ASCCP COLPOSCOPY RECOMMENDATIONS

ASCCP Colposcopy Standards: Colposcopy Quality

Improvement Recommendations for the United States
Edward J. Mayeaux, Jr, MD, DABFM, FAAFP, DABPM,1 Akiva P. Novetsky, MD, MS,2,3 David Chelmow, MD,4
Francisco Garcia, MD, MPH,5 Kim Choma, RN, DNP, APN,6 Angela H. Liu, MD,7
Theognosia Papasozomenos, MD, MPH,8 Mark H. Einstein, MD, MS,9 L. Stewart Massad, MD,10
Nicolas Wentzensen, MD,11 Alan G. Waxman, MD, MPH,12 Christine Conageski, MD,13
Michelle J. Khan, MD, MPH,14 and Warner K. Huh, MD15

Objectives: The American Society for Colposcopy and Cervical Pathol-

ogy (ASCCP) Colposcopy Standards recommendations address the role of
V ariability in healthcare delivery has led to inconsistent out-
comes in the United States. In 1966, Donabedian1 published
a sentinel article that proposed measuring the quality of health care
and approach to colposcopy and biopsy for cervical cancer prevention in the through the examination of its structure, processes, and outcomes,
United States. The recommendations were developed by an expert working setting into motion multiple movements to address quality improve-
group appointed by ASCCP's Board of Directors. The ASCCP Quality Im- ment and patient safety. The healthcare industry has broadened its
provement Working Group developed evidence-based guidelines to promote approach to improve patient care by following quality improvement
best practices and reduce errors in colposcopy and recommended indicators processes initiated by other industries. One major example is that of
to measure colposcopy quality. aviation,2 which uses a collaborative approach to improve safety.
Materials and Methods: The working group performed a systematic The Institute of Medicine's report “To Err Is Human: Building a
review of existing major society and national guidelines and quality indica- Safer Health System”3 stated that up to 98,000 Americans die each
tors. An initial list of potential quality indicators was developed and refined year as a direct result of medical errors. In addition to morbidity and
through successive iterative discussions, and draft quality indicators were mortality, medical errors cost as much as US $29 billion annually.
proposed. The draft recommendations were then reviewed and commented The Institute of Medicine recognized that this level of healthcare
on by the entire Colposcopy Standards Committee, posted online for public delivery–related patient harm is unacceptable in the United States.
comment, and presented at the International Federation for Cervical Pathology In response, agencies and professional societies develop and imple-
and Colposcopy 2017 World Congress for further comment. All comments ment evidence-based guidelines to promote best practices and re-
were considered, additional adjustments made, and the final recommendations duce errors in medical care.
approved by the entire Task Force. A core concept of quality improvement is the measurement of
Results: Eleven quality indicators were selected spanning documentation, relevant outcomes, including the evaluation of outliers and the iter-
biopsy protocols, and time intervals between index screening tests and ative refinement of contributing processes. Although many coun-
completion of diagnostic evaluation. tries and groups, including the United Kingdom,4 Australia,5 the
Conclusions: The proposed quality indicators are intended to serve as a European Union,6 and Canada7 have quality improvement guide-
starting point for quality improvement in colposcopy at a time when colpos- lines and measures in place for colposcopy, there are no recog-
copy volume is decreasing and individual procedures are becoming techni- nized standards in the United States. To achieve these goals for
cally more difficult to perform. colposcopy, the American Society for Colposcopy and Cervical
Key Words: colposcopy, cervical intraepithelial neoplasia, Pathology (ASCCP) organized the ASCCP Colposcopy Standards
quality assurance, quality improvement, healthcare quality assessment Committee, which represented multiple disciplines (including
physicians, advanced practice providers, and researchers in the
(J Low Genit Tract Dis 2017;21: 242–248)

1
USC Department of Family and Preventive Medicine University of South
Carolina School of Medicine, Columbia, SC; 2Division of Gynecologic There was no source of financial support for the project. For 1 author, the project
Oncology, Department of Obstetrics & Gynecology and Women's Health, described was partially supported by Grant Number D33HP26995 from the
Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, Health Resources and Services Administration, an operating division of the
NY; 3Albert Einstein College of Medicine and Montefiore Medical Center US Department of Health and Human Services. Its contents are solely the
Cancer Center, Bronx, NY; 4Department of Obstetrics and Gynecology, responsibility of the authors and do not necessarily represent the official
Virginia Commonwealth University School of Medicine, Richmond, VA; views of the Health Resources and Services Administration or the US
5
Pima County Health Department, Tucson AZ; 6Women's Health Nurse Department of Health and Human Services.
Practitioner, Scotch Plains, NJ; 7Division of Cancer Epidemiology and M.H.E. has advised but does not receive an honorarium from any companies. In
Genetics, National Cancer Institute, Rockville, MD; 8Preventive Medicine specific cases, his employer has received payment for his consultation from
Residency Program, Palmetto Health/University of South Carolina School Photocure, Papivax, Inovio, PDS Biotechnologies, Natera, and
of Medicine, Columbia, SC; 9Department of Obstetrics, Gynecology, & Immunovaccine. If travel is required for meetings with any industry, the
Women's Health, Rutgers New Jersey Medical School, Newark, NJ; company pays for M.H.E.'s travel-related expenses. In addition, his
10
Division of Gynecologic Oncology, Department of Obstetrics and employers have received grant funding for research-related costs of clinical
Gynecology, Washington University of Medicine, St. Louis, MO; 11Division trials that M.H.E. has been the overall project investigator or local project
of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, investigator for the past 12 months from Astra Zeneca, Baxalta, Pfizer,
MD; 12Department of Obstetrics and Gynecology, University of New Mexico Inovio, Fujiboro, and Eli Lilly. K.C. reports that she is on a speaker's bureau
School of Medicine, Albuquerque, NM; 13Department of Obstetrics and and advisory board for Hologic, Inc and an advisory board for Symbiomix
Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO; Therapeutics. The rest of the authors have declared they have no conflicts
14
Departments of Obstetrics and Gynecology, and Adult and Family Medicine, of interest.
Kaiser Permanente Northern California, San Leandro, CA; and 15Division of No institutional review board approval or written consent was required because
Gynecologic Oncology, Department of Obstetrics and Gynecology, University the research was literature based and did not involve human subjects.
of Alabama at Birmingham School of Medicine, Birmingham, AL Colposcopy Quality Improvement Recommendations for the United States. The
Reprint requests to: Edward J. Mayeaux, Jr, MD, DABFM, FAAFP, DABPM, Report of the Quality Improvement Working Group of the Colposcopy
USC Department of Family and Preventive Medicine, University of South Standards Task Force.
Carolina School of Medicine, 3209 Colonial Dr, Columbia, SC 29203. © 2017, American Society for Colposcopy and Cervical Pathology
E-mail: [email protected] DOI: 10.1097/LGT.0000000000000342

242 Journal of Lower Genital Tract Disease • Volume 21, Number 4, October 2017

Copyright © 2017 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
Journal of Lower Genital Tract Disease • Volume 21, Number 4, October 2017 Colposcopy QI Indicators for the US

disciplines of obstetrics and gynecology, family medicine, gyne- by the working group based on the abstracted evidence and expert
cologic oncology, preventive medicine, and pathology) all in- consensus. The recommendations were presented to the steering
volved in cervical cancer screening, diagnosis, and prevention. committee in October 2016 and reviewed for content and consis-
The Standards Committee initiated a process to develop comprehen- tency. Revisions were presented to all working group members for
sive, evidence-based recommendations to address colposcopy qual- discussion and further revision in January 2017, and a vote among
ity, documentation, and practice. The quality improvement working working group members was held shortly after. Sixty-seven per-
group was charged with developing guidelines for quality assurance cent affirmative votes were required for approval of individual rec-
to serve as a starting point for developing quality improvement pro- ommendations. All recommendations were approved at the first
grams in the United States. vote, and most were approved unanimously with only minor com-
Recognizing the limitations of current colposcopy approaches ments. After further editing and notification of stakeholder profes-
in the United States, the ASCCP, in collaboration with investigators sional organizations, recommendations were posted on the ASCCP
from the US National Cancer Institute, set out to review evidence Web site for public comments between March 13 and 22, 2017,
and develop recommendations for US colposcopy practice. The which resulted in additional modifications in response to the com-
ASCCP leadership formed a steering committee, who selected ad- ments. Finally, recommendations were presented at the Interna-
ditional working group members with expertise in colposcopy and tional Federation for Cervical Pathology and Colposcopy's 16th
guideline development. World Congress in Orlando, Florida, on April 5, 2017, followed
by a plenary discussion. Final revisions were made by the steering
committee based on comments received at this meeting. Col-
MATERIALS AND METHODS poscopy terminology defined by the ASCCP Colposcopy Stan-
In developing quality indicators, the Quality Improvement dards Committee for the United States was used for reporting
Working Group performed a systematic review of existing major quality indicators.
society and national guidelines.8 The completed systematic re-
view was supplemented with input from the steering committee RESULTS
to develop a list of proposed US quality measures and guidelines.
Table 2 presents the ASCCP Colposcopy Standards Commit-
The list of proposed US quality measures was refined through
tee's quality indicator recommendations. All of these indicators
successive iterative discussions by the working group members
fall into the process category of the Donabedian model. Each indi-
in collaboration with the other working groups of the ASCCP Col-
cator is presented along with a brief rationale for its inclusion and
poscopy Standards Committee. Because of the paucity of evidence
a summary of other organizations that are already using it. A total
and the volume of potential measures, a Delphi style method9 aug-
of 11 quality indicators were chosen. Both minimum and compre-
mented with group conference calls was used to derive specific pro-
hensive standards are presented for most indicators. The minimum
posed quality indicators for the United States. Guiding principles
value represents the lowest performance measure that the working
were created by the working group to inform the key values in
group determined was acceptable for a provider or colposcopy
guideline development (see Table 1). Specific quality indicators
unit. The comprehensive goal was felt to be reasonably attainable
were chosen based on the guiding principles, availability of neces-
and an appropriate measure for a quality colposcopy provider or
sary informatics infrastructure, and anticipated ability of US clinical
unit. Instructions for determining numerators and denominators
practice settings to implement the required changes. The working
for calculating the measure are included. There are no specific
group considered all of the indicators in the identified international
minimum denominator values specified.
guidelines (enumerated in the companion systematic review) as
well as recommendations of the other working groups.10 When
there was no evidence to support a recommendation and interna- DISCUSSION
tional guidelines varied, criteria were selected based on expert opin- Colposcopy has been performed in the United States for de-
ion. In general, the working group began with consideration of the cades without formal standards. This is at odds with many other
varying international recommendations but was not limited to them. parts of the world, where standards for colposcopy are widely
Expert opinion was used most frequently to determine follow-up implemented, measured, and enforced by professional societies
time intervals. and payors.8 A number of forces at work will promise to make
The output of the working group was regularly reviewed maintenance of colposcopy skills notably more difficult in the
by the steering committee for appropriateness and direction. After future, because procedure volume drops and difficulty in-
multiple cycles of revision, draft quality indicators were proposed creases. Procedure volume has already started to fall with the

TABLE 1. Guiding Principles for Colposcopy Standards Development

1. Greater enforced provider record-keeping results in less time for providers to directly interact with patients. In choosing quality measures, we
emphasized relevant routinely recorded clinical data that can be captured and retrieved from an electronic medical record to minimize burden on
the provider and staff.
2. The minimum number of measures should be used to minimize burden on providers. A minimum number of measures should be adequate for a
number of reasons. There is likely to be a high degree of correlation between quality measures. Providers who do well on 5–6 key measures will
probably do well on others. There are no data that increasing the number of measures would improve outcomes compared to a smaller number of
measures. A number of potentially important measures were considered, but not included to ensure the total number of measures was manageable.
3. Outcome measures should be reliably “measurable” and reinforce optimal clinical outcomes.
4. At present, the measures are intended for self-monitoring and improvement, and were not developed with public reporting in mind. In the future,
there may be a need for reporting of quality measures to outside entities such as healthcare payers including the Center for Medicare and Med-
icaid Services, and the measure proposed here may be used to inform future requirements.
5. The list of measures will not be static, and there will be opportunities to revise them in the future as some measures become routinely complied
with and new ones become relevant.

© 2017, American Society for Colposcopy and Cervical Pathology 243

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 244
TABLE 2. Proposed Minimum and Comprehensive Quality Measures for the Colposcopic Examination
Mayeaux et al.

Minimum Comprehensive
Recommendation Context/background Calculation for provider or unit target, % target, % References and notes
1. Document that squamocolumnar Adequate visualization at the time of Numerator: no. colposcopy notes 90 100 European Federation of
junction is visualized (fully visualized/ colposcopy is important in managing with documentation of visualized Colposcopy 2013,6
not fully visualized) abnormal screening tests. Lack of (fully/not) Massad et al.,11
documentation may impact current Denominator: no. total colposcopies WHO/IARC 2003,12
or future management. performed by individual provider New Zealand 201313
or group Germany 201514
2. Documentation of whether any Documentation of the presence of a lesion Numerator: no. colposcopy notes with 90 100 Massad et al.,11 British
acetowhite lesion is present (yes/no) is important in correlating cytology, documentation of lesion present 2016, New Zealand
histology, clinical impression, and clinical Denominator: no. total colposcopies 2013,13 Italy 200615
management. Lack of documentation can performed by individual provider
alter management and lead to or group
suboptimal outcomes
3. Documentation of colposcopic Documentation of colposcopic impression Numerator: no. colposcopy notes with 80 100 Massad et al.,11 WHO/
impression (normal/benign; low is clinically important and is a quality documentation of colposcopic impression IARC 2003,12 New
grade; high grade; cancer) assurance and precision metric for Denominator: no. total colposcopies Zealand 201313
colposcopy performed by individual provider Germany 201514
or group
4. Documentation of cervix visibility Adequate visualization of the cervix at the time Numerator: no. colposcopy notes with 70 100 Britain 20164 WHO/
(fully visualized, not fully visualized) of colposcopy is important in management of documentation of adequate visualization IARC 2003,12 New
abnormal screening tests. Lack of documentation of the cervix at the time of colposcopy Zealand 201313
may result in over or under treatment of Denominator: no. total colposcopies
abnormal findings. performed by individual provider
or group
5. Documentation of extent of lesion Adequate visualization of the extent of the Numerator: no. colposcopy notes with 70 100 Britain 20164 WHO/
visualized (fully/partial) lesion(s) at the time of colposcopy is important documentation of visualization of extent IARC 2003,12 New
in management of abnormal screening tests. of any/all lesion(s) or no lesion Zealand 201313
Partial visualization of the lesion(s) can alter Denominator: no. total colposcopies
management. Lack of documentation may performed by individual provider
result in over or under treatment of or group
abnormal findings.
6. Documentation of location of lesion(s) Knowledge of the location of the cervical lesions Numerator: no. colposcopy notes with 0 100 New Zealand 201313
and size of the lesion allows the practitioner to documentation of location of the
tailor any necessary extirpative procedure to the lesion(s) or no lesion
abnormal pathology. Lack of documentation may Denominator: no. total colposcopies
result in overly large or inadequate cervical excision. performed by individual provider
or group
7. Provider should take multiple biopsies A single biopsy, targeting the worst appearing lesion Numerator: no. colposcopy notes with 85 100 Britain 2016,4 Canada
targeting all areas with acetowhitening, may miss up to a third of prevalent precancers. documentation of any acetowhite lesion 2012,7 Gage et al16
metaplasia or higher abnormalities and 2 to 4 biopsies taken OR a biopsy Stoler et al.,17
(at least 2 and up to 4 biopsies) and endocervical sampling taken. Pretorius et al.18
Denominator: no. colposcopy notes with Wentzensen et al.19
documentation of any acetowhite lesion

Copyright © 2017 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
© 2017, American Society for Colposcopy and Cervical Pathology
Journal of Lower Genital Tract Disease • Volume 21, Number 4, October 2017
 8. An attempt should be made to contact a Optimally a patient with suspected invasive Numerator: no. patients with suspected 60 90 New Zealand 2013,13
patient with suspected invasive diseasea disease should be seen as soon as possible invasive disease with attempted contact expert/committee
within 2 week of receipt of report after the diagnosis has been confirmed. within 2 week opinion.
or referral. Multiple factors may impact the ability to Denominator: no. patients with suspected
complete that contact among patients with invasive disease
a high acuity abnormality were
identified including:
1. screening environment
2. insurance status
3. health literacy
4. social/cultural/language barriers
9. Patients with suspected invasive Time to definitive treatment for invasive cervix Numerator: no. patients with suspected 60 90 New Zealand 2013,13
diseasea should be seen within 2 week cancer is associated with improved outcomes. invasive disease seen within 2 week expert/committee
of contact. Therefore, timely evaluation, diagnosis, and of contact opinion.
referral are integral to appropriate care and Denominator: no. patients with suspected
patients should be provided prompt treatment. invasive disease
10. An attempt should be made to contact Patients with high-grade cytology resultsb have Numerator: no. patients with high-grade 60 90 New Zealand 2013,13
a patient with high-grade cytology a risk of CIN 2+ of >10%. Therefore, timely cytology resultsb with attempted contact expert/committee
resultsb within 4 week of receipt of evaluation is critical for diagnosis and within 4 week opinion.
report or referral. management of dysplastic disease. Denominator: no. patients with high-grade
cytology results

© 2017, American Society for Colposcopy and Cervical Pathology

11. Patients with high-grade cytology See #9. Numerator: no. patients with high-grade 60 90 New Zealand 2013,13
resultsb should be seen within 4 week cytology resultsb seen within 4 week expert/committee
of contact. of contact opinion.
Denominator: no. cytology tests with
high-grade disease
Contact is defined as communications by any Health Insurance Portability and Accountability Act (HIPAA) compliant means for the purpose of informing the patient of the status of their clinical investigation and the
Journal of Lower Genital Tract Disease • Volume 21, Number 4, October 2017

plan for their continued follow up. The communication should document a response from the patient acknowledging the future plan, acknowledging understanding of the information being discussed, and documen-
tation of the interaction.
a
Suspected invasive disease includes cytology tests with neoplasia or suspected neoplasia or with clinical suspicion for invasive disease.
b
A high-grade cytology result includes any of the following cytology results: high-grade squamous intraepithelial lesion, atypical squamous cells: cannot exclude high-grade squamous intraepithelial lesion, atypical
glandular cells.
CIN indicates cervical intraepithelial neoplasia.

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245
Colposcopy QI Indicators for the US
Mayeaux et al. Journal of Lower Genital Tract Disease • Volume 21, Number 4, October 2017

implementation of the 2012 American Cancer Society / American on the events. In this instance, time intervals were determined
Society for Clinical Pathology Screening Guidelines,11 which by the risk of underlying invasive cancer and the natural course
increased the testing intervals and consequently decreased the of HPV disease rather than the particulars of the range of
number of abnormal tests. At the University of Alabama, aver- practice settings.
age monthly colposcopy volume dropped to nearly one third The guidelines group did not set minimum numbers of pro-
of its peak from 2010 to 2015.20 With increased uptake of human cedures to review in assessing adherence with the quality mea-
papillomavirus (HPV) vaccination, numbers of abnormal screen- sures. The guidelines groups appreciated that some units and
ing tests will decline further. Predictive values of cytology for providers may have sophisticated electronic medical records
cervical intraepithelial neoplasia 3+ already seem to be dropping allowing global review of all colposcopy procedures performed.
in vaccinated populations.21 Lesions associated with HPV 16 are Other practices may still use paper charts or have electronic
typically more acetowhite and easier to visualize.22 Because vac- medical records that do not allow summary review, requiring
cination will prevent many of these infections, lesions from the individual records review to determine adherence with quality
remaining HPV types will be harder to visualize at colposcopy. measures. In this setting, review of a minimum of approxi-
The ASCCP Colposcopy Standards Working Group 3 found mately 30 procedures is likely adequate. The group was also
that 32% of respondents to the ASCCP survey indicated that not specific about whether the measures should be applied to
they did fewer than 6 colposcopies per month.23 In the setting individual providers or entire units. It was felt that the measures
of lower volumes of harder to perform procedures, training could be calculated either way depending on the organization of
new providers and maintaining proficiency of existing providers the practice or unit. The working group also did not make rec-
will be more challenging and quality measurement will be much ommendations about frequency with which the indicators
more important.
should be reviewed. For stable practices with minimal staff
Maintaining quality is further challenged by the varied practice
turnover, intervals of 1 to 3 years may be reasonable. For new
settings in which colposcopy is currently performed and the geo-
practices or practices undergoing staff or provider changes,
graphically and socioeconomically diverse population of women
undergoing the procedure. In developing the standards, we defined more frequent assessments may be required.
a set that would be applicable across practice settings, including This iteration of the ASCCP Colposcopy Standards Commit-
public and private clinics, low or high volume, and insured and un- tee and its working groups did not assess or address types and uses
insured patients. These factors were particularly relevant to setting of particular colposcopy instruments or colposcopes. We only as-
thresholds for follow-up, which needed to encompass both easy- sessed the colposcopy procedures and documentation, not screen-
to-reach patients with resources for follow-up testing and poten- ing tests or treatments. It is expected that these will be addressed
tially difficult-to-reach uninsured populations in public settings and by future committees.
rural communities. There were no patients or patient advocates in the working
The proposed minimum and comprehensive quality mea- group. It is anticipated that when providers and clinics develop
sures for colposcopic practice can be divided into 2 general cate- or continue to develop their quality improvement program, there
gories. The first has to do with the documentation of minimum will be patients and/or patient advocates involved in the process
elements of a technically complete and clinically well-performed as recommended by quality groups such as the Agency for Health-
colposcopic evaluation. At a minimum, these must include docu- care Research and Quality.24
mentation of the visualization (or not) of the cervix. Additional For the purposes of these quality indicators, follow-up could
documentation of the entire squamocolumnar junction, the pres- be either with the original provider or with a provider who can
ence (or absence) and location of acetowhite lesion(s), as well as continue providing care at the same or a more advanced level.
whether biopsies were performed and how many must also be in- The goal is to make sure that patients get appropriate continuity
cluded. These standards should be achievable by any type of pro- of care. This could be with the original provider who performed
vider with any patient population in any practice setting. Efforts to testing, a partner within a practice, or with other providers who
incorporate these elements into templates in the electronic medical provide services that the original provider does not.
record (when available) should facilitate clinicians' ability to meet The working group examined the question of how many
these standards. quality indicators adopt. In the United States, quality improve-
The second category sets minimum standards for patient ment program is often carried out in the form of continuous qual-
follow-up in the setting of the management of cervical disease. ity improvement, which is a process that continually assesses,
The expectation is for documented attempts at contacting a patient improves, reassesses, and further adjusts the system (Plan, Do,
with high-grade cervical cancer screening within 4 weeks of re- Study, Act or PDSA cycles) to produce a steady and constant flow
ported results and to be scheduled for evaluation within 4 weeks of improvement to the system. High-yield, high-impact quality
of that contact. Likewise, women with suspected invasive disease measures are often first chosen to focus considerable resources
on laboratory report or referral should have contact attempted to devote to improving outcomes. The working group decided to
within 2 weeks and evaluation scheduled within 2 weeks of that assume this paradigm and selected 11 measures as a starting point
contact. Similar to many of the quality improving standards from for quality improvement for colposcopy. This contrasts with some
other countries, the working group put a differential in the urgency national society programs where comprehensive programs with
of follow-up based on cytology results to allow clinics with high numerous quality indicators are employed. To produce a limited
volumes to prioritize more severe cases. We based our goals list of desirable indicators that would be feasible to implement
mostly on the New Zealand recommendations, but the British, in clinical settings not currently practicing quality improvement,
the Canadians, and others have a similar differential in follow- it was necessary to exclude some potentially useful international
up scheduling.4,7,13 This should help not unduly burden high- measures. These guidelines are intended to be a starting point,
volume safety net clinics while still increasing and measuring especially for those clinical settings without a strong clinical
the quality being delivered. The guideline group appreciated quality improvement focus. The authors anticipate that be-
that achieving these targets would be profoundly affected by cause infrastructure is developed and practices and healthcare
the adherence of the patient population and the resources of systems become more adept at conducting colposcopy quality
the provider and practice setting; it accounted for this by focus- improvement activities, additional helpful indicators will
ing on the process of patient contact and evaluation rather than be added.

246 © 2017, American Society for Colposcopy and Cervical Pathology

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Journal of Lower Genital Tract Disease • Volume 21, Number 4, October 2017 Colposcopy QI Indicators for the US

Other national and society guidelines included a number of Academies Press; 1999. Available at: http://www.nationalacademies.org/
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not have any national data repository for cytology or histologic 4. Britain 2016. NHS Cervical Screening Programme: Colposcopy and
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