Examining the association of clinician characteristics with perceived changes in cervical cancer screening and colposcopy practice during the COVID-19 pandemic: a mixed methods assessment
- H. Lee Moffitt Cancer Center & Research Institute, Health Outcomes and Behavior, United States
- Medical University of South Carolina, United States
- University of Hawaii at Manoa, Nancy Atmospera-Walch School of Nursing, United States
- Boston University, Chobanian & Avedisian School of Medicine, United States
- H. Lee Moffitt Cancer Center & Research Institute, Office of Community Outreach, Engagement, and Equity, United States
Figures
Figure 1
Flow diagram depicting potentially eligible, enrolled, and final analytic samples.
Figure 2
Forest plots depicting adjusted odds ratios and 95% confidence intervals for variables associated with odds of reporting reduced cervical cancer screening (N=1239) in 2021* compared with before the COVID-19 pandemic.
Variables associated with odds of reporting reduced cervical cancer screening include Panel A: Age; B: Race; C: Region; D: Clinician Type; E: Practice Type. *Note. Data collected during the COVID-19 pandemic period of March 2021–July 2021, with participants asked to report whether they were doing ‘fewer’ or ‘the same number or more Pap/HPV/co-tests now than before the pandemic’.
Figure 3
Forest plots depicting adjusted odds ratios and 95% confidence intervals for variables associated with odds of reporting reduced colposcopies (N=669), in 2021* compared with before the COVID-19 pandemic.
Variables associated with odds of reporting reduced colposcopies include Panel A: Gender; B: Region; C: Clinician Type; D: Practice Type. *Note. Data collected during the COVID-19 pandemic period of March 2021–July 2021, with participants asked to report whether they were doing ‘fewer’ versus ‘the same number or more colposcopies now than before the pandemic’.
Tables
Table 1
Demographic and practice characteristics for the full sample of respondents, and sub-groups of colposcopists and qualitative interview participants.
| Variable | Total sample | Colposcopist sub-group | Qualitative interview sub-group | ||||||
|---|---|---|---|---|---|---|---|---|---|
| N | % | Valid N | N | % | Valid N | N | % | Valid N | |
| Clinician characteristics | |||||||||
| Age | 1250 | 674 | 52 | ||||||
| Less than 40 | 277 | 22.2 | 105 | 15.6 | 8 | 15.4 | |||
| 40–49 | 313 | 25.0 | 157 | 23.3 | 17 | 32.7 | |||
| 50–59 | 344 | 27.5 | 216 | 32.0 | 12 | 23.1 | |||
| 60+ | 316 | 25.3 | 196 | 29.0 | 15 | 28.8 | |||
| Gender identity | 1250 | 674 | 55 | ||||||
| Female (includes transgender/gender non-binary and other)* | 934 | 74.7 | 474 | 70.3 | 38 | 69.1 | |||
| Male | 316 | 25.3 | 200 | 29.7 | 17 | 30.9 | |||
| Race | 1245 | 671 | 55 | ||||||
| Asian | 151 | 12.1 | 71 | 10.6 | 10 | 18.5 | |||
| Black/African American | 61 | 4.9 | 30 | 4.5 | 1 | 1.9 | |||
| Mixed race/other† | 64 | 5.1 | 38 | 5.7 | 5 | 9.3 | |||
| White | 969 | 77.8 | 532 | 79.3 | 38 | 70.4 | |||
| Hispanic/Latinx | 101 | 8.1 | 1247 | 51 | 7.6 | 672 | 2 | 3.6 | 55 |
| Clinician type (training and specialty) | 1250 | 674 | 55 | ||||||
| APP (total) Sub-groups: Nurse Practitioner Certified Nurse Midwife Physician Assistant | 609 521 71 11 | 48.7 85.6 11.7 1.8 | 244 202 36 6 | 36.2 82.8 14.8 2.5 | 674 | 21 19 1 1 | 38.2 90.4 4.8 4.8 | ||
| MD/DO OB/GYN | 332 | 26.6 | 317 | 47.0 | 16 | 29.1 | |||
| MD/DO family medicine | 200 | 16.0 | 93 | 13.8 | 12 | 21.8 | |||
| MD/DO internal medicine | 109 | 8.7 | 20 | 3.0 | 6 | 10.9 | |||
| Practice characteristics, patterns, and behaviors | |||||||||
| Type of practice | 1251 | 675 | 51 | ||||||
| Academic medical center | 154 | 12.3 | 88 | 13.0 | 4 | 7.8 | |||
| Hospital-based practice (includes ‘other’) | 169 | 13.5 | 85 | 12.6 | 7 | 13.7 | |||
| Private practice/group practice | 678 | 54.2 | 395 | 58.5 | 27 | 52.9 | |||
| FQHC/community health center/planned parenthood or public health department | 250 | 20.0 | 107 | 15.9 | 13 | 25.5 | |||
| US region | 1251 | 675 | 55 | ||||||
| Northeast | 230 | 18.4 | 122 | 18.1 | 8 | 14.5 | |||
| South | 361 | 28.9 | 190 | 28.1 | 10 | 18.2 | |||
| Midwest | 271 | 21.7 | 121 | 17.9 | 8 | 14.5 | |||
| West | 277 | 22.1 | 152 | 22.5 | 5 | 9.1 | |||
| Non-responders | 112 | 9.0 | 90 | 13.3 | 24 | 43.6 | |||
-
*
Due to small numbers, transgender/non-binary/other were unable to be analyzed as their own category. They were assigned to female for analyses because female was the most common response. No difference was noted when grouped with male.
-
†
Due to small numbers, the following categories were combined: mixed race n=36, Hawaiian/AAPI n=3, American Indian/Alaska Native n=3, other n=22.
Table 2
COVID-19 and pandemic-related responses for the full sample of respondents and for colposcopists.
| Variable | Total sample | Colposcopist sub-sample | ||||
|---|---|---|---|---|---|---|
| N | % | Valid N | N | % | Valid N | |
| How has the pandemic affected your cervical cancer screening practice? (data collected March-July 2021) | 1246 | 672 | ||||
| Doing fewer Pap/HPV/co-tests now than before the pandemic | 586 | 47.0 | 295 | 43.9 | ||
| Doing the same number of Pap/HPV/co-tests now than before the pandemic | 604 | 48.5 | 345 | 51.3 | ||
| Doing more Pap/HPV/co-tests now than before the pandemic | 56 | 4.5 | 32 | 4.8 | ||
| How has the pandemic affected your colposcopy practice? (data collected March-July 2021) | - | 671 | ||||
| Doing fewer colposcopies now than before the pandemic | - | - | - | 296 | 44.1 | |
| Doing the same number of colposcopies now than before the pandemic | - | - | - | 352 | 52.5 | |
| Doing more colposcopies now than before the pandemic | - | - | - | 23 | 3.4 | |
| How has the pandemic affected the ability to provide LEEP in your practice? (data collected March-July 2021) | - | 667 | ||||
| We provided LEEP to patients on site before COVID-19 and are still doing so with the same capacity | - | - | - | 341 | 51.1 | |
| We provided LEEP to patients on site before COVID-19 and are still doing so but with reduced capacity | - | - | - | 124 | 18.6 | |
| We provided LEEP to patients on site before COVID-19 but now are referring to another facility | - | - | - | 9 | 1.3 | |
| We have always referred to another facility for LEEP and continue to do so | 193 | 28.9 | ||||
Table 3
Final models for variables associated with odds of reporting reduced cervical cancer screenings (Panel A) and with odds of reporting reduced colposcopies (Panel B) in 2021* compared with before the COVID-19 pandemic.
| Panel A. Final model of clinician and practice characteristics associated with odds of reporting reduced cervical cancer screenings in 2021 compared with before the COVID-19 pandemic (N=1239). Using backward selection, the following variables sequentially fell out of the model (p>0.10): (1) gender, (2) ethnicity. (A priori we planned to retain clinician type, practice type, and region even when p>0.10.) | ||||||
|---|---|---|---|---|---|---|
| Overall p | B | SE | Odds ratio | p | CI | |
| Age | <0.001 | |||||
| <40 | –0.77 | 0.18 | 0.47 | <0.001 | 0.33-0.66 | |
| 40–59 | –0.44 | 0.17 | 0.64 | 0.009 | 0.46-0.90 | |
| 50–59 | –0.35 | 0.16 | 0.70 | 0.029 | 0.51-0.97 | |
| 60+ (ref) | - | - | - | - | - | |
| Race | 0.085 | |||||
| Mixed race/other | 0.52 | 0.27 | 1.69 | 0.055 | 0.99–2.88 | |
| Black/African American | 0.50 | 0.28 | 1.65 | 0.070 | 0.96–2.84 | |
| Asian | 0.03 | 0.19 | 1.03 | 0.882 | 0.71–1.50 | |
| White (ref) | - | - | - | - | - | |
| Region | 0.391 | |||||
| No response | –0.38 | 0.25 | 0.69 | 0.123 | 0.42–1.11 | |
| South | 0.08 | 0.18 | 1.08 | 0.650 | 0.77–1.52 | |
| Midwest | –0.03 | 0.19 | 0.97 | 0.859 | 0.67–1.40 | |
| West | 0.05 | 0.19 | 1.05 | 0.795 | 0.73–1.51 | |
| Northeast (ref) | - | - | - | - | - | |
| Clinician type | <0.001 | |||||
| AAP | –0.03 | 0.15 | 0.97 | 0.846 | 0.72–1.31 | |
| MD/DO Internal Med | 0.95 | 0.24 | 2.59 | <0.001 | 1.62–4.13 | |
| MD/DO Fam Med | 0.49 | 0.19 | 1.64 | 0.008 | 1.14–2.36 | |
| MD/DO OB/GYN (ref) | - | - | - | - | - | |
| Practice type | 0.014 | |||||
| Academic medical center | 0.03 | 0.19 | 1.03 | 0.889 | 0.71–1.48 | |
| Hospital-based practice | –0.11 | 0.19 | 0.90 | 0.554 | 0.62–1.29 | |
| Public health dept/ FQHC/community health center/planned parenthood | 0.48 | 0.16 | 1.62 | 0.003 | 1.17–2.23 | |
| Private practice/group practice (ref) | - | - | - | - | - | |
| Panel B. Final model of clinician and practice characteristics associated with odds of reporting reduced colposcopies in 2021 compared with before the COVID-19 pandemic for colposcopists only (N=669). Using backward selection, the following variables sequentially fell out of the model (p>0.10): (1) ethnicity, (2) race, (3) age. (A priori we planned to retain clinician type, practice type, and region even when p>0.10.) | ||||||
| Overall p | B | SE | Odds ratio | p | CI | |
| Gender | 0.063 | |||||
| Male | 0.38 | 0.20 | 1.46 | 0.063 | 0.98–2.18 | |
| Female (ref) | - | - | - | - | - | |
| Region | 0.414 | |||||
| No response | 0.08 | 0.30 | 1.08 | 0.785 | 0.61–1.94 | |
| South | 0.43 | 0.24 | 1.54 | 0.077 | 0.96–2.47 | |
| Midwest | 0.27 | 0.27 | 1.30 | 0.320 | 0.77–2.20 | |
| West | 0.33 | 0.25 | 1.39 | 0.200 | 0.84–2.28 | |
| Northeast (ref) | - | - | - | - | - | |
| Clinician type | 0.052 | |||||
| Advanced practice professional | 0.26 | 0.20 | 1.30 | 0.197 | 0.87–1.92 | |
| MD/DO Internal Med | 1.33 | 0.54 | 3.79 | 0.013 | 1.33–10.80 | |
| MD/DO Fam Med | 0.00 | 0.25 | 1.00 | 0.995 | 0.62–1.62 | |
| MD/DO OB/GYN (ref) | - | - | - | - | - | |
| Practice type | .266 | |||||
| Academic medical center | 0.15 | 0.25 | 1.16 | 0.554 | 0.71–1.88 | |
| Hospital-based practice | 0.09 | 0.25 | 1.09 | 0.725 | 0.67–1.79 | |
| Public health dept/ FQHC/community health center/planned parenthood | 0.47 | 0.24 | 1.59 | 0.048 | 1.01–2.53 | |
| Private practice/group practice (ref) | - | - | - | - | - | |
-
*
Note. Data collected during the COVID-19 pandemic period of March 2021–July 2021, with participants asked to report whether they were doing ‘fewer, the same number, or more Pap/HPV/co-tests’ or ‘colposcopies’ ‘now than before the pandemic’.
Table 4
Themes demonstrating screening and colposcopy changes during COVID-19 pandemic, with related quotes (interviews conducted June-December 2021).
| Reduced screening | Example quotes |
|---|---|
| Closure of primary care services | “Clinics were shut down... Staff were furloughed. So, a lot of things that were going on. So, there was a pause for a time in the clinic. I don’t know, maybe for a few months.” (APP, private practice) “Screenings, wellness visits were almost at a standstill for almost 6 months out of the 15 months we've had COVID for. And we started back three months ago, where we started the wellness and screening test again. Then I don't know how long we can continue to do it with the second and the fourth waves.” (MD/DO int med, private practice) |
| Prioritization of COVID-related or urgent services | “Screening was the least of the problems with clinics and hospitals and urgent cares full of the pandemic. So it kind of took a back seat for a long time, which was helpful, you know, treating the disease, but not helpful in the screening world.” (MD/DO Ob/Gyn, academic medical center) “Most people have had their wellness exam delayed because we’re seeing patients – we will give priority to patients with problems.” (APP, private practice) |
| De-prioritization of screening/ focus on abnormal follow-up | “Knowing that pap smears and dysplasia don't progress fast, we did postpone and delay for a period of time, it was three to six months from what I recall during the early days of the pandemic.” (MD/DO Ob/Gyn, academic medical center) “For the people who needed them, they were getting them throughout, not those, not those first three months unless it was a CIN-2 or higher, but if it was a CIN-1 we were like, let’s just wait a few more months… see what’s going on with COVID at that point.” (APP, private practice) |
| Patient fear of attending medical care | “You can only do so much; patients are scared to come to doctors’ offices for screening test. If it’s not urgent or not emergent, very few patients actually want to go to a healthcare setting.” (MD/DO int med, private practice) “We still have a significant number who are not comfortable with an in-office visit unless they need something like their birth control pill or something else.” (APP, private practice) |
| Telehealth reduces screening | “We do telehealth but obviously – we can possibly do STD health and STD screenings on telehealth, but aside from that unless there’s some symptomatic issues that we can try to take care of over the telehealth platform, we – there’s just been a lot less women coming into the office over the last year due to COVID.” (MD/DO fam med, private practice) “I'm sure the Pap smear volume is much more you know, reduced due to the Telemedicine. And so that’s one effect of COVID. It’s reduced COVID, yeah it reduced the Pap smear.” (MD/DO int med, private practice) |
| Patient volumes remain below pre-COVID levels | “The rate of visits and doing their regular checkups, not only cancer screening has dropped significantly, more than 75% during the year of COVID. I'm sure that the results of these problems will arise in the next few years, if not, decades; We're almost back 80%, so we're still 20% lower than…usually we see at this time of the year.” (MD/DO fam med, private practice) “Getting patients into the office has been challenging because we were doing more telemedicine visits, not as many in-person visits, and the perceived need of preventative care had changed during COVID as well.” (MD/DO fam med, safety net setting) |
| Rebound in screening to pre-pandemic levels | Example quotes |
| Offered cervical cancer screening and colposcopy throughout pandemic | “Absolutely no impact because we were open throughout, and I was doing full scope everything, because we just… staggered patients. And so we were just working longer hours with time in between patients and cleaning up and so absolutely no impact.” (MD/DO Ob/Gyn, safety net setting) “There was an executive order by the governor who said there will be no elective surgeries done.” And, you know, there are, there are people that said, "Oh, well, colposcopy is like an elective office surgery, theoretically.” Or a LEEP is – “And I said, screw that. I created a form saying in my opinion, you know, delaying this biopsy or delaying this treatment may cause whatever abnormality [to] worsen.” (MD/DO Ob/Gyn, private practice) |
| Patients willing to come in once services were restored | “Now we do have patients come in and… we're almost back to regular business except for masking. So, I would say now, it’s just no different than it was before.” (APP, safety net setting) “Instead of doing 10 annuals a day, probably three annuals a day throughout COVID before vaccination, then after vaccination, people started coming in in droves for their annuals.” (APP, private practice) |
| Increased screening to compensate for patient backlogs | “Literally, from June [2021], it started backed up open full force. I have more patients that I had before.” (MD/DO Ob/Gyn, practice type not specified) “I will say that coming back off a furlough we might, not only my schedules, our schedules are packed, so we were kind of making up for lost time.” (APP, private practice) “So, we do outreach and do pap clinics on Saturdays to help folks get caught up.” (APP, safety net setting) |
| Patients no longer afraid of COVID | “They became more complacent. So, now, they are not as afraid. So, well, that may have helped the screening process, but it may not help the fact that they are going to get infected.” (MD/DO int med, private practice) “You know we are in Alabama. People here don’t think we have COVID even though they die with the same numbers as everybody else.” (APP, academic medical center) |
| Patient tracking and outreach | Example quotes |
| Active follow-up system | “We can run lists based on who needs annual wellness visits, who needs mammograms, who needs Pap smears, who needs diabetic follow up, -you name it, we can run the list. And so, since we opened back up …We have people that call [patients]. …that’s their job.” (APP, practice type not specified) “I think we’ve got dedicated staff who actually run through the charts and see who has missed their well-woman exams, and they either make a phone call or send a postcard.” (MD/DO fam med, private practice) |
| Limitations of tracking/ follow-up systems | [There was a list] “but that’s gone by the wayside. I don’t know how they did that. They were like, ‘Oh, we’re going to call all the old people [previous patients]…’. I don’t know if that worked.” (APP, practice type not specified) “We're trying to call, to arrange for phone calls to get them back, but of course, it’s very time, labor consuming process to go through each patient see when was the last time they were here. The good thing is we start implementing the year before COVID, the Epic, myChart portal. You can adjust it to send the patient’s notification when their checkups are due. From there, of course at least 50% of our population, they are not tech savvy. They don't check that on regular basis, but we try to reach as much as we can. It’s definitely a challenging issue based on human factor and administrative factors, too.” (MD/DO fam med, private practice) “We are being proactive and our EMR will send the messages and reminders. But specifically, for patients who didn't come last year, we do not have a system.” (MD/DO fam med, private practice) “It’s up to the patient to kind of know that they needed a Pap test or a colposcopy or something like that and then make an appointment.” (MD/DO Ob/Gyn, practice type not specified) |
| EMR facilitates tracking | “We have a portal that our patients have access to. Once we knew that [COVID-19] vaccination was really prevalent in our area… then we, through the portal, sent out a mass announcement to everyone.” (MD/DO Ob/Gyn, private practice) “In my PracticeSuite, I have this alert system. So, somebody who has an abnormal pap… I put an alert in... and then it will pop up, and then I just call them.” (APP, safety net setting) |
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Examining the association of clinician characteristics with perceived changes in cervical cancer screening and colposcopy practice during the COVID-19 pandemic: a mixed methods assessment
eLife 12:e85682.
https://doi.org/10.7554/eLife.85682
