Medical Research Involving Human Participants, including research using identifiable human material or data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCONSENT FOR PUBLICATION\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eAVAILABILITY OF DATA AND MATERIALS\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCOMPETING INTERESTS\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests\u003c/p\u003e\n\u003cp\u003eFUNDING\u003c/p\u003e\n\u003cp\u003eThis research was supported by funding from the Myra W and Jean Kent Angus Foundation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAUTHORS’ CONSTRIBUTIONS\u003c/p\u003e\n\u003cp\u003eDr. Asia Ayabe was responsible for writing the manuscript and creating the figures and tables. Ariana Antoku was responsible for formatting the references. All authors were responsible for proofreading and reviewing the entire manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eACKNOWLEDGEMENTS\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the Biomedical Research and Innovation Center of Hawaii for support with creation of the manuscript.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWright TC, Jr., Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D, et al. 2006 consensus guidelines for the management of women with abnormal cervical screening tests. J Low Genit Tract Dis. 2007;11(4):201-22.\u003c/li\u003e\n\u003cli\u003eMassad LS, Einstein MH, Huh WK, Katki HA, Kinney WK, Schiffman M, et al. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis. 2013;17(5 Suppl 1):S1-S27.\u003c/li\u003e\n\u003cli\u003ePerkins RB, Guido RS, Castle PE, Chelmow D, Einstein MH, Garcia F, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors. J Low Genit Tract Dis. 2020;24(2):102-31.\u003c/li\u003e\n\u003cli\u003eEgemen D, Cheung LC, Chen X, Demarco M, Perkins RB, Kinney W, et al. Risk Estimates Supporting the 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis. 2020;24(2):132-43.\u003c/li\u003e\n\u003cli\u003eLangsjoen J. Improving Compliance with Cervical Cancer Screening Guidelines. Baylor University Medical Center Proceedings. 2021;28(4):450-3.\u003c/li\u003e\n\u003cli\u003eTeoh DG, Marriott AE, Isaksson Vogel R, Marriott RT, Lais CW, Downs LS, Jr., et al. Adherence to the 2012 national cervical cancer screening guidelines: a pilot study. Am J Obstet Gynecol. 2015;212(1):62 e1-9.\u003c/li\u003e\n\u003cli\u003eTeoh D, Isaksson Vogel R, Hultman G, Monu M, Downs L, Geller MA, et al. Single Health System Adherence to 2012 Cervical Cancer Screening Guidelines at Extremes of Age and Posthysterectomy. Obstet Gynecol. 2017;129(3):448-56.\u003c/li\u003e\n\u003cli\u003eConrad SK, Dahman B, Kumar A, Hylton J, Isaacs C. Adherence to the American Society for Colposcopy and Cervical Pathology guidelines: an observational study. Obstet Gynecol Sci. 2022;65(1):84-93.\u003c/li\u003e\n\u003cli\u003eVerrilli L, Winer RL, Mao C. Adherence to cervical cancer screening guidelines by gynecologists in the Pacific Northwest. J Low Genit Tract Dis. 2014;18(3):228-34.\u003c/li\u003e\n\u003cli\u003eVadaparampil ST, Fuzzell LN, Brownstein NC, Fontenot HB, Lake P, Michel A, et al. A cross-sectional survey examining clinician characteristics, practices, and attitudes associated with adoption of the 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines. Cancer. 2023;129(17):2671-84.\u003c/li\u003e\n\u003cli\u003eFuzzell L, Brownstein NC, Fontenot HB, Lake P, Michel A, Perkins RB, et al. Clinician Characteristics Associated With Adoption of Updated National Colposcopy Guidelines. J Low Genit Tract Dis. 2025.\u003c/li\u003e\n\u003cli\u003eInstitute NC. Cervical Cancer Screening. National Cancer Institute, Cancer Trends Progress Report 2020.\u003c/li\u003e\n\u003cli\u003eMin CJ, Massad LS, Dick R, Powell MA, Kuroki LM. Assessing Physician Adherence to Guidelines for Cervical Cancer Screening and Management of Abnormal Screening Results. J Low Genit Tract Dis. 2020;24(4):337-42.\u003c/li\u003e\n\u003cli\u003eBoone E, Lewis L, Karp M. Discontent and Confusion: Primary Care Providers\u0026apos; Opinions and Understanding of Current Cervical Cancer Screening Recommendations. J Womens Health (Larchmt). 2016;25(3):255-62.\u003c/li\u003e\n\u003cli\u003ePerkins RB, Adcock R, Benard V, Cuzick J, Waxman A, Howe J, et al. Clinical follow-up practices after cervical cancer screening by co-testing: A population-based study of adherence to U.S. guideline recommendations. Prev Med. 2021;153:106770.\u003c/li\u003e\n\u003cli\u003eHaas JS, Vogeli C, Yu L, Atlas SJ, Skinner CS, Harris KA, et al. Patient, provider, and clinic factors associated with the use of cervical cancer screening. Prev Med Rep. 2021;23:101468.\u003c/li\u003e\n\u003cli\u003eForce UT. Draft Recommendation Statement: Cervical Cancer: Screening 2024 [Available from: http://www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/cervical-cancer-screening-adults-adolescents. .\u003c/li\u003e\n\u003cli\u003eMarcus JZ, Cason P, Downs LS, Jr., Einstein MH, Flowers L. The ASCCP Cervical Cancer Screening Task Force Endorsement and Opinion on the American Cancer Society Updated Cervical Cancer Screening Guidelines. J Low Genit Tract Dis. 2021;25(3):187-91.\u003c/li\u003e\n\u003cli\u003eSilver MI, Rositch AF, Burke AE, Chang K, Viscidi R, Gravitt PE. Patient concerns about human papillomavirus testing and 5-year intervals in routine cervical cancer screening. Obstet Gynecol. 2015;125(2):317-29.\u003c/li\u003e\n\u003cli\u003eMacLaughlin KL, Angstman KB, Flynn PM, Schmitt JR, Weaver AL, Shuster LT. Predictors of patient comfort and adherence with less frequent cervical cancer screening. Qual Prim Care. 2011;19(6):355-63.\u003c/li\u003e\n\u003cli\u003eHawkins NA, Benard VB, Greek A, Roland KB, Manninen D, Saraiya M. Patient knowledge and beliefs as barriers to extending cervical cancer screening intervals in Federally Qualified Health Centers. Prev Med. 2013;57(5):641-5.\u003c/li\u003e\n\u003cli\u003eBenavidez GA, Zgodic A, Zahnd WE, Eberth JM. Disparities in Meeting USPSTF Breast, Cervical, and Colorectal Cancer Screening Guidelines Among Women in the United States. Prev Chronic Dis. 2021;18:E37.\u003c/li\u003e\n\u003cli\u003eAnderson KE, McGinty EE, Presskreischer R, Barry CL. Reports of Forgone Medical Care Among US Adults During the Initial Phase of the COVID-19 Pandemic. JAMA Netw Open. 2021;4(1):e2034882.\u003c/li\u003e\n\u003cli\u003eHernandez J, Batio S, Lovett RM, Wolf MS, Bailey SC. Missed Healthcare Visits During the COVID-19 Pandemic: A Longitudinal Study. J Prim Care Community Health. 2024;15:21501319241233869.\u003c/li\u003e\n\u003cli\u003eArcher S. Remedial agents: missionary physicians and the depopulation of Hawai\u0026apos;i. Pac Hist Rev. 2010;79(4):513-44.\u003c/li\u003e\n\u003cli\u003eBlaisdell RK. Health Status of Kanaka Maoli (Indigenous Hawaiians). Asian Am Pac Isl J Health. 1993;1(2):116-60.\u003c/li\u003e\n\u003cli\u003eThompson LM, Murray KA, Jarvis S, Scarr E. Exploring the Relationship between Health Insurance, Social Connectedness, and Subjective Social Status among Residents of O\u0026apos;ahu. Hawaii J Med Public Health. 2016;75(11):323-31.\u003c/li\u003e\n\u003cli\u003eCassel K, Lee HR, Somera LP, Badowski G, Hagiwara MKI. Cultural Considerations for Conducting the Health Information National Trends Survey with Micronesian Communities: Lessons from a Qualitative Study. Hawaii J Health Soc Welf. 2020;79(6 Suppl 2):64-9.\u003c/li\u003e\n\u003cli\u003eWalters KL, Johnson-Jennings M, Stroud S, Rasmus S, Charles B, John S, et al. Growing from Our Roots: Strategies for Developing Culturally Grounded Health Promotion Interventions in American Indian, Alaska Native, and Native Hawaiian Communities. Prev Sci. 2020;21(Suppl 1):54-64.\u003c/li\u003e\n\u003cli\u003eKaholokula JK, Ing CT, Look MA, Delafield R, Sinclair K. Culturally responsive approaches to health promotion for Native Hawaiians and Pacific Islanders. Ann Hum Biol. 2018;45(3):249-63.\u003c/li\u003e\n\u003cli\u003ePayne T, Fellner J, Dugowson C, Liebovitz D, Fletcher G. Use of more than one electronic medical record system within a single health care organization. Appl Clin Inform. 2012;3(4):462-74.\u003c/li\u003e\n\u003cli\u003ePerloff J, Sobul S. Use of electronic health record systems in accountable care organizations. Am J Manag Care. 2022;28(1):e31-e4.\u003c/li\u003e\n\u003cli\u003eHuh WK, Ault KA, Chelmow D, Davey DD, Goulart RA, Garcia FAR, et al. Use of Primary High-Risk Human Papillomavirus Testing for Cervical Cancer Screening: Interim Clinical Guidance. Obstetrics \u0026amp; Gynecology. 2015;125(2):330-7.\u003c/li\u003e\n\u003cli\u003eRonco G, Dillner J, Elfstrom KM, Tunesi S, Snijders PJ, Arbyn M, et al. Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. Lancet. 2014;383(9916):524-32.\u003c/li\u003e\n\u003cli\u003eWang J, Elfstrom KM, Dillner J. Human papillomavirus-based cervical screening and long-term cervical cancer risk: a randomised health-care policy trial in Sweden. Lancet Public Health. 2024;9(11):e886-e95.\u003c/li\u003e\n\u003cli\u003eVahteristo M, Leinonen MK, Sarkeala T, Anttila A, Heinavaara S. Similar effectiveness with primary HPV and cytology screening - Long-term follow-up of randomized cervical cancer screening trial. Gynecol Oncol. 2024;180:146-51.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cervical cancer screening, practice guidelines, clinician behavior","lastPublishedDoi":"10.21203/rs.3.rs-6897373/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6897373/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e In 2019, the American Society for Colposcopy and Cervical Pathology (ASCCP) released updated guidelines for cervical cancer screening. While these guidelines are heavily evidence-based, we anticipated poor adherence as providers have been notoriously non-adherent to prior cervical cancer screening guidelines. The purpose of this study is to assess provider adherence to the 2019 ASCCP guidelines, within a single group of academic ObGyn providers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We collected all cytology and HPV requisition forms ordered by a group of ObGyn providers from November 2022 to February 2023. Each patient’s prior cervical cancer screening results were determined through a review of the laboratory electronic database and the patient’s electronic medical record. Screening results, type of test ordered, and the time interval between successive tests were compiled and compared against the 2019 ASCCP guidelines to determine whether a given order was adherent. Adherence rates were also analyzed by provider, by clinic, and by month, and reported as median adherence rates with interquartile ranges.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 336 requisition forms from 14 clinics and 24 providers were included in the analysis. We found an overall adherence rate of 65.2%. The median adherence rate per provider was 74.0% (57.5% to 83.3%). The median adherence rate per clinic was 67.3% (53.6% to 82.3%). There was no significant trend in adherence per given month with adherence rates of 70.9% in November, 65.0% in December, 53.0% in January, and 74.2% in February.\u003c/p\u003e\n\u003cp\u003eThe most common reasons for non-adherence were 1) too long of an interval between successive screen/follow up (41%) 2) incorrect order (35%), and 3) too short of an interval between successive screen/follow-up (16.2%). From the last group, 41.7% were patients who did not show up for appointments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Within our group, the overall adherence to the 2019 ASSCP guidelines is suboptimal (65.2%). The most common reason for non-adherence was too long of an interval between successive screen/follow up results. This suggests that non-adherence may be influenced by factors outside of a provider’s control. However, the high rate of incorrect orders indicates a lack of knowledge, which may be improved with outreach and education.\u003c/p\u003e","manuscriptTitle":"Provider Adherence to the 2019 American Society for Colposcopy and Cervical Pathology Guidelines: A Retrospective Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-06 09:36:00","doi":"10.21203/rs.3.rs-6897373/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-08-18T20:49:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"122657742238567605966463009519259406888","date":"2025-08-18T20:41:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-05T18:46:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"190289952756971515262443176551340128467","date":"2025-08-05T15:47:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-31T14:38:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-23T14:50:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-01T15:26:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-30T05:05:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-06-30T04:39:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"75968333-f223-457f-89af-a91f6530fb56","owner":[],"postedDate":"August 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-06T09:36:00+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-06 09:36:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6897373","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6897373","identity":"rs-6897373","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}