Att D3_Outline for planned provider intervention

Outline for Planned Provider Education Intervention with Suggested Websites

This study will implement clinic-focused interventions and patient-education materials, to be delivered in combination, or not at all, depending upon study arm. As a reminder, the control clinics will be given clinical practice guidelines that describe the algorithm for using the HPV DNA test along with the Pap test as part of routine cervical cancer screening and will be told that if they use the HPV DNA test, its cost will be reimbursed by the project. The clinic-focused intervention includes provider training for clinicians and clinical staff, focusing on both person-level skills building and systems-level office changes (e.g., reminder systems). The patient-focused intervention includes the education brochures to patients.

Six organizations (representing a total of 18 clinics) have been chosen with three each assigned to the intervention or control group. There are 10 clinics in the intervention and 8 in the control group.

Patient-focused Intervention

HPV and cervical cancer education packets, based upon previously developed CDC patient education materials, have been adapted to include co-testing and emphasize on screening intervals. The patient packet is presented in Appendix C. These HPV/cervical cancer screening packets will be available at the intervention clinics to women aged 35-60 years who are due for routine Pap test screening (based on electronic records) and who schedule a Pap test in clinics assigned to the intervention (exclusion criteria: women without a history of a previous abnormal Pap in the past year who are not under surveillance). The packets will be mailed approximately 2 weeks before the commencement of the intervention.

The clinics and clinical staff assigned to clinic-based intervention will be given copies of the patient intervention materials.

Clinic-focused Intervention: Provider Training

The clinics that are assigned to clinic-focused intervention will not be informed of their study arm assignment. The clinicians and clinic staff in each of these clinics will then be subject to receive three types of educational interventions:

1) Grand Rounds

2) Access to web-based CME, podcasts, and articles through access through website

3) Academic detailing sessions

Grand Rounds. The grand rounds style CME will encourage all providers who are conducting Pap testing at these sites to attend. The guest speakers at these grand rounds will consist of two speakers to discuss about the guidelines that incorporate HPV testing as part of the Pap test and also discuss the importance of extending the screening interval from a risk and cost effectiveness. If at all possible, the grand rounds will be held in each of the three intervention sites and will allow for an interactive session.

Web-based Access. CDC or subcontractor will give all study participants (docs or actual patients) access to a website that is a repository of widely available web-based programs for CME, podcasts that will stress the screening interval issues in more detail, and peer-reviewed articles.

(See attachment 1 of a summary of existing CME’s that could be added on the website)

Academic Detailing. Provider training to target clinicians and clinical staff, and will be conducted in two separate sessions of approximately 3 hours total duration. The two sessions will be scheduled to accommodate the clinic schedule, but will be held with no more than 1 month between them. This component will also attempt to find a physician advocate from the clinical system who can carry on the message.

This component will also introduce key office tools that can reinforce positive behaviors on the part of the patient (Prescription pad that will inform the women of her results via email and a health diary that informs patients of key preventive services with the age and intervals of these preventive services.

Lastly, intervention staff will review reminder system to ensure that annual Pap testing is not reinforced among women who have a negative HPV and normal Pap test results. Intervention staff will also promote ASCCP guidelines through ASCCP brochures and algorithms in key office areas.

The objectives of the provider training sessions are to:

1. Provide clinicians and clinical staff with the most current information about the natural history of HPV and new developments in cervical cancer screening.

2. Provide succinct and tailored messages to motivate clinicians and clinical staff to actively encourage and endorse HPV DNA test with the Pap test as the main mode of cervical cancer screening among their patients.

3. Motivate clinicians to engage in cervical cancer screening conversations with their patients, especially about the new guidelines of using HPV as an adjunct and the potential implications it would have on being HPV positive, possible further surveillance, and in the majority of cases, extension of screening intervals among the HPV-negative, cytology-negative women.

4. Motivate and facilitate staff to review their office systems and to modify their systems to improve clinicians’ ability to:

   • identify patients due for cervical cancer screening;

   • identify patients that are not due for cervical cancer screening (HPV-negative, cytology-negative women)

   • remind clinicians to discuss cervical cancer screening with patients, and

   • tracking of cervical cancer screening among patients

Table 1 presents the training modules and their objectives. The curriculum and materials used for the provider training (e.g., training curriculum and handouts) were reviewed by clinicians and clinic staff in each participating clinic and their comments/suggestions were incorporated to finalize the curriculum. Clinicians and clinical staff will receive the complete curriculum with presentations and resources (handouts) in hard copy form. Modules will be presented by peers at all clinics and participants will receive continuing education credit. The patient education materials will be given to the clinicians and clinic staff in the training sessions, as potential tools they can use to initiate and discuss HPV testing as part of adjunct cervical cancer screening with patients. .

Table 1. Clinic-focused Intervention Modules and Objectives

SESSION 1
Module	Objectives
I: Cervical Cancer and HPV Epidemiology and Natural History	Review cervical cancer Epidemiology and Cervical Cancer screening statistics Briefly review cervical cancer screening modalities, with some evidence of efficacy and pros/cons of each Review natural history of HPV and cervical cancer development Review the concept of risk in cervical cancer and risk prediction Leave CDC Provider Booklet
II: Review Current Guidelines, Discuss the implications of a less than annual Pap test, and Enhance Skills for HPV and Pap Screening Conversations with Patients	Review current management guidelines for abnormal cytology (GIVE ASSCP Guidelines) Review USPSTF cervical cancer screening recommendations, American Cancer Society screening guidelines, and American College of Obstetric screening guidelines for average risk patients (Provide copies of ASCCP, ACOG, ACS guidelines, and USPSTF for completeness) Review adolescent guidelines Provide tools for effective patient-clinician and patient-clinical staff HPV testing and cervical cancer screening conversations that result in a shared screening decision (hand out counseling sheet) Key messages (based upon common patient attitudes, beliefs, social influence, and barriers/facilitators regarding cervical cancer screening) to motivate clinicians and clinical staff to actively encourage and endorse cervical cancer screening among their patients (Leave CDC patient brochures, and screening interval card with clinician/ office staff
III: Role-Playing for Cervical Cancer Screening Conversations with Patients	Provide opportunities for clinicians and clinical staff to practice conversational techniques for HPV testing and cervical cancer screening to include patients who are identified as a) HPV positive, normal cytology b) HPV negative, positive cytology, and c) HPV positive, abnormal cytology and d) discussion of screening interval
SESSION 2
Module	Objectives
IV. HPV Vaccine	Role of HPV 16/18 in precancerous and cancers Current ACIP recommendations Current ACS recommendations Discuss current practice and pros and cons of HPV vaccine Discuss role of HPV vaccine among HPV- exposed women
V: Office Reminder Systems for cervical cancer Screening with extended screening intervals	Engage clinicians and clinical staff in a discussion to review their existing office-based Pap test tracking system and to generate potential improvements or alternate solutions Provide clinical staff with options for office-based reminder systems for cervical cancer screening that can be separate for other annual reminders Reach group consensus about office system changes that fit best within their clinic structure
VI. Reemphasize the adjunctive HPV testing guidelines	Review information covered in Module II

Attachment D3. Outline for planned provider education intervention - 3 -