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ABSTRACT & COMMENTARY
Spitzer and colleagues reviewed the records of all patients presenting for initial colposcopic examination at the Queens Hospital Center between 1984 and 1995. The purpose of the study was to determine whether their routine practicerepeating the Pap smear at the time of the colposcopic examinationwas clinically useful. Spitzer et al considered a repeat Pap smear as being clinical useful if it would have changed the patient’s management by changing the follow-up interval or by suggesting the need for cervical conization. In addition, Spitzer et al performed a cost-effectiveness analysis.
The average age of the 2969 patients that were reviewed was 29 years. Of these patients, 910 had an initial cytology read as ASCUS, 1286 as LGSIL, 367 as HGSIL, and 22 as carcinoma. An additional 277 women with normal Pap smears and abnormalities such as genital warts were also examined.
In 312 cases, the Pap smear obtained at the time of the colposcopy was of a higher grade than the initial referral Pap smear. In 76% of these cases, the colposcopic examination identified the higher grade lesion. This left 76 women who had normal colposcopic examinations but Pap smears that suggested the presence of LGSIL (44) or HGSIL (14). According to the authors’ practice, only the 14 women with cytology indicating HGSIL would have undergone excisional conization.
Of those women referred for other reasons such as genital warts, abnormal cervicography, or HIV infection, a similarly low number of Pap smears performed at the time of colposcopy was more than one grade higher than the initial cytology.
Overall, repeating the Pap smear changed the management of 2.7% of the cases. In only 1.1% of the cases, a cone biopsy would have been indicated because of the repeat cytology result and a negative or minimally atypical colposcopic examination.
The authors’ cost-effectiveness analysis indicates that repeating the Pap smear adds, on average, a cost of $24.23 per patient. When this is extrapolated to the approximately one million initial colposcopic examinations that are performed in the United States each year, more than $24,000,000 was spent on repeat Pap smears. Spitzer et al argue that repeating the Pap smear at the time of initial colposcopic examination is not cost-effective.
I was very happy to see this paper. For far too long, we have performed Pap smears at the time of colposcopy for no very good reason. For most of us, it was the way we were taught. Now, Spitzer et al argue (in my view quite convincingly) that these cytology examinations are rarely clinically useful and are not cost-effective.
For far too long, we have passed down practice patterns from one generation to the next without critically looking at their importance. For example, many physicians still perform a hematocrit at the time of each prenatal visit or at the time of each annual examination, despite the fact that such practice has not been shown to be either clinically useful or cost-effective. In many places, chest x-rays are still routinely performed (and even required) prior to surgery under general anesthesia, though many published papers have shown that this practice is not useful. The list of such practices goes on and on and on.
Unfortunately, we have entered a period of time in the United States when all clinicians must pay attention to cost-effectiveness. The percentage of the gross national product that is spent on health care each year remains far too large. Unless we want a federal or state agency telling us how to practice medicine (and presumably how to save health care costs), we should be more closely examining our practices to determine those things that we are currently doing that could be eliminated while still maintaining patient safety. Spitzer et al have certainly identified one such practice.