Over the last 50 years, the incidence of cervical cancer has dramatically decreased. However, health disparities in cervical cancer screening (CCS) persist for women from racial and ethnic minorities and those residing in rural and poor communities. For more than 45 years, federally funded health centers (HCs) have been providing comprehensive, culturally competent, and quality primary health care services to medically underserved communities and vulnerable populations. To enhance the quality of care and to ensure more women served at HCs are screened for cervical cancer, over eight HCs received funding to support patient-centered medical home (PCMH) transformation with goals to increase CCS rates. The study conducted a qualitative analysis using Atlas.ti software to describe the barriers and challenges to CCS and PCMH transformation, to identify potential solutions and opportunities, and to examine patterns in barriers and solutions proposed by HCs. Interrater reliability was assessed using Cohen’s Kappa. The findings indicated that HCs more frequently described patient-level barriers to CCS, including demographic, cultural, and health belief/behavior factors. System-level barriers were the next commonly cited, particularly failure to use the full capability of electronic medical records (EMRs) and problems coordinating with external labs or providers. Provider-level barriers were least frequently cited.
Over the last 50 years, the incidence of cervical cancer has dramatically decreased as a result of available screening tests for early detection and intervention [
To improve the overall quality of health care service delivery, the Patient Protection and Affordable Care Act of 2010 contained several provisions, which targeted the establishment and promotion of the patient-centered medical home (PCMH) model [
In 2012, federally funded health centers (HCs) served 21 million patients or nearly 1 in 15 Americans [
Given that adoption of the PCMH model has shown promise in increasing preventive services among underserved populations, HCs undergoing PCMH transformation have the potential to increase rates of CCS. To enhance the quality of care at HCs and to ensure more women from underserved communities are screened for cervical cancer, the Health Resources and Services Administration (HRSA) provided funding in 2012 to assist over eight hundred HCs with PCMH transformation and CCS rates improvements. In this study, we conducted a qualitative analysis with project narratives submitted by the HCs aimed at the following: (1) describe the barriers and challenges to conducting CCS in HRSA-supported HCs undergoing PCMH transformation, (2) describe the potential solutions and opportunities to improve screening rates, and (3) examine whether there were any patterns in barriers or solutions by HC characteristics, including PCMH recognition, screening rate, and proportion of uninsured patients. To our knowledge, this is the first study to examine the barriers and solutions to increase CCS in HCs within the context of the PCMH model.
In September 2012, HRSA received a total of 811 applications for funding for PCMH transformation and improvements in CCS. Applicants were asked to describe the key clinical and nonclinical activities that would support PCMH transformation/recognition and improve CCS and delineate challenges that would be addressed with the funding. In addition, the applications required a work plan, including key milestones and personnel responsible for each activity. As of February 2013, when sampling for this study took place, 809 grantees had accepted the supplemental funding.
To select a representative sample of subject HCs, we conducted a purposive sample of the HCs using a number of characteristics from the 2011 UDS. The UDS is a core dataset of annual operation and performance of HCs where the data are aggregated at the HC organizational level. We considered the following factors to ensure that the sample reflected the diversity of federally funded HCs and their patients: total patient volume, geographical region, number of full-time clinicians per 10,000 medical patients, urban/rural location, CCS rate adjusted quartile (i.e., relative ranking of Pap test rates compared with other HCs nationwide, after accounting for differences that influence clinical performance), PCMH recognition status, percentage of homeless patients, percentage of agricultural workers patients, percentage of uninsured patients, percentage of major racial/ethnic minority groups, and percentage of patients best served in a language other than English [
We used Atlas.ti software to assist with the coding of project narratives from subject HCs. We assessed interrater reliability by calculating Cohen’s Kappa for the subsample of project narratives [
The study was approved by the Institutional Review Board at the University of Maryland, College Park.
Table
Comparison of all grantees and sample grantees by general health center characteristics and patient demographics.
FY12 supplemental funding grantees ( |
Final sample ( |
|
---|---|---|
|
||
% large (>10,000 patients per year) | 60.4% | 57.5% |
Mean clinical FTEs/10,000 patients | 24.8 | 25.9 |
HHS regions | ||
% I | 9.3% | 8.8% |
% II | 9.3% | 8.8% |
% III | 9.6% | 8.8% |
% IV | 15.5% | 15.0% |
% V | 13.8% | 13.8% |
% VI | 10.9% | 10.0% |
% VII | 5.3% | 6.3% |
% VIII | 4.9% | 5.0% |
% IX | 13.8% | 15.0% |
% X | 7.5% | 8.8% |
% urban | 52.1% | 51.3% |
Pap test quartile | ||
1 (highest 25% screening rate) | 24.2% | 21.3% |
2 | 27.2% | 26.3% |
3 | 26.3% | 28.8% |
4 (lowest 25% screening rate) | 22.1% | 23.8% |
% PCMH recognized | 23.5% | 23.8% |
|
||
>10% homeless | 6.7% | 10.0% |
>10% agricultural Worker | 6.1% | 7.5% |
>10% uninsured | 22.5% | 23.8% |
>10% Hispanic/Latino | 33.9% | 32.5% |
>10% Asian | 5.1% | 6.3% |
>10% African American | 29.4% | 26.3% |
>10% best served in language other than English | 17.4% | 18.8% |
FY: fiscal year. FTEs: full-time equivalents. HHS: Health and Human Services. PCMH: patient-centered medical home.
HHS regions: US Department of Health and Human Service divided the country into 10 regions with offices to oversee regional operations.
Table
Barriers to cervical cancer screening and solutions to increase screening rates.
Barriers | ||
---|---|---|
Patient barriers | Provider barriers | System barriers |
Demographic ( |
Lack of HIT training (6) | Not using full capability of EMR (20) |
Financial issues/uninsured (18) | Noncompliance with established protocols/guidelines (4) | Coordination with external labs or providers (13) |
Transportation barriers (7) | Preventive care not embedded into practice (2) | Inadequate staff hours or employees: |
Transient patient population (5) | General lack of education/training (2) | Limited clinical hours (3) |
Lack of childcare (3) | No policy/procedure to document all practices (2) | |
High patient turnover rate (1) | Lack of supplies/equipment for procedures (2) | |
Other/general (13) | EMR not yet implemented (1) | |
Cultural factors ( |
Lack accurate patient contact information (1) | |
Fear of procedure or results (9) | Health professional shortage area (1) | |
Language barrier (5) | No patient surveys (1) | |
Trust issues (4) | Primary care providers do not provide cervical cancer screening (1) | |
Discomfort with male providers (3) | No OB/GYN specialist at HC (1) | |
Immigration status (2) | ||
Health beliefs/behaviors ( |
||
Lack of awareness/knowledge of cervical cancer screening need (10) | ||
Not seeking preventive care (8) | ||
Do not keep appointments (7) | ||
Lack knowledge of available cervices (2) | ||
Late for appointments (1) | ||
|
||
Solutions | ||
Patient-targeted | Provider-targeted | System-targeted |
|
||
Outreach, education, or health promotion for patient population, 59 (74%) | Education/training for providers, 44 (55%) | Utilize HIT/EMR, 63 (79%) |
Improve/increase communication with patients, 53 (66%) | Feedback to providers |
Staffing: hire new employee or increase hours, |
Facilitate access to care, 29 (36%) | Regular quality improvement process, 39 (49%) | |
Implement protocol to better manage care, 32 (40%) | ||
Improve recording keeping, 24 (30%) | ||
Improve coordination with external providers, labs, 21 (25%) |
Table
Strategies to facilitate patient access to care.
Strategies to improve communication with patient.
Fewer HCs proposed using email and text messages, which can be advantageous strategies to communicate with a transient patient population. Examples of other strategies to improve communication included providing a health care plan for patients, improving the telephone system, and conducting home visits to patients.
Our study found that HCs that have already attained PCMH recognition were more culturally sensitive in the preparation of educational materials and utilization of cultural brokers in patient navigation. Furthermore, these HCs have developed more flexibility in promoting access to screening through walk-in appointments and mobile clinics. The majority of HCs proposed multilevel approaches to improve CCS rates by simultaneously targeting patient-level, provider-level, and system-level barriers. Such multipronged approaches have been demonstrated to be more successful in serving low-income minority populations of underscreened women [
Overall, the most frequently proposed solution was at the system level, specifically enhancing utilization of HIT/EMRs (80% of subject HCs). EMR tools have been successful in assisting OB/GYN physicians in adherence to CCS guidelines transformation [
Patients may not receive up-to-date screening for a wide variety of reasons, including limited access to services due to geographic location or lack of insurance, psychological barriers such as mistrust of providers or fear of pain, or lack of knowledge regarding the need to schedule a preventive visit [
This study sought to investigate barriers to CCS reported by HCs and proposed solutions to increase screening rates, among HCs undergoing PCMH transformation. Although PCMH transformation is associated with higher HC operating costs, three-quarters of all eligible HCs applied for PCMH supplemental funding, which is a strong indication of their eagerness to participate in PCMH transformation and improve quality of clinical care including increasing CCS rates [
The views expressed in this paper are those of the authors and do not necessarily reflect the official policies of the US Department of Health and Human Services (HHS) or the Health Resources and Services Administration (HRSA) nor does mention of HHS or HRSA imply endorsement by the US government.
The authors report no conflict of interests or financial relationships relevant to this paper.
The authors would like to sincerely thank Nina Brown, MPH, for her preliminary work on the PCMH supplemental funding applications that contributed to the final development of analytical framework for this paper.