Anal Cancer Screening in a High-Risk Population: A Quality Improvement Initiative

dc.contributor.advisorReed, W. Garyen
dc.contributor.committeeMemberAnandam, Joselinen
dc.contributor.committeeMemberLau, Abbyen
dc.contributor.committeeMemberQuinn, Andrewen
dc.creatorBieterman, Andrewen
dc.creator.orcid0000-0003-4246-5765 2019
dc.description.abstractBACKGROUND: The main risk factor for the development of anal cancer is acquisition of the human papilloma virus (HPV). Individuals infected with the human immunodeficiency virus (HIV) have a higher prevalence of HPV and subsequently developing HPV induced dysplasia. The incidence of anal cancer among HIV positive men who have sex with men (MSM) has been estimated to be approximately twice that of HIV negative MSM with rates as high as 112-144 per 100,000. By relying on similarities between the anus and the cervix, and the established success of cervical cytology screening in reducing the incidence of cervical cancer, anal cancer screening programs have been established to identify pre-cancerous lesions. LOCAL PROBLEM: A retrospective chart review of anal cancer incidence at Parkland Hospital revealed a significant burden of anal cancer amongst HIV positive patients. As such, Parkland has decided to implement a policy of annual anal cancer screening among all HIV patients via anal cytology screening and referrals to proctology for any abnormal anal cytology samples. METHODS: In order to assess the monthly anal cancer screening rate, we looked at the absolute number of anal cytology samples performed in a 28 day period. The list of anal cytology samples performed was pulled from the Cerner laboratory information system (LIS) and correlated with a quarterly chart review using the electronic medical record (EMR). Utilizing, QI MACROS in EXCEL, we were able to create a run chart to identify trends in anal cancer screening rates over the duration of the project. We used chi-squared test of independence and unpaired t-test to determine statistical significance. INTERVENTIONS: We implemented a multi-step process involving over 10 Plan-Do-Study Act (PDSA) cycles for increasing the number of anal cytology samples performed in the clinic. The three most impactful PDSA cycles are discussed in the article. RESULTS: The primary outcome of monthly anal cancer screening rate increased over the duration of the project from an average of 19.5 in 2015 to 58.6 samples collected per month in 2018, a 199.3% increase relative to baseline (p < 0.001). While the interventions implemented were successful in increasing anal cancer screening rates, we were unable to determine which of the PDSA intervention cycles had the biggest impact on altering the clinic practice. Over the duration of the project, we screened 1908 patients. Of the patients screened, we identified 249 patients with abnormal anoscopy findings. Amongst the patients that had anal lesions on anoscopy, 10 developed anal cancer, 4.0%. When taking a closer look at these individuals and the electronic medical record, 3 patients were found to be completely asymptomatic at the most recent clinic prior to collection of the anal pap and would not have been referred to proctology if it weren't for the screening test, which ultimately resulted in an earlier diagnosis CONCLUSION: We were successful in taking previously proven interventions for increasing cervical cancer and adapting them for anal cancer. By increasing awareness to both patients and providers on the risks of anal cancer, instructing providers on the methods to screen for the disease, and providing timely feedback, we were able to increase the anal cancer screening rate in this large urban clinic with limited resources.en
dc.subjectAnal Canalen
dc.subjectAnus Neoplasmsen
dc.subjectHIV Infectionsen
dc.subjectMass Screeningen
dc.subjectPapillomavirus Infectionsen
dc.subjectPrecancerous Conditionsen
dc.titleAnal Cancer Screening in a High-Risk Population: A Quality Improvement Initiativeen
dc.type.materialtexten Southwestern Medical Schoolen Improvement and Patient Safetyen Southwestern Medical Centeren with Distinctionen


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