Cervical Cancer Screening and Follow-up

State: FL Type: Model Practice Year: 2004

Brevard County has a population of approximately 500,000. The economics of the county are quite diverse, with employment equally diverse. The county health department has three clinical sites. Health department clients are traditionally low-income, uninsured or underinsured. The health department has a longstanding history within the community for providing Pap screening and family planning, completing over 7,000 screenings per year. Abnormal pathology rates fluctuate, but at the time the need was identified, these rates were approximately between 10 percent and 30 percent of those screened per year. The staff was frustrated because they were unable to get diagnostic and intervention services for clientele whose tests showed abnormal results. The question was how to provide expensive services for this population with limited resources. Evaluating the problem, the department determined it needed an established screening service, a desire to provide timely intervention, and a very qualified staff. Additional training was needed so that staff could provide colposcopies, LEEPS (Looped Electro Excision Procedure) and prescribed treatment for resulting abnormal Paps. Funding was needed to train staff and buy equipment. Start-up and second year funding was provided by one the local hospitals, with follow-up years funding provided by the County Health Department budget. Outcomes of the practice include: Contracting with a new lab for Paps, which resulted in 10 percent of screenings returning as abnormal (closer to the national standard). An average of 500 colposcopies per year, with approximately 50 high-grade lesions/carcinoma in-situ per year that require treatment. Key elements to replication include initiative and perseverance to identify a critical need; a willing, trainable staff; and community partners willing to help finance the endeavor. Every year, the department has realized its goal of providing timely, effective, clinically appropriate intervention for abnormal Paps to these clients at no or very-low cost.
The public health need addressed by this practice is diagnostic treatment and intervention following abnormal Pap screenings, resulting in a lower incidence rate of cervical cancer within the treated population. Cervical cancer is 100 percent curable with early detection and treatment. Brevard County Health Department provides over 7,000 Pap screenings a year to low-income, uninsured, and underinsured clients. In 1996, the health department found an increase in the number of abnormal screening results. These required further diagnostic services such as colposcopy, biopsy and/or LEEP. Unfortunately, the health department provided only limited colposcopy service by OB/GYN on staff, and only at the South Brevard location. This did not meet the increased need throughout the county. In 1999, the director of the health department developed an agreement with Orlando Regional Medical Center, Orlando, FL whereby their OB residents would perform colposcopy and cryosurgery services for the department’s clients. This arrangement expanded the number of clients who could be seen.
Agency Community RolesIn 1996 a partnership was formed between the Florida Department of Health and the Regional Training Center for Family Planning, Emory University.. At that time, Brevard County Health Department applied to send one of its advanced registered nurse practitioners (ARNP) to be trained in the colposcopy procedure. In 2001, two more ARNPs accomplished the training through this same partnership. While in training, each ARNP’s time was supported by the county health department. Through grant opportunities, the county health department was able to buy additional colposcopy and biopsy instruments. However, the cost of the program start-up was high and partnerships were sought within the community to offset these expenses. Health First, Holmes Regional Medical Center, a local hospital and frequent partner, stepped to the plate and financed $50,000 for initial funding and $20,000 for second-year funding. Key players in establishing the program were the local Women’s Advisory Board, the CEO of the hospital, the Oncology Department Chair, local OB/GYNs who had also identified this need, and the hospital’s HOPE Program. Although several OB/GYN offices in the area provided limited numbers of diagnostic services for indigent clients with abnormal Paps (one to two per year), the disparity between the number of services available and the number of clients requiring services was fast increasing. As the lead agency and the service provider, the county health department played an integral part in the identifying, developing, and carrying out the program to address this issue. Since the end of the two-year start-up period, the health department budget has funded this program. The hospital continues to pay for the pathology services performed at their institution. Costs and ExpendituresInvestigation showed the average cost of a colposcopy in the private sector to be $300, while the LEEP could exceed $600—costs far higher than the county health department clients could afford. ImplementationThe following tasks allowed the county health department to achieve program objectives: Training of three Brevard County Health Department ARNPs to provide colposcopy, biopsy and cryosurgery for clients with abnormal Pap smears. OB residents added to practice to continue with colposcopy and cryosurgery services. Support from and partnership with Health First, Holmes Regional Medical Center. Forming an advisory board including key players in the medical community. Start-up and second year funding provided by Health First, Holmes Regional Medical Center. Continued dedication of Brevard County Health Department staff in the scheduling and follow-up of these clients. The cost to the health department has been mainly associated with the training time and service delivery time of county health department staff. Existing facilities, equipment, and warehouse stores have significantly lowered the program costs . The partners as well as many of the private sector providers with whom this agency has working relationships, have recognized the program is cost effective.  
This program has established a reduction in the wait time and an increase in the number of women receiving follow-up of abnormal pap screenings. Currently, Cervical Cancer Incident Rate for Brevard County (4.3 per 100,000 [female] population) is well below that of the state rate (10.4 per 100,000 [female] population). While there are definitely challenges to be seen in the development and implementation of any new health care program, those encountered with this program proved to be insignificant due to the well defined vision and plan of the health department staff, the support of local health care partners and the willingness of all to work towards a common goal. Evaluation of this program is through statistical reports and client satisfaction surveys. As there are currently no other programs within the community providing this service, the county health department is assured that all outcomes are attributable to this program. This program has clearly achieved its objectives and goals and is well worth the investment involved. Unintended consequences have been positive in the renewed health and increased wellness of the population served which in turn increases the wellness of the community.
Sustainability This program becomes more viable and sustainable as the support of community partners continues to develop and expand. There is sufficient stakeholder commitment to ensure that the program has long-term sustainability. Lessons LearnedThe lessons learned were invaluable: Have a clear, well-defined vision. Sell the plan to your agency first then develop it within the community. Be flexible and ready to make changes as the need occurs. Most importantly, do not lose sight of taking care of people and meeting the client’s needs.