Assessing adherence with preventive screening recommendations among ED patients: Piloting an effective use of wait time
Correspondence / American Journal of Emergency Medicine 36 (2018) 1098–1120 1105
Assessing adherence with preventive screening recommendations among ED patients: Piloting
an effective use of wait time?
Recommendations provided by the U.S. Preventive services Task Force (USPSTF) call for a variety of Screening procedures to identify treatable diseases at an early stage. While a relatively high percentage of adults will visit a primary care doctor annually, fewer adults will do so for routine Preventative services such that adherence to USPSTF guidelines often does not reach desired thresholds [1,2]. The current study examined the extent to which the wait time inherent in an emergency department (ED) visit (e.g., for labs, imaging, etc.) could be utilized to assess adherence to preventive service guidelines without adding burden to clinical providers. Specifically, we sought to pilot these efforts towards cervical cancer screening, with the first step being doc- umentation of the extent to which screening deficiencies could be effi- ciently identified at the bedside during an ED visit using parallel service providers. Cervical cancer was selected for this pilot based upon the Centers for Disease Control and Prevention’s (CDC) finding that the pa- tients most likely to be non-adherent with screening recommendations are those who use the ED as their usual source of care [3,4].
Implementation of widespread cervical cancer screening has result- ed in a tremendous decrease in the incidence of cervical cancer in the
U.S. Still, only 80.7% of U.S. women aged 21-65 years report adherence to USPSTF cervical cancer screening recommendations [3], far below the Healthy People 2020 target of 93% [5].
While clinical providers in the ED are occupied with the care of acutely ill and injured patients, parallel service providers such as trained research enrollers, students, patient care technicians, or volunteers have been shown to be able to effectively promote or deliver preventive health services [6,7]. We conducted a pilot study utilizing our Emergen- cy Department Research Enrollers (EDREs) to evaluate a convenience sample of female patients aged 21-65 who presented to the for Review> ED during Fall 2016 for adherence to USPSTF cervical can- cer screening recommendations. EDREs stationed in the ED approached eligible patients, introduced the study, and obtained written informed consent from interested patients. Patients answered electronic survey questions [8] on demo- Approximately 25% of subjects stated they had received an HPV vaccination. Adherence was significantly higher among women of child-bearing age (<= 49 years), than among women of N 49 years (83% and 70%, respec- tively), p = 0.015. Rates of non-adherent and uncertain statuses were higher among Hispanic women (38% and 8%, respectively) than among non-Hispanic women (12% and 3%, respectively), p = 0.002. Rates of non-adherence among women without a usual provider of women’s healthcare (27%) were nearly double those with a provider (14%), p = 0.083. Table 1 Descriptive statistics. M SD Frequency % Age 36.43 12.08 Race White 81 43% Black/African american 71 38% Asian 2 1% Native american 1 1% Multi-racial/other 32 17% Hispanic or Latino/Latina No 163 87% Yes 24 13% 5 3% Private insurance 107 57% Medicaid 77 41% Medicare 23 12% Other 4 2% Educational level Less than high school 19 10% High school degree/GED/equivalent 58 31% Some college 69 37% 4 Year college degree 27 15% Professional degree (MA/PhD/MD) 13 7% Has a normal provider for women’s health issues Yes 161 86% No 26 14% Table 2 Cervical cancer screening variables. graphic characteristics and cervical cancer screening-related topics (i.e., “Have you ever had a Pap test?”; “When was your last Pap test?”; “Do you know the results of your last Pap test?”; “When are you due for your next Pap test?”, “Have you ever been tested for HPV?” and “Have you ever received and HPV vaccination?”). Women found to be non-ad- herent with USPSTF screening recommendations were informed of this and referred to either the A total of 187 subjects were enrolled (see Table 1). The majority (94%) reported that they had previously had a Pap test, and 98% of these individuals were able to provide a time frame during which their most recent Pap test occurred (see Table 2). Approximately 82% of subjects knew the results of their most recent Pap test, and 79% knew when their next Pap test was due. Results indicated that 81% of subjects (n = 152) were adherent to cervical cancer screening guidelines (similar to national estimates but well below the Federal Government goal [9]). A total of 29 subjects (16%) were shown to be non-adherent based on never having received a Pap test or receiving a test N 3 years ago. The remaining 3% (n = 6) was determined to have uncertain adherence status due to their inability to report if they had ever received a Pap test or estimate when their last Pap test occurred. With regard to HPV co-testing, 50% reported past testing, 27% reported they had never been tested, and the remaining 23% did not know. Frequency % Have you ever had a Pap test? Yes 175 94% No 9 5% Unsure When was your last Pap test? 3 2% b6 months ago 50 27% Between 6 months and 1 year ago 55 29% Between 1 and 2 years ago 35 19% Between 2 and 3 years ago 12 6% N 3 years ago 20 11% Doesn’t know 3 2% Do you know the results of your last Pap test? No 24 13% Yes – normal 145 78% Yes – abnormal 7 4% When are you due for your next Pap test? Within 6 months 76 41% Between 6 months and 1 year 43 23% Between 1 and 2 years 10 5% Between 2 and 3 years 7 4% Doesn’t know or refused to answer 40 21% Have you ever been tested for HPV No 51 27% Yes 94 50% Doesn’t know Have you ever received an HPV vaccination? 42 23% No 112 60% Yes 46 25% Doesn’t know 29 16% ? BA, LD, MS, JP, DA report no conflicts of interest. 1106 Correspondence / American Journal of Emergency Medicine 36 (2018) 1098–1120 Our findings support the value of future research evaluating the efficacy of ED-based behavioral interventions that aim to increase adherence to screening guidelines. Many types of trained parallel service providers could potentially be utilized to deliver these types of interventions. While our departmental research enrollers were used for this pilot study, techni- cians, volunteers, students, or other personnel have the potential to fulfill this roll. Given the routine waiting periods in ED visits, focused interven- tions aimed at promoting preventive health could conceivably be delivered without impacting length of stay, acute clinical care, or ED workflow. Beau Abar, PhD? Layne Dylla, MD, PhD Michael Sergeant, BA Julie Pasternack, MD David Adler, MD, MPH University of Rochester Medical Center, 265 Crittenden Blvd, Box 655c, Rochester, NY 14620, United States *Corresponding author. E-mail address: [email protected] (B. Abar). 28 September 2017 https://doi.org/10.1016/j.ajem.2017.09.053 References cervical collar and safety: Lessons for the future, insights from the past Dear Editor, We read the article by Woster et al. [1] with great interest. cervical collars are used in severe Trauma victims so as to reduce the risk of sec- ondary damage to the spinal cord, even though it contributes to eleva- tion of intracranial pressure and lead to secondary brain injury [2] in those with traumatic brain injury. Woster et al. [1] measured optic nerve sheath diameter before and after applying rigid cer- vical collar in healthy volunteers and demonstrated significant increase in ONSD, an indirect/a surrogate marker of ICP. We would like to share our experience [3] on the application and ef- fects of four different types of cervical collars such as Rigid cervical collar, Laerdal Stifneck collar, Tynor adjustable Hard Cervical Collar and Philadel- phia collar in emergency departments as well as sand bags on ONSD. In addition, we would like to highlight on the status of teaching, learning and evaluation (TLE) on the assessment of cervical spine, application of cervical collar and its effect on ICP in severe trauma victims, and the need for early removal or intervention after appropriate imaging. In our study with healthy volunteers, the base line ONSD was 4.6 +- 1.4 mm and it increased significantly with Rigid cervical collar as noted by Worster et al. [1] as well as with Laerdal Stifneck and Tynor adjust- able Hard Cervical Collar after five minutes of application probably due its distinct biomechanical qualities during immobilization of the neck, but not significantly with Philadelphia collar even after 30 min. We also measured ONSD in our volunteers before and after immobilizing their cervical spine with sandbags and tape which did not reveal any alteration of ONSD from the base line. Karason and his associates [4] examined the effects cervical collar on jugular venous pressure following the placement of four different col- lars in healthy volunteers and concluded that well molded collars like Stifneck and Miami J collars offered the most efficient for immobiliza- tion of the neck with the least effect on jugular venous pressure. Our observations do not discourage the routine use of cervical collar in emergency departments or situations, but suggest immobilization of cervical spine with Philadelphia collar or sandbags and tape in resource constrained environ. However, we stress on early imaging and exclu- sion of cervical spine injury, and removal of the cervical collar so as to avoid secondary brain injury in those with severe trauma. The students of health sciences and health care providers involved in handling trauma victims shall be trained to protect cervical spine with cervical collar or sand bags and tape. They have to be informed and get familiarized on the adverse effects of cervical collar and subsequent care of such victims. Efforts have to be taken to include evaluation and protection of cervical spine in TLE similar to that of BLS and ALS. Subramanian Senthilkumaran Department of Emergency & Critical Care, Be Well Hospital, Erode, Tamil Nadu, India Corresponding author at: Department of Emergency & Critical Care Medicine, Be Well Hospitals, Erode, Tamil Nadu, India. E-mail address: [email protected]. Nanjundan Karthikeyan Department of Emergency Medicine, Hamad Medical Corporation, Doha, Qatar Narendra Nath Jena Department of Emergency Medicine, Meenakshi Mission Hospital and Research Centre, Madurai, Tamil Nadu, India Ponniah Thirumalaikolundusubramanian Department of Internal Medicine, Chennai Medical College Hospital & Research Center, Irungalur, Trichy, India https://doi.org/10.1016/j.ajem.2017.09.054 References
Woster CM, Zwank MD, Pasquarella JR, Wewerka SS, Anderson JP, Greupner JT, Motalib S. Placement of a cervical collar increases the optic nerve sheath diameter in Healthy adults. Am J Emerg Med 2018;36:430-4.