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Roles of Health Care Providers and Patients in Initiation of Unnecessary Papanicolaou Testing After Total Hysterectomy Fangjian Guo, MD, PhD, and Yong-Fang Kuo, PhD Objectives. To assess Papanicolaou (Pap) testing use among US adult women with a history of a total hysterectomy for a benign condition and the roles of health care providers and patients in the initiation of screening Pap tests. Methods. We used 2000 to 2013 data from the National Health Interview Survey on women aged 20 years or older who had undergone a hysterectomy (n = 11 616) to estimate unnecessary Pap test use. Results. The percentage of self-reported Pap testing in the preceding 3 years among women who had undergone a hysterectomy decreased from 72.2% in 2000 to 53.3% in 2013. In 2013, 42.4% of women who had undergone a hysterectomy reported receiving recommendations for screening from a health care provider in the past year (32% of which were unnecessary), and 32.1% reported undergoing Pap tests in the preceding year (22.1% of which were unnecessary). Although the majority of Pap tests were performed at a clinician’s recommendation, approximately one fourth were initiated by patients without clinician recommendations. Conclusions. Health care providers should advise women who have had a total hysterectomy for a benign condition on appropriate use of screening services. (Am J Public Health. 2016;106: 2005–2011. doi:10.2105/AJPH.2016.303360) See also Miller, p. 1900.
W
ith few exceptions, national guidelines consistently recommend against cervical cancer screening among women who have had a hysterectomy,1–3 but screening Papanicolaou (Pap) testing is common among US women who have undergone this procedure.4–6 In the past 2 decades, the US Preventive Services Task Force has recommended that women who have had a total hysterectomy for a benign condition discontinue Pap testing.7 Women who have had a supracervical hysterectomy (leaving the cervix intact) or a CIN2+ (cervical intraepithelial neoplasia grade 2+) hysterectomy still need cervical cancer screening. In a study involving data from the 2010 version of the National Health Interview Survey (NHIS), Kepka et al. estimated that approximately 65% of women 30 aged years or older have a Pap test in the 3 years after their hysterectomy.4,8 To design effective strategies to prevent overuse of screening Pap tests, it is important
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to identify the roles of health care providers and patients in initiation of screening. In a recent study, we observed that most Pap tests among women aged 70 years or older are performed on the advice of their health care providers, especially obstetricians– gynecologists, whereas about 20% of Pap tests are initiated by patients themselves.9 No study to our knowledge has quantitatively assessed the proportion of providerrecommended and patient self-initiated Pap testing among women who have had a hysterectomy. We used 2000 to 2013 data from the NHIS to assess Pap test use among
women with a history of total hysterectomy for benign conditions and quantify the roles of doctors and patients in the initiation of screening Pap tests.
METHODS In this cross-sectional study, we used data from women aged 20 years or older with a history of hysterectomy who took part in the NHIS in 2000, 2005, 2010, or 2013. The NHIS collects health information through annual, in-person household surveys conducted among a representative cross-sectional sample of noninstitutionalized US adults.10 A complex, stratified, multistage sample design is used to provide nationally representative data. We excluded from our sample women with a history of cervical cancer (n = 342), women who had undergone a Pap test for a health problem (n = 928), and women with no valid information on their most recent Pap test (n = 235). We included 11 616 women who had undergone a hysterectomy in our analyses (Table A, available as a supplement to the online version of this article at http://www.ajph.org).
Sociodemographic Information We included information on the following sociodemographic characteristics in our analyses: age, race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, other),
ABOUT THE AUTHORS Fangjian Guo is with the Department of Obstetrics & Gynecology and the Center for Interdisciplinary Research in Women’s Health, University of Texas Medical Branch, Galveston. Yong-Fang Kuo is with the Office of Biostatistics, Department of Preventive Medicine and Community Health, University of Texas Medical Branch. Correspondence should be sent to Fangjian Guo, MD, PhD, Department of Obstetrics & Gynecology, Center for Interdisciplinary Research in Women’s Health, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0587 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted June 24, 2016. doi: 10.2105/AJPH.2016.303360
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immigration status (US-born, not US-born), region of residence (Northeast, Midwest, South, West), marital status (married or living with a partner; widowed, divorced, or separated; single), educational level (less than high school, high school, more than high school), and ratio of family income to the federal poverty threshold (less than 1, 1–3, above 3). Health insurance coverage (public, private, none), usual source of health care (yes, no), and visit to an obstetrician–gynecologist in the past year (yes, no) were used to reflect access to health care. Emergency rooms were not considered usual sources of care.
Most Recent Pap Test Participants reported when they received their most recent Pap test (month/year, number of days/weeks/months/years ago, or time interval grouping [if the respondent did not answer in any of the other formats]), and we used the 2000 NHIS method to recode this information.11 In addition, women were asked whether they had received a recommendation for a Pap test from their health care provider in the past year. If they had not received such a recommendation but underwent a Pap test anyway, they were coded as having initiated Pap testing themselves.
Unnecessary Pap Testing To estimate the number of women being screened unnecessarily, we used 2013 NHIS data to determine the total number of Pap tests in the preceding year among women who had undergone a hysterectomy (including hysterectomies for benign conditions, supracervical hysterectomies, and CIN2-indicated hysterectomies). We used data from the National Hospital Discharge Survey to estimate the numbers of women who might still need cervical screening (i.e., women with supracervical and CIN2+ hysterectomies).12,13 Because not many women had CIN2+ hysterectomies performed, we combined data from the 2008, 2009, and 2010 versions of the National Hospital Discharge Survey to calculate reliable estimates. According to these estimates, 12.0% of hysterectomies performed among women aged 20 to 50 years were supracervical (cervix intact), as were 10.4% among women aged 51 to 65 years and 4.8%
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among women aged 66 years or older. A total of 2.8% of hysterectomies among women aged 20 to 50 years were CIN2+ hysterectomies; the corresponding percentages were 2.3% and 1.2% among women aged 51 to 65 years and women aged 66 years or older. We assumed that these estimates were similar to the proportions among women from the NHIS and then subtracted the numbers of women with supracervical and CIN2+ hysterectomies from the total and derived the number of unnecessary Pap tests. For age subgroup analyses, we used specific estimates of the proportions of women in each age group with supracervical hysterectomies or CIN2-indicated hysterectomies. All of our estimates were adjusted to 2010 US Census population figures.
Statistical Analysis We examined trends during the period 2000 to 2013 in self-reported Pap test use in the preceding 3 years and in the past year among adult women who had undergone a hysterectomy. We used data from the 2013 NHIS to assess the roles of health care providers and patients in the initiation of screening Pap testing. Multivariate logistic regression models were used to assess differences in screening use, recommendations for Pap testing, and completion of Pap testing according to recommendation status. Controlled variables included age, race/ethnicity, educational level, and income level. All of our analyses were weighted to account for
differential probabilities of selection and the complex NHIS sample design.10 We incorporated sample weights for final annual person weights into all of our analyses to account for nonresponse and poststratification adjustment (i.e., adjustment of data on age, gender, and race/ethnicity to 2010 Census population control totals). Standard errors were calculated via Taylor series linearization. We conducting sensitivity analyses by including only women aged 20 to 65 years. SAS version 9.4 (SAS Institute Inc, Cary, NC) was used in conducting all of our analyses.
RESULTS Data on the estimated numbers of unnecessary Pap tests among adult women taking part in the 2013 NHIS are presented in Table 1 (see also Table B, available as a supplement to the online version of this article at http://www.ajph.org). These data show that 53.3% of women had received Pap tests in the preceding 3 years and that 32.1% had received Pap tests in the past year. An estimated 42.9% of women had undergone unnecessary Pap tests in the preceding 3 years, and 22.1% had undergone unnecessary tests in the past year. According to standard 2010 US Census population figures, about 4.9 million unnecessary Pap tests are performed annually among women who have had a hysterectomy. At approximately $30 per test,14 $150 million in direct medical costs
TABLE 1—Estimation of Unnecessary Papanicalaou (Pap) Testing in the Preceding Year Among Women Who Have Had a Hysterectomy: National Health Interview Survey, United States, 2013 Women Who May Need Screening, No. Age, y
Women With Hysterectomy, No.a
Women With Pap Test in Past Year, No.
CIN2+ Hysterectomy
Women Screened Unnecessarily, No. (%)
20–50
4 398 000
2 260 000
527 000
123 000
1 610 000 (36.6)
51–65
8 585 000
‡ 66
9 196 000
3 206 000
895 000
197 000
2 115 000 (24.6)
1 733 000
443 000
114 000
1 177 000 (12.8)
Total
22 179 000
7 199 000
1 865 000
433 000
4 902 000 (22.1)
Supracervical Hysterectomy
Note. CIN = cervical intraepithelial neoplasia. All figures were adjusted to 2010 US Census population figures. a Total hysterectomy for a benign condition, supracervical hysterectomy, or CIN2-indicated hysterectomy.
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could be saved annually if screening guidelines were followed.
Trends in Pap Testing The percentage of women with a history of hysterectomy (including hysterectomies for benign conditions, supracervical hysterectomies, and CIN2-indicated hysterectomies) who self-reported receiving a Pap test in the preceding 3 years decreased from 72.2% in 2000 to 53.3% in 2013 (Figure 1). With the exception of Hispanic women, significant decreases were observed among women in all age, racial/ethnic, and regional subgroups (Figure A, available as a supplement to the online version of this article at http://www. ajph.org). The proportion of women who self-reported receiving a Pap test within the past year also decreased significantly from 2000 to 2013 (from 49.1% to 32.1%; Figure 1). Only non-Hispanic Black and Hispanic women did not show significant decreases in Pap test use in the past year (Figure B, available as a supplement to the online version of this article at http://www.ajph.org).
Roles of Providers and Patients
Proportion, %
Among women with a reported history of a hysterectomy taking part in the 2013 NHIS, 1689 were aged 20 to 65 years and 1549 were older than 65 years (Table 2). Approximately 7% of the overall sample of 3238 women did not have health insurance 100 90 80 70 60 50 40 30 20 10 0 2000
coverage, about 5% did not have a usual source of care, and 27% had visited an obstetrician–gynecologist in the preceding year. A total of 42.4% of women reported receiving a clinician’s recommendation for Pap testing in the past year, and 32% received unnecessary recommendations. Among those who had received a recommendation for testing, 56.5% had undergone a Pap test in the preceding year, and 32.1% received Pap testing unnecessarily. The prevalence of Pap testing in the past year was much higher among women who received screening recommendations than among those who did not (56.5% vs 14.2%; P < .001 after adjustment for age, race/ethnicity, educational level, and income level). Among women who had undergone Pap testing in the preceding year, 74.5% received a recommendation for screening from a clinician and 25.5% initiated screening themselves (Table 3). Only in the group without a usual source of care did the proportion of Pap tests attributable to patients’ self-initiation exceed the proportion attributable to clinicians’ recommendations (54.4% vs 45.4%). Even under the assumption that all Pap testing among women who did not receive a clinician’s recommendation was unnecessary, still more than 60% of the estimated unnecessary Pap tests observed here were the result of clinician recommendations. As noted, we conducted a sensitivity analysis by restricting our sample to include
In the past 3 years In the past year
2005
2010
2013
Year Note. Data are percentages and 95% confidence intervals. Percentages were age adjusted to the 2010 US population. See the text for hysterectomy definitions.
FIGURE 1—Adjusted Prevalence of Papanicalaou Testing in the Preceding 3 Years and in the Past Year Among Women Who Have Had a Hysterectomy: National Health Interview Survey, 2000–2013
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only women from the 2013 NHIS who were aged 20 to 65 years and had undergone a hysterectomy. The results of these analyses were similar to those of our primary analyses (Tables C and D, available as supplements to the online version of this article at http:// www.ajph.org).
DISCUSSION Use of screening Pap tests among women who have had a hysterectomy decreased significantly between 2000 and 2013. However, screening recommendations and receipt of Pap testing were still common among US adult women who had undergone hysterectomies. Even though national guidelines have recommended against unnecessary posthysterectomy screening for more than 2 decades, data from the 2013 NHIS show that 42.4% of women with a hysterectomy received screening recommendations and 32.1% underwent Pap testing in the past year. Consistent with the results of other researchers,6,13 we also found that the majority of hysterectomies were performed as total hysterectomies for benign diseases (approximately 90%), with only small proportions being supracervical hysterectomies (approximately 8%) or CIN2-indicated hysterectomies (approximately 2%). After exclusion of women who still had a cervix (i.e., those who had undergone a supracervical hysterectomy) and those with a CIN2+ hysterectomy, our findings showed that more than 4.9 million unnecessary Pap tests were still performed annually among the study population (at $150 million in direct medical costs). However, an overall improvement was found during the study period. In their study, involving 2002 data from the Behavioral Risk Factor Surveillance System, Sirovich and Welch6 reported that 45.6% of adult women with hysterectomies had received unnecessary Pap tests in the preceding 3 years; our results, by contrast, showed that 42.9% of women with a hysterectomy had received unnecessary Pap testing in the past 3 years. Efforts are needed to further reduce unnecessary screening among women with hysterectomies. Screening Pap tests among women who have had total hysterectomies for benign
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TABLE 2—Screening Papanicalaou (Pap) Test Recommendations and Screening Use Among Women With a Hysterectomy in the Preceding Year: National Health Interview Survey, United States, 2013 Pap Test in Past Year, % (95% CI) Women, No. (%)a
Women With Screening Recommendation, % (95% CI)
All Women
Women With Screening Recommendation
Women Without Screening Recommendation
3238 (100.0)
42.4 (40.2, 44.6)
32.1 (29.8, 34.4)
56.5 (53.3, 59.7)
14.2 (12.1, 16.3)
20–50
529 (18.8)
60.6 (55.1, 66.2)
51.4 (45.4, 57.4)
63.4 (57.0, 69.8)
32.9 (24.9, 40.9)
51–65
1160 (38.7)
46.0 (42.4, 49.6)
37.4 (33.6, 41.2)
57.7 (52.6, 62.8)
20.1 (15.8, 24.4)
‡ 66
1549 (42.5)
31.0 (27.9, 34.2)
18.8 (16.1, 21.6)
49.0 (42.9, 55.1)
5.3 (3.5, 7.1)
Non-Hispanic White
2261 (76.5)
39.7 (37.1, 42.3)
29.1 (26.5, 31.7)
55.0 (50.9, 59.1)
12.1 (9.8, 14.4)
Non-Hispanic Black
520 (11.7)
52.0 (46.7, 57.3)
47.7 (41.8, 53.6)
65.4 (59.0, 71.9)
28.8 (20.0, 37.6)
Hispanic
311 (7.7)
53.2 (46.7, 59.8)
39.0 (32.8, 45.3)
56.0 (47.1, 64.9)
19.7 (12.0, 27.3)
Other
146 (4.1)
45.1 (34.8, 55.4)
30.7 (20.1, 41.4)
52.5 (35.2, 69.8)
12.9 (4.1, 21.6)
2960 (91.6)
41.3 (39.0, 43.7)
31.6 (29.2, 34.0)
56.5 (53.1, 59.9)
14.2 (12.0, 16.4)
278 (8.4)
53.9 (46.8, 61.0)
37.3 (29.8, 44.9)
56.7 (46.4, 66.9)
14.7 (7.4, 22.1)
425 (13.2)
49.8 (42.9, 56.6)
37.8 (31.5, 44.1)
56.3 (48.1, 64.6)
19.6 (12.1, 27.1)
652 (22.3)
37.0 (32.7, 41.2)
27.9 (23.9, 31.9)
57.1 (50.3, 63.8)
10.8 (7.1, 14.4)
South
1421 (44.9)
44.6 (41.4, 47.8)
34.9 (31.1, 38.7)
58.0 (53.1, 63.0)
16.3 (12.8, 19.8)
West
740 (19.5)
38.5 (33.3, 43.7)
26.7 (21.9, 31.4)
51.9 (45.1, 58.8)
10.9 (7.3, 14.5)
Married/living with partner
1412 (58.6)
46.6 (43.5, 49.7)
34.2 (31.1, 37.2)
56.1 (51.9, 60.3)
15.0 (11.9, 18.2)
Widowed/divorced/separated
1596 (36.1)
35.3 (32.2, 38.5)
27.7 (24.7, 30.7)
56.3 (51.0, 61.6)
12.3 (9.5, 15.0)
228 (5.2) 2 (0.0)
43.9 (35.6, 52.1)
39.5 (31.6, 47.5)
63.3 (51.2, 75.4)
21.3 (11.5, 31.0)
Characteristic Total Age group, y
Race/ethnicity
Immigration status US-born Not US-born Region of residence Northeast Midwest
Marital status
Single Data missing Educational level < high school
535 (13.5)
40.5 (35.1, 45.9)
25.5 (20.3, 30.6)
50.5 (41.7, 59.3)
8.6 (4.5, 12.6)
High school
1016 (32.3)
36.8 (33.2, 40.4)
28.4 (24.8, 32.1)
54.8 (49.1, 60.6)
13.1 (9.5, 16.6)
> high school
1679 (54.0)
46.3 (43.3, 49.3)
36.1 (33.0, 39.2)
58.6 (54.3, 63.0)
16.7 (13.5, 19.8)
Data missing
8 (0.2)
Family income to poverty threshold ratio 3
1350 (48.4)
24.3 (19.0, 29.5)
36.7 (33.6, 39.8)
59.3 (54.5, 64.0)
16.7 (13.2, 20.2)
Health insurance coverage None
232 (7.2)
38.5 (30.6, 46.4)
19.5 (13.0, 26.1)
33.0 (21.0, 45.0)
11.1 (3.8, 18.4)
Private
1909 (63.5)
45.6 (42.9, 48.3)
36.1 (33.3, 39.0)
58.5 (54.4, 62.6)
17.4 (14.6, 20.2)
Public
1090 (29.2)
36.4 (32.5, 40.4)
26.6 (23.0, 30.2)
57.2 (51.0, 63.4)
9.2 (6.2, 12.1)
26.0 (18.3, 33.7) 43.2 (41.0, 45.5)
19.0 (11.4, 26.5) 32.8 (30.4, 35.2)
33.2 (17.5, 48.9) 57.2 (53.9, 60.5)
14.0 (5.7, 22.3) 14.2 (12.0, 16.4)
Data missing
7 (0.1)
Usual source of care No Yes
168 (4.9) 3070 (95.1)
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TABLE 2—Continued Pap Test in Past Year, % (95% CI) Women, No. (%)a
Women With Screening Recommendation, % (95% CI)
All Women
Women With Screening Recommendation
No
2418 (72.9)
34.1 (31.6, 36.5)
17.2 (15.2, 19.2)
38.1 (34.1, 42.1)
6.4 (4.9, 8.0)
Yes
816 (27.0)
64.6 (60.7, 68.5)
72.2 (68.2, 76.2)
82.5 (78.3, 86.7)
53.3 (45.8, 60.9)
Characteristic
Women Without Screening Recommendation
Visited an obstetrician–gynecologist in past year
Data missing
4 (0.1)
Note. CI = confidence interval. a Sample weights were used to calculated weighted percentages.
conditions are not only unnecessary but also harmful.15,16 Despite strong evidence and clinical recommendations against routine screening in this group, however, Pap tests are still commonly conducted. Patient, provider, and health care system factors may help explain the common use of screening Pap tests in this population. Women may continue to request Pap testing, regardless of its limited benefits, because they are unaware of their low risk for cervical cancer, they are enthusiastic about cancer screening, or they have established a screening interval with their primary care provider.17,18 Clinicians’ lack of access to the most recent medical evidence and their reluctance to invest time in educating their patients about the benefits and harms of screening may also contribute to overuse of Pap testing after total hysterectomies for benign conditions.6 Our results regarding Pap testing among women with hysterectomies are consistent with our previous findings among older women (aged 70 years or older) without a history of hysterectomy, who also frequently received unnecessary Pap tests.9 Screening recommendations were strongly associated with Pap test uptake, a finding consistent with previous reports that health providers’ attitudes toward a screening test greatly influence patient uptake.19
Strengths and Limitations The primary strength of our study is that the NHIS provides a large, nationally representative sample with high response rates and available information on
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sociodemographic characteristics and health care access. These data allowed us to assess trends in screening Pap test use among women with a history of hysterectomy from 2000 to 2013. We were also able to assess cervical cancer screening in specific subpopulations and the roles of providers and patients in the initiation of screening, which will help in the development of appropriate strategies to target the cause of the problem. A limitation of the study is that data on Pap test use and provider recommendations for Pap tests were self-reported and subject to recall bias. Research has shown that Pap test use may be overestimated.20,21 Women may not be able to distinguish speculum exams conducted for other reasons from actual Pap sampling, and we did not have medical records to confirm patients’ reports. In addition, the NHIS lacks information on history of precancerous cervical lesions and hysterectomy procedures. Women aged 20 to 65 years who had received a supracervical hysterectomy (leaving the cervix intact) would still be eligible for cervical cancer screening according to the screening guidelines.16 Although the majority of hysterectomies were performed for benign diseases, we followed the analytical approach used in a previous study6 and excluded women who had received supracervical or CIN2-indicated hysterectomies in estimating numbers of unnecessary screening Pap tests. This estimation may have led to an underestimation of unnecessary screening Pap testing because of the assumption that all of these women had undergone a Pap test in the preceding year.
Implications If overuse of screening Pap testing among women with a history of total hysterectomy for a benign condition is to be reduced, a patient-centered, evidence-based, and value-added model is needed to improve the decision process with respect to cancer preventive care.22 Electronic alerts23 within computerized physician order entry systems may be adopted to improve compliance with practice guidelines for ordering Pap tests and to help reduce unnecessary screening. We suggest that providers refrain from recommending screening for these patients and discuss with them the limited benefits and potential harms of unnecessary cervical cancer screening after a total hysterectomy for a benign condition. Specific attention should be focused on women with no usual source of care, because we found that more than half of these women self-initiated their Pap testing. When they request Pap tests, providers should educate them to help them choose screening services wisely.
Conclusions Our results showed that use of Pap testing among women who have had a total hysterectomy for a benign condition is still common. The approximately 5 million unnecessary Pap tests performed annually among these women result in $150 million in direct medical costs wasted each year. In our study, the majority of Pap tests were performed according to a clinician’s recommendation; however, a significant portion (approximately 25%) were initiated by the patients themselves, and this was especially
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TABLE 3—Percentages of Provider-Recommended and Self-Initiated Screening Papanicalaou Tests Among Women Who Underwent Testing in the Preceding Year: National Health Interview Survey, United States, 2013 Characteristic
Pa
testing. Future studies should focus on innovative approaches to enhancing communication between clinicians and patients, which can help facilitate decision-making processes that are patient centered and evidence based.
Recommended, % (95% CI)
Self-Initiated, % (95% CI)
74.5 (71.3, 77.7)
25.5 (22.3, 28.7)
20–50 51–65
74.8 (68.8, 80.8) 71.0 (65.5, 76.4)
25.2 (19.2, 31.2) 29.0 (23.6, 34.5)
‡ 66
80.5 (74.4, 86.7)
19.5 (13.3, 25.6)
Non-Hispanic White
74.9 (70.8, 79.1)
25.1 (20.9, 29.2)
Non-Hispanic Black
71.1 (63.0, 79.2)
28.9 (20.8, 37.0)
Hispanic
76.4 (67.0, 85.8)
23.6 (14.2, 33.0)
Other
77.0 (61.4, 92.6)
23.0 (7.4, 38.6)
73.7 (70.3, 77.1) 81.8 (73.0, 90.6)
26.3 (22.9, 29.7) 18.2 (9.4, 27.0)
74.0 (63.8, 84.1)
26.0 (15.9, 36.2)
Midwest
75.7 (68.3, 83.0)
24.3 (17.0, 31.7)
South
74.1 (69.6, 78.6)
25.9 (21.4, 30.4)
West
74.8 (68.8, 80.8)
25.2 (19.2, 31.2)
Married/living with partner
76.5 (72.2, 80.8)
23.5 (19.2, 27.8)
Widowed/divorced/separated Single
71.5 (65.7, 77.3) 69.9 (56.8, 83.1)
28.5 (22.7, 34.3) 30.1 (16.9, 43.2)
< high school
80.1 (71.5, 88.6)
19.9 (11.4, 28.5)
HUMAN PARTICIPANT PROTECTION
High school
70.9 (64.3, 77.6)
29.1 (22.4, 35.7)
> high school
75.2 (70.9, 79.5)
24.8 (20.5, 29.1)
No protocol approval was needed for this study because secondary data were used and no human participants were involved.
3
75.9 (71.1, 80.8)
24.1 (19.2, 28.9)
65.0 (45.3, 84.7)
35.0 (15.3, 54.7)
1. Smith RA, Manassaram-Baptiste D, Brooks D, et al. Cancer screening in the United States, 2015: a review of current American cancer society guidelines and current issues in cancer screening. CA Cancer J Clin. 2015;65(1): 30–54.
Private
73.8 (70.1, 77.6)
26.2 (22.4, 29.9)
Public
78.2 (72.0, 84.4)
21.8 (15.6, 28.0)
No
45.4 (24.4, 66.4)
54.6 (33.6, 75.6)
Yes
75.4 (72.1, 78.6)
24.6 (21.4, 27.9)
75.4 (70.1, 80.6) 73.9 (69.5, 78.2)
24.6 (19.4, 29.9) 26.1 (21.8, 30.5)
Total Age group, y
.041
Race/ethnicity
.78
Immigration status
Region of residence
.97
Northeast
Marital status
.19
Educational level
Health insurance coverage None
.88
.25
Roles of Health Care Providers and Patients in Initiation of Unnecessary Papanicolaou Testing After Total Hysterectomy Fangjian Guo, MD, PhD, and Yong-Fang Kuo, PhD Objectives. To assess Papanicolaou (Pap) testing use among US adult women with a history of a total hysterectomy for a benign condition and the roles of health care providers and patients in the initiation of screening Pap tests. Methods. We used 2000 to 2013 data from the National Health Interview Survey on women aged 20 years or older who had undergone a hysterectomy (n = 11 616) to estimate unnecessary Pap test use. Results. The percentage of self-reported Pap testing in the preceding 3 years among women who had undergone a hysterectomy decreased from 72.2% in 2000 to 53.3% in 2013. In 2013, 42.4% of women who had undergone a hysterectomy reported receiving recommendations for screening from a health care provider in the past year (32% of which were unnecessary), and 32.1% reported undergoing Pap tests in the preceding year (22.1% of which were unnecessary). Although the majority of Pap tests were performed at a clinician’s recommendation, approximately one fourth were initiated by patients without clinician recommendations. Conclusions. Health care providers should advise women who have had a total hysterectomy for a benign condition on appropriate use of screening services. (Am J Public Health. 2016;106: 2005–2011. doi:10.2105/AJPH.2016.303360) See also Miller, p. 1900.
W
ith few exceptions, national guidelines consistently recommend against cervical cancer screening among women who have had a hysterectomy,1–3 but screening Papanicolaou (Pap) testing is common among US women who have undergone this procedure.4–6 In the past 2 decades, the US Preventive Services Task Force has recommended that women who have had a total hysterectomy for a benign condition discontinue Pap testing.7 Women who have had a supracervical hysterectomy (leaving the cervix intact) or a CIN2+ (cervical intraepithelial neoplasia grade 2+) hysterectomy still need cervical cancer screening. In a study involving data from the 2010 version of the National Health Interview Survey (NHIS), Kepka et al. estimated that approximately 65% of women 30 aged years or older have a Pap test in the 3 years after their hysterectomy.4,8 To design effective strategies to prevent overuse of screening Pap tests, it is important
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to identify the roles of health care providers and patients in initiation of screening. In a recent study, we observed that most Pap tests among women aged 70 years or older are performed on the advice of their health care providers, especially obstetricians– gynecologists, whereas about 20% of Pap tests are initiated by patients themselves.9 No study to our knowledge has quantitatively assessed the proportion of providerrecommended and patient self-initiated Pap testing among women who have had a hysterectomy. We used 2000 to 2013 data from the NHIS to assess Pap test use among
women with a history of total hysterectomy for benign conditions and quantify the roles of doctors and patients in the initiation of screening Pap tests.
METHODS In this cross-sectional study, we used data from women aged 20 years or older with a history of hysterectomy who took part in the NHIS in 2000, 2005, 2010, or 2013. The NHIS collects health information through annual, in-person household surveys conducted among a representative cross-sectional sample of noninstitutionalized US adults.10 A complex, stratified, multistage sample design is used to provide nationally representative data. We excluded from our sample women with a history of cervical cancer (n = 342), women who had undergone a Pap test for a health problem (n = 928), and women with no valid information on their most recent Pap test (n = 235). We included 11 616 women who had undergone a hysterectomy in our analyses (Table A, available as a supplement to the online version of this article at http://www.ajph.org).
Sociodemographic Information We included information on the following sociodemographic characteristics in our analyses: age, race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, other),
ABOUT THE AUTHORS Fangjian Guo is with the Department of Obstetrics & Gynecology and the Center for Interdisciplinary Research in Women’s Health, University of Texas Medical Branch, Galveston. Yong-Fang Kuo is with the Office of Biostatistics, Department of Preventive Medicine and Community Health, University of Texas Medical Branch. Correspondence should be sent to Fangjian Guo, MD, PhD, Department of Obstetrics & Gynecology, Center for Interdisciplinary Research in Women’s Health, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0587 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted June 24, 2016. doi: 10.2105/AJPH.2016.303360
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immigration status (US-born, not US-born), region of residence (Northeast, Midwest, South, West), marital status (married or living with a partner; widowed, divorced, or separated; single), educational level (less than high school, high school, more than high school), and ratio of family income to the federal poverty threshold (less than 1, 1–3, above 3). Health insurance coverage (public, private, none), usual source of health care (yes, no), and visit to an obstetrician–gynecologist in the past year (yes, no) were used to reflect access to health care. Emergency rooms were not considered usual sources of care.
Most Recent Pap Test Participants reported when they received their most recent Pap test (month/year, number of days/weeks/months/years ago, or time interval grouping [if the respondent did not answer in any of the other formats]), and we used the 2000 NHIS method to recode this information.11 In addition, women were asked whether they had received a recommendation for a Pap test from their health care provider in the past year. If they had not received such a recommendation but underwent a Pap test anyway, they were coded as having initiated Pap testing themselves.
Unnecessary Pap Testing To estimate the number of women being screened unnecessarily, we used 2013 NHIS data to determine the total number of Pap tests in the preceding year among women who had undergone a hysterectomy (including hysterectomies for benign conditions, supracervical hysterectomies, and CIN2-indicated hysterectomies). We used data from the National Hospital Discharge Survey to estimate the numbers of women who might still need cervical screening (i.e., women with supracervical and CIN2+ hysterectomies).12,13 Because not many women had CIN2+ hysterectomies performed, we combined data from the 2008, 2009, and 2010 versions of the National Hospital Discharge Survey to calculate reliable estimates. According to these estimates, 12.0% of hysterectomies performed among women aged 20 to 50 years were supracervical (cervix intact), as were 10.4% among women aged 51 to 65 years and 4.8%
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among women aged 66 years or older. A total of 2.8% of hysterectomies among women aged 20 to 50 years were CIN2+ hysterectomies; the corresponding percentages were 2.3% and 1.2% among women aged 51 to 65 years and women aged 66 years or older. We assumed that these estimates were similar to the proportions among women from the NHIS and then subtracted the numbers of women with supracervical and CIN2+ hysterectomies from the total and derived the number of unnecessary Pap tests. For age subgroup analyses, we used specific estimates of the proportions of women in each age group with supracervical hysterectomies or CIN2-indicated hysterectomies. All of our estimates were adjusted to 2010 US Census population figures.
Statistical Analysis We examined trends during the period 2000 to 2013 in self-reported Pap test use in the preceding 3 years and in the past year among adult women who had undergone a hysterectomy. We used data from the 2013 NHIS to assess the roles of health care providers and patients in the initiation of screening Pap testing. Multivariate logistic regression models were used to assess differences in screening use, recommendations for Pap testing, and completion of Pap testing according to recommendation status. Controlled variables included age, race/ethnicity, educational level, and income level. All of our analyses were weighted to account for
differential probabilities of selection and the complex NHIS sample design.10 We incorporated sample weights for final annual person weights into all of our analyses to account for nonresponse and poststratification adjustment (i.e., adjustment of data on age, gender, and race/ethnicity to 2010 Census population control totals). Standard errors were calculated via Taylor series linearization. We conducting sensitivity analyses by including only women aged 20 to 65 years. SAS version 9.4 (SAS Institute Inc, Cary, NC) was used in conducting all of our analyses.
RESULTS Data on the estimated numbers of unnecessary Pap tests among adult women taking part in the 2013 NHIS are presented in Table 1 (see also Table B, available as a supplement to the online version of this article at http://www.ajph.org). These data show that 53.3% of women had received Pap tests in the preceding 3 years and that 32.1% had received Pap tests in the past year. An estimated 42.9% of women had undergone unnecessary Pap tests in the preceding 3 years, and 22.1% had undergone unnecessary tests in the past year. According to standard 2010 US Census population figures, about 4.9 million unnecessary Pap tests are performed annually among women who have had a hysterectomy. At approximately $30 per test,14 $150 million in direct medical costs
TABLE 1—Estimation of Unnecessary Papanicalaou (Pap) Testing in the Preceding Year Among Women Who Have Had a Hysterectomy: National Health Interview Survey, United States, 2013 Women Who May Need Screening, No. Age, y
Women With Hysterectomy, No.a
Women With Pap Test in Past Year, No.
CIN2+ Hysterectomy
Women Screened Unnecessarily, No. (%)
20–50
4 398 000
2 260 000
527 000
123 000
1 610 000 (36.6)
51–65
8 585 000
‡ 66
9 196 000
3 206 000
895 000
197 000
2 115 000 (24.6)
1 733 000
443 000
114 000
1 177 000 (12.8)
Total
22 179 000
7 199 000
1 865 000
433 000
4 902 000 (22.1)
Supracervical Hysterectomy
Note. CIN = cervical intraepithelial neoplasia. All figures were adjusted to 2010 US Census population figures. a Total hysterectomy for a benign condition, supracervical hysterectomy, or CIN2-indicated hysterectomy.
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could be saved annually if screening guidelines were followed.
Trends in Pap Testing The percentage of women with a history of hysterectomy (including hysterectomies for benign conditions, supracervical hysterectomies, and CIN2-indicated hysterectomies) who self-reported receiving a Pap test in the preceding 3 years decreased from 72.2% in 2000 to 53.3% in 2013 (Figure 1). With the exception of Hispanic women, significant decreases were observed among women in all age, racial/ethnic, and regional subgroups (Figure A, available as a supplement to the online version of this article at http://www. ajph.org). The proportion of women who self-reported receiving a Pap test within the past year also decreased significantly from 2000 to 2013 (from 49.1% to 32.1%; Figure 1). Only non-Hispanic Black and Hispanic women did not show significant decreases in Pap test use in the past year (Figure B, available as a supplement to the online version of this article at http://www.ajph.org).
Roles of Providers and Patients
Proportion, %
Among women with a reported history of a hysterectomy taking part in the 2013 NHIS, 1689 were aged 20 to 65 years and 1549 were older than 65 years (Table 2). Approximately 7% of the overall sample of 3238 women did not have health insurance 100 90 80 70 60 50 40 30 20 10 0 2000
coverage, about 5% did not have a usual source of care, and 27% had visited an obstetrician–gynecologist in the preceding year. A total of 42.4% of women reported receiving a clinician’s recommendation for Pap testing in the past year, and 32% received unnecessary recommendations. Among those who had received a recommendation for testing, 56.5% had undergone a Pap test in the preceding year, and 32.1% received Pap testing unnecessarily. The prevalence of Pap testing in the past year was much higher among women who received screening recommendations than among those who did not (56.5% vs 14.2%; P < .001 after adjustment for age, race/ethnicity, educational level, and income level). Among women who had undergone Pap testing in the preceding year, 74.5% received a recommendation for screening from a clinician and 25.5% initiated screening themselves (Table 3). Only in the group without a usual source of care did the proportion of Pap tests attributable to patients’ self-initiation exceed the proportion attributable to clinicians’ recommendations (54.4% vs 45.4%). Even under the assumption that all Pap testing among women who did not receive a clinician’s recommendation was unnecessary, still more than 60% of the estimated unnecessary Pap tests observed here were the result of clinician recommendations. As noted, we conducted a sensitivity analysis by restricting our sample to include
In the past 3 years In the past year
2005
2010
2013
Year Note. Data are percentages and 95% confidence intervals. Percentages were age adjusted to the 2010 US population. See the text for hysterectomy definitions.
FIGURE 1—Adjusted Prevalence of Papanicalaou Testing in the Preceding 3 Years and in the Past Year Among Women Who Have Had a Hysterectomy: National Health Interview Survey, 2000–2013
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only women from the 2013 NHIS who were aged 20 to 65 years and had undergone a hysterectomy. The results of these analyses were similar to those of our primary analyses (Tables C and D, available as supplements to the online version of this article at http:// www.ajph.org).
DISCUSSION Use of screening Pap tests among women who have had a hysterectomy decreased significantly between 2000 and 2013. However, screening recommendations and receipt of Pap testing were still common among US adult women who had undergone hysterectomies. Even though national guidelines have recommended against unnecessary posthysterectomy screening for more than 2 decades, data from the 2013 NHIS show that 42.4% of women with a hysterectomy received screening recommendations and 32.1% underwent Pap testing in the past year. Consistent with the results of other researchers,6,13 we also found that the majority of hysterectomies were performed as total hysterectomies for benign diseases (approximately 90%), with only small proportions being supracervical hysterectomies (approximately 8%) or CIN2-indicated hysterectomies (approximately 2%). After exclusion of women who still had a cervix (i.e., those who had undergone a supracervical hysterectomy) and those with a CIN2+ hysterectomy, our findings showed that more than 4.9 million unnecessary Pap tests were still performed annually among the study population (at $150 million in direct medical costs). However, an overall improvement was found during the study period. In their study, involving 2002 data from the Behavioral Risk Factor Surveillance System, Sirovich and Welch6 reported that 45.6% of adult women with hysterectomies had received unnecessary Pap tests in the preceding 3 years; our results, by contrast, showed that 42.9% of women with a hysterectomy had received unnecessary Pap testing in the past 3 years. Efforts are needed to further reduce unnecessary screening among women with hysterectomies. Screening Pap tests among women who have had total hysterectomies for benign
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TABLE 2—Screening Papanicalaou (Pap) Test Recommendations and Screening Use Among Women With a Hysterectomy in the Preceding Year: National Health Interview Survey, United States, 2013 Pap Test in Past Year, % (95% CI) Women, No. (%)a
Women With Screening Recommendation, % (95% CI)
All Women
Women With Screening Recommendation
Women Without Screening Recommendation
3238 (100.0)
42.4 (40.2, 44.6)
32.1 (29.8, 34.4)
56.5 (53.3, 59.7)
14.2 (12.1, 16.3)
20–50
529 (18.8)
60.6 (55.1, 66.2)
51.4 (45.4, 57.4)
63.4 (57.0, 69.8)
32.9 (24.9, 40.9)
51–65
1160 (38.7)
46.0 (42.4, 49.6)
37.4 (33.6, 41.2)
57.7 (52.6, 62.8)
20.1 (15.8, 24.4)
‡ 66
1549 (42.5)
31.0 (27.9, 34.2)
18.8 (16.1, 21.6)
49.0 (42.9, 55.1)
5.3 (3.5, 7.1)
Non-Hispanic White
2261 (76.5)
39.7 (37.1, 42.3)
29.1 (26.5, 31.7)
55.0 (50.9, 59.1)
12.1 (9.8, 14.4)
Non-Hispanic Black
520 (11.7)
52.0 (46.7, 57.3)
47.7 (41.8, 53.6)
65.4 (59.0, 71.9)
28.8 (20.0, 37.6)
Hispanic
311 (7.7)
53.2 (46.7, 59.8)
39.0 (32.8, 45.3)
56.0 (47.1, 64.9)
19.7 (12.0, 27.3)
Other
146 (4.1)
45.1 (34.8, 55.4)
30.7 (20.1, 41.4)
52.5 (35.2, 69.8)
12.9 (4.1, 21.6)
2960 (91.6)
41.3 (39.0, 43.7)
31.6 (29.2, 34.0)
56.5 (53.1, 59.9)
14.2 (12.0, 16.4)
278 (8.4)
53.9 (46.8, 61.0)
37.3 (29.8, 44.9)
56.7 (46.4, 66.9)
14.7 (7.4, 22.1)
425 (13.2)
49.8 (42.9, 56.6)
37.8 (31.5, 44.1)
56.3 (48.1, 64.6)
19.6 (12.1, 27.1)
652 (22.3)
37.0 (32.7, 41.2)
27.9 (23.9, 31.9)
57.1 (50.3, 63.8)
10.8 (7.1, 14.4)
South
1421 (44.9)
44.6 (41.4, 47.8)
34.9 (31.1, 38.7)
58.0 (53.1, 63.0)
16.3 (12.8, 19.8)
West
740 (19.5)
38.5 (33.3, 43.7)
26.7 (21.9, 31.4)
51.9 (45.1, 58.8)
10.9 (7.3, 14.5)
Married/living with partner
1412 (58.6)
46.6 (43.5, 49.7)
34.2 (31.1, 37.2)
56.1 (51.9, 60.3)
15.0 (11.9, 18.2)
Widowed/divorced/separated
1596 (36.1)
35.3 (32.2, 38.5)
27.7 (24.7, 30.7)
56.3 (51.0, 61.6)
12.3 (9.5, 15.0)
228 (5.2) 2 (0.0)
43.9 (35.6, 52.1)
39.5 (31.6, 47.5)
63.3 (51.2, 75.4)
21.3 (11.5, 31.0)
Characteristic Total Age group, y
Race/ethnicity
Immigration status US-born Not US-born Region of residence Northeast Midwest
Marital status
Single Data missing Educational level < high school
535 (13.5)
40.5 (35.1, 45.9)
25.5 (20.3, 30.6)
50.5 (41.7, 59.3)
8.6 (4.5, 12.6)
High school
1016 (32.3)
36.8 (33.2, 40.4)
28.4 (24.8, 32.1)
54.8 (49.1, 60.6)
13.1 (9.5, 16.6)
> high school
1679 (54.0)
46.3 (43.3, 49.3)
36.1 (33.0, 39.2)
58.6 (54.3, 63.0)
16.7 (13.5, 19.8)
Data missing
8 (0.2)
Family income to poverty threshold ratio 3
1350 (48.4)
24.3 (19.0, 29.5)
36.7 (33.6, 39.8)
59.3 (54.5, 64.0)
16.7 (13.2, 20.2)
Health insurance coverage None
232 (7.2)
38.5 (30.6, 46.4)
19.5 (13.0, 26.1)
33.0 (21.0, 45.0)
11.1 (3.8, 18.4)
Private
1909 (63.5)
45.6 (42.9, 48.3)
36.1 (33.3, 39.0)
58.5 (54.4, 62.6)
17.4 (14.6, 20.2)
Public
1090 (29.2)
36.4 (32.5, 40.4)
26.6 (23.0, 30.2)
57.2 (51.0, 63.4)
9.2 (6.2, 12.1)
26.0 (18.3, 33.7) 43.2 (41.0, 45.5)
19.0 (11.4, 26.5) 32.8 (30.4, 35.2)
33.2 (17.5, 48.9) 57.2 (53.9, 60.5)
14.0 (5.7, 22.3) 14.2 (12.0, 16.4)
Data missing
7 (0.1)
Usual source of care No Yes
168 (4.9) 3070 (95.1)
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TABLE 2—Continued Pap Test in Past Year, % (95% CI) Women, No. (%)a
Women With Screening Recommendation, % (95% CI)
All Women
Women With Screening Recommendation
No
2418 (72.9)
34.1 (31.6, 36.5)
17.2 (15.2, 19.2)
38.1 (34.1, 42.1)
6.4 (4.9, 8.0)
Yes
816 (27.0)
64.6 (60.7, 68.5)
72.2 (68.2, 76.2)
82.5 (78.3, 86.7)
53.3 (45.8, 60.9)
Characteristic
Women Without Screening Recommendation
Visited an obstetrician–gynecologist in past year
Data missing
4 (0.1)
Note. CI = confidence interval. a Sample weights were used to calculated weighted percentages.
conditions are not only unnecessary but also harmful.15,16 Despite strong evidence and clinical recommendations against routine screening in this group, however, Pap tests are still commonly conducted. Patient, provider, and health care system factors may help explain the common use of screening Pap tests in this population. Women may continue to request Pap testing, regardless of its limited benefits, because they are unaware of their low risk for cervical cancer, they are enthusiastic about cancer screening, or they have established a screening interval with their primary care provider.17,18 Clinicians’ lack of access to the most recent medical evidence and their reluctance to invest time in educating their patients about the benefits and harms of screening may also contribute to overuse of Pap testing after total hysterectomies for benign conditions.6 Our results regarding Pap testing among women with hysterectomies are consistent with our previous findings among older women (aged 70 years or older) without a history of hysterectomy, who also frequently received unnecessary Pap tests.9 Screening recommendations were strongly associated with Pap test uptake, a finding consistent with previous reports that health providers’ attitudes toward a screening test greatly influence patient uptake.19
Strengths and Limitations The primary strength of our study is that the NHIS provides a large, nationally representative sample with high response rates and available information on
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sociodemographic characteristics and health care access. These data allowed us to assess trends in screening Pap test use among women with a history of hysterectomy from 2000 to 2013. We were also able to assess cervical cancer screening in specific subpopulations and the roles of providers and patients in the initiation of screening, which will help in the development of appropriate strategies to target the cause of the problem. A limitation of the study is that data on Pap test use and provider recommendations for Pap tests were self-reported and subject to recall bias. Research has shown that Pap test use may be overestimated.20,21 Women may not be able to distinguish speculum exams conducted for other reasons from actual Pap sampling, and we did not have medical records to confirm patients’ reports. In addition, the NHIS lacks information on history of precancerous cervical lesions and hysterectomy procedures. Women aged 20 to 65 years who had received a supracervical hysterectomy (leaving the cervix intact) would still be eligible for cervical cancer screening according to the screening guidelines.16 Although the majority of hysterectomies were performed for benign diseases, we followed the analytical approach used in a previous study6 and excluded women who had received supracervical or CIN2-indicated hysterectomies in estimating numbers of unnecessary screening Pap tests. This estimation may have led to an underestimation of unnecessary screening Pap testing because of the assumption that all of these women had undergone a Pap test in the preceding year.
Implications If overuse of screening Pap testing among women with a history of total hysterectomy for a benign condition is to be reduced, a patient-centered, evidence-based, and value-added model is needed to improve the decision process with respect to cancer preventive care.22 Electronic alerts23 within computerized physician order entry systems may be adopted to improve compliance with practice guidelines for ordering Pap tests and to help reduce unnecessary screening. We suggest that providers refrain from recommending screening for these patients and discuss with them the limited benefits and potential harms of unnecessary cervical cancer screening after a total hysterectomy for a benign condition. Specific attention should be focused on women with no usual source of care, because we found that more than half of these women self-initiated their Pap testing. When they request Pap tests, providers should educate them to help them choose screening services wisely.
Conclusions Our results showed that use of Pap testing among women who have had a total hysterectomy for a benign condition is still common. The approximately 5 million unnecessary Pap tests performed annually among these women result in $150 million in direct medical costs wasted each year. In our study, the majority of Pap tests were performed according to a clinician’s recommendation; however, a significant portion (approximately 25%) were initiated by the patients themselves, and this was especially
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TABLE 3—Percentages of Provider-Recommended and Self-Initiated Screening Papanicalaou Tests Among Women Who Underwent Testing in the Preceding Year: National Health Interview Survey, United States, 2013 Characteristic
Pa
testing. Future studies should focus on innovative approaches to enhancing communication between clinicians and patients, which can help facilitate decision-making processes that are patient centered and evidence based.
Recommended, % (95% CI)
Self-Initiated, % (95% CI)
74.5 (71.3, 77.7)
25.5 (22.3, 28.7)
20–50 51–65
74.8 (68.8, 80.8) 71.0 (65.5, 76.4)
25.2 (19.2, 31.2) 29.0 (23.6, 34.5)
‡ 66
80.5 (74.4, 86.7)
19.5 (13.3, 25.6)
Non-Hispanic White
74.9 (70.8, 79.1)
25.1 (20.9, 29.2)
Non-Hispanic Black
71.1 (63.0, 79.2)
28.9 (20.8, 37.0)
Hispanic
76.4 (67.0, 85.8)
23.6 (14.2, 33.0)
Other
77.0 (61.4, 92.6)
23.0 (7.4, 38.6)
73.7 (70.3, 77.1) 81.8 (73.0, 90.6)
26.3 (22.9, 29.7) 18.2 (9.4, 27.0)
74.0 (63.8, 84.1)
26.0 (15.9, 36.2)
Midwest
75.7 (68.3, 83.0)
24.3 (17.0, 31.7)
South
74.1 (69.6, 78.6)
25.9 (21.4, 30.4)
West
74.8 (68.8, 80.8)
25.2 (19.2, 31.2)
Married/living with partner
76.5 (72.2, 80.8)
23.5 (19.2, 27.8)
Widowed/divorced/separated Single
71.5 (65.7, 77.3) 69.9 (56.8, 83.1)
28.5 (22.7, 34.3) 30.1 (16.9, 43.2)
< high school
80.1 (71.5, 88.6)
19.9 (11.4, 28.5)
HUMAN PARTICIPANT PROTECTION
High school
70.9 (64.3, 77.6)
29.1 (22.4, 35.7)
> high school
75.2 (70.9, 79.5)
24.8 (20.5, 29.1)
No protocol approval was needed for this study because secondary data were used and no human participants were involved.
3
75.9 (71.1, 80.8)
24.1 (19.2, 28.9)
65.0 (45.3, 84.7)
35.0 (15.3, 54.7)
1. Smith RA, Manassaram-Baptiste D, Brooks D, et al. Cancer screening in the United States, 2015: a review of current American cancer society guidelines and current issues in cancer screening. CA Cancer J Clin. 2015;65(1): 30–54.
Private
73.8 (70.1, 77.6)
26.2 (22.4, 29.9)
Public
78.2 (72.0, 84.4)
21.8 (15.6, 28.0)
No
45.4 (24.4, 66.4)
54.6 (33.6, 75.6)
Yes
75.4 (72.1, 78.6)
24.6 (21.4, 27.9)
75.4 (70.1, 80.6) 73.9 (69.5, 78.2)
24.6 (19.4, 29.9) 26.1 (21.8, 30.5)
Total Age group, y
.041
Race/ethnicity
.78
Immigration status
Region of residence
.97
Northeast
Marital status
.19
Educational level
Health insurance coverage None
.88
.25
