Introduction 
Cervical cancer screening and colposcopy have played an integral role in reducing the prevalence of cervical cancer over the past 40 years (1). The guidelines for cervical cancer screening and colposcopy were established more than 15 years ago by the American Society for Colposcopy and Cervical Pathology (ASCCP) and modified over the years as a broader understanding of cervical cancer screening has increased (2). While all women are at risk for cervical cancer, women over the age of 30 are at a greater risk of developing cervical cancer (1). Furthermore, the majority of human papillomavirus (HPV) in women under the age of 24 resolve spontaneously within one to three years (3). The 2012 ASCCP guidelines were developed to identify cervical pathology as well as minimize overtreatment of lesions that may resolve spontaneously. Colposcopy and loop electrosurgical excision procedures (LEEP) allow for the identification and treatment of pre-invasive lesions, and aid in early detection of invasive cervical lesions when treatment is more effective (4). Unnecessary colposcopy procedures may result in increased cost, unnecessary treatment, and serious psychological consequences for women (5). Additionally, the 2019 ASCCP guidelines have transitioned from result-based algorithms to risk based (6).
There have been several studies that evaluated the adherence of health care providers to the 2012 guidelines in terms of correct screening intervals and knowledge of HPV co-testing (7,8). According to Teoh et all, 15% of providers were unaware of 2012 guideline changes however, this study did not report on adherence to guidelines regarding referring abnormal cytology results for colposcopy (7).
Virginia Commonwealth University (VCU) Department of Obstetrics and Gynecology
conducts diagnostic procedures such as colposcopies for referred patients. The gynecology trained faculty physicians at VCU review all referrals and based on the referred cytology and HPV results make recommendations for subsequent care. The objectives of this study include evaluation of adherence to the 2012 ASCCP guidelines by outside physicians referring patients to a large academic center for a colposcopy and by the large academic center physician’s recommendations following a colposcopy procedure, as well as, the identification of factors associated with referrals that are considered non-adherent to the 2012 ASCCP guidelines. An understanding of the factors associated with incorrect referrals for the 2012 ASCCP guidelines allows for identification of potential areas for concern in the implementation of the 2019 ASCCP guideline updates.
Methods
A retrospective study was performed evaluating the women referred to VCU for colposcopy or LEEP from January 2015 to December 2016. Electronic health records of 430 patients referred to the VCU clinic were utilized to identify patient demographics, cervical cytology, HPV status, prior cervical dysplasia, type of referring provider, patient show rate, the length of time from when the ASCCP guidelines were published and when the referral was received, and the recommended intervention. Except in specific clinical scenarios, pap tests are not recommended until 21 years of age and many women after the age of 65 stop receiving screening for cervical cancer therefore patients under the age of 21 and over the age of 65 were excluded from the study. The final study population consisted of 430 patients. The institutional review board approved this study (IRB HM2004659) as exempt on March 3, 2018, as it was a review of already existing information and posed minimal/no risk to subjects. Figure 1 is a pictorial reference of the methods process. All p-values less than 0.05 are considered statistically significant.